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— An aristocratic Frenchman went on a quest to understand democracy in America in 1831. Alexis de Tocqueville went on to write a book in which he extrapolated "the most horrible of civil wars" from the cruel data of African-American slavery in the South. He also extrapolated that as blacks became more and more equal by law, they would be increasingly discriminated against by custom. "If I were called upon to predict the future," Tocqueville wrote, "I should say that the abolition of slavery in the South will, in the common course of things, increase the repugnance of the white population for the blacks. I base this opinion upon the analogous observation I have already made in the North. I have remarked that the white inhabitants of the North avoid the Negroes with increasing care in proportion as the legal barriers of separation are removed by the legislature...." In a word, "slavery recedes, but the prejudice to which it has given birth remains stationary." More than 150 years later, Dr. Rodney Hood, who treats African-Americans in Southeast San Diego, thinks that -- unfortunately -- Tocqueville got that right.

Dr. Hood is president-elect of the Washington, D.C.-headquartered National Medical Association, a 25,000-member African-American physicians' association founded in 1895. "I don't want to spend another 100 years arguing whether racism exists," asserts Dr. Hood, who will become the NMA's 100th president in 2000. "People are dying."

That's not hyperbole. Last month, the New England Journal of Medicine published a study showing that "the rate of surgery was 12.7 percentage points lower for black patients than for white patients (64.0 percent vs. 76.7 percent), and the five-year survival rate was also lower for blacks (26.4 percent vs. 34.1 percent)." The researchers, based at Memorial Sloan-Kettering Cancer Center in New York and the National Cancer Institute in Bethesda, Maryland, said that small-cell lung cancer, if discovered early enough, is potentially curable by surgery. But from the different rates of surgery, they extrapolated that, given 1000 white patients and 1000 black patients with small-cell lung cancer, five years later 341 white patients will still be alive as opposed to 264 blacks. The researchers wrote that "of the 77 more deaths per 1000 black patients, the majority (44) could be attributed to lack of surgical treatment."

That lack of surgical treatment is just the latest symptom of a racist attitude toward health care in America, in Dr. Hood's mind. The first African-American to graduate from UCSD medical school in 1973, he completed his residency in internal medicine at University Hospital in San Diego. Dr. Hood began providing primary health-care services for an average of 30 patients a day in 1976. While the majority have Medicare or Medical, patients without coverage are not turned away. "If they can afford $10, that's what I take," Dr. Hood said.

"I'm from Boston," he said in a recent interview in his Euclid Avenue office. "I was born and raised in Roxbury, which is a ghetto of Boston. So when I graduated, I had no other desire than to practice in an area like this." He declines to say how much money he makes, other than "I make a good living; the amount of money I make is not as much as I could make in another part of town." Dr. Hood has been joined by other like-minded African-American physicians, and a generation later, "We still find that there's a need for the existence of the National Medical Association to see to it that African-Americans receive quality healthcare," he said. "And unfortunately, that mission is still relevant today.... We still see huge gaps: African-Americans have the worst outcome, the worst health status with cardiovascular diseases, diabetes, asthma, cancer. There are certainly basic genetic differences, the socioeconomic factor, the compliance factor -- compliance as far as taking medications, exercise -- but clearly over the past 20 years there's been a huge literature pointing out that this population is being treated differently."

This latest study was designed to filter out factors other than racial bias: for example, it looked at only Medicare-eligible patients, so lack of insurance was not a factor. Socioeconomic variables were factored out by studying both black and white patients from the poorest zip code areas. In summing up, the researchers wrote, "We cannot determine from our data why black patients have a lower rate of [surgery] than their white counterparts, but we can conclude that the difference in treatment has a substantial effect on survival. Others have argued that the preferences of black patients may differ from those of white patients or that black patients may weigh the risks of surgical therapy differently. An alternative explanation is that black patients are offered optimal treatment less frequently than their white counterparts."

While allowing that the discrepancy of treatment can be in part attributed to the "attitude of African-Americans not wanting surgery," Dr. Hood maintains that the attitude of the health-care practitioners is also to blame. The discrepancy bespeaks racial bias, Hood says, and "racial bias is a byproduct of racism," he said. "I think the term 'racism' is kind of abused, but I think racism in this country is as common as apple pie. Sometimes it's very subtle and it's very institutionalized. If you ask one of these practitioners, he might say that he doesn't have racist views; but he nonetheless suffers from the 'disease' of racism.

"I don't think you can deal with a solution until first you admit the problem exists," Dr. Hood went on. "Because up until now, I think the medical community has been in denial that this racial bias exists."

Has he seen medical racism in action?

"Unfortunately, I have," replied Dr. Hood, who is married with four children, "too many times." He gave as an example "patients that I would see that had unnecessary hysterectomies. African-American women get offered the more aggressive treatment.... I'm not sure they value the humanity of African-Americans as much as they do non-African-Americans. And that's what racism is.

"I should say that it's not just the European provider," he added. "We all have our own bias."

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