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OCR for page 51
6. Racial and Ethnic Minorities
An undue proportion of the disease and disability that
the Year 2000 Health Objectives are intended to
alleviate is concentrated in racial and ethnic minority
populations, especially Blacks, Hispanics, and Native
Americans. Although mortality rates for all these
groups are falling, substantial differences in mortality
and morbidity remain. In 1985, for instance, life ex-
pectano,r was 75.3 years for Whites, but only 69.5
years for Blacks.t The gap between White and minor-
ity health status in the United States is so great that
one testifier, Lester Breslow of the UCLA School of
Public Health, labeled it "a national disgrace," and he
and others called for special attention to reducing the
gap in the year 2000 objectives-setting process.
(~026)
In all, more than 125 testifiers stated the need to
explicitly address minority populations in the Year
2000 Health Objectives. According to some witnesses,
not only is the gap between White and minority
health status so great that it must be addressed in
such a forum, but targeted national objectives for such
issues as infant mortality, teenage pregnancy, cancer
mortality, violence and homicide reduction, and other
problems will not be met unless minority rates are
reduced. Furthermore, because both the conditions
that lead to differentials in health status and the most
effective interventions vary from group to group, the
national objectives should contain specific objectives
for racial and ethnic minorities, according to wit-
nesses.
In his testimony, John Walter of Wayne State
University proposes a specific way of setting minority
objectives based on analyses of the differential health
status of minorities documented in the Carter Center's
report Closing the Gap2 and the Report of the
Secreta~y's Task Force on Black and Minored Health.3
These differentials, he suggests, indicate where
progress in mortality and morbidity reduction for
minorities is possible, given the currently available
knowledge and technology. Thus, Walter argues,
these differentials should guide the selection of
specific minority objectives. (#314)
Setting objectives that will reduce the disparity in
health status between the White and non-White
populations, and implementing the necessary programs
and interventions to realize them, represent a for-
midable challenge. Providing universal access to
health care is an important component of improving
the health status of many ethnic groups, but it alone
is not sufficient. Witnesses suggested that a broad
spectrum of programs will be required to raise
socioeconomic status, advance educational levels,
provide social supports such as job protection and
adequate housing, resolve language or cultural bar-
riers, and clarifier population-specific problems and
Issues.
Consistent statistics are difficult to find for minor-
ity groups. Obtaining more and better data on mi-
nority populations, especially non-Black groups, is
seen as crucial. Without data, the need for health
programs and health financing targeted at specific
groups is neither apparent nor compelling, says Jane
Delgado of the National Coalition of Hispanic Health
and Human Services Organizations. (#193) Further-
more, as Sandral Hullet of West Alabama Health
Services explains, health research and policies fail to
differentiate among the sometimes very different
special needs of subgroups within racial, ethnic, and
social communities. She suggests that more informa-
tion is necessary on the determinants of health and
illness in each subgroup to account for the different
susceptibilities and resistances of these groups to risk
factors. Furthermore, with more specific information
on the determinants, intervention strategies could be
better tied to the needs of subgroups. Nutrition
education, for example, would be different for a
middle class home than for a home with chronic
unemployment where nutritious food is not accessible.
(#671J The need for more detailed data on minori-
ties is discussed in Chapter 3.
Despite current limits to data on minority popula-
tions, testifiers were able to discuss specific health
needs and disease patterns of Blacks, Hispanics,
Native Americans, Asians, and Arab Americans in the
United States. The emergent picture is that health
promotion and disease prevention efforts have not yet
closed the gap in health status between the majority
population and racial or ethnic minorities. As in the
White population, the incidence of, and mortality
from, major killers such as cancer, heart disease, and
diabetes, and the levels of infant mortality, teenage
pregnancy, violence, and suicide in minoring com-
munities are largely associated with modifiable condi-
tions and behaviors. Affecting behavioral changes in
Racial and Ethnic Minorities 51
OCR for page 52
minority populations requires fundamental organiza-
tional changes, intensive effort, and cultural sensitivity.
Though the task is difficult, witnesses say, the poten-
tial for health promotion and disease prevention
activities in minority populations is great.
This chapter highlights the issues that hinder
health promotion and disease prevention efforts in
minority communities. These include many social,
economic, and political forces, as well as communica-
tion and data gaps. It also discusses specific health
problems affecting Blacks, Hispanics, and Native
Americans that are amenable to prevention and the
implications for establishing realistic and viable
national health objectives for these disparate popula-
tions.
SOCIAL, BEHAVIORAL, AND CULTURAL
FACTORS
To design better interventions to improve the health
status of minorities, the social, economic, genetic,
behavioral, and cultural factors that divide racial or
ethnic minorities and the majority population must
be understood. These groups have a disproportionate
prevalence of factors known to be associated with
poor health status, such as poverty, unemployment,
low educational attainment, substance abuse, and poor
diet. Some testifiers believe that these factors account
for most, if not all, of the observed differences in
health status. Others, however, believe that additional
genetic and cultural components affect health status.
These witnesses underline the importance of culturally
appropriate interventions for minority populations.
Socioeconomic Factors
Poverty. Poverty is the single most important factor
affecting the health of the non-White population,
according to testimony. Harold Freeman, President of
the American Cancer Society, defines poverty as Ha
lack of jobs, inadequate education, inadequate hous-
ing, poor nutrition, inadequate medical care, and
concentration on day-to-day survival." (#443J In
1987, 31 percent of Blacks were living in poverty,
whereas 28 percent of Hispanics, 39 percent of Puerto
Ricans, and 28 percent of Native American families
were below the poverty line. In comparison, the
White poverty rate was 11 percent.4 This calculation
does not include many working poor or others who
subsist just above the officially recognized standards
of poverty.
