Transcript Health Disparities: isms, privileges, and differences.

Racial Health Disparities:
Appearances, mirages, and new realities.
Steven Miles MD.
US 2000 Census
• 97.6% said that they were
one race,
– My daughter said that she was
“human” (answer not
accepted).
• 2.4% said that they were
multi-racial;
– The proportion of European
genes in self declared African
Americans is 12% to 23%.
• What does it mean to claim a
person is of a race? Is it
– Submitting to a social caste?
– Asserting cultural affiliation?
– Noting a genetic category?
97% of these call themselves Hispanic
Racial Genetics
Does Not Explain Health Disparities.
Although allele-based diseases are often relatively more
frequent in intra-bred populations.
– Hemoglobinopathies
– Metabolic disorders
– Degenerative conditions.
“Race Genetics” does not explain pandemic differences in
• birthweight and
• maternal mortality and
• life expectancy and
• survival or functional outcome from diseases as diverse as
squamous cell cancer, adenocarcinomas, myocardial
infarction, asthma, diabetes, etc.
It has become clear that human populations are not clearly demarcated,
biologically distinct groups. . . . The continued sharing of genetic materials has
maintained humankind as a single species. . . .
Any attempt to establish lines of division among biological populations is both
arbitrary and subjective.
American Anthropological Association 1999
• 0.1% genetic difference between
two randomly selected humans.
– 5-10% of this difference “racial”
“old segregation.”
– 5-10% continental separation,
“new segregation.”
– 80% individual variation.
Kyushu Museum. 2002.
Biological
Caste
Sex
Gender
Male-Female
Women-Men
Bio-Race
Caste-Race
Asian, African, Caucasian, Pacific
Islander
Japanese or Japanese-American,
etc
Throughout history scientists have used social and politically determined racial
categories to make scientific comparisons between races—with little or no discussion
about the meaning or rationale. . . .
Race might be a proxy for discriminatory experiences, diet or other environmental
factors. . . .
There is no justification, however, to use race as a substitute for other parameters that
can be measured . . ..
Nature Genetics 2000:24:97-8.
Multivariate “caste-race” Analysis
Univariate “bio-race” Analysis
Socioeconomic
status (poverty,
access to health
care, literacy,
education)
Environment
(Physical and
psychological
toxins)
Behaviors
(compliance, diet,
sex, exercise,
practitioner bias,
etc)
“Race”
Disease
incidence,
outcome
Race as a Medical Variable
Useful Variable
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Whether African Americans, Hispanics,
Native Americans, Pacific Islanders or Asians
respond equally to a drug is an empirical
question that can only be addressed by
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studying these groups individually.
We strongly support the search for candidate
genes that contribute to disease
susceptibility and treatment response, within
and across racial/ethnic groups.
A lot of the problem is terminology. I'm not
even sure what race means, people use it in
many different ways. . . . but that doesn't
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preclude you from using it or the fact that it
has utility.
– Risch N
Distracting Relic
Scientific Grounding:
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Race was constructed by a false biology, misused
for repression and neglect and remains unvalidated.
Given that cultural factors:
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Are poorly controlled for by most studies using
race as a variable (partly as a legacy of the social
construction of race categories)
Are a more plausible explanation for the huge
diversity of race disparities (longevity, birthweight,
cancers, heart disease, disabilities etc)
Are more susceptible to cost effective intervention
than gene targeted therapy,
Therefore, unless new research finds otherwise,
bio-race should not be used as an explanatory
variable for profiling or explaining health care
states, except for allele based diseases that
highly sort to narrowly inbred populations.
Race Medicine
The Example of Stroke
Stroke: 3RD Cause of Death in US
Age Adjusted Deaths/100,000
“Facts”
• Blacks have 2X the risk of first strokes as whites.
• Blacks have ↑ stroke death rates than whites.
CDC 2009
Images from American Stroke Assn Home Page.
Most Powerful Voices Choir
Competition
PTES and the Gospel Music
Channel are looking for the
Most Powerful Voices in an
online choir competition.
PR Week Awards
Power To End Stroke
received honorable
mention in the category
of Multicultural
Marketing Campaign of
the Year...
Power Gospel Tour Dates
Revised!
The Power Gospel Tour is a
celebration of faith and health,
punctuated by key messages
about stroke prevention.
Power Finance
Having a stroke can be a lifechanging event. In addition to
impacting your health, the
effects can be equally
devastating to your finances.
Healthy Soul Food Recipes
Consumer Publications has
created an oversized hardcover
cookbook to honor Ms. Yolanda
King, the first national
Ambassador for Power To End
Stroke.
Black / White Stroke incidence
after SocioEconomic Status (SES) adjustment.
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Disadvantage in early childhood
may confer increased risk in
adulthood, perhaps mediated by
infectious diseases, nutritional
conditions, or poverty-related
stresses.
Cardiovascular risk factors are
established early in life and begin
to diverge in black and white
subjects during childhood.
–
Ann Epi 2008;18:904 -12. 24000
Whites and 24000 Blacks
Given that socioeconomic
variables strongly condition the
expression of chronic disease,
is it fair to simply assert that they
do not also condition the
response to various therapies,
(such as Bidil)?
Hypertension in Blacks
by Country of Residence
SES data says that this does not indicate a “susceptibility” to
developed country diet.
Could it represent a consequence of the catecholamine
response to the stress of disadvantage?
Am J Pub Health 1997;87:160-8.
MIGRATION MATTERS!
SES adjusted incidence of asthma in
Hispanics is same as non-Hisp Whites BUT
foreign born Hispanics and their children
have a much lower risk of Asthma.
Asian women who move to the US,
increase their chance of getting PostMenopausal Breast Cancer.
Epidem 1995;6;181-3.
