Race, Ethnicity, and Social Class: Implications for Health Disparities Research

1. Race, Ethnicity, and Social Class: Implications for Health Disparities Research Anna Nápoles-Springer, PhD Assistant Adjunct Professor Division of General Internal Medicine Center for Aging in Diverse Communities Medical Effectiveness Research Center for Diverse Populations

2. Summary of Presentation • Race/Ethnicity/Culture • US Census Questions and OMB 15 • Race and Genetics • Social Class • Perceived Discrimination/Racism • Examples How Race/ethnicity Matter 2

3. Race in the Headlines 10 people dead in Minnesota after a 16-year-old went on a shooting rampage on the Red Lake Native American Reservation • Remote area 75 miles south of Canadian border, one of poorest indigenous groups in US with 40% of residents unemployed and below poverty line • Red Lake High scored 2nd lowest of all Minnesota schools in math and 3rd lowest in reading 3

4. Race in the Headlines (cont) • Jeff Weise posting on a neo Nazi web site: “As a result of cultural dominance and interracial mixing, there is barely any full-blooded Natives left. Where I live, less than 1% of all the people on the reservation can speak their own language. Under a Nationalist Socialist government, things for us would improve vastly.” • His father committed suicide 4 years earlier and mother was in a nursing home with brain injuries 4

5. Question What are the social, political, economic and historical factors that might have contributed to this event? 5

6. Race: Biological vs Real • Physical anthropologists no longer view race as a valid concept • Biologically distinct human races do not exist; however: “Even though race may be a biological fiction, it is nevertheless… a profoundly important determinant of health status and health care quality.” La Viest T. Race, Ethnicity and Health: A Public Health Reader, JosseyBass, 2002. 6

7. Race as a Social Category • US historically has applied race as a concept to justify the treatment of certain social groups as inferior, with differential access to power and valuable resources • Slavery lasted 244 years in US • In 1830, US Congress enacted the Indian Removal Act resulting in forcible removal of tribes to reservations in Oklahoma • Chinese Exclusion Act of 1882 - 1st US immigration law targeting specific ethnicity 7

8. Definition of Race • Societally constructed taxonomy that reflects the intersection of particular historical conditions with economic, political, legal, social and cultural factors, as well as racism. Williams D, Health Serv Res 1994;29:261 8

9. Ethnicity • Groups that share a common heritage • Similar history, language, customs, rituals, foods 9

10. Culture • Groups that share a set of beliefs, norms, and values • System of shared meanings • Can apply to any group regardless of race or ethnicity, e.g., adults trained to be in a profession (physicians, attorneys) or religion 10

11. Why Study Minority Groups? • Growth of minority groups, especially Latinos and Asians • Every major racial/ethnic group tracked by US Census has higher fertility rate than Whites • US Census predicts that by the middle of this century the US will be a “majority-minority” with Whites making up < 50% • Nation’s health = minority health 11

12. Why is it Important to Study Race and Ethnicity? • Public health surveillance • Due to treatment disparities: track processes and outcomes of care • Assess the impact of health organization and policy changes on quality of care for vulnerable groups 12

13. OMB Directive 15 • Sets guidelines for the collection of racial and ethnic categories to “provide for the collection and use of compatible, nonduplicated, exchangeable racial and ethnic data by Federal agencies.” 13

14. 2000 U.S. Census: New OMB Standards • Allow for reporting more than 1 race • Separate Asian/Pacific Islander into categories: Asian subgroups, Native Hawaiian or Other Pacific Islander • Change to Hispanic or Latino • Change to black or African American • Strongly endorse self-identification 14

15. 2000 U.S. Census Questions Ethnicity question preceding race question: Is this person Spanish/Hispanic Latino? __ No, not Spanish/Hispanic/Latino __ Yes, Mexican, Mexican-Am, Chicano __ Yes, Puerto Rican __ Yes, Cuban __ Yes, other Spanish/Hispanic/Latino 15

