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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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." (i253J 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

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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

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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