JOE TORRES: To what do you attribute that?

MAXINE GOLUB: It's due in part to poverty, which certainly has a huge effect on people's educational attainment and the educational messages that they receive in school. But we think it's more likely due to racial bias in the health care system and racial profiling on the part of doctors.

JOE TORRES: Profiling in the sense that...

MAXINE GOLUB: One study that was done last year by a physician named Kevin Schulman and written up in the New England Journal of Medicine* actually used actors… he taped four actors, a black woman, a white woman, a black man and a white man with exactly the same symptoms.

JOE TORRES: Going to a doctor's office?

MAXINE GOLUB: Going to a doctor's office complaining about heart symptoms. And he showed that tape to 750 doctors at a convention; and what he found is, if you consider what the optimum treatment was, which in this case was an aggressive cardiac intervention, black men and white women only received that treatment 60% of the time. And black women only received that treatment 40% of the time. And I don't know what else to call that except racial profiling. There's no economic factor there. There was no insurance status factor there. There was simply a doctor listening to the exact same words said by a person of a different color and coming to a different conclusion.

JOE TORRES: You mentioned education also as perhaps being one reason why the quality of care is not good. How does education effect quality of care?

MAXINE GOLUB: In two ways. One is that patients really need to learn to advocate for themselves and take care of themselves. If you're diabetic you need to know that you should go to get your eyes checked once a year. You need to know that you should go to get your feet checked once a year. So if patients don't have that basic information, they're not going to say to their doctor, "Gee you forgot to send me for my foot exam." And that will end up in worse outcome. That ends up in much, much higher rates of amputations for diabetics in communities like the Bronx than in communities like Westchester County.

JOE TORRES: Because they simply don't know, right?

MAXINE GOLUB: They don't know...

JOE TORRES: They don't know the questions to ask.

MAXINE GOLUB: ...and they don't get the care. It's that patients don't know how to advocate for themselves and the doctors aren't advocating for the patients because of this bias.

JOE TORRES: A double-edged sword.

MAXINE GOLUB: Absolutely.

JOE TORRES: We highlight a problem. What's the solution?

MAXINE GOLUB: Well there are a couple of solutions, and the coalition that we're working with in the Bronx is hoping to implement a community action plan that will actually implement these solutions. The first and obvious solution is that everyone in the country needs to have health insurance. The second is that we need to change who we're recruiting to become doctors, because currently only 7% of the doctors in the United States are people of color...and how we train those doctors. We need to teach them more cultural competency, cultural sensitivity, whichever words you prefer. And we need to eliminate the racial bias in medicine. We need to overcome people's previous training. And then we need to educate community residents about how to advocate for themselves in the system.

JOE TORRES: What can the individuals do for themselves?

MAXINE GOLUB: They need to learn about their diseases and learn what constitutes optimum care for their diseases. And they need to be fairly aggressive when they're in their doctor's office to say, "I didn't understand what you told me. Would you explain that again please?" So that they don't walk out of a doctor's office feeling like they're not sure what's the matter with them or what they're supposed to do to maintain their health.

JOE TORRES: How do you overcome entrenched ideas and approaches used by doctors?

MAXINE GOLUB: What we're hoping to do is really involve the community-based coalition. We're going to use community members to help us train doctors; and the community members are also going to monitor those healthcare facilities so that ultimately patients can vote with their feet as to who's catching on and who's not.

JOE TORRES: The Institute spent how many months coming up with this study?

MAXINE GOLUB: We spent the last year in the planning phase of this program. That involved a literature review and the focus groups that came up with the conclusions that you mentioned, as well as the action plan. And now we've been funded for the coming four years to the tune of $4 million to begin to address this problem in the Bronx.

JOE TORRES: Did you know what to expect when the report came and you opened it? Shock and amazement, or not really much surprise?

MAXINE GOLUB: Unfortunately, no surprises. And I've spent a lot of time in the last year talking to community people in the Bronx and unfortunately they're not surprised either. And that's the real tragedy here. The one good thing is that the Federal Government has opened up this dialogue and put money on the table so that we can begin to address this problem.

JOE TORRES: Is that where you go from here? Using the money that you got from the Centers for Disease Control?

MAXINE GOLUB: We're very excited about having the money. We're very excited about the coalition we've built to address the problem and the cooperation we've gotten. I think that we're going to be able to do something, and that what we do will become a model for the rest of the nation. That's what I'm excited about.

JOE TORRES: Do you give yourself a timeline...a year from now, six months...before you say "Let's re-look at the situation, see how we're doing?"

MAXINE GOLUB: Different pieces of the project can be measured over different periods of time. To suggest that we're going to eliminate racial discrimination in medicine in a four-year period is pretty optimistic, but we're committed.

JOE TORRES: You've got to set high goals.

MAXINE GOLUB: Absolutely.

JOE TORRES: Maxine, a pleasure. Thank you so much for being with us on Saturday morning on Tiempo.

MAXINE GOLUB: Thank you.