Those in poverty often live in inadequate housing
52 Healthy People 2000: Citizens Chart the Course
or have no regular housing at all. Blacks constitute
more than 50 percent of the homeless, according to
Ann Brunswick and David Rier of Columbia Univer-
sity.s (#031) For those who live in poor and
overcrowded housing, there is greater risk of spread-
ing and contracting communicable diseases. Accord-
ing to Stephen Joseph, New York City's Commission-
er of Health, for example, tuberculosis is on the rise
in New York City, especially in poverty-stricken
communities. (~437)
Unempioymenf. Blacks and Hispanics, as well as
other minority groups, are disproportionately un-
employed. In 1987 the unemployment rates were 12
percent for Me~ncan-Americans, 11 percent for Puerto
Ricans, 6 percent for Cubans, 13 percent for Blacks,
and 5 percent for Whites, according to Brunswick and
Delgado.6~7 f#O31; #193) The Black unemployment
rate is 20 percent if underemployed and discouraged
job seekers are included,8 and more than 45 percent
of Black youth are unemployed.9 (~031)
Such high levels of unemployment and under-
employment have devastating effects on communities
and the health of their members. Unstable economic
conditions are associated with high rates of crime,
racism, and general despair, and these contribute to
high levels of stress in many ethnic communities,
according to witnesses. Reduced employment oppor-
tunity also contributes to increased levels of teenage
pregnancy and to subsequent single-parent households,
infant mortality, substance abuse, and violence.
(~031)
Education. Educational attainment influences an
individual's ability to survive and flourish in society.
Many minority communities are currently affected by
low levels of educational achievement. For example,
high school dropout rates for Blacks in some major
cities are as high as 40-50 percent.~° Dropouts have
greater rates of teenage childbearing and substance
abuse, and minorities without education often get
trapped in low-paying service industry jobs, many of
which do not provide health insurance. (#031J
Lack of education often means limited knowledge
of health matters and poor understanding of the
causes and prevention of disease, according to tes-
tifiers. For example, in a study of beliefs about
cardiovascular disease among Blacks and Whites,
researchers found that educational level was the most
important variable in being able to state the risk
factors for cardiovascular disease. The impact of this
conclusion on minority populations is significant.
OCR for page 53
With lower levels of educational attainment, Hispanics
and Blacks are less likely to know the risk factors for
cardiovascular disease. Efforts to reduce card~ovas-
cular disease morbidity and mortality among these
groups may be hampered, and interventions will have
to include an attempt to improve general educational
attainment in these communities.
Furthermore, medical communication or health
promotion outreach frequently "requires one to have
or share traditional middle class values and income in
order to effect positive behavioral change," according
to Wailer. I his tends to exclude impoverished,
uneducated minority groups. (#314J
Behavioral Factors
As discussed in other chapters of this report, smoking,
drinking heavily, using illegal drugs, or eating an
improper diet can harm one's health In many
minority communities, especially where poverty and
low educational achievement are found, these destruc-
tive behaviors are especially prevalent. Abuse of
chemical substances is more widespread in minority
populations. This abuse is harmful not only because
of its immediate effect on the individual's well-being
but also, as Joseph says, because substance abuse is
a dynamic that is integral to all major health prob-
lems. (#43 7J
Although there has been much concern recently
over the spread of AIDS through intravenous drug
abuse and the onslaught of crack cocaine, the effects
of tobacco and alcohol abuse cause substantially more
mortality and morbidity among minority groups such
as Hispanics, Blacks, and Native Americans. Smok-
ing, for instance, leads to a variety of illnesses, among
the most important of which are cancer, heart disease,
stroke, and lung disease. Alcohol contributes directly
to cirrhosis and cancer. Acute and chronic alcohol
intoxication is also a major factor in violence, homi-
cide, and unintentional injuries. Smoking, alcohol,
and other drugs likewise lead to low birth weight,
infant mortality, and other poor pregnancy outcomes.
Jose Lopez of the San Antonio Tumor and Blood
Clinic and others report that Blacks and Mexican-
Americans are known to have high-fat diets, which are
a risk factor for cancer and cardiovascular disease.
(#488) Dietary factors may contribute to more than
one-third of all cancer deaths, says Margaret
Hargreave\s and the staff of the Cancer Control
Research Unit of Meharry Medical College. (#615J
Obesity, a risk factor for heart disease and diabetes,
is especially prevalent among Native Americans,
Mexican-Americans, and Black women. (~255; #567)
The Role of Culture
Testifiers generally agreed that poverty and related
socioeconomic factors are the greatest source of
disparity in health status between Whites and minori-
ties. This led some witnesses to question whether
poverty and other socioeconomic differences should be
targeted in intervention plans' or whether race or
ethnicity should underlie prevention designs.
The American Cancer Society recently studied
cancer survival in the economically disadvantaged and
found that ethnic differences in cancer survival are
related primarily to economic status. However,
according to Freeman, the study found that
race also exerted a significant effect indepen-
dently of income, but only among the low-
income population. That is, at identical low-
income levels for both racial groups (the same
dollar amounts), non-White mortality rates were
significantly higher than White, while at identi-
cal middle- and upper-income levels for both
racial groups, the mortality rates for the two
groups converged. (#443)
Freeman cautions that race itself should not be
construed as a health determinant. Rather, he says,
race "is to be understood here as a prosy for adverse
environmental and social conditions perhaps affecting
non-Whites at low-income levels more strongly than
they do Whites at identical income levels. (~443)
Others, however, say that race and ethnicity should
be given greater weight in planning interventions.
