Why Minorites Get Sicker

Why minorities get sicker and what to do about it
By Alicia Ritchey

During one of his presidential campaigns, Franklin Roosevelt said, “Nothing can be more important to a state than its public health; the state’s paramount concern should be the health of its people.”

With advances in medicine and technology, people today are healthier than ever. Yet, ethnic, racial and cultural minorities are finding themselves on unequal footing when it comes to disease incidence and medical care. “Addressing this issue is important because everyone should have the same chance for health their education level, race and income,” said Sharon Schweikhart, associate professor in SPH’s Division of Health Services Management and Policy (HSMP).

The National Cancer institute defines disparities in health as “differences in the incidence, prevalence, mortality, and burden of cancer and related adverse health conditions that exist among specific population groups in the United States.” However, disparities in health may also be apparent between groups when compared on the basis of income or insurance status.

Some examples of medical conditions that affect ethnic/racial groups in unequal proportion include cancer, cardiovascular disease, diabetes and obesity. For example, one report from the Centers for Disease Control and Prevention (CDC) noted that the age-adjusted prevalence of hypertension is 40.5 percent among non-Hispanic blacks compared to 27.4 percent among non-Hispanic whites.

Patients from different racial and ethnic backgrounds are not reaping the full benefits of technological advances in cardiac care.

After a heart attack, patients who are smokers need to quit smoking in order to reduce the risk of subsequent cardiac events. However, according to the U.S. Department of Health and Human Services, the proportion of elderly Medicare beneficiaries hospitalized for acute myocardial infarction who received smoking cessation counseling was lower among black and Hispanic elderly compared with non-Hispanic white elderly.

Ann Scheck McAlearney, assistant professor in our HSMP Division, is involved in a study designed to improve cardiovascular care for minority Americans. Her research is part of the Expecting Success program, a major initiative of the Robert Wood Johnson Foundation focused on both quality improvement and reducing health disparities.

“The major goals of this study are to improve cardiovascular care for minorities and to reduce disparities in care, while increasing awareness of disparities as an important health issue,” said McAlearney.

McAlearney is part of a team of experts in quality improvement, evidence-based practice, survey and sampling methodologies, and collection of race and ethnicity data. The team is applying quality improvement methods to improve care for all patients with cardiovascular disease, while investigating the nature of disparities in care that may exist in the participating hospitals.

Ten hospitals are part of the project, and McAlearney’s role includes working to each hospital to assess its institutional readiness for change. She will be helping the hospitals to create site-specific Cardiovascular Improvement Plans that will guide quality improvement activities aimed to improve cardiovascular care and reduce disparities care.

The causes of health disparities can be complex and varied.

“There are many hypotheses about the origin of disparities in U.S. health care. One is that there may be subconscious discrimination, evidenced when providers offer differing health care advice to patients based on perceptions of potential patient compliance, understanding, or ability to pay for treatment. For example, language barriers create a major challenge in many U.S. hospitals, and because some hospitals have insufficient interpreter services, clinicians may be saying or doing different things when they are unable to clearly communicate with their patients,” said McAlearney.

In many regions, ethnic, racial and economic minority groups are more likely to have lower incomes, lower insurance coverage levels, and less education when compared to the dominant population.

Statistics released in 2005 from the U.S. Census Bureau, tell the troubling story of income and medical coverage for certain minority groups.

•    White, non-Hispanic households have a median income of $48,977. Black households have a median income of $30,134.

•    Estimates are that 11.3% of non-Hispanic white households are not insured compared to 20% of black households.

•    The bureau also reports that 30.6 percent of non-Hispanic white people had bachelor’s degrees, compared to 17.6 percent of African Americans. Socioeconomic status has real effects on health and medical care. Low-income Americans run the highest risk of being uninsured. Census bureau figures show that 24.3 percent of people with incomes below $25,000 were uninsured, almost triple the rate of 8.4 percent for people with incomes over $75,000.

Low-income and uninsured populations are more likely to suffer from cardiovascular disease, infectious diseases, cancer and dental disease.

Cost-effective operations may result in practices that create real or perceived barriers to low-income individuals. Policies with regard to the treatment of uninsured patients have a selective effect on the care of minorities when these populations have lower rates of insurance coverage.

“For example, a provider might make a decision about treatment based on what he or she predicts about patient compliance. If you think a patient won’t get follow-up care, you might do more at the time you see them. Alternatively, if you think a patient does not have enough money to buy an expensive drug, you might prescribe a different medication,” said McAlearney.

Schweikhart echoes this sentiment.

“Sometimes it is difficult to gain access, but once access is granted, there are still inequalities. Cultural competence is a problem that must be addressed because sometimes health care must be tailored to cultural needs,” she said.

The 2004 National Healthcare Disparities Report from the U.S. Department of Health and Human Services reported that from 1992 to 2001, rates of late stage colorectal cancer were higher among blacks compared with whites.

“Persons of any racial group, including whites, who are poor, have a lower level of education, and/or have inadequate health care coverage, are more likely to have higher incidence and/or higher mortality rates associated with cancer,” said Michele Shipp, Research Assistant Professor in the SPH’s Division of Health Behavior and Health Promotion.

Shipp conducted a study in Alabama exploring how disparities in colon cancer are affected by race, ethnicity and socioeconomic status. She examined differences in incidence, stage at diagnosis, and method of therapy between blacks and white men and women diagnosed with colorectal cancer in that state.

Shipp said colorectal cancer (CRC) is the second most common cause of cancer death in the United States. However, incidence and mortality are highest among African American men and women in the U.S. She hopes that the findings will contribute to the understanding of variations in stage at diagnosis, treatment and survival associated with CRC in white and black patients and the extent to which race and socioeconomic status may affect these outcomes.

CDC has indicated that the future health of the nation will depend on how effectively the U.S. reduces health disparities. Success in closing these gaps could result in greater economic productivity and a better-informed public. These possibilities are just becoming apparent.

“Awareness of and sensitivity to health disparities is relatively recent, and this has become more urgent because of recent studies showing that this is a big problem. However, the issue of health disparities is a long-term problem and we have only begun to study it,” said McAlearney.