Racial Health Disparities: Appearances, mirages, and new realities.

1. Racial Health Disparities: Appearances, mirages, and new realities. Steven Miles MD.

2. US 2000 Census • 97.6% said that they were one race, • My daughter said that she was “human” (answer not accepted). • 2.4% said that they were multi-racial; • The proportion of European genes in self declared African Americans is 12% to 23%. • What does it mean to claim a person is of a race? Is it • Submitting to a social caste? • Asserting cultural affiliation? • Noting a genetic category? 97% of these call themselves Hispanic

3. Racial Genetics Does Not Explain Health Disparities. Although allele-based diseases are often relatively more frequent in intra-bred populations. • Hemoglobinopathies • Metabolic disorders • Degenerative conditions. • “Race Genetics” does not explain pandemic differences in • birthweight and • maternal mortality and • life expectancy and • survival or functional outcome from diseases as diverse as squamous cell cancer, adenocarcinomas, myocardial infarction, asthma, diabetes, etc.

4. It has become clear that human populations are not clearly demarcated, biologically distinct groups. . . . The continued sharing of genetic materials has maintained humankind as a single species. . . . Any attempt to establish lines of division among biological populations is both arbitrary and subjective. American Anthropological Association 1999 Kyushu Museum. 2002. • 0.1% genetic difference between two randomly selected humans. • 5-10% of this difference “racial” “old segregation.” • 5-10% continental separation, “new segregation.” • 80% individual variation.

5. Throughout history scientists have used social and politically determined racial categories to make scientific comparisons between races—with little or no discussion about the meaning or rationale. . . . Race might be a proxy for discriminatory experiences, diet or other environmental factors. . . . There is no justification, however, to use race as a substitute for other parameters that can be measured . . .. Nature Genetics 2000:24:97-8.

6. Multivariate “caste-race” Analysis Univariate “bio-race” Analysis • Socioeconomic status (poverty, access to health care, literacy, education) Environment (Physical and psychological toxins) “Race” Disease incidence, outcome • Behaviors (compliance, diet, sex, exercise, practitioner bias, etc)

7. Race as a Medical Variable Useful Variable • Whether African Americans, Hispanics, Native Americans, Pacific Islanders or Asians respond equally to a drug is an empirical question that can only be addressed by studying these groups individually. • We strongly support the search for candidate genes that contribute to disease susceptibility and treatment response, within and across racial/ethnic groups. • A lot of the problem is terminology. I'm not even sure what race means, people use it in many different ways. . . . but that doesn't preclude you from using it or the fact that it has utility. • Risch N Distracting Relic • Scientific Grounding: • Race was constructed by a false biology, misused for repression and neglect and remains un-validated. • Given that cultural factors: • Are poorly controlled for by most studies using race as a variable (partly as a legacy of the social construction of race categories) • Are a more plausible explanation for the huge diversity of race disparities (longevity, birthweight, cancers, heart disease, disabilities etc) • Are more susceptible to cost effective intervention than gene targeted therapy, • Therefore, unless new research finds otherwise, bio-race should not be used as an explanatory variable for profiling or explaining health care states, except for allele based diseases that highly sort to narrowly inbred populations.

8. Race Medicine The Example of Stroke

9. Stroke: 3RD Cause of Death in US Age Adjusted Deaths/100,000 • “Facts” • Blacks have 2X the risk of first strokes as whites. • Blacks have ↑ stroke death rates than whites. CDC 2009

10. Images from American Stroke Assn Home Page. Most Powerful Voices Choir Competition PTES and the Gospel Music Channel are looking for the Most Powerful Voices in an online choir competition. Power Gospel Tour Dates Revised! The Power Gospel Tour is a celebration of faith and health, punctuated by key messages about stroke prevention. Power Finance Having a stroke can be a life-changing event. In addition to impacting your health, the effects can be equally devastating to your finances. Healthy Soul Food Recipes Consumer Publications has created an oversized hardcover cookbook to honor Ms. Yolanda King, the first national Ambassador for Power To End Stroke. PR Week Awards Power To End Stroke received honorable mention in the category of Multicultural Marketing Campaign of the Year...

11. Black / White Stroke incidence after SocioEconomic Status (SES) adjustment. • Disadvantage in early childhood may confer increased risk in adulthood, perhaps mediated by infectious diseases, nutritional conditions, or poverty-related stresses. • Cardiovascular risk factors are established early in life and begin to diverge in black and white subjects during childhood. • Ann Epi 2008;18:904 -12. 24000 Whites and 24000 Blacks Given that socioeconomic variables strongly condition the expression of chronic disease, is it fair to simply assert that they do not also condition the response to various therapies, (such as Bidil)?

12. Hypertension in Blacks by Country of Residence SES data says that this does not indicate a “susceptibility” to developed country diet. Could it represent a consequence of the catecholamine response to the stress of disadvantage? Am J Pub Health 1997;87:160-8.

13. MIGRATION MATTERS! SES adjusted incidence of asthma in Hispanics is same as non-Hisp Whites BUT foreign born Hispanics and their children have a much lower risk of Asthma. Asian women who move to the US, increase their chance of getting Post-Menopausal Breast Cancer. Epidem 1995;6;181-3. Am J Pub Health;2009;99;690-97.

