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

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Racial Health Disparities Appearances, mirages,
and new realities.

• Steven Miles MD.

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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
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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.

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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

• 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.

Kyushu Museum. 2002.
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Biological Caste
Sex Gender
Male-Female Women-Men

Bio-Race Caste-Race
Asian, African, Caucasian, Pacific Islander Japanese or Japanese-American, etc
Throughout history scientists have used social
and politically determined racial categories to
make scientific comparisons between raceswith
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
20002497-8.
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Multivariate caste-race Analysis
Univariate bio-race Analysis
Socioeconomic status (poverty, access to health
care, literacy, education)
Race
Environment (Physical and psychological toxins)
Disease incidence, outcome
Behaviors (compliance, diet, sex, exercise,
practitioner bias, etc)
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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.

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Race Medicine

• The Example of Stroke

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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
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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...
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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 200818904 -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)?
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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 199787160-8.
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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 19956181-3.
Am J Pub Health200999690-97.
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Class, 5 yr Cancer Survival Access matters.
Low Income
AJPH 2000 901866-72
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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 2008661719-32.
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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.
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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 lt 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 172946-53, 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.

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Pain Treatment
JAMA 199326915379. Single ED in TN. Adjusted
for gender, language, insurance, severity,
intoxication.
Ann Emerg Med 200035116. 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 20034277-94.
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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.
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Cultural Competency Training Well-intended. No
evidence of effectiveness.

• Teaching culturally appropriate care a review of
  educational models and methods. Acad Emerg Med
  2006131288-95.
• 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 200324(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
  1181-217, 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

• 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. 638, 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.

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US African-American Physicians
Note African American male MDs have not
increased in 30 years.
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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 20098413176.

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?
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Slides Available

• Steven Miles, MD
• University of Minnesota
• miles001_at_umn.edu