WASHINGTON—Ethnic 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 we’ve 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 intervention.
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 aren’t considered Americans no matter how long we’ve lived here, because we don’t look American,” she said.
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 government.
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 I’m 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 diseases—Tay Sachs, for instance, or sickle cell disease—are 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 didn’t 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 they’re 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 populations.
