Improvements in health care delivery have contributed to a dramatic increase in the longevity and health status of the U.S. population, with average life expectancy increasing from 50 in 1900 to 76 in 1996. Unfortunately not all racial and ethnic groups have experienced these gains equally. In general, African-Americans fare worse than any other group and Native Americans and Hispanics are often disadvantaged relative to whites. In 1998, President Clinton set national goals of eliminating disparities in six areas of health status as part of an overall effort to improve the health of the nation, "Healthy 2010," a continuation of Healthy 2000. The selected indicators, which include heart disease, cancer, infant mortality, diabetes and HIV infection, reflect the most salient and pervasive differences in the health status of minority populations.
The age-adjusted death rate for Coronary Heart Disease (CHD), the leading cause of death for all people combined and within population groups, declined by 20 percent from 1987 to 1995 for the total population. However, for blacks, the overall decrease was only 13 percent. Compared with rates for whites, CHD mortality was 40 percent lower for Asian-Americans, but 40 percent higher for blacks in 1995. The mortality rate from congestive heart failure is 1.8 times as high for black men as for white men and 2.4 times as high for black women as for white women.
According to Richard Klausner, MD, Director of the National Cancer Institute, the incidence rate for all cancers combined, the second leading cause of death for all groups, declined an average of nearly one percent per year between 1990 to 1995. However, incidence rates for black males continued to increase and rates for Asian and Pacific Islander females were level. Death rates due to cancer are also disproportionately high in minority populations. According to the Department of Health and Human Services (DHHS), African-Americans have a cancer death rate about 35 percent higher than that of whites (171.6 vs. 127 per 100,000), with lung cancer and prostate cancer deaths hitting African-American men significantly harder.
In 1993, the U.S. ranked 22nd of 25 developed countries in overall infant mortality. The infant mortality rate has dropped for all groups combined, reaching approximately 7.2 deaths per 1,000 live births in 1996. However, 1996 death rates remained much higher among African-American (14.2), Native American (9), and Hispanic (7.6 or higher) infants. In New Jersey Black Infant Mortality (BIM) is currently 16.3 per 1,000 live births; it ranks 13th among the states which document BIM rates.
Diabetes-related illness is the seventh leading cause of death in the U.S., at 40 deaths for every 100,000 people for all groups combined. The incidence and death statistics for minority populations are startling. According to DHHS, in 1996 diabetes was the fourth leading cause of death for African-American and Hispanic women. African-Americans are 1.7 times more likely to have diabetes than Non-Hispanic whites, and African-Americans with diabetes are 2.6 to 5.6 times more likely to suffer from kidney disease. Within the Hispanic population approximately 24 percent of Mexican-Americans and 26 percent of Puerto Ricans between the ages of 45 and 74 have diabetes.
The Centers for Disease Control and Prevention (CDCP) estimate about 40,000 new HIV infections a year, according to data released on August 21, 1999. African-American men represent approximately 50 percent of all new male cases and African-American women represent over 64 percent of new female cases. According to the data, sexual transmission, not drug use, was the most prevalent cause for new infection.
The factors leading to such disparities in health status are multifaceted. Adult health status is often a manifestation of many years of disease risk and exposure and many disease conditions are interrelated, such as hypertension and diabetes with heart and renal disease. A report released by DHHS in July 1998 discusses a large contributing factor to disparities in minority health: socioeconomic status (SES). According to DHHS, "For almost all health indicators considered in Health, United States, 1998, each increase in either income or education increased the likelihood of being in good health." SES is attributed to influence nearly all aspects of health care, including access to care, behaviors predisposing individuals to health risks and attitudes surrounding health care.
Individuals with poor access to care, often considered the greatest contributing factor to minority health status, are more likely to receive less preventive care, to delay care when symptoms develop, and to suffer more severely from and be hospitalized for conditions which can be effectively managed with preventive and outpatient treatment. One of the strongest predictors of access to care is access to health insurance, which eludes many minorities. According to a February 1999 Commonwealth Fund study, Employer-Sponsored Health Insurance: Implications for Minority Workers, overall, 31 percent of minority Americans, ages 18-64, and 14 percent of white Americans lack health insurance, and minority adults cite low or no insurance and financial reasons most often as barriers for receiving care. Numerous studies show that health insurance is highly tied to employment status. However, after controlling for poverty and employment status, fewer minorities benefit from health insurance, even when considering different racial groups within similar professions and salary levels. One potential explanation for this, according to the Commonwealth Fund, is that as employees pay more of the costs of health care, overall wealth, not necessarily wages alone, plays a significant role in affording health care.
