Racial and Ethnic Disparities in Health and Health

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					Racial and Ethnic Disparities
 in Health and Health Care

           Kevin Fiscella, MD, MPH

  University of Rochester School of Medicine & Dentistry
             Departments of Family Medicine
            Community & Preventive Medicine
         What is race?

How we define race strongly affects how
   we conceptualize the relationships
between race and health and health care.
                What is race?
• “A group of people of common ancestry
   distinguished by physical characteristics such
   as hair type, eye or skin color, etc.”
  -Collins English dictionary, 1998

• Geographic origin of ancestry –1997 OMB standards

• “Ideology of inequality devised to rationalize
  European attitudes and treatment of the
  conquered and enslaved peoples.”- American
  Anthropological Association Statement, 1998
              What is ethnicity?
• Shared cultural, national, religious or
  linguistic heritage

• Hispanic or non-Hispanic origin –1997 OMB
Racial and ethnic disparities in
• African Americans have the highest age-
  adjusted mortality rate of any group, followed
  by whites, American Indians/Alaska Natives,
  Hispanics, and Asians, Native Hawaiians or
  other Pacific Islanders.

• Deaths for American Indians/Alaska Natives
  and Hispanics tend to be misclassified on death
  certificates, so vital statistics underestimate
  mortality rates for these groups.
           Disparities in
      cause-specific mortality
• Blacks have higher death rates than whites
  from all the leading causes of death except
  suicide and chronic lung disease. HIV death
  rates are 10 times higher and homicide rates
  are more than 7 times higher among blacks
  than whites.

• Hispanics have 3 times higher rates of death
  from HIV and homicide than whites and higher
  rates from liver disease and diabetes, but lower
  rates than whites for all other major causes
  including heart disease and cancer.
           Disparities in
      cause-specific mortality
• Asians have lower death rates than whites in all
  categories except homicide.

• American Indians/Alaska Natives have higher
  death rates than whites from liver disease,
  diabetes, HIV, accidents and homicide, but
  lower death rates from heart disease and
Life expectancy for African
Americans is nearly six years
      less than whites
• Disparities in socioeconomic status
  explain much of this gap.
• Disparities in cardiovascular mortality
  explain nearly one third of the gap.
• Hypertension represents the single
  largest contributor to this gap.
     Black-white disparities in
       health begin in utero
• Black infant mortality rate is two and half
  times higher than that of whites.
• Most of this gap is due to racial differences in
  rates of very low birth weight.
• The primary causes of very low birth weight
  are intrauterine infection and hypertensive
  disorders that result in preterm birth.
• Sudden infant death is the major cause of
  racial disparities in post neonatal mortality.
    Black-white disparities in
       maternal mortality
• African American women die during
  pregnancy and child birth at five times
  the rate of whites.

• The primary causes of this gap is
  disparities are vascular and infection
  related complications and homicide.
      Fundamental causes
  of racial disparities in health
          and well being
• Poverty

• Segregation

• Racism
• More than one out of three black children
  under the age of 6 lived in poverty in 2000
  (twice the rate of whites).

• Blacks earn on average 62% of that of whites.

• Among equivalent income or educational levels,
  blacks have far less wealth than whites.
• African Americans experience greater and more
  persistent residential segregation than any other
  group “hypersegregation.”
  – Massey, 1989

• Residential segregation and confinement to
  impoverished central cities has a devastating
  impact on the economic, educational,
  psychological, and physical well-being of African
  Americans. –Williams, 2002

• Segregation undermines social cohesion,
  reinforces individual, institutional, and
  internatalized racism.
Institutional and individual practices that
create and reinforce oppressive systems
of race relations whereby people and
institutions engaging in discrimination
adversely restrict by judgment and
action, the lives of whom they
discriminate against. -Krieger 2003
         Categories of racism
• Individual racism - Ideology of inherent,
  biological superiority of one race over another that
  is used to justify discrimination.

• Institutional racism - Policies and practices that
  systematically reinforce the power and privilege of
  one racial group over another.

• Internalized racism - Introjection of pejorative
  messages by stigmatized racial group regarding
  their capabilities and behavior.
    These categories reinforce
           each other
• Unconscious racist assumptions (individual
  racism) result in national, state, and local
  policies (institutional racism) that reinforce
  racial stratification. Examples include
  educational, correctional, and economic

• Persistent poverty, despair, stigma, and loss of
  community role models reinforce internalized
         Context matters
• Poverty, segregation, and racism do not
  operate in isolation from each other. It is the
  confluence of these factors that undermines the
  well being of African Americans.

• Current conditions cannot be understood in the
  absence of their historical context.

• The impact of poverty on a black child growing
  up in the inner-city is qualitatively different
  than that of a first generation Mexican or
  Asian child.
             Race and genetics
• Race is a social construct without biological basis; there
  is far greater genetic diversity within racial categories
  than between them.

• Because race is associated with geographic ancestral
  origin and because differences in geographic origin are
  associated with genetic allele frequency, allele
  frequency occasionally differs by race.

• These differences do not negate the social construction
  of race.

• Only a few conditions result from the effects of single
  alleles. Genetic differences by race are unlikely to
  explain most disparities in chronic diseases.
 Causal pathways across the life course
• The pathways through which racism,
  segregation, and poverty affect black well-
  being are complex.

• Effects early in life may have lasting effects, e.g.
  fetal nutrition, lead toxicity, cognitive

• Risk factors among disadvantaged groups tend
  to cluster and generate downward trajectories.