For instance, Michael Greenberg of Rutgers Univer-
si~ cites studies showing that socioeconomic variables
cannot explain all the differences between Blacks and
Whites.~3~4~is Because of this, interventions must
contain an ethnic component and not solely a poverty
component, or else the interventions uphill not be
culturally sensitive. Furthermore, Greenberg says,
programs must attack the underlying problem, which
may be different for minority groups. For example,
tobacco companies have been targeting Blacks in their
advertising, and antismoking programs have to
respond. (#537)
In light of these ideas, many of those who testified
called for culturally appropriate interventions for
minority groups. Such interventions could be as
conceptually simple as providing health information
in the language that the group speaks, or recruiting
Racial and Ethnic Minorities 53
OCR for page 54
and training health professionals from the populations
they are to serve. Mario Orlandi of the American
Health Foundation in New York, for instance, lists 10
barriers that must be overcome in designing health
promotion programs for racial and ethnic minorities:
· Language: Failure to appreciate health promo-
tion messages when language or symbols are used that
are not understandable or are misunderstood by the
subgroup
· Reading level: Using printed materials that are
too - sophisticated or beyond the reading level of
subgroup members
· Models: Using endorsements for the health
promotion campaign from prominent individuals or
organizations that are not well known to subgroup
members
· Inappropriate messages: Using motivational
messages that are not salient to subgroup members
· Inappropriate target: The belief that the health
promotion campaign is worthwhile, but that program
designers never really intended the subculture to
participate or benefit
· Motivational issues: Fear that the primary
motivation for the health promotion campaign is the
desire to control the subculture, robbing from it the
specific practices that have defined it historically
· Welfare stigma: A tendency to view the health
promotion campaign as a "handout" and to avoid it as
a matter of pride
· Perceived responsibility: The attitude that the
campaign deals with subject areas and life choices that
concern the family and the individual, not the public
health establishment
· Relevance of health promotion: A belief that
more pressing concerns such as poverty, crime,
unemployment, and hunger should be addressed prior
to health promotion
· Entropy: The tendency for subgroup members
to perceive themselves as powerless or helpless when
confronted with enormous economic and sociocultural
barriers and to express a lack of motivation to engage
in self-improvement activities (~167)
ACCESS TO HEALTH CARE
Another consequential element in the equation of
good health is access to health care services. In
general, poor and minority populations use health
care services differently than the majority population.
In large part, witnesses agreed, this is due to econo-
mic constraints. The problem of access is compli-
cated, however.
54 Healthy People 2000: Citizens Chart the Course
Differentials between Black and White utilization
of medical services have declined since the 1960s, in
large part because of Medicaid and Medicare; in some
cases, Blacks have higher utilization rates than
Whites.~6~7 When Blacks do seek care, however, they
are more likely than Whites to receive it in
emergency rooms. This arrangement is obviously not
conducive to preventive care, screening sentences, or
the continuity of care needed for health promotion
efforts, says Freeman. (~443J In general, Blacks are
less likely to have a regular primary care physician.
Minorities also receive fewer preventive services.
Their childhood vaccination rates lag considerably
behind those of Whites, as do their rates of screening
for chronic diseases such as cancer, hypertension, and
diabetes. In 1980, 12 percent of Hispanics, 8.8
percent of Blacks, and 4.3 percent of Whites did not
receive prenatal care until the third trimester of
pregnancy, or not at all, according to Peggy Smith of
Baylor College of Medicine.~9~20 (#308) Such lack
of preventive and screening services is, in large
measure, the reason for the higher mortality rates.
For example, 50 percent of the differences in fi~ve-
year survival rates for cancer between Blacks and
Whites are due to late diagnosis, according to Alvin
Mauer and Mona Arreola of the University of
Tennessee Memphis Cancer Center. (~256)
Some of the difference in access to preventive
services is due to discrepancies in insurance coverage.
Because minorities are more likely to be impoveri-
shed, unemployed, or employed without health bene-
fits, they are more likely to be uninsured and unable
to afford either preventive or necessary health ser-
vices. (#193) In particular, 26 percent of Hispanics
and 18 percent of Blacks have no insurance, compared
to 9 percent of Whites.
Evidence suggests that Medicaid and uninsured
patients receive care of inferior quality.2t A represen-
tative from the American College of Obstetricians and
Gynecologists cites a 1987 General Accounting Office
report on the prenatal care of women who are on
Medicaid or are uninsured, which indicates that these
women are more likely to receive insufficient care.22
(#279) High rates of infant mortality, heart disease,
diabetes, etc., suggest a need for services from
obstetricians/gynecologists, cardiologists, and other
specialists. However, many physicians, particularly
specialists, will not accept Medicaid, let alone treat an
indigent patient, says Katherine Carr of the American
College of Nurse-Midwives. (~690) Also, because of
their lack of insurance and Medicaid status, many
poor and indigent patients are often transferred from
OCR for page 55
private hospitals to public facilities, according to
Clyde Kay of the Louisiana Primary Care Association.
(#688)
Some of the racial and ethnic differences in utiliza-
tion of health services are due to cultural and geogra-
phic factors. Many ethnic groups live in areas with
shortages of health providers. Inner cities and rural
areas, particularly in the South, are medically under-
served and have high concentrations of Blacks or
Hispanics. One solution, proposed by many, is to
increase the availability of minority health care
providers. Studies have shown that increases in the
number of physicians of a particular minority group
in underserved communities of that population have
raised the level of service utilization and provision
within these communities.23
Programs to train and provide health care profes-
sionals for these communities, such as the National
Health Service Corps Scholarship program and other
favorable university admissions and financial aid
policies, were established more than a decade ago.
However, Rebecca Work of the American College of
Nurse-Midwives says that in recent years, many
programs have been terminated and policies re-
versed.24 (~268J Thus, the increase in numbers of
Black, Hispanic, and Native American physicians and
the concomitant strides in cultural sensitivity and
commitment to minority communities have been
halted.
SPECIFIC HEALTH PROBLEMS OF MINORITY
GROUPS
There are nearly 6O,000 excess Black deaths yearly,
according to the Report of the Secretary's Task Force
on Black and Minored Health; that is, if Blacks had
the same age- and sex-specific death rates as Whites,
60,000 fewer Blacks would die each year. These
excess deaths have six principal causes: heart disease
and stroke, homicide and accidents, cancer, infant
mortality, cirrhosis, and diabetes. Together, these six
causes represent 80 percent of the total excess deaths
of Blacks. The ranking is not the same for other
minority groups, but these six causes remain critical
target priorities for reducing excess mortality in all
minority populations.