16. 2000 U.S. Census Questions Race question: What is this person’s race?Mark one or more… __White __Black, African American, or Negro __ American Indian or Alaska Native __Asian Indian __Japanese __Native Hawaiian __Chinese __Korean __Guamanian or Chamorro __Filipino __Vietnamese __Samoan __Other Asian __Other Pacific Islander __Some other race 16

17. Ethnicity - Preferred Terminology • Admixture will lead to racial categoriesbecoming less valid • Ethnicity is consistent with self-identity with a group • Supplement with national background, cultural identity, language proficiency 17

18. Race and Biology • Greater genetic variation within a racial group than across groups–99.9% the same • Most diseases are multi-factorial • Genetic predisposition often confused with “racial” characteristic • HTN in Caribbean Blacks < Whites < AA • Race/ethnicity identifies group more likely to share specific alleles 18

19. The 0.1% matters-represents 3 million differences in individuals’ DNA Categorize by allele frequencies Based on similarity of certain sections of their genetic code, individuals cluster into five groups that loosely correspond to social categories of race: White, African American, East Asian or Latino Tang H et al Am J Hum Genet 2005;76:275. Race and Genetics 19

20. Self-identified Race and Genetic Variation • Ability to cluster into groups relies on • Starting with individuals whose recent ancestors derive from same geographic area, # of markers, geographic areas sampled • Linking self-identified race to disease: • Self-id race is surrogate for ancestral geographic origin • Which is surrogate for variation across genome • Which is surrogate for variation in disease-relevant alleles • Which is surrogate for individual disease risk Bonham V. Am Psych 2005:60;9. 20

21. Ancestry Informative Markers in Mexican Latinos Markers with large differences in allele frequencies between ethnicities provide ancestry information that can be applied to genetic studies. 21

22. Role of Admixture • What is the clinical relevance of this? • Useful in epidemiological analyses where many individuals are analyzed together to make very general statements about differences in risk; almost no meaning regarding the level of risk for any one person . • What are the risks? • Some ancestries are viewed more positively by some • Discrimination 22

23. Complexity of Constructs • Genomic research aims to disentangle complex gene-environment interactions • “Studies using genetic clusters instead of racial/ethnic labels are likely to simply reproduce racial/ethnic differences, which may or may not be genetic [and may result from social, cultural, economic, behavioral and other environmental factors].” Tang H. Am J Hum Genet 2005;76:268 • Need to maintain awareness of potential for genomic research to harm those who have historically been most vulnerable Bonham V. Am Psych 2005:60;9. 23

24. Social Class and Race/Ethnicity • Has race been a substitute for defining social class in the U.S.? • Socioeconomic position is the major explanatory factor for differences in death rates between Blacks and Whites • Inverse mortality-SES gradient at all levels within race/ethnic group--especially true for African Americans • “Racism is still a driving force in determining economic opportunities for minorities.” Williams DR. 2001Income, Socioeconomic Status, and Health. 24

25. 166.3 million 35.5 million 31.8 million 11.3 million 2.7 million Poverty Status of <65 Population by Race/Ethnicity, 2001 Non-Poor (200% + FPL) Near Poor (100% + 199% FPL) Poor (<100%FPL) White Latino African American Asian Only American Indian/Alaska Native NOTE: FPL = Federal Poverty Level. SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured, analysis of March 2002 Current Population Survey. 25

26. Social Class Measures • Education and income are insufficient measuresof social class • Wealth–assets, property • Multilevel measures: individual, family, neighborhood • Community measures are needed– segregation, safety, inequality, acculturation, social capital, social isolation, exercise venues 26

27. Race and Education • Charleston Health Study: less education not risk factor for CAD mortality among Blacks • Education stronger RF than race in other studies • Correlation of education with life expectancy in patients > 65 is stronger than race • Accounts for observed racial difference in cancer survival 27

28. Discrimination:Does It Affect Health? • Physical and mental health status of African Americans--U.S. • Obtaining health care • Administering analgesics to Latinos with long bone fractures—UCLA • Revascularization procedures for CAD • Surgery for lung cancer • Renal transplants for ESRD 28

29. “Let’s just forget for a moment that you’re black.” 29

30. Examples from Clinical Research Race/Ethnicity as a Significant Predictor

31. No Usual Source of Health Care: Ages 18-64, by Race/Ethnicity American Indian/Alaska Native White Latino African American Asian Only 1993-1994 2000-2001 31 DATA: National Center for Health Statistics, National Health Interview Survey. SOURCE: Health, United States, 2003, Table 76.

