WASHINGTONEthnic and racial disparities in health care are too
often the result of racism, said Thomas Perez, director of the Office
for Civil Rights in the US Department of Health and Human Services.
He was one of a number of speakers at the 7th Biennial Symposium on
Minorities, the Medically Underserved, and Cancer.
When we see the problems of disparities, we frequently want to
define them in terms other than discrimination, Mr. Perez said.
We want to talk about them solely in economic terms.
While it is true that the poor are less likely to have access to
health care, he said, it seems to me the issue of
discrimination also plays a role in explaining racial and ethnic
disparities. I know this because weve seen it in research and
in our work in the Office for Civil Rights.
Mr. Perez cited a study in which male and female actors of various
races described to doctors symptoms that pointed to the need for
cardiac catheterization. Referral rates varied by ethnic group and
gender, with black females the least likely to be referred for the
Another example came from Marjorie Kagawa-Singer, PhD, RN, MN,
assistant professor, UCLA School of Public Health and Asian-American
Studies. Dr. Singer displayed a headline: American Beats Kwan
for the Gold. It referred to California-born and raised figure
skater Michelle Kwan and her silver-medal performance in the Nagano
Olympics competition that was won by Tara Lipinski.
We arent considered Americans no matter how long
weve lived here, because we dont look American, she
US Surgeon General David Satcher, MD, PhD, cited some of the medical
disparities. Cancer mortality dropped in the general population for
the first time in the 1990s. However, although there was a 5% decline
in whites, the decrease was only 1% for blacks. Black women are as
likely as white women to be screened for breast cancer, so the
question is: What happens afterward? he said.
The rate of prostate cancer among black US men is the highest in the
world, some 33% greater than among white US men. Black men also are
less likely than whites to be insured, Dr. Satcher said, and to have
access to quality health care.
We are committed to eliminating disparities in health, and we
will, he said. To the extent that we respond to the
health needs of the most vulnerable among us, we do the most to
promote the health of the nation.
Solving the Problem
LaSalle D. Leffall Jr., MD, Charles R. Drew Professor of Surgery,
Howard University College of Medicine, said that the Intercultural
Cancer Council, which sponsored the conference, has asked Congress to
double funding for cancer research and control aimed at addressing
disparities among minorities.
Mr. Perez suggested two other ways to solve the problem: dialogue and
coalition building. Coalition building contributed to every
single piece of civil rights legislation, he said. It is
now time to apply the method to health care disparities.
Dialogue about racism occurs less frequently, he said, and is often
triggered only after a horrific incident.
Charles McDonald, MD, professor of dermatology, Brown University,
said it is also important for research and health care organizations
to understand minorities attitudes toward them. The American
Cancer Society found through focus groups that many poor and minority
groups are suspicious of large minority organizations and of the
Among the suspicions voiced were beliefs that the system cares mainly
about making money, that the system has yet to deliver on many of its
promises, and that those with low income get less favorable treatment
than those with high incomes.
Richard Klausner, MD, director of the NCI, said that two things are
needed to defeat cancer and the disparities that affect so many
patients: We need a medical and public health system that
applies best practices to everyone, and, of course, medicine and
research need to define what those best practices are.
Francis Collins, MD, PhD, director, National Human Genome Research
Institute, said that to have equal access to something that
does not work does none of us any good. The NCI is constantly
working on new and improved treatments, he said. Among the efforts is
the Human Genome Project, which is showing that the races are far
more similar to each other than they are different.
Most people assume that race has some profound biological
basis, and Im going to argue that it has very little of that.
Our concepts of ethnicity and race are largely socially and
culturally based, Dr. Collins said.
He noted that 99.9% of the human genetic sequence is the same
regardless of race. The remaining portion can offer clues to
inherited tendencies to chronic medical conditions. However, he
cautioned against thinking that certain diseasesTay Sachs, for
instance, or sickle cell diseaseare the exclusive province of
one group or another.
Disease prevalences in ethnic groups are now described as the result
of the founder effect, ie, the existence of long-ago
ancestors who carried a genetic variation and passed it on to
subsequent generations. In groups that didnt have such a
founder, that variant may not appear with such frequency, Dr.
Collins said. He added, however, that diet, lifestyle, and other
factors also play a role in disease development and prevalence.
He also cautioned against describing humanity as part of a
family tree upon which branches veer off, never to
reconnect. We are more of a trellis than a tree, he said.
We are all part of historical extended families. Thus,
genetic research, rather than promoting separatism, has enormous
potential to pull us together and help us realize how much alike we are.
It is useful for different races to participate in chronic disease
studies, but theyre often afraid to, he said, for fear of
discrimination or withdrawal of health insurance. This kind of
discrimination is illegal for federal employees, he said, and such
protections should be instituted for the rest of the population.
Bone Marrow Transplants
Dennis Confer, MD, medical director of the National Bone Marrow
Transplant Program, Minneapolis, said that the majority of
transplants in the United States have been in whites. There is
a long way to go, he said, but the program is making efforts to
recruit potential donors more actively in minority populations.
Some minorities have lower rates of certain cancers than do whites,
said Malcolm Pike, MD, PhD, of the University of Southern California,
and studies are attempting to discern the cause. A study of 50,000
people has begun to help determine some of the factors that
contribute to the lower colon cancer rates observed in Hispanic