The following section highlights health problems
that are especially salient for minority groups.
Witnesses frequently remarked that discussion of
disease and incidence rates in these populations is
limited by data gaps. In some instances, others said
that the preliminary level of discussion helps shed
light on how much is not yet known. (#495; #683)
Although testifiers were optimistic that prevention
programs could be undertaken now in all of these
areas, they encouraged more research efforts.
Infant Mortality
The mortality rate during the first year of life for
Blacks in 1985 was twice that of Whites (18.2 per
1,000 and 9.3 per 1,000, respectively).25 National
infant mortality rates for Hispanics are not available.
George Flores of the San Antonio Metropolitan
Health District says a step in the direction of reduc-
ing unacceptable rates is to set two priorities: (1) to
provide prenatal care for indigent women where none
exists and (2) to provide appropriate interventions to
high-risk pregnant women and their infants. (i'745)
The first priority, if met, could likely improve the
national infant mortality rate. According to Ezra
Davidson of the American College of Obstetricians
and Gynecologists, 76 percent of mothers across all
groups began care in the first trimester of pregnancy
in 1987, but only 61 percent of Hispanic women and
61 percent of Black women began care in the first
trimester.26 (#2 79J Those who do not receive ade-
quate prenatal care are largely the poor and indigent.
The age of the mother also plays a role in determin-
ing whether or not prenatal care is obtained. Adoles-
cents in all populations are less likely to receive
prenatal care than older women. (~279j Blacks and
Hispanics both have a higher rate of adolescent preg-
nancy and, therefore, are at greater risk of having a
low-birth-weight baby or of losing their baby.
Donald Schiff of the American Academy of Pediat-
rics writes that the poorly educated segments of
society have the "greatest risks to the fetus and
newborn infant," that a mother's self-worth "increases
as dependency on welfare decreases and this is related
to the availability of employment," and that "a high
divorce rate, single-parent families, and early sexual
activity is the milieu in which there is high infant
mortalin,r.n No single professional group can resolve
these social problems. Rather, they require the
combined efforts and resources of different segments
of society. Schiff recommends more research into the
causes of low birth weight among Blacks; increased
funding for outreach, prevention, and support services;
greater private and public financing for insurance
programs to provide coverage to all adolescents,
women, and children; and increased Medicaid eligibi-
liW. (#371)
Racial and Ethnic Minorities 55
OCR for page 56
Chronic Diseases
Heart Disease and Stroke. Public education and
awareness efforts to reduce heart disease and stroke
in the U.S. population over the past two decades
appear to have had at least some effect in reducing
the mortality rates from these diseases in all popula-
tion groups. However, Black mortality rates remain
higher than White rates, according to testifiers. In
1987 the mortality rate for heart disease was 287 per
100,000 for Black males, compared to 226 per 100,000
for White males, and 181 per 100,000 for Black fe-
males, compared to 116 per 100,000 for White fe-
males. For Black and White males, stroke rates were
57 versus 30 per 100,000, respectively; for Black and
White women, they were 46 versus 26 per 100,000,
respectively.27 Both the Hispanic and Black popula-
tions also have significant problems with obesity, high
serum cholesterol levels, and high blood pressure, all
of which are risk factors for cardiovascular disease.
(#269; #743) To reduce obesity, high cholesterol,
and hypertension in these populations, risk factors
such as cigarette smoking, and compliance with
treatment and diet, must be addressed, say witnesses
including Eleanor Young of the University of Texas
Health Science Center at San Antonio. (#261; #496)
According to Osman Ahmed of Meharry Medical
College, Blacks are generally less compliant with
treatment for hypertension than Whites. f#269)
Michael Crawford of the University of Texas Health
Science Center at San Antonio says that only 7
percent of Hispanic males in Texas with moderate to
high levels of cholesterol are aware of this fact,
compared to 17 percent of White males with similar
cholesterol levels. Furthermore, of those Hispanic
men under treatment for high cholesterol, only 40
percent are adequately controlled. (#743J
To design effective interventions for cardiovascular
disease, say William Neser and John Thomas of
Meharry Medical College, cultural sensitivity is
necessary. In the Black community, stress, smoking,
diet, and obesity, as well as compliance with treat-
ment, should be dealt with through community
interventions that include the church and schools.
(#261 J Similarly, Crawford encourages interventions
that focus on Hispanic men and their behavior related
to diet, exercise, and weight control. (#743J
Cancer. Cancer currently takes a greater share of
Black life than is necessary, according to witnesses.
Unscientific evidence indicates that social and environ-
mental factors either cause the majority of cancers or
56 Healthy People 2000: Citizens Chart the Course
promote their development," say Hargreaves and her
colleagues. Bringing Blacks into treatment at earlier
stages and educating them about the connection
between certain cancers and behavioral risk factors,
such as smoking, alcohol consumption, or dietary
habits, would be effective measures. (~615)
Since 1950, Blacks have witnessed an increase in
age-adjusted mortality from lung cancer, due primarily
to increases in smoking two decades earlier. (#443)
Blacks also suffer from the highest rate of prostate
cancer in the world2* and have among the highest
rate of esophageal cancer. (~537)
"Why is there such a serious Black male cancer
problems asks Michael Greenberg of Rutgers Univer-
sity. HA combination of poverty, culture, and racism
has led to a greater likelihood of smoking, poor
nutrition, weakened immunity, occupational exposure,
and lesser chance of rapid and successful diagnosis
and treatment of tumors. Heredity cannot explain the
rapid increase of Black cancers, but should not be
overlooked. (#537)
Blacks and Mexican-Americans show only moderate
awareness of the major risk factors for cancer and are
also unaware of most of the warning signs of cancer.