32. Percent with No Health Care Visits in Past Year, by Race/Ethnicity and Poverty Status African American African American White Latino Latino White 200% + of Poverty < 100% of Poverty 32 DATA: National Center for Health Statistics, National Health Interview Survey, 2000. Health, United States, 2002, Table 72. SOURCE: Kaiser Family Foundation, Key Facts: Race, Ethnicity and Medical Care, 2003, Figure 20b.

33. Disparities in Quality of CareMedicare Managed Care • HEDIS – 4 measures of quality, Blacks compared to Whites • Breast cancer screening: 63% vs. 71% • Eye exams in diabetes: 44% vs. 50% • Beta-blocker after MI: 64% vs. 74% • Follow-up after mental illness hospitalization: 33% vs. 54% • Schneider E, JAMA 2002; 287: 1288-94 33

34. Disparities in Diabetes Treatment and Outcomes • CDC report--compared to Whites, Latinos were less likely to have: • Dilated eye exam(56% vs. 60%) • Foot exam (47% vs. 56%) • Glycosylated Hb test (18% vs. 27%) • Latinos have more LE amputations • Mexican Ams have more retinopathy • More proteinuria and ESRD 34

35. Ethnicity in Patient-Doctor Relationship • Refusal: whose issue? • DNR discussions–Race of clinician is an independent predictor • Cultural competence • Language factors • Racism- fewer cardiology referrals in Blacks • More patient-centered decision making 35

36. Ethnicity and Attitudes toward Patient Autonomy among Persons ≥ 65 yrs 36

37. Mortality Ratios, by Age and Race/Ethnicity, 2000 African American American Indian White Latino Asian Age in Years DATA: National Center for Health Statistics, National Vital Statistics (Vol. 50, No. 15, September 16, 2002.). SOURCE: Kaiser Family Foundation, Key Facts: Race, Ethnicity and Medical Care, 2003, Figure 7. 37

38. Percent Reporting Fair or Poor Health, by Race/Ethnicity, 2001 African American Asian American Indian/Alaska Native White Latino 38 DATA: National Center for Health Statistics, National Health Interview Survey. SOURCE: Health, United States, 2003, Table 57.

39. < 100% of Poverty 200% + of Poverty % Fair or Poor Health, by Race/Ethnicity and Income, 2001 White African American African American Latino White Latino 39 DATA: National Center for Health Statistics, National Health Interview Survey. SOURCE: Health, United States, 2003, Table 57.

40. CHD Prediction Scores By Ethnicityin Framingham? • Applied sex specific CHD functions to 6 ethnically diverse cohorts • White and Black men and women prediction of CHD events works well • Japanese & Latino men and American Indian men & women – risk is overestimated • Adjust for different rates of risk factors and underlying rate of CHD • JAMA 2001; 286:180-7 40

41. Summary • In general, those who are poor and of color: • are more likely than whites to be publicly insured or uninsured; and • less likely to have a regular source of medical care. • Adjusting for differences in income, health status, and coverage, numerous studies show racial/ethnic disparities in receipt of medical care. Source: Caya Lewis, Senior Policy Analyst, Access to Care for Vulnerable Populations, Kaiser Family Foundation 41

42. Recommendations on Use of Race/Ethnicity • This is a critical construct • Essential in clinical research • Self-report category is gold standard • Variance explained overlaps but is distinct from SES measures • Contributes and predicts a lot • Measure in standard way • Administrative data has limitations 42