Disparities in the US health care system toward minorities prompted Congress to request the Institute of Medicine (IOM), of the National Academy of Sciences in Washington, D.C., to study the issues and report the findings.

The 562-page report on Unequal Treatment assessed the evidence in both historic and current social and economic contexts. The report revealed racial and ethnic biases and discrimination within health care settings, workforce, and education in medically underserved communities. It also pointed to patients who mistrust their health care providers and the system.

Included in the report were studies concerning African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanic/Latino Americans.

Because the disparities in health care exist, and because they are associated with worse outcomes in many cases, "they are unacceptable," the authors wrote. The committee on understanding and eliminating racial and ethnic disparities in health care was chaired by Alan R. Nelson, MD.

Minority groups were less likely to have health insurance than whites, and more likely to have language and cultural barriers.

Add to the mix problems with time pressure, need to control costs, and complex medical problems, the result is medical care poorly matched to the needs of minorities.

The sad reality is that the end result is higher death rates for African Americans and others for a number of medical conditions, including cancer.

In cancer care, there has long been the question whether increased cancer deaths found for African Americans is related to ethnic factors, such as more aggressive disease, or economic factors.

But problems with race and cancer care abound, according to the report.

For example, a 1989 study pointed out that African-American women with breast cancer were less likely to have health insurance, were less likely to be treated by a board-certified doctor, and were more likely to be treated in large, public hospitals.

They were also less likely to have hormone studies done on their cancers, and were less likely to receive radiation as part of their treatment for breast cancer.

For men with prostate cancer, another study showed that African-American men were more likely to be treated with radiation than have the newer surgical procedures. And, twice as many African-American men as white men received no treatment at all for their prostate cancer.

In diagnosing colon cancer, African Americans were more likely to have only a barium enema, rather than the more thorough barium enema with a sigmoidoscopy (a test looking through the rectum into the bowel with a tube), or a colonoscopy (using a longer tube to look all the way around the bowel to find colon cancer) compared with whites.

One of the important issues highlighted in the report is the fact that treatment of pain in African-American patients was inadequate compared to whites. And, doctors tended to underestimate the severity of pain in their African-American patients.

The report included general suggestions to increase awareness that bias does exist, and that it affects medical care delivery. Doctors in training must be made aware of the issues of bias and stereotyping throughout their medical training, wrote the committee.

Legal and policy interventions were recommended to avoid division of health plans along socioeconomic lines, strengthen patient-provider relationships in publicly funded health plans, and provide greater resources to enforce civil rights laws.

Health systems interventions were noted to use guidelines to promote equity of care; structure payment systems to ensure supply of services to minority patients; provide financial incentives for practices that reduce barriers; support use of interpretation services and use of community health workers; and, start treatment and preventive care teams.

Patient education and empowerment programs were recommended to increase patients' knowledge of how to best access care and participate in treatment decisions.

Cross-cultural education into the training of all current and future health professionals was suggested by the committee.

Data collection so sources of disparities and promising intervention strategies could be researched to eliminate disparities was recommended.

The spirit of Unequal Treatment was underscored by the quote from Goethe, included on the title page: "Knowing is not enough; we must apply. Willing is not enough; we must do."