Miami Herald - Tuesday, August 4, 1998
Brigid Schulte, Herald Washington Bureau

Even minority members of the well-educated, well-insured middle class are more likely to have difficult births, higher rates of certain cancers, more deaths from diabetes and far less adequate medical care than their white counterparts.

And little is being done to change that.

No group suffers a wider health gap than blacks. In practically every type of illness and cause of preventable death but suicide, blacks suffer and die younger, faster and at higher rates than whites. Fewer black women get breast cancer than white women, but proportionately more black women die from it. Black men have the highest rate of prostate cancer in the world.

Among blacks, the biggest killer is the severe high blood pressure that leads to greater rates of stroke, heart attack and kidney failure.

The pattern is not as stark for other ethnic groups. But still, some Asians, Hispanics and American Indians endure higher rates of certain diseases with graver consequences.

Compared with whites, Hispanics and American Indians have two to three times the rate of diabetes, and the numbers are growing fast. Vietnamese-American women contract cervical cancer five times more often. In 1997, four times as many Hispanics and eight times as many blacks as non-Hispanic whites contracted AIDS, once the deadly disease of middle-class gay white men.

And while immigrants often arrive on these shores in good health, within 10 years they become sicker as they adopt the American way of high-fat, fast-food eating and sedentary living and as they lose ties to extended families and culture.

Perhaps more disturbing than the statistics themselves is the fact that they are not new. In 1914, black leader Booker T. Washington said the time had come for equal health. In 1985, a high-level government report called on the country's conscience to change the grim equation of minority health.

Clinton's proposal

Now the unfair facts of life and death have caught President Clinton's attention. He is proposing to spend $400 million over five years to "close the gaps" for minorities in six areas: infant mortality, cancer, cardiovascular disease, diabetes, HIV and immunization.

With U.S. demographics changing and minority groups slated to become the majority by the middle of the next century, continuing to do little or nothing sets the stage for a major -- and costly -- health crisis.

The consequences are "serious," said U.S. Surgeon General David Satcher, the point person on the President's race and health initiative. "We're at the point now where these disparities actually define our health status in this country."

Despite the calls for action, the disparities among racial groups have remained entrenched and in some cases widened, even as health has improved and life expectancy grown for everyone. Government action has been piecemeal at best.

Largely white researchers have simply assumed that medical breakthroughs would "trickle down" to minorities. And the medical establishment -- the American Medical Association has called the gaps a "nightmare" and "this collective shame of neglect" -- has done little to close them.

The public has been either unknowing, powerless or uncaring. And those who are sickest often remain unaware that their own smoking, drinking and unhealthy eating are what makes them so. Blacks have the worst nutrition of any ethnic group, despite years of well-meaning public-health education campaigns. Those often miss the minority communities that most need them.

'Our greatest failure'

Dr. Louis Sullivan, secretary of health and human services in the Bush administration, described the official response this way: "Nice words. No action. And protestations to the contrary when the issues are raised."

"These gaps have been our greatest failure. They just haven't been viewed as a priority," said Jim Marks, a top official at the federal Centers for Disease Control and Prevention. "But we've got to recognize that they're changeable. And unacceptable."

Poverty explains a lot of the health differences; it can literally make you sick.

Those who are poor often can't afford to go to the doctor, nor can they find fruits and vegetables for a healthy diet because there are no supermarkets in the inner city. They are more likely to live in crime-infested neighborhoods that keep their adrenaline pumping and are less likely to exercise.

The poor are likely to be less educated and haven't been taught the warning signs for chronic illnesses. If they get sick, they'll probably go to an overcrowded public health clinic or rush to the emergency room. If a doctor writes a prescription, there's a good chance they can't read the label.

In a study of the lifestyles and health of 3,617 people, Paula Lantz, assistant professor of health management and policy at the University of Michigan, found that those with annual family incomes of less than $10,000 were more than three times as likely to die at any given time as those with incomes of more than $30,000 a year.

Government data show that poor blacks and Hispanics are more than twice as likely as whites to live within a one-mile radius of an uncontrolled toxic hazardous-waste site.

More than poverty

But the picture is far more complicated. While an important factor, poverty itself can explain only about one-third of the health differences, according to Marks of the Centers for Disease Control and Prevention.

For instance, a black baby is more than twice as likely as a white baby to die before its first birthday. The gap is just as wide or wider between higher-income, college-educated blacks and whites as for poorer families. Babies of largely poor West African immigrants, however, survive just as well as whites.

Poverty also doesn't explain what scientists call the "Mexican Paradox." The poverty rate is high for Mexican Americans, and many have no health insurance. Yet they are less likely to die from common illnesses like heart disease and cancer than either whites or blacks.

If not poverty, what accounts for the difference? It could simply be the sense of having control over one's life.