Am J Pub Health;2009;99;690-97.
Class, 5 yr Cancer Survival: Access matters.
Low Income
AJPH 2000;
90:1866-72
High Wealth
Inequality
USA, Norway,
Australia.
Medium
Wealth
Inequality
Italy, Finland
France, Austria,
Netherlands,
Switzerland.
Low Wealth
Inequality
Spain, UK,
Australia,
Sweden,
Denmark,
Germany
Previous slide does not take account of
relatively wider gap between rich and
poor in the US relative to Canada.
Lower Inequality
associated with:
 Education,
 Obesity,
 Heart disease,
 Stroke,
 Unhealthy behaviors
Soc Sci & Med 2008;66:1719-32.
A Problem
Ethnic community targeted
health campaigns can be an
important to reducing
disparities.
Ethnicity-targeted health
campaigns risk ethnic
branding that reinforces
fatalism about the health
consequences of cultural
difference and
socioeconomic stratification.
Minneapolis, Minn. - January 21, 2010 - HealthPartners Medical Group today
announced that it has launched an initiative aimed at saving lives by
providing more timely colorectal cancer screening for African American
patients. Organizations, such as the American College of Gastroenterology
recommend that regular colorectal cancer screening for African Americans
should begin at age 45, compared to age 50 for other races.
"Nationally, colorectal cancer deaths are 48 percent higher among African
Americans than among Caucasians," said Brian Rank, M.D. an oncologist and
medical director of the HealthPartners Medical Group. "Our goal is to save
lives by ensuring that more African American patients in our clinics receive
recommended colorectal cancer screening in a timely manner.“ . . . "We have
made reducing health disparities a top priority," said Rank. . . .
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Participants exposed to “disparity” (e.g. Blacks are doing worse than Whites) articles:
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reported more negative emotional reactions to the information and
were less likely to want to be screened for CRC than those in other groups (both P < 0.001).
Progress articles (e.g., Blacks are improving, but less than Whites, Blacks are
improving over time) elicited more positive emotional reactions and participants were
more likely to want to be screened.
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Cancer Epidemiology, Biomarkers & Prevention 2008; 17:2946-53, 2008. Double-blind RCT
compared emotional and behavioral reactions to 4 versions of the same colon cancer (CRC)
information in mock news articles to a community sample of 300 African-American adults.
All articles said colon cancer important problem for African-Americans.
Pain Treatment
JAMA 1993;269:1537–9. Single ED in TN. Adjusted for
gender, language, insurance, severity, intoxication.
Ann Emerg Med 2000;35:11–6. Retrospective cohort study of patients
single ED in GA.
These findings also apply to post-op pain tx after hip fx and to nursing home residents.
This disparity is not due to decreased pain perception by clinicians.
It is due to a failure to act on the perception of pain in minority patients.
Pain Med 2003;4:277-94.
Possible Solutions
Culturally competent health care providers.
Cultural competence courses.
Desegregation and immersion.
Health care multi-lingualism
Disparities-Targeted Health Programming.
Private and government offices of minority health.
Recruitment of health workers from underrepresented groups (will fail
without addressing preschool, K-12, and college disparities).
More clinics, pharmacies and outreach in under-served communities.
Interpreter services.
Addressing Socioeconomic Castes.
Ending substandard schools and neighborhoods,
Ending disparities in transportation, libraries, housing segregation, access to loans, etc.
Universal health care so that all people have comparable health opportunities.
Cultural Competency Training:
Well-intended. No evidence of effectiveness.
After competency
training at 2 of 4
practice groups, there
was no change in
patient
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Patient Satisfaction
Weight
Systolic blood pressure
Glycosylated hemoglobin
– p = NS for all).
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BMC Medical Education.
6:38, 2006. 53 primary
care MDs at 4 clinics with
429 of their patients with
diabetes and/or
hypertension. Cultural
competency training was
then provided to
physicians at 2 of the sites.
Teaching culturally appropriate care: a review of educational models
and methods. Acad Emerg Med 2006;13:1288-95.
The literature addressing the true efficacy of such programs in
leading to long-lasting change and improvement in minority
patients' clinical outcomes remains insufficient. [References: 50]
Culturally competent healthcare systems. A systematic review. Amer J
Prevent Med 2003;24(3 Suppl):68-79.
We could not determine the effectiveness of any of these
interventions, because there were either too few comparative
studies, or studies did not examine the outcome measures
evaluated in this review: client satisfaction with care,
improvements in health status, and inappropriate racial or ethnic
differences in use of health services or in received and
recommended treatment. [References: 43]
Can cultural competency reduce racial and ethnic health disparities? A
review and conceptual model. Medical Care Research & Review. 57
Suppl 1:181-217, 2000.
While there is substantial research evidence to suggest that
cultural competency should work, health systems have little
evidence about which cultural competency techniques are effective
and less evidence on when and how to implement them properly.
[References: 205]
US African-American Physicians
Note: African American male MDs have not increased in 30 years.
Epigenetics: The twilight of “race?”
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Epigenetic marks turn on
and off genes and thus
affect many metabolic
conditions including those
affecting cardiovascular
mortality, diabetes etc.
Gene switch differences are
heritable even though the
DNA sequence is the same.
Gene switch positions can
be flipped by minor
environmental factors.
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Quart Rev Biol
2009;84:131–76.
These genetically identical
mice had gene switches
changed by minor changes
in prenatal maternal diet.
They will pass on their traits
for several generations.
The genes can be flipped
on and off.
Randy L. Jirtle
Given that there are more epigenetic control marks than genes, is it fair to
assert that nature, not nurture, is the primary determinant of who we are?
Slides Available
Steven Miles, MD
University of Minnesota
[email protected]