Minority health

The United States is a nation of immigrants. By the year 2050, one-half of the country's population will be members of minority groups, defined as NativeAmericans and Alaska Natives, African Americans, Asian Americans and PacificIslanders, and Hispanics. Because racial and ethnic minority populations havepoorer health than the general population and suffer disproportionately fromthe added stresses of poverty, their health care needs are different from those of much of the majority population.

Racial division has been a feature of the American experience, and the healthcare system reflects the race and class divisions within society. Nonwhiteshave historically suffered from higher mortality rates, higher incidence of major diseases, and lower availability and use of medical services.

Discrimination may be obvious, for example, in location and number of providers to serve minority groups. In the United States, an insufficent number of physicians choose to practice in inner cities. Physicians from minority groupsare more likely to choose such settings, but overall even minority physicians tend to practice in other locales. A similar problem exists in rural areas,which puts Native Americans and many Hispanics at a disadvantage in obtaining medical attention.

There may be more subtle problems, as well. Minority patients may distrust white health care workers or may fear that the clinicians are not seriously concerned about them. Patients and clinicians may have trouble communicating because of literal language barriers, or because of different ways of describingdiscomfort and illness.

The special health care needs of minorities are also a concern in other countries with substantial mixed immigrant populations, such as Canada and the United Kingdom.

Disparities in health care that affect minorities negatively are reflected byhigher rates of infant mortality; diabetes; cardiovascular diseases; HIV infection; breast and cervical cancer screening and management; and deficits inchild or adult immunization rates. African Americans in particular have a higher death rate than whites for 12 of the 15 leading causes of death. Some studies have shown that for serious diseases such as heart attacks or lung cancer, minority patients are treated less aggressively than white patients, whichmay account for some of the difference in death rates from those diseases.

Infant mortality is an important measure of a nation's health and a worldwideindicator of health status. In the United States, the infant mortality ratefor blacks is twice that of whites. Blacks have twice the mortality rate forcardiovascular disease as whites, and all racial and ethnic minorities have higher risk factors for cardiovascular disease, including high blood pressure,obesity, and higher levels of cholesterol. Although black women have a lowerrate of breast cancer than white women, they are less likely to survive it.Minority women in general have low rates of screening and treatment for breast and cervical cancer, diseases for which early intervention can significantly reduce the risk of death.

Rates of diabetes and diabetic complications are higher among all minoritiesthan among whites. Underimmunization in urban areas with traditionally underserved populations increases the likelihood of vaccine-preventable diseases among both children and adults. Racial and ethnic minorities constitute approximately 25% of the total U.S. population, yet they account for nearly 54% of all cases of AIDS. Many studies indicate that minority group members tend notto receive state-of-the-art treatment for AIDS. Also, with fragmented followup from medical professionals, they are less likely to follow the complex regimens that seem to work best against AIDS.

The case of multi-drug resistant tuberculosis is an example of what happens when people lack convenient access to medical care. For decades, tuberculosishas been treated successfully with antibiotics. These antibiotics need to betaken for a year in order to eradicate the bacteria causing TB. With poor medical followup and sometimes chaotic lives, minority group members have tendednot to complete the course of antibiotics. As a result, bacteria that can survive the effects of antibiotics for a relatively brief time remain infective. When these bacteria are spread to another person, they become harder to kill. Over time, some tuberculosis bacilli have developed resistance to all, orvirtually all, known antibiotics. When this form of tuberculosis spreads, itis difficult or impossible to cure. Multi-drug resistant tuberculosis is a major problem in prisons, general hospitals, and homeless shelters.

Ethnicity and Disease

Although socioeconomic factors such as poverty and discrimination clearly play an important role in minority health experiences, genetic and other biological factors seem to be involved, as well.

The most clearcut example of this is sickle cell, which is clearly traced toa single genetic mutation that disproportionately affects Africans and African Americans. An individual is said to have sickle cell trait if he or she hasreceived the gene from one parent. In tropical climates such as Africa, people with sickle cell trait are far less susceptible to the deadly disease malaria, so experts believe that people with this mutation actually had an advantage over other people. In temperate climates such as the United States malaria is rare, and as a result sickle cell trait offers no biological advantage.

When a child receives the mutated gene from both parents, then sickle cell anemia is the result. In sickle cell anemia, red blood cells assume an abnormal"sickle" shape in conditions when oxygen is in relatively short supply. Thiscan happen under the stress of physical exertion, or many other circumstances. The sickled red blood cells cannot pass through the tiny blood vessels known as capillaries, and the result is pain caused by the lack of oxygen in body tissues. Pains in the joints, the back, and the abdomen are common in sickle cell crises. Over time, chronic disruption of the circulation may cause skin ulcers around the ankle, damage to the leg bone (femur) where it joins thehip, and eventually kidney and respiratory problems.

A less clearcut biologic difference seems to occur in cases of high blood pressure or diabetes. In people of African descent, these disorders are more difficult to control with medicines that in other racial groups. Also, even allowing for the severity of the diseases, blacks seem more susceptible to severelong-term damage to the kidneys, eyes, and general circulation. Black peopleare far more likely than whites to undergo kidney dialysis, as a result.

