A Double Whammy + 1



A double whammy + 1 is a triple part difficulty; e.g. limitations in health care based on 1) race, 2) ethnicity, plus 3) disabilities.

A double whammy is a situation that is bad in two different ways: a situation in which two bad conditions exist at the same time or two bad things happen one after the other.”1

For example: “The high cost of health care and a lack of medical insurance is a double whammy.” 2 A double whammy + 1 is a triple part difficulty; e.g. limitations in health care based on 1) race, 2) ethnicity, plus 3) disabilities. The title of a recent article in the Journal of American Dental Association sums up this triple threat, “Disparities in dental care associated with disability and race and ethnicity.” (emphasis added) 3 A triple whammy is comparable to the mythical character Mr. Joe Btfsplk (who lived under a perpetual rain cloud) in the long ago newspaper satirical comic strip Li’l Abner by cartoonist Al Capp. (March 20, 1947 strip4)

Race refers to a person’s physical characteristics, such as bone structure and skin, hair, or eye color.
Ethnicity refers to cultural factors, including nationality, regional culture, ancestry, and language. An example of race is brown, white, or black skin (all from various parts of the world), while an example of ethnicity is Japanese or Spanish ancestry (regardless of race).5
Whammy refers to the evil eye, jinx, bad luck or misfortune.6

The World Health Organization’s latest report on disability and health specified that:
• “Over a billion people, about 15% of the world’s population, have some form of disability.
• Between 110 million and 190 million adults have significant difficulties in functioning.
• Rates of disability are increasing due to population ageing and increases in chronic health conditions, among other causes.
• People with disabilities have less access to health care services and therefore experience unmet health care needs.” 7
• “About 1 in 68 children has been identified with autism spectrum disorder.” 8

People with disabilities report seeking more health care than people without disabilities and have greater unmet needs. “For example, a recent survey of people with serious mental disorders, showed that between 35% and 50% of people in developed countries, and between 76% and 85% in developing countries, received no treatment in the year prior to the study.”7

People with disabilities are particularly vulnerable to deficiencies in health care services. “Depending on the group and setting, persons with disabilities may experience greater vulnerability to secondary conditions, co-morbid conditions, age-related conditions, engaging in health risk behaviors and higher rates of premature death.”

Secondary conditions
• “Secondary conditions occur in addition to (and are related to) a primary health condition, and are both predictable and therefore preventable.
• Examples include pressure ulcers, urinary tract infections, osteoporosis and pain.”

Co-morbid conditions
• “Co-morbid conditions occur in addition to (and are unrelated to) a primary health condition associated with disability.
• For example, the prevalence of diabetes in people with schizophrenia is around 15% compared to a rate of 2-3% for the general population.” 5

Age-related conditions
• “The ageing process for some groups of people with disabilities begins earlier than usual.
• For example, some people with developmental disabilities show signs of premature ageing in their 40s and 50s;” 7 e.g. individuals with Down syndrome and those with dementia.

Engaging in health risk behaviors
“Some studies have indicated that people with disabilities have higher rates of risky behaviors such as smoking, poor diet and physical inactivity.”

Higher rates of premature death
“Mortality rates for people with disabilities vary depending on the (overall) health condition. However an  investigation in the United Kingdom found that people with mental health disorders and intellectual impairments had a lower life expectancy.” 7

Barriers to health care
• Prohibitive costs
• Limited availability of services
• Physical barriers
• Inadequate skills and knowledge of health providers. 7

“Aside from the public health issues that most racial/ethnic minorities face, minorities with disabilities experience additional disparities in health, prejudice, discrimination, economic barriers, and difficulties accessing care as a result of their disability…”9

The Centers for Disease Control and Prevention estimate that approximately 62 million Americans experience some ‘basic’ movement, cognitive, sensory, or emotional problems. About 14% of people experience ‘complex activity limitations in their ability to participate in society, including maintaining a household, working, or pursuing hobbies. Rates also increase with age. About 42% of individuals over the age of 65 report a disability, compared with 18.6% who are younger. 10
• African Americans and Hispanics over age 50 are more likely to have a mobility disability than whites and also use more hospitals than whites. “An Institute of Medicine report observed that … persistent effect of race/ethnicity (in medical services utilization) could be the results of culture, class, and/or discrimination.” 11
• 31% of people with disabilities report fair or poor health in comparison to 6% of the general population. Among  adults with disabilities, 55% of Hispanic persons and 47% of African Americans report fair or poor health, as compared with 37% of whites. 10
• Almost 5% of deaf persons are infected with HIV/AIDS, four times the rate for the African American population.12
• Adults with disabilities are three times more likely to commit suicide than peers without disabilities. 12
• African Americans with severe mental health disabilities are less likely than whites to access mental health services, more likely to drop out of treatment, more likely to receive poor-quality care and more likely to be dissatisfied with care.13
• Asian Americans and Hispanics are less than half as likely as whites to receive mental health treatment.14
• 15% of people with disabilities report not seeing a doctor due to cost in comparison to 6% of the general population. 10

“Compared with non-Hispanic whites, other racial and ethnic groups (are) less likely to receive annual dental  examinations. There are significant disparities for people with disabilities in receipt of (dental) examinations, delays in obtaining needed care, and being unable to obtain needed care. The combination of disability status and  membership in an underserved racial or ethnic group was associated with a greater magnitude of disparity… especially for American Indians, Alaska Native and multiracial adults with disabilities.” 3 (emphasis added)

No matter how we name it or spell it, the reality is that individuals with disabilities, be they residents of the United States or other countries, young or old, male or female, and members of minority racial or ethnic groups (as perceived in the respective country) are confronted by the modern day rendition of the biblical The Four Horsemen of the Apocalypse [Conquest, War, Famine and Death] (as described in the last book of the New Testament of the Bible). Today we refer to the “four horsemen” as: 1) Prohibitive costs, 2) Limited availability of services, 3) Physical barriers and 4) Inadequate skills and knowledge of health providers.

