ELIMINATING HEALTH DISPARITIES IN AN URBAN AREA VIRGINIA A. CAINE, M.D., DIRECTOR MARION COUNTY HEALTH DEPARTMENT INDIANAPOLIS, INDIANA May 1, 2002
Racial and ethnic disparities in health care are unacceptable in a country that values equality and equal opportunity for all. And that is why we must act now with a comprehensive initiative that focuses on health care and prevention for racial and ethnic minorities. President Bill Clinton February 21, 1998
President s Initiative to Eliminate Racial and Ethnic Disparities in Health Target conditions Infant mortality Cancer screening and management Cardiovascular disease Diabetes HIV infection/aids Immunizations
Healthy People 2010 Two Overarching Goals: Increase Quality and Years of Healthy Life Eliminate Health Disparities
What Are Health Disparities? Differences in the incidence, prevalence,mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.
Why The Interest In Disparities? The changing demography of the American population The persistence of disparities in the health status of racial and ethnic minorities
Percent Distribution of U.S. Population by Race and Ethnicity, 2000 African American/ Black 12.2% Asian/Pacific Islander 3.8% White, not Hispanic/ Latino 71.4% Hispanic/ Latino 11.9% American Indian/Alaska Native 0.7% Source: U.S. Census Bureau, 2000
Percent of the Population by Race and Hispanic Origin, 2000 and 2050 3.9% 12.2% 11.4% 8.2% 13.6% 24.5% American Indian/Alaska Native Asian/Pacific Islander Black/African American 71.8% 52.8% Hispanic/Latino White, not Hispanic/Latino 2000 2050 Source: U.S. Bureau of the Census 2000
Emerging Majorities Minority people are the majority in three states California (50.1%) Hawaii (71%) New Mexico (53%) District of Columbia (71%)
Emerging Majorities Minority people are now at least 30% of the population in ten states: Texas (45%) Mississippi (38%) Maryland (36%) New York (35%) Georgia (34%) Arizona (32%) Florida (32%) New Jersey (32%) South Carolina (32%) Nevada (30%)
Percent of the Population by Race and Hispanic Origin, Indiana 1990 White, not Hispanic: 90.1% 2000 White, not Hispanic: 86.5% Black/African American: 7.8% Black/African American: 8.3% Asian/Pacific Islander: 0.2% Asian/Pacific Islander: 1.0% Hispanic/Latino: 1.7% Hispanic/Latino: 3.6% American Indian/Alaska Native: 0.3% American Indian/Alaska Native: 0.7%
Life Expectancy at Birth, 1900-1998 Years 80 70 60 White Black 77.3 71.3 50 40 47.6 30 33.0 20 0 1900 1950 1980 1998 SOURCE: CDC/NCHS, National Vital Statistics Systems, 1900-98
Infant Mortality Rates, 1980-1998 25 22.2 20 15 10 5 10.9 14.3 6.0 White Black 0 1980 1985 1990 1995 1998 Deaths <1 year/1000 live births SOURCE: CDC/NCHS, National Vital Statistics System, 1980-1998
Infant mortality rates by race and Hispanic origin of mother Total Hispanic Non-Hispanic white 6.3 6.3 Non-Hispanic black 14.3 Asian/Pacific Islander SOURCE: CDC/NCHS, National Vital Statistics System, 1995 5.3 0 4 8 12 16 Deaths <1 year per 1000 live births
Infant mortality rates by Hispanic origin of mother Total Hispanic Mexican 6.0 6.3 Puerto Rican 8.9 Cuban Central/South American 0 2 4 6 8 10 5.3 5.3 SOURCE: CDC/NCHS, National Vital Statistics Systems, 1995 Deaths <1 year per 1000 live births
Infant mortality rates by Asian/Pacific Islander subgroup Asian/Pacific Islander 5.3 Chinese 3.8 Japanese 5.3 Hawaiian 6.6 Filipino 5.6 SOURCE: CDC/NCHS, National Vital Statistics Systems, 1995 0 1 2 3 4 5 6 7 Deaths <1 year per 1000 live births
Coronary heart disease death rates White Black 111.4 102.1 151.3 140.4 1990 1996 A/PI AI/AN Hispanic 63.1 56.7 81.2 74.5 78.1 72.7 0 50 100 150 200 Per 100,000 population NOTE: Death rates are age-adjusted to 1940 standard million age distribution. A/PI is Asian American or Pacific Islander; AI/AN is American Indian or Alaska Native. SOURCE: CDC/NCHS, National Vital Statistics System, 1990 and 1996
Racial and Ethnic Disparities: Morbidity and Mortality African American men have a 40 percent higher heart disease rate than White men Women of Vietnamese origin in the United States suffer from cervical cancer at nearly five times the rate than White women
Racial and Ethnic Disparities: Morbidity and Mortality Native Americans have a diabetes rate that is nearly three times the rate of Whites. The Hispanic rate is nearly double that of Whites African American women are 28% more likely to die from breast cancer, although the incidence is greater in White women
How Do We Explain Racial And Ethnic Disparities In Health?