(#488; #615) Blacks and Hispanics routinely under-
estimate the prevalence of cancer and overestimate its
deadliness. Thus, delay in treatment and resignation
to a fatal conclusion of the disease are common.
(#488; #615J
Although overall cancer rates are lower for
Hispanics, cultural norms can affect health outcomes
for cancer in the Hispanic population, according to
Lopez.
There is an evident paradox then; whereas
cancer may be less frequent a problem among
Hispanics, particularly for some of the most
common malignancies (colon and breast cancer),
Hispanics are at greater risk if one considers
factors such as stage of cancer at diagnosis,
nutritional habits including use of high fat
products in the preparation of foods, lack of
access to the health care delivery system, and
certain knowledge, attitudes, and practices
regarding cancer that are very peculiar to the
Hispanic population. (~488)
Lopez cites a study of 800 New York Hispanics and
their attitudes and knowledge about cancer. "Fifty-
seven percent of Hispanic women did breast self-
examination within the last year. This percentage lags
behind women in general. Only 29 percent of
OCR for page 57
Hispanic women indicated that a doctor had shown
them how to do breast self-examination." This study
revealed some important information regarding service
utilization preferences. Lopez writes, Spanish was
the language spoken at home by 63 percent of the
study population. Two out of three preferred to use
a doctor who was fluent in Spanish. There was
clearly a strong preference that information programs
be given in Spanish. Half of the study population
had either been born in the United States or had
lived here for more than 30 years. (~488)
Freeman suggests improving the cost-effectiveness
of screening techniques and providing cancer screen-
ing to all Americans. (~443) Greenberg suggests
concentrating resources on screening for prostatic
carcinoma and smoking cessation programs among
Black males. Cancer of the prostate and respiratory
cancer cause almost 50 percent of Black male cancer
deaths.29 (#537)
Diabetes. According to testimony, one of the great
differences in disease status between Hispanics and
Whites is the rate of diabetes. Native Americans also
have especially high rates of diabetes, according to
Spero Manson of the University of Colorado Health
Sciences Center. (#706J Mexican-Americans also
appear to develop diabetes at an earlier age, suggest-
ing the possibility of more complications of the
disease. In fact, says Steven Haffner of the University
of Texas Health Science Center at San Antonio,
Mexican-Americans have a much higher rate of severe
retinopathy and of end-stage renal disease. (#491)
The prevalence of diabetes is 33 percent higher in the
Black population than in the White population
(#457), and Blacks have twice the rate of blindness
secondary to diabetic retinopathy as Whites.30
Interventions to reduce diabetes involve improving
nutrition, reducing obesity, and retraining primary
physicians who treat these underserved populations in
how to use the most modern techniques of diabetes
detection and treatment. (#457J Young reports that
"diabetes is perhaps the most significant nutrition-
related health problem faced by adults in Texas,
especially by Mexican-American adults, and still there
is little prevention activity or funding in this area.
She outlines specific nutrition objectives, which
include reducing the incidence of obesity, encouraging
more professional education on the fundamentals of
nutrition, and establishing baseline data for all nutri-
tion goals. (#496) However, according to Hullet,
nutrition is an especially difficult area to work with in
the Black population. Her recommendations that "we
involve more minorities in research in their own
community" and that We encourage more minorities
to go into research" are pertinent to developing
effective nutrition intervention programs for Black
communities. (#671)
Common Risk Factors and Interventions
Despite the differences in these three diseases (heart
disease and stroke, cancer, and diabetes), they share
common behavioral risk factors. Furthermore, all
three benefit from early detection and treatment.
Because of these commonalities, general programs
aimed at risk factor intervention and screening for
chronic diseases offer some promise.
In terms of implementing prevention programs,
Ahmed and Hargreaves suggest that special emphasis
should be placed on diversified interventions, includ-
ing (1) education and awareness programs focusing on
the lay person as well as on professionals, to en-
courage changes in knowledge, attitudes, and prac-
tices; (2) primary prevention programs with special
emphasis on smoking cessation and dietary changes;
and (3) secondary prevention programs emphasizing
screening practices. (#269; #615)
In a description of several community intervention
programs being sponsored by a Cancer Control
Consortium group made 11p of MeharIy, Morehouse,
and Drew Universities, Ahmed discusses reducing
smoking among Blacks.