For instance, a famous health study of largely middle-class British civil servants, the Whitehall study, found that with every rise in power and position, there was a corresponding rise in health and life expectancy.

Similarly, the U.S. Department of Health and Human Services released a sweeping report last Thursday that found a stair-step health pattern from rich to poor that holds true for virtually every risk factor, every disease, whether a chronic illness like cancer or a communicable disease like HIV, and every cause of death.

The same economic ladder is found within racial and ethnic groups. For example, wealthier blacks not only live longer, healthier lives than poor blacks, but they report that they are in better health than even middle-income and poor whites.

But because both Hispanics and blacks have three times the poverty rate of whites, and a far smaller middle- and upper-income population, that stair-step effect is often lost in broad statistical reports.

Advantages help

"If you have money, if you have knowledge, if you have social connections, you can get yourself in a position to get yourself better health," said Bruce Link, a social epidemiologist. "You have power."

Racism can rob that sense of personal control. In a new and controversial area of study, some researchers say experiencing discrimination influences health by increasing stress and raising blood pressure. Researchers in Detroit surveyed mundane racism -- being eyed with suspicion as a shoplifter in a store or being treated as less intelligent -- and found it directly related to the health gaps.

Another common perception is that if only minorities had health insurance and went to the doctor more often, they'd be healthier. But some cancer studies of active-duty military, who share equal insurance, equal access to doctors and equal treatment, also show that blacks have higher incidence and death rates than whites.

A 1994 survey by the Commonwealth Fund, a New York-based philanthropy, found that about 38 percent of Hispanic adults, 26 percent of black adults and 23 percent of Asian adults do not have health insurance, compared with 14 percent of white adults.

Even with good health insurance, many minorities receive substandard care. Studies published in the Journal of the American Medical Association and the New England Journal of Medicine have shown that blacks, in particular, receive far less aggressive or outdated treatment, even when their conditions and health insurance are identical to those of whites.

Doctors are less likely to perform high-tech diagnostic procedures on blacks and less likely to go to extreme measures to keep them alive if they go into cardiac arrest on the table. Whites are two-thirds more likely to receive kidney transplants than nonwhites.

When hospitalized for pneumonia, whites are more likely to receive intensive care than blacks. And whites with HIV are far more likely to receive advanced drug therapies -- a troubling trend that slowed the white death rate from AIDS considerably more for whites than for blacks.

A number of factors

Poverty. Racism. Genes. Unequal medical treatment. Dangerous, stressful and isolated environments. Risky behavior. Unhealthy lifestyle. No one really knows how much each of these factors contributes to the gaps in health. Because, until recently, no one has looked.

Until 1992, more than 90 percent of all federally funded clinical trials, where the latest and most innovative drugs and technologies are tested, comprised only white men. Although a 1993 law changed that, requiring that such research include women and minorities, only a scant number of studies are exploring ethnic health differences.

There are only a handful of minority scientists in the country -- about 4 percent of all medical school faculty -- and even fewer sit on the panels at the National Institutes of Health that set the nation's research priorities.

In this incremental political climate, where a massive health-care overhaul failed and where the affirmative action backlash runs strong, it is hard to imagine the government adopting a sweeping program that would bring about societal change.

Instead, many of the solutions are likely to be small and localized. While not abundant, there are examples of people making a difference.

Some black churches train community members to take blood pressure and refer those with hypertension to clinics. Two doctors in North Carolina run Save Our Sisters to get more black women screened for breast cancer. In Philadelphia, a nonprofit organization sends the Mom Mobile into the inner city looking for pregnant teens. The organization provides prenatal medical care.

Herald Washington Bureau reporter Elsa C. Arnett contributed to this report.

Coming Wednesday: While scientists try to determine what role genes play in disease disparities, critics find such inquiries troubling.

CAPTION: color photo: Sisters Shautear and Latarshia Matthews and their children wait for a checkup at a Baltimore health clinic (a); chart: Diseases that reveal the gap

CHUCK KENNEDY / KRT SEEKING HELP: Sisters Shautear and Latarshia Matthews and their children wait for a checkup at a Baltimore health clinic. Nationwide, unequal health is a fact of life for minority groups.

Always watch for outdated information. This article first appeared in 1998. This material is designed to support, not replace, the relationship that exists between you and your doctor.

AEGiS presents published material, reprinted with permission and neither endorses nor opposes any material. All information contained on this website, including information relating to health conditions, products, and treatments, is for informational purposes only. It is often presented in summary or aggregate form. It is not meant to be a substitute for the advice provided by your own physician or other medical professionals. Always discuss treatment options with a doctor who specializes in treating HIV.

Copyright ©1980, 1998. AEGiS. All materials appearing on AEGiS are protected by copyright as a collective work or compilation under U.S. copyright and other laws and are the property of AEGiS, or the party credited as the provider of the content. .