Several Causal Factors Socioeconomic status (SES) Health risk behaviors Psycho-social factors Acculturation Biologic/Genetic factors Health care
Socioeconomic Status Education Occupation Income Environment Culture
Infant Mortality Rates in the United States Deaths/1000 Live births <12 12 13-15 16+ Education in years 15 14.8 13.9 10 10.0 11.6 10.4 6.5 5 5.0 4.1 0 NHW=Non-Hispanic White NHB=Non-Hispanic Black SOURCE: CDC/NCHS/NVSS
Health Risk Behaviors
Health Risk Behaviors Female Current smokers 16.3 23.4 21.2 White Black Hispanic >1 oz. alcohol per day 1.8 1.2 1.7 Regular exercise or sports 39.1 27.9 31.9 0 10 20 30 40 50 percentage engaging in activity SOURCE: CDC/NCHS, National Health Interview Survey, 1990
Health Risk Behaviors Male White Current smokers 28.0 32.5 30.9 Black Hispanic >1 oz. alcohol per day 10.1 8.2 8.8 Regular exercise or sports 44.1 42.2 38.4 0 10 20 30 40 50 percentage engaging in activity SOURCE: CDC/NCHS, National Health Interview Survey, 1990
Age-adjusted Prevalence of Obesity (BMI > 30.0) Female Non-Hispanic Whites 14.8 22.4 NHANES II NHANES III Non-Hispanic Blacks 30.0 37.4 Mexican Americans 25.4 43.2 0 10 20 30 40 50 Percent SOURCE: CDC/NCHS, Second National Health and Nutrition Examination Survey, 1976-80 Third National Health and Nutrition Examination Survey, 1988-94
Age-Adjusted Prevalence of Obesity (BMI > 30.0) Non-Hispanic Whites Male 12.0 NHANES II NHANES III 20.0 Non-Hispanic Blacks 15.0 21.3 Mexican Americans 15.4 23.1 0 5 10 15 20 25 Percent SOURCE: CDC/NCHS, Second National Health and Nutrition Examination Survey, 1976-80 Third National Health and Nutrition Examination Survey, 1988-94
Psychosocial Factors
Psychosocial Factors Large complex literature relating factors such as stress and discrimination with racial/ethnic differences in hypertension
Acculturation
Acculturation Some health behaviors worsen with acculturation
Biological and Genetic Factors
Health Care
Percentage Uninsured Under Age 18 United States Percent of Population 50 45 40 35 30 25 20 15 10 5 0 21.0 20.0 30.0 White Black Hispanic Source: CPS, USCB
Health Care Coverage of Persons Under 65 (Age-adjusted) All Hispanic NH White NH Black 5.0 15 19 25.0 25.0 35 55 55 80 Private Medicaid/ Public Assistance Not covered Asian/PI 15.0 18.05 65.4 0 20 40 60 80 Percent SOURCE: CDC/NCHS, National Health Interview Survey, 1996
Health Care Extensive evidence of racial and/or ethnic Differences in utilization of health care Diagnostic tests and procedures Therapeutic procedures Intensity of care Pain control Transplants Preventive services
Possible Explanations for the Racial and Ethnic Differences in Utilization Socioeconomic status Language Insurance status Severity of illness Patient health behaviors Provider bias
IOM Report Findings Racial and ethnic disparities in healthcare exist and, because they are associated with worse outcomes in many cases, are unacceptable.
IOM Report Findings Factors contributing to racial and ethnic disparities in healthcare: Health systems Healthcare providers Patients and utilization managers Bias, stereotyping, prejudices Clinical uncertainty on the health of care providers
IOM Report Recommendations Increase awareness of racial and ethnic disparities among the general public, key stakeholders, and healthcare providers Legal, regulatory, and policy interventions Health systems interventions
Factors Influencing Optimal Medical Care Effective patient-physician communication Overcoming cultural and linguistic barriers Access to affordable health insurance Alternatives to hospital emergency rooms Improvement in continuity of care Improving information for patients Participate in the latest quality improvement innovations
Of all the forms of inequality, injustice in health is the most shocking and the most inhumane. -- Dr. Martin Luther King, Jr.