Our experience suggests that to achieve a
reduction in smoking rates in Blacks to about
30 percent or less by 1990 and to modify other
health behaviors related to diet and nutrition,
national outreach programs should be designed
to reach Blacks. These programs should address
Black needs and contain culturally-sensitive
curricula. In this respect, the expertise and
resources of a coalition of interested community
organizations should be fully explored and
properly utilized. (~269)
HIV Infection and AIDS
According to witnesses, AIDS has levied a dispropor-
tionate toll on both Blacks and Hispanics in this
country. Although considered by many to be a gay
White male's disease, increasing numbers of minority
heterosexuals have been infected. Alvin Thompson of
the Washington State Association of Black Profes-
sionals in Health Care writes, "We recommend urgent
Racial and Ethnic Minorities 57
OCR for page 58
implementation of improved outreach campaigns of
public education and particularly of health education,
devising effective techniques for changing the behavior
of the noncompliant IV [intravenous] drug-using
population." (~358)
Of all the 1989 AIDS cases reported to the Centers
for Disease Control (CDC), Blacks made up 29
percent and Hispanics 16 percent, compared to their
proportions of 12 percent and 6 percent, respectively,
in the overall population.3t The cumulative risk of
AIDS then was almost three times higher in Blacks
and Hispanics than in Whites. For men, the relative
risks of AIDS were 2.S and 2.7 for Blacks and
Hispanics, respectively; for women, the relative risks
were 13.2 for Blacks and 8.1 for Hispanics. For
children, the relative rislo; were 11.6 for Blacks and
6.6 for Hispanics. Much of the difference between
the minority and White populations is due to a higher
prevalence of intravenous drug use among Blacks and
Hispanics. According to CDC researchers, however,
Blacks and Hispanics also have been more likely than
Whites to contract AIDS through most of the impor-
tant routes, especially bisexuality in men, suggesting
that other AIDS risk factors also may be more
prevalent in Blacks and Hispanics.32
Ignorance of AIDS and its risk factors is a special
area of concern for minority youth. Ralph DiClemente
of the University of California, San Francisco says
that Black, Asian, and Hispanic adolescents are less
knowledgeable than Whites about AIDS, its risk
behaviors, and preventive measures.33 f#2 73'
Homicide, Suicide, and Violence
Homicide and interpersonal violence are significant
problems in the Black community. Indeed, homicide
is the leading cause of death for Black men between
the ages of 15 and 44 and for Black women age 15
to 24. The lifetime risk for homicide is ~ in 21 for
Black men and 1 in 104 for Black women. In com-
parison, the risk for White men is 1 in 131 and for
White women, 1 in 369.34
"As a Black psychiatrist practicing community
psychiatry in a predominantly Black communing on
the south side of Chicago," says Carl Bell, Executive
Director of the Community Mental Health Council,
"I have seen the lethal and nonlethal effects of
interpersonal violence firsthand. For example, based
on a suIvey of his clinic population, Bell says that one
out of three women has been raped, 40 percent of
the male and female patients have been physically
assaulted, and one in four people reports personally
58 Healthy People 2000: Citizens Chart the Course
knowing someone who has been murdered. Other
studies that he and others have conducted indicate
that most violence in Black communities stems from
conflict in interpersonal relations, and not from a
desire to acquire resources from another person.
t~018'
Bell also argues that homicide prevention strategies
are hampered by myths, ethnic tensions, and igno-
rance of homicide dynamics, which vary according to
local culture and circumstance. He points out that
the lack of clarity on homicide dynamics prevents
suitable solutions from being adopted. For example,
reducing drug-related }homicides would require dif-
ferent strategies than reducing domestic violence.
Similarly, designing a prevention program for reducing
Hispanic violence does not mean copying an existing
intervention targeted at a different population, accord-
ing to Bell. `#018J
Still, Bell says that many interventions can be
undertaken immediately, within the existing social
structures. First, a major media effort can be made
to encourage handgun owners to keep their guns
unloaded. This reduces the immediate availability of
a deadly weapon. Second, primary physicians, espe-
cially in high-risk communities, can screen patients for
victimization and perpetration of violence and at least
provide them with a list of follow-up services. Third,
antiviolence curricula should be introduced in the
schools. Fourth, the community can provide emotion-
al and medical services to the victims of violence and
their families. t~0189
Hispanics also have homicide rates that exceed
those of White Americans. Age-adjusted homicide
rates for Hispanic men in five southwestern states
from 1976 to 1980 were 2.5 times those of Whites,
whereas those of Hispanic women were approximately
the same as those of White women, according to
Delgado.3s (#193) John Bruhn, representing the
American Society of Allied Health Professions, writes
that mortality due to violent deaths is fairly high
among Cuban-, Mexican-, and Puerto Rican-born
adolescents and young adults, particularly males. He
states that a specific objective "to reduce these deaths
by one-half of their current prevalence, through
education and prevention programs, should be of high
priority." (#235)
According to David Besaw of the Wisconsin Tribal
Health Directors, the higher incidence of alcohol and
drug abuse problems, coupled with a younger, more
impoverished population, puts Native' Americans at
greater risk for both intentional and unintentional
injuries. Alcohol is involved in many Native
OCR for page 59
American suicides and is related to the high number
of unintentional injuries among Native Americans.
(#514j
Native Americans also have suicide rates that are
much higher than those of the general population.
Although rates vary among tribes, most suicides are
in the 15-39 age group and peak rates are reached in
the 20-24 age range. Unlike in the general popula-
tion, it's basically a youth and young adult problem as
opposed to an older adult problem, which is more
common in the mainstream population," according to
Manson. A recent series of suicide epidemics has
prompted tribal leaders and other community mem-
bers to research the causes of such despair and to
devise interventions for the young population. In one
study of over 300 Native Americans in the Pacific
Northwest, "only 16 percent knew of agencies or other
types of resources for coping with stressful life
experiences." (#706)
To combat suicide among Native Americans,
testifiers suggested several intervention strategies.
Among them, for example, are programs to develop
stress-coping skills among young people, drug educa-
tion and peer counseling programs, and crisis hotlines
to provide immediate access to counseling.
Tobacco, Alcohol, and Substance Abuse
The prevalence of cigarette smoking in the Black
community is a distressing sign of the gap between
White and Black health behaviors. Smoking rates are
39 percent for Black men age 18 or older and 27
percent for Black women, whereas the rates are 30
percent for White males and 27 percent for White
females.36 Although Black men tend to be lighter
smokers than White men, successful interventions to
reduce the smoking rate in this population are not
widespread, according to Hargreaves. (~615J
Thompson says that as the White community
decreases its consumption of tobacco, the tobacco
industry has begun to direct its advertising and
promotional efforts increasingly toward the Black
community. (#358) He calls the Black community
to action: fin addition to the present admirable
activities of the Public Health Service, the Black
community and the Black media must resolve this
competition of vital communication to the Black
community and the health of Black people by dis-
couraging tobacco advertising and smoking among
Blacks." (#358)
Jacqueline Morrison, representing the National
Black Alcoholism Council, considers alcoholism the
number one public health problem in the Black
community. In addition to high rates of liver
cirrhosis and esophageal cancer, alcohol consumption
is linked to auto accidents, domestic violence, and
homicide. Morrison calls for government and private
agencies to coordinate their efforts to develop alcohol
prevention and treatment services that are sensitive to
Black culture. She also argues that the Year 2000
Health Objectives should address the problems of
children of alcoholics. One such program, called "B
Co-Adapt, developed by the council, includes estab-
lishing groups to repair children's self-esteem, training
qualified professionals, and improving public and
professional awareness. (#723J
James Sail of the Detroit Department of Health
also focuses on community interventions for substance
abuse prevention. He offers three strategies: (1) vi-
gorous enforcement of drug laws; (2) strengthening
the value systems in public schools; and (3) support-
ing a community movement toward parenting educa-
tion by developing a culturally specific curriculum
without literacy barriers that addresses issues of
achievement, as well as the prevention of violence,
teenage pregnancy, and drug use. (~389)
Although alcohol abuse varies tremendously among
Native American tribes, it remains the major health
problem of that population. Manson notes that
Native American youth "use alcohol and marijuana,
earlier, more frequently, and with significantly greater
consequences than any other minority youth."