Though insurance is widely believed to be the cornerstone to access, studies also show that having a regular care provider is as significant a factor in receiving health care. According to the Commonwealth Fund survey, nearly two of five (39 percent) black adults and almost half (46 percent) of Hispanic adults report that they do not have a regular doctor, compared with one of four (26 percent) white adults. Dr. Colin Sox, et al, from the Harvard School of Public Health, in a 1998 study published in the American Journal of Public Health (AJPH), concluded that a relationship with a regular physician is as strong or a stronger predictor of access to care than insurance status. In this study, among patients with a regular physician, both uninsured and privately insured patients had equally good access. However, among patients with no regular physician, both uninsured and privately insured patients had significantly worse access. More recently, a February 1999 study in the Annals of Internal Medicine, conducted by Dr. Gail Daumit, et al, from Johns Hopkins Medical Institutions (JHMI), showed that a substantial disparity existed in the number of cardiac procedures given to whites and blacks within privately insured and Medicare study subgroups, but that this gap was narrowed when blacks could access greater regular medical care. Many minorities also site the lack of transportation and language barriers as reasons for delaying physician visits.
Some researchers believe not just SES, but also cultural differences among ethnic groups account for variations in disease. A study by Marilyn Winkleby, PhD, et al, from Stanford University, published in the July 22/29, 1999 JAMA, reports that after holding SES and age constant, highly significant differences in Body Mass Index (BMI), blood pressure, diabetes and physical inactivity remained between white women and both black and Mexican-American women and among women of low SES, showing minority women and women with low SES to be at high risk for cardiovascular disease. A May 1997 study by Raynard Kington, MD, PhD, et al, from the Rand Corporation, published in the AJPH, suggested that SES plays a much lower role in explaining who has chronic illnesses than in explaining the racial and ethnic differences in the ability to function once a person has a chronic illness. Despite the debate of SES, one thing most researchers agree upon is that minorities and individuals of low SES suffer significant stress in everyday living, a factor highly associated with chronic disease and poorer health status.
Most recently, researchers have been studying the possible effects of physiology on the incidence of disease in minorities. One such study, by Ralph Caraballo, PhD, et al, from the CDCP, released in the July 8, 1998 JAMA, found that African-Americans appear to absorb more nicotine per cigarette than smokers of other races, and suggested this as a reason why blacks find it harder to quit smoking and are more likely to experience higher rates of lung cancer than whites. Yet, this study also indicated that the differences in absorbed nicotine may result from cultural patterns of smoking, such as how long smoke is inhaled and the type of cigarettes smoked. Another study from the National Heart, Lung and Blood Institute, by Daniel Dries, MD, PhD, et al, published in the February 25, 1999 New England Journal of Medicine (NEJM), concluded that higher mortality in blacks due to congestive heart failure was evident even after adjusting for differences in age, sex, severity and cause of disease, coexisting conditions, SES and follow-up care.
Of particular concern is the gap in trust and confidence between minorities and the health care delivery system. Minorities report greater distrust and dissatisfaction with the health care system, and thus are less likely to use it. A national poll by the Kaiser Family Foundation and the National Association of Black Journalists found that only 63 percent of blacks, compared with 79 percent of whites, trusted their doctors always or most of the time. According to a study conducted at JHMI released in the August 11, 1999 issue of JAMA, African-American and white patients rated their visits with same-race physicians as significantly more participatory than with different-race doctors. Thus minority patients, who, on the whole, are most likely to have a different race doctor, are more likely to feel less empowered to participate in their own health care decision making. According to the Commonwealth Fund, for those with a choice of doctor, minority adults were more likely to say that the doctor’s nationality, race or ethnicity influenced their choice (12 percent) than were white adults (5 percent). Unfortunately, choosing a minority physician is difficult at best. According to the Association of American Medical Colleges (AAMC), blacks, Native Americans, and selected Hispanic populations comprise 21 percent of the U.S. population, but only 8.6 percent of the U.S. physician population.
The experience of minorities within the health care system was captured in a Georgetown University Medical Center study released in the February 25, 1999 NEJM, which concluded that the race and sex of the patient influenced recommendations of physicians independent of other factors and suggested bias may play a part in the physician decision-making process. This study, in which physicians were presented taped interviews of racially diverse patients--played by actors-- presenting with similar symptoms of chest pain, showed that black women were significantly less likely to be referred for catheterization procedures than white men. While bias was cited as a significant reason for lower referral rates, the study said that bias could be the result of subconscious perceptions of the physicians, rather than deliberate action or thought.
Numerous efforts at the national and state levels are targeted at closing the gap in health status. The largest federal effort, President Clinton’s Healthy 2010 program, calls for $400 million in spending on minority health research and outreach over the next five years through such agencies such as DHHS and the National Institutes of Health. Healthy 2010 also provides directives to individual states in assuring that identified goals of health status are achieved by the year 2010. In New Jersey, the most publicized effort is Black Infants--Better Survival (BIBS). In addition to conducting research into the causes and potential remedies for high black infant mortality, BIBS will be conducting a public awareness campaign, cultural competency training and community-based programs. To commemorate New Jersey’s Minority Health Month, on September 21-22, 1999, DHHS is holding a Minority Health Summit, bringing together state and national health experts and community leaders to focus on issues affecting minority health.
Vivian H. Lubin
Vice President for Planning