• Risk factors tend to have cumulative effects
  over time.
     Specific mediators of disparities
• Intrauterine environment - Fetal origins of disease
  hypothesis suggests that low birth weight infants are at
  higher risk for diabetes, hypertension, obesity, renal
  disease, and heart disease.

• Physical environment - Exposure to lead and other toxins,
  violence, availability of food, alcohol, and illicit drugs.
  allergens, passive smoke, crowding, infections, and diet.

• Family environment - Presence of two adult age parents,
  early cognitive stimulation, absence of abuse, and role

• Social environment - Impact of peers, expectations of
  future, risk of violence, opportunities for self expression,
  social network and support, and opportunities for marriage.
     Specific mediators of disparities
• Psychological environment - Psychosocial stress from
  discrimination, autonomy/control, stigma, and internalized

• Educational environment - Levels of expectations,
  concentration of students at risk, and resources.

• Work environment - Job opportunities, control of work,
  opportunities for advancement, risk of physical injury.

• Cultural environment - Norms of health related behavior
  e.g. breast feeding, infant sleeping position, douching,
  attitudes towards immunizations and health care.

• Health care environment – Large disparities documented.
 Exposure                       Racism
to toxins,   segregation
&                                                      effects
infections                    Childhood
                               poverty                  Cognitive
  Marriage                                             stimulation
                           Family function
Community                                              Access to
decline                     cognitive and              health care
  Peer                      development
                                                          Access to
                            stress          behavior      networks
                                     Health              poverty
Racial and ethnic disparities in
         health care
• Disparities differ by type of health care and
  by racial and ethnic group.

• Disparities are best documented and most
  severe for African Americans.
  Disparities in types of health
• Preventive services

• Medical treatment

• Surgical procedures

• Interpersonal care
    Disparities in preventive care
•    Prenatal care (number of visits and quality)
•    Child immunizations
•    Well child visits
•    Adolescent immunizations
•    Pap smear screening
•    Breast cancer screening
•    Colon cancer screening
•    Influenza & Pneumococcal immunization
•    Smoking cessation advice
       Disparities in medical
• Acute & chronic pain   •   Diabetes
• Asthma                 •   Dialysis
• Chemotherapy           •   HIV
• Congestive heart       •   Hypertension
  failure                •   Myocardial Infarction
• Coronary artery        •   Pneumonia
  disease                •   Stroke
• Depression
      Disparities in surgical or
        invasive procedures
•   Organ transplantation
•   Curative cancer surgery
•   Cardiovascular procedures/surgery
•   Cerebrovascular procedures/surgery
•   Hip and knee replacement surgery
    Disparities in satisfaction and
         interpersonal care
•   Health care satisfaction
•   Physician satisfaction
•   Physician trust
•   Involvement in care
•   Perceived discrimination
   Causes of disparities in
        health care
•Societal factors - Differences in presence and
type of health insurance and systems of care.

•Patient factors - Literacy, knowledge, beliefs,
attitudes, language and norms.

•Physician factors - Unconscious stereotyping,
cultural insensitivity, and poor communication
            Societal factors
• More than 50% of Hispanics and 40% of
  African Americans lacked health insurance at
  some point during 2001.

• Minorities more likely to be seen by residents.

• Presence and type of health insurance
  contribute to, but do not fully explain,
  disparities in health care.
            Patient factors
• Patients beliefs, attitudes, knowledge,
  preferences and literacy contribute to
• Patient factors do not fully explain
• Patient factors are strongly influenced by
  system and provider factors.
             Physician factors
• Overt prejudice - “I won’t recommend bypass surgery
  because this patient is black.”

• Stereotyping - “I won’t recommend kidney transplantation
  because most blacks do not adhere to treatment.”

• Clinical uncertainty - “I won’t recommend angiography
  because the patient’s symptoms are too dramatic (or not
  dramatic enough) to warrant the risk of this procedure.”

• Poor communication - Absence of patient-centered care
  and patient-physician partnership.
        Patient-centered care
• Represents a core dimension of health quality as
  defined by the IOM.
• Involves a set of core communication skills
  necessary to insure patient involvement in their
• Skills include obtaining knowledge of the patient
  as a person, eliciting the patient’s perspective on
  their condition.
• Explaining treatment options in understandable
• Eliciting the patients preferences for treatment
• Confirming the patient’s understanding of the
  specifics of the treatment plan.
Minorities receive less patient-
        centered care
 • Physicians adopt a more directive style,
   provide less information, and engage in less
   partnership with minority patients.

 • The result is lower rates of adherence and
   lower quality care.
   Equity is a core dimension
           of quality
• Equity recognized by the Institute of
  Medicine in 2001.
• Quality assurance must include measures of
• Quality Improvement represents an
  important means for addressing disparities
  in care.
• Recent data suggest that quality
  improvement reduces disparities.
   Implications for addressing
  disparities in health & health
• The Healthy People 2010 goal of eliminating disparities
  in health requires addressing fundamental causes of
• Academic-community partnerships represent an important
  means for addressing fundamental and proximate causes of
  disparities at the local level.
• The elimination of disparities in health care will require
  initiatives leverage existing quality improvements efforts
  that address physician and patient factors.
• Quality improvements offer the greatest potential for
  change when they are strongly tied to the community.
• Disparities in access including insurance must be

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