According to Jerome West of the Five Sandoval
Pueblo Villages, the Albuquerque Area Tribal Coor-
dinating Committee in conjunction with the Bureau of
Indian Affairs and the Indian Health Service has
established a regional alcohol treatment center and is
training 175 alcohol and drug counselors to provide
counseling in New Mexico. (~565)
High rates of inhalant abuse are reported among
Mexican-American and Native American youth.
Studies performed in San Antonio suggest that
"barrios children and adolescents are 14 times more
likely than a national sample to abuse inhalants and
also more likely to use other substances.37 (#494)
To reduce inhalant abuse, Ricardo Jasso of Nosotros
Human Services Development urges a comprehensive
continuum of interventions at the inclividual, com-
munity, and national levels. (~494J
Racial and Ethnic Minorities 59
OCR for page 60
Teenage Pregnancy
Edna Batiste of the Detroit Department of Health
feels that adolescent childbearing in an impoverished
Black community is only one part of a syndrome that
makes the Black teenager an "endangered species."
The cycle, as she sees it, is as follows: have a baby;
drop out of school; get a low-paying job (if she can
get one at all); not marry the child's father because
he does not have a job, is on drugs, doesn't care, or
disappears; go on welfare; develop low self-esteem;
and so on. Batiste concludes that "no community,
especially the Black community, can afford to keep
losing one-fifth of each generation because of failure
to complete their high school education, because of
an unplanned pregnancy or for any of the reasons of
the syndrome." Batiste's solution to adolescent preg-
nancy, as well as many other health problems of poor
communities, is a Resurgence of the public health
model" where teams of professional community
workers would provide care in primary care health
centers. (~016)
Louis Bernard, Dean of Diehard Medical College,
supports Batiste's view and reports that unwanted
childbearing in the Black community is especially high
among teenagers and is exacerbated by Lack of
income and job protection, limited access to essential
services, and the indifference of society to their
aspirations." (ią253J
Smith discusses the problems of adolescent preg-
nancy in the Hispanic population in Texas. Like oth
REFERENCES
1988
ers, she mentions social factors that help determine
fertility rates, age of pregnancy, attitudes toward
seeking family planning services, marital status, and
attitudes toward childbearing among Hispanics. She
also outlines some childbearing patterns that are
unique. One-half of all Hispanic women migrating to
Texas are 18 years of age or younger, and in 1980, the
fertility rate for Hispanic women age 15 to 44 was 95
births per 1,000 women. This rate is 33 percent
higher than the rate for White women (62 per
1,000~.38 Finally, Smith says, "estimates suggest that
from 22 to 63 percent of Hispanic adolescents stated
their pregnancies were planned and that for them the
negative consequences associated with the out-of-
wedlock conception status of the infant were
negligible.n39 (#308)
Smith emphasizes the need to develop intervention
models appropriate to the community and to improve
data collection for this population. Reluctance to use
services because of the citizenship, employment, or
residency status of family members affects the utiliza-
tion of services by Hispanic immigrants.
The effect of acculturation and its impact on
health care practices should be determined. If
the degree of acculturation turns out to be one
of the independent variables in effective con-
traceptive utilization and health care, providers
must be prepared to assess the patient's
sociocultural status as well as her contraceptive
and maternity needs. (~308)
. National Center for Health Statistics: Health United States, 1987 (DHHS Publication No. [PHS] 88-1232),
2. Amler RW, Dull HB (Eds.~: Closing the Gap: The Burden of Unnecessary Illness. New York: Oxford
University Press, 1987
3. U.S. Department of Health and Human Services: Report of the Secretary's Task Force on Black and
Minority Health. Washington, D.C.: U.S. Government Printing Office, 1987
4. U.S. Bureau of the Census: Statistical Abstract of the United States, 1989 (109th Edition). Washington, D.C.:
U.S. Government Printing Office, 1989
5. Brown LP: Crime in the black community. The State of Black America, 1988. Edited by J Dewart. New
York: National Urban League, Inc., 1988
6. U.S. Bureau of the Census: Current Population Reports. The Hispanic Population in the United States, 1986
and 1987. March (Advance Report). Series P-20, No. 416, August 1987
60 Healthy People 2000: Citizens Chart the Course
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7. U.S. Bureau of the Census: op. cit., reference 4
