Health Care Disparities Add Insult to Spinal Cord Injury

Abstract

The authors describe the disparities and increased risk of traumatic spinal cord injury Black Americans face because of violence. This article should serve as a realization of these inequities and as a call to action to improve the equity of rehabilitation services in this population to improve outcomes.

Shackles, guns, and other tools of oppression ensured the ongoing enslavement of Black Africans. Four centuries later, horrific stories of violence against Black Americans pervade headlines. Jacob Blake was shot 7 times in the back at close range by police in Kenosha, WI. According to family reports, one of the bullets severed Mr. Blake's spinal cord causing him to be paralyzed from the waist down. The story of a young, Black man being injured or killed at the hands of violence is all too commonplace. Black Americans are overwhelmingly the victims of violence and are killed by police at twice the rate of those who are White.¹

There are over 17,000 spinal cord injuries per year in the United States, with 24% of injuries occurring in non-Hispanic Black persons, nearly double the percentage of the Black population in the United States.² From 1972 to 2014, 27% of traumatic spinal cord injuries (SCIs) in young men were because of acts of violence with a disproportionate 42.9% of those cases being in Black men, a trend that continues today (Figure).^2,3 Black persons with SCI face many health disparities. After a traumatic SCI, Black Americans have lower odds of receiving decompressive surgery, a treatment known to improve clinical outcomes.⁴ Being Black in the United States also means a person is less likely to receive acute inpatient rehabilitation with expert clinicians, therapists, and psychologists trained in helping persons with SCI maximize function and return to social life, school, and/or work (odds ratio 0.73–0.98).⁵

Figure. Rates of Violent and Nonviolent Spinal Cord Injury by Race.

The bar diagram shows the rates of violent and nonviolent spinal cord injuries by race per million individuals. Rates from 2019, distribution (violent vs nonviolent) based on aggregate Spinal Cord Injury Model Systems data from 1972 to 2019²

Those patients who are Black and do receive care from a rehabilitation team continue to be faced with health disparities and inequities. Among physiatrists who specialize in the rehabilitation of persons with SCI, there is an anti-Black racial implicit bias.⁶ Physiatrists are not alone in having implicit bias, and institutional racism permeates all facets and fields. It is no surprise then that after a SCI, Black Americans are more likely to be rehospitalized, develop pressure injuries, and develop recurrent urinary tract infections than White persons with SCI.^7-9 In addition to the inequities that Black Americans with SCI experience in medical care, Black Americans with SCI are even adjusting for factors that could limit employability, significantly less likely to be employed than White persons with SCI.¹⁰

Traumatic SCI has significant effects on the quality of life and mental health, not only on the persons who suffered the trauma but also on those around them. After SCI, Black persons experience lower social integration and decreased physical quality of life when compared with White persons with SCI.^11,12 The rate of depression after SCI has been found to be as high as 50%, much higher than rates for the general population estimated by the National Institute of Mental Health (6%–10%).^13,14 Similarly, posttraumatic stress disorder (PTSD) has higher rates (10%) after SCI than in the general population (6.8%).^15,16 Although to this point, a person's race is not known to be a risk factor for depression or PTSD after SCI, Black persons in the United States are proportionately more likely to suffer from a traumatic SCI that then places them in a group of persons more likely to suffer from depression or PTSD. Children are also affected by violence leading to traumatic SCI. Many persons with traumatic SCIs have children, and their children must live with the ramifications to their mental health and well-being of a family member or parents suffering a devastating injury because of violence. The medical and psychological literature is replete with evidence of the long-term health consequences of adverse childhood experiences (ACEs) of which witnessing violence is one and unfair treatment because of race or ethnicity is another.⁷ As neurorehabilitation specialists, we know that adults who lived with ACEs have much higher rates of chronic health problems and disability. We know that although we do our best to help patients mitigate the negative consequences of their health conditions, it would be better if they never experienced them at all.

Black Americans are more likely to experience SCI because of violence and are less likely to be hired after an SCI, and because of this, their children are disproportionately suffering ACEs.¹⁷ All in all, this creates a cycle of systematic injustice. Understanding these inequities is key in preventing them, studying them, and fixing them. Prevention is essential, it should be the expectation that no one group of persons in the United States be more at risk of SCI because of violence than another.

It is still unclear how physicians can most effectively help reduce disparities in care, such as those caused by violence. However, there have been effective programs, such as the Stop the Bleed program, spearheaded by physicians designed to empower communities to help reduce the severity of injuries suffered because of trauma.¹⁸ Moving forward, physicians should consider creating and participating in similar programs focused on SCI. Although physicians cannot correct all the social factors that lead to the disparities, physicians should study these disparities and their causes so that they can be addressed through policy changes and by society at large. Physicians should lobby for funding mechanisms to study and research the effects of violence, including gun violence and police brutality. In addition, physicians should engage in activities that promote population health and become involved in advocacy, community education, community programs (such as youth mentorship programs), and local government.

The change required to reduce disparities starts internally in the way that we as physicians produce and understand data, recognize our own unconscious biases, and hold affecting groups responsible for the injustices and deficiencies in our healthcare systems. Physicians care for patients and care about people. We must continue to push for positive change that will result in prevention of violence and health disparities, and because we commit to antiracism in medicine, we must be horrified at the inequities that Black Americans have in receiving biased care.

Appendix. Authors

Study Funding

No funding or grant was obtained or awarded in direct relation to this work, but it should be noted that for Dr. Skelton's contribution, this material is based on work supported (or supported in part) by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, and the Center for Innovations in Quality, Effectiveness and Safety (CIN 13–413) and HSR&D Career Development Award 1 IK2 HX002484-04.

Disclosure

The authors report no disclosures relevant to the manuscript. Unrelated to this work, Dr. Verduzco-Gutierrez has been a consultant with Allergan, Merz, Ipsen, and Medtronic in the past 12 months. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.