Biologic differences may account for some significant medical challenges in Native Americans, as well. For instance, Pima Indians living in the American Southwest have an extraordinarily high rate of obesity, leading to very severediabetes and other diseases. Like other Americans, many Pima Indians eat unhealthy diets, with too much fat and sugar. However, the response to these diets seem to be unusually severe. Many experts believe there is also a biological explanation for the extremely high rate of alcoholism among some Native American tribes. Although social factors such as geographic isolation of reservations and poverty clearly have a role in alcoholism, these do not seem to account for the severity of the problem.

Families and Illness

In some minority ethnic groups, the entire family is closely involved in thecare of a sick family member. Typical American medical practices make it difficult for families to become involved, posing practical problems ranging fromtiny examining rooms to restrictive visiting policies in hospitals. Some minority people will choose to forego medical care rather than shut out their families from participation.

For immigrant families, language barriers may create family stress. Because children are quick to acquire a new language, youngsters may be called upon tofunction as interpreters for older relatives. Thus, even very young childrencan effectively become the negotiators for the entire family, and they alsolearn intimate details of older relatives' physical problems. This is a significant stress to place on any child, and in some cultures it is regarded as inappropriate.

Practical Challenges

In addition to perceptions of inadequate treatment related to race or ethnicity, other factors affect access to care. Minorities have higher rates of unemployment, and may not be covered by health insurance. Even among the workingpoor, employment benefits may not include health insurance, and salaries maybe too low for workers to purchase their own. As people are leaving the welfare system in large numbers, this appears to be an increasingly large problem.People leaving welfare may still be eligible for Medicaid or other subsidized health care, but there is no infrastructure to tell them about this or to help them apply.

Because many minority group members do not have regular access to a physician, they seek medical care only when they are in acute distress. For instance,even though people with asthma can usually live a normal, active life, many children in the inner city make repeated visits to the emergency room and evenreceive frequent in-patient hospital care for their asthma. Harried emergency room doctors are not able to explain the need for the child to take medicine on a regular schedule, even if he or she feels well, so some minority patients come to see asthma strictly as a series of breathing crises. Lack of ongoing primary care seems to be a factor in such other disorders as glaucoma, high blood pressure, and cancer. By the time many minority group people see a physician for such chronic diseases, they have suffered significant damage.

Cultural differences, such as language difficulties or use of alternative types of health care treatment, may also create obstacles to care. For some groups, there is a stigma attached to seeking care for a problem such as depression. Research efforts to include minorities may be hampered by suspicion of researchers' hidden agendas. These fears are grounded in experiences such as the Tuskegee syphilis study, in which patients were left untreated in ways thatwould not have been tolerated in the majority population.

Most physicians have little or no knowledge of folk medicines, which can be important in the health care of many immigrants. In some cases, folk medicinesmay have well documented physiological effects, which can work either to theadvantage or the disadvantage of a conventional treatments. If the physicianis unfamiliar with the folk remedy or does not recognize the name that a particular patient uses to identify it, he or she may prescribe too large or toosmall a dose of a familiar medicine.

Minority groups are more likely to have to rely on mass transportation for access to health care, which restricts their mobility and therefore presents another barrier to prevention or timely treatment.

At the highest technological levels, minorities are at a disadvantage with regard to organ transplantation. The problem here is that minorities are less likely to be organ donors. Both potential donors and their families may distrust the medical system and may therefore think the worst when asked to allow the use of organs from a deceased young family members. Also, many minority groups have religious or cultural beliefs that would regard removal of organs as disrespect to the deceased. They would also distrust the idea of undergoinga major surgical procedure, as would be required if a living donor were to donate a kidney to a family member.

Because organ transplants generally work best when there is a close genetic match between donor and recipient, organs often need to be from a member of the same race as the recipient. Thus, a member of a minority group who needs atransplant finds that few suitable organs are available. As noted earlier, this creates a notable problem with regard to end-stage kidney disorders. African Americans experience a much higher rate of kidney failure than do whites when they suffer from diseases such as hypertension and diabetes, yet far fewer donor kidneys are available to provide the best possible relief.

Minorities comprise about 30% of the poor living in rural areas. The particular problems of rural minorities include chronic poverty in some areas, a lackof stable medical care for migrant workers, and language and other barriers,for example, clashes between Native American culture and mainstream medicine.

Improving Minority Health Care

Not only do minorities have less access to the best care, but, though the situation has been improving in more recent years, researchers have sometimes failed to include them in studies and have not taken into account the role of ethnic differences and their distinctive needs in defining health. National databases lack useful information to improve services for minorities, althoughthis is changing.

A 1985 landmark report by the U.S. Department of Health and Human Services Task Force on Black and Minority Health led to the institutionalization of minority-related health and service initiatives at the federal and state level, including President Clinton's 1998 racial and ethnic health disparities initiative. National, state, and local agencies have all improved their data collection methods, which makes it possible to measure the health problems of minorities with increasing sophistication. Serious study of class, race, ethnicity, and health has much to offer in the way of answers to major scientific andpolicy questions.

A variety of programs attempt recruit more minority-group members to become physicians, and to encourage physicians to practice in underserved areas. Through the efforts of many medical schools and other organizations, the proportion of minorities and women in medical school has increased significantly, although African Americans in particular are still under-represented at most medical schools. In addition, programs such as the National Health Service Corpsrecruit medical students who are willing to commit three years of service asa physician in underserved areas. In exchange, the young physicians receivesignificant relief from their student loan debts.

In addition, immigration rules permit thousands of foreign-trained physiciansto come to the United States for specialty training. Many of them join programs in underserved areas and effectively become the physicians for many innercity and rural areas.

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