8. Jacob JE: Black Amenca, 1987: An overview. The State of Black America, 1988. Edited by J Dewart. New
York: National Urban League, Inc., 1988
9. Hare BR: Black youth at risk. The State of Black America, 1988. Edited by J Dewart. New York: National
Urban League, Inc., 1988
10. Chavez L: Crisis over dropouts: A look at two youths," New York Times, 2/16/88, p.B1.
11. Doll R. Peto R: The causes of cancer: Qualitative estimates of avoidable risks of cancer in the United
States today. J Natl Cancer Inst 66~6~:1191-1308, 1981
12. American Cancer Society: Cancer in the Economically Disadvantaged: A Special Report. The Subcommittee
on Cancer in the Economically Disadvantaged. American Cancer Society, June 1986
13. U.S. Department of Health and Human Services: op. cit., reference 3
14. Levin D: Cancer Rates and Risks (NIH Publication No. 75-691), 1975
15. Haan M, Kaplan G. Camacho T: Poverty and health: Prospective evidence from the Alameda County study.
Amer J Epid 125:989-998, 1987
16. Davis K, Lillie-Blanton M, Lyons B. et al.: Health care for Black Americans: The public sector role.
Milbank Q 65(Suppl. 1):213-47, 1987
17. Manton KG, Patrick CH, Johnson KW: Health differentials between Blacks and Whites: Recent trends in
mortality and morbidity. Milbank Q 65(Suppl. 1~:129-99, 1987
18. Davis, et al.: op. cit., reference 16
19. National Center for Health Statistics: Health United States, 1989 (DHHS Publication No. [PHS] 90-1232),
1990
20. Ventura SJ: Births of Hispanic parentage, 1980. Hyattsville, Md.: U.S. National Center for Health Statistics
32:6, 1983
21. Manton, et al.: op. cit., reference 17
22. U.S. General Accounting Office: Prenatal care: Medicaid recipients and uninsured women obtain insufficient
care. Report to the Chairman, Subcommittee on Human Resources and Intergovernmental Relations, Committee
on Government Operations, House of Representatives. GAO/HAD 87-137, September 1987
23. Davis, et al.: op. cit., reference 16
24. Ibid.
25. National Center for Health Statistics: op. cit., reference 1
26. National Center for Health Statistics: op. cit., reference 19
27. Ibid.
Racial and Ethnic Minorities 61
OCR for page 62
28. U.S. Department of Health and Human Services: op. cit., reference 3
29. National Center for Health Statistics: op. cit., reference 19
30. U.S. Department of Health and Human Services: op. cit., reference 3
31. Centers for Disease Control: HIV/AIDS Surveillance. Atlanta, Gal, January 1990
32. Selik RM, Castro KG, Pappaioanou M: Racial/ethnic differences in the risk of AIDS in the United States.
Am J Pub Health 78:1539-1545, 1988
33. Diclemente RJ, Corn J. Temoshok L: Adolescents's knowledge of AIDS near an AIDS epicenter. Am J Pub
Health 77:876-877, 1987
34. U.S. Department of Health and Human Services: op. cit., reference 3
35. Ibid.
36. National Center for Health Statistics: op. cit., reference 19
37. Padilla AM, Trimble JE, Bell CS: Drug Abuse Among Ethnic Minorities. National Institute on Drug Abuse
(DHHS Publication No. [ADM1 87-1474), 1987
38. Smith, PB, Wait RB: Adolescent fertility and childbearing trends among Hispanics in Texas. Texas Medicine
82:29-32, 1986
--a ~r
39. Smith PB: Sociologic aspects of adolescent fertility and childbearing among Hispanics. J Dev Behav
Ped 7~6~:346-349, 1986
TESTIFIERS CITED IN CHAPTER 6
016 Batiste, Edna; Detroit Department of Health
018 Bell, Carl; Community Mental Health Council (Chicago)
026 Breslow, Lester; University of California, Los Angeles
031 Brunswick, Ann and Rier, David; Columbia University
167 Orlandi, Mario; American Health Foundation
193 Delgado, Jane; The National Coalition of Hispanic Health and Human Services Organizations (COSSMHO)
235 Bruhn, John; University of Texas Medical Branch at Galveston
253 Bernard, Louis; Meharry Medical College
255 Blumenthal, Daniel; Morehouse School of Medicine
256 Mauer, Alvin and Arreola, Mona; University of Tennessee, Memphis
261 Thomas, John and Neser, William; Mehar~y Medical College
268 Work, Rebecca; University of Alabama at Birmingham
269 Ahmed, Osman; Meharty Medical College
273 DiClemente, Ralph; University of California, San Francisco
279 Davidson, Ezra; King-Drew Medical Center (Los Angeles)
308 Smith, Peggy B.; Baylor College of Medicine
314 Wailer, John; Wayne State University
358 Thompson, Alvin; University of Washington
371 Schiff, Donald; American Academy of Pediatrics
389 Sail, James; Detroit Department of Health
437 Joseph, Stephen; New York City Department of Health
62 Healthy People 2000: Citizens Chart the Course
OCR for page 63
443 Freeman, Harold; State University of New York at Buffalo
457 Altschuler, Alan; Prudential-Bache Securities, Inc.
488 Lopez, Jose; San Antonio Tumor and Blood Clinic
491 Hardener, Steven; University of Texas Health Science Center at San Antonio
494 Jasso, Ricardo; Nosotros Human Services Development (San Antonio)
495 Andrew, Sylvia; Our Lady of the Lake University (San Antonio)
496 Young, Eleanor; University of Texas Health Science Center at San Antonio
514 Besaw, David; Wisconsin Tribal Health Directors
537 Greenberg, Michael; Rutgers University
565 West, Jerome; Five Sandoval Indian Pueblos, Inc. (Bernalillo, New Mexico)
567 Diehl, Andrew and Stern, Michael; University of Texas Health Science Center at San Antonio
615 Hargreaves, Margaret et al.; diehard Medical College
671 Hullet, Sandral; West Alabama Health Services
683 Watanabe, Michael; Asian Pacific Planning Council (Los Angeles)
688 Kay, Clyde; Louisiana Primary Care Association
690 Carr, Katherine; American College of Nurse-Midwives
706 Manson, Spero; University of Colorado Health Sciences Center
723 Morrison, Jacqueline; Wayne State University
743 Crawford, Michael; Universitr of Texas Health Science Center at San Antonio
745 Flores, George; Metropolitan Health District, San Antonio
Racial and Ethnic Minorities 63
Representative terms from entire chapter:
black community