14. Class, 5 yr Cancer Survival: Access matters. Low Income AJPH 2000; 90:1866-72

15. Previous slide does not take account of relatively wider gap between rich and poor in the US relative to Canada. High Wealth Inequality USA, Norway, Australia. Medium Wealth Inequality Italy, Finland France, Austria, Netherlands, Switzerland. Lower Inequality associated with:  Education,  Obesity,  Heart disease,  Stroke,  Unhealthy behaviors Low Wealth Inequality Spain, UK, Australia, Sweden, Denmark, Germany Soc Sci & Med 2008;66:1719-32.

16. A Problem Ethnic community targeted health campaigns can be an important to reducing disparities. Ethnicity-targeted health campaigns risk ethnic branding that reinforces fatalism about the health consequences of cultural difference and socioeconomic stratification.

17. Minneapolis, Minn. - January 21, 2010 - HealthPartners Medical Group today announced that it has launched an initiative aimed at saving lives by providing more timely colorectal cancer screening for African American patients. Organizations, such as the American College of Gastroenterology recommend that regular colorectal cancer screening for African Americans should begin at age 45, compared to age 50 for other races. "Nationally, colorectal cancer deaths are 48 percent higher among African Americans than among Caucasians," said Brian Rank, M.D. an oncologist and medical director of the HealthPartners Medical Group. "Our goal is to save lives by ensuring that more African American patients in our clinics receive recommended colorectal cancer screening in a timely manner.“ . . . "We have made reducing health disparities a top priority," said Rank. . . . • Participants exposed to “disparity” (e.g. Blacks are doing worse than Whites) articles: • reported more negative emotional reactions to the information and • were less likely to want to be screened for CRC than those in other groups (both P < 0.001). • Progress articles (e.g., Blacks are improving, but less than Whites, Blacks are improving over time) elicited more positive emotional reactions and participants were more likely to want to be screened. • Cancer Epidemiology, Biomarkers & Prevention 2008; 17:2946-53, 2008. Double-blind RCT compared emotional and behavioral reactions to 4 versions of the same colon cancer (CRC) information in mock news articles to a community sample of 300 African-American adults. All articles said colon cancer important problem for African-Americans.

18. Pain Treatment • JAMA 1993;269:1537–9. Single ED in TN. Adjusted for gender, language, insurance, severity, intoxication. • Ann Emerg Med 2000;35:11–6. Retrospective cohort study of patients single ED in GA. These findings also apply to post-op pain tx after hip fx and to nursing home residents. This disparity is not due to decreased pain perception by clinicians. It is due to a failure to act on the perception of pain in minority patients. Pain Med 2003;4:277-94.

19. Possible Solutions • Culturally competent health care providers. • Cultural competence courses. • Desegregation and immersion. • Health care multi-lingualism • Disparities-Targeted Health Programming. • Private and government offices of minority health. • Recruitment of health workers from underrepresented groups (will fail without addressing preschool, K-12, and college disparities). • More clinics, pharmacies and outreach in under-served communities. • Interpreter services. • Addressing Socioeconomic Castes. • Ending substandard schools and neighborhoods, • Ending disparities in transportation, libraries, housing segregation, access to loans, etc. • Universal health care so that all people have comparable health opportunities.

20. Cultural Competency Training: Well-intended. No evidence of effectiveness. After competency training at 2 of 4 practice groups, there was no change in patient • Patient Satisfaction • Weight • Systolic blood pressure • Glycosylated hemoglobin • p = NS for all). • BMC Medical Education. 6:38, 2006. 53 primary care MDs at 4 clinics with 429 of their patients with diabetes and/or hypertension. Cultural competency training was then provided to physicians at 2 of the sites. Teaching culturally appropriate care: a review of educational models and methods. AcadEmerg Med 2006;13:1288-95. The literature addressing the true efficacy of such programs in leading to long-lasting change and improvement in minority patients' clinical outcomes remains insufficient. [References: 50] Culturally competent healthcare systems. A systematic review. Amer J Prevent Med 2003;24(3 Suppl):68-79. We could not determine the effectiveness of any of these interventions, because there were either too few comparative studies, or studies did not examine the outcome measures evaluated in this review: client satisfaction with care, improvements in health status, and inappropriate racial or ethnic differences in use of health services or in received and recommended treatment. [References: 43] Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Medical Care Research & Review. 57 Suppl 1:181-217, 2000. While there is substantial research evidence to suggest that cultural competency should work, health systems have little evidence about which cultural competency techniques are effective and less evidence on when and how to implement them properly. [References: 205]

21. US African-American Physicians Note: African American male MDs have not increased in 30 years.

22. Epigenetics: The twilight of “race?” • Epigenetic marks turn on and off genes and thus affect many metabolic conditions including those affecting cardiovascular mortality, diabetes etc. • Gene switch differences are heritable even though the DNA sequence is the same. • Gene switch positions can be flipped by minor environmental factors. • Quart Rev Biol 2009;84:131–76. These genetically identical mice had gene switches changed by minor changes in prenatal maternal diet. They will pass on their traits for several generations. The genes can be flipped on and off. Randy L. Jirtle Given that there are more epigenetic control marks than genes, is it fair to assert that nature, not nurture, is the primary determinant of who we are?

23. Slides Available Steven Miles, MD University of Minnesota miles001@umn.edu