Writing in the mid 1990s, Cornelius and Altman summed up earlier research with the comments that, “… (the) research indicates that overall African and Hispanic Americans are disproportional encountering barriers to care. Unfortunately very little is known regarding the status of African and Hispanic Americans with disabilities.”15 (emphasis added) Their findings from a review of the 1987 National Medical Expenditure Survey indicated, “… that as in the case of other African and Hispanic Americans, African and Hispanic Americans with disabilities  disproportionately encounter barriers to care. They are more likely than whites to lack insurance, a regular provider and less likely to see a doctor during the year.” 15

That was then; this is now! The Agency for Healthcare Research and Quality indicated in its 2014 report on Disparities in Healthcare Quality Among Racial and Ethnic Groups that, “despite improvements, differences persist in health care quality among racial and ethnic minority groups.” 16
• “Disparities in quality of care are common…
• Disparities in access are also common, especially among Hispanics and poor people. Racial and ethnic minorities are more likely than non-Hispanic whites to be poor or near poor… In addition, Hispanics, blacks and some Asian subgroups are less likely than non-Hispanic whites to have a high-school education…
Few disparities in quality of care are getting better.” 16 (emphasis added)

Decades have passed since persons with disabilities were hidden in state institutions and in the back room of homes as though they were modern day reincarnations of medieval plagues. Isn’t it about time we recognized that the many minority groups of individuals with disabilities deserve better than a double whammy + 1? •

H. Barry Waldman, DDS, MPH, PhD – Distinguished Teaching Professor, Department of General Dentistry at Stony Brook University, NY; E-mail: h.waldman@stonybrook.edu
Rick Rader, MD is Director, Morton J. Kent Habilitation Center, Orange Grove, Chattanooga , TN and EP magazine’s Editor in Chief.
Steven P. Perlman, DDS, MScD, DHL (Hon) – Global Clinical Director, Special Olympics, Special Smiles and Clinical Professor of Pediatric Dentistry, The Boston University Goldman School of Dental Medicine, Private pediatric dentistry practice – Lynn MA.
Misha Garey, DDS is Director of Dental Services at the Orange Grove Center.

Source Exceptional Parent Magazine

1. Merriam Webster Dictionary. Web site: http://www.merriam-webster.com Accessed June 19, 2015.
2. Urban Dictionary. Web site: http://www.urban dictionary.com Accessed June 19, 2015
3. Horner-Johnson W, Dobbertin K, Bellstein-Wedel E. Disparities in dental care associated with disability and race and ethnicity. Journal American Dental Association, 2015;146(6):366-374.
4. Joe Btfsplk. Wikipedia. Web site: https://en.wikipedia.org/wiki/Joe_Btfsplk Accessed June 19, 2015.
5. Diffen.com. Compare anything. Web site: http://www.diffen.com Accessed June 20, 2015.
6. Dictionary.com Web site: http://dictionary.reference.com/browse/whammy Accessed June 20, 2015.
7. WHO Disability and Health. Web site: http://www.who.int/mediacentre/factsheets/fs352/en/ Accessed June 17, 2015.
8. Centers for Disease Control and Prevention. Autism: data and statistics. Spectrum Disorder Web site:
http://www.cdc.gov/ncbddd/autism/data.html Accessed June 22, 2015.
9. HHS Advisory Committee on Minority Health. Assuring health equity for minority persons with disabilities.
Web site: http://minorityhealth.hhs.gov/Assets/pdf/Checked/1/ACMHHealthDisparitiesReport.pdf Jul 2, 2011… July 2011. Accessed June 20, 2015.
10. Yee S. Health and health care disparities among people with disabilities. Disability Rights Education and Defense Fund. Web site: http:dred.org/healthcare/Health-and-Health-Care-Disparities-Among-Peoplewith Disabiltiies.pdf Accessed June 20, 2015.
11. Institute of Medicine. The Future of Disability in America. Washington, DC: The National Academies Press, 2007.
12. Curtis S, Heaphy D. Disability Policy Consortium. Disabilities and Disparities: Executive Summary, 2009.
13. Whitley R, Lawson W. The psychiatric rehabilitation of African Americans with severe mental illness. Psychiatric Services, 2010;61(5):508-511.
14. 2008 National Healthcare Disparities Report. Web site: http://www.ahrq.gov/qual/qrdr08/index.html Accessed June 20, 2015.
15. Cornelius LJ, Altman BM. Have succeeded in reducing barrier to medical care for African and Hispanic  Americans with disabilities? Social Work Health Care 1995;22(2)1-17.
16. Agency for Healthcare Research and Quality. Disparities in healthcare quality among racial and ethnic groups. 2014: Pub. # 12-0006. Web site: http://www.ahrq.gov/research/findings/nhqrdr/nhqrdr11/minority.html Accessed June 22, 2015.


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