Race and wealth a factor in health disparities

Friday, December 19, 2008 | 12:00 p.m. CST; updated 1:10 p.m. CST, Friday, December 26, 2008

COLUMBIA — If you are black , you are more likely to have diabetes than anyone else.

In 2006, the rate of inpatient hospitalization of blacks in Boone County for diabetes was 63 per 10,000 people compared to 12 per 10,000 for whites — even though the percentage of blacks is far less.


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In addition to diabetes, blacks are also more likely to have heart and skin diseases, asthma, respiratory infections, epilepsy and other diseases. Rates of heart disease, such as hypertension, brain dysfunction and diseases of the blood vessels, are more prevalent among minority communities, including blacks, Native Americans, Asians and Pacific Islanders.

But apart from race, wealth — or lack of it — is also a very strong indicator of health.

A 2007 statewide health survey done by the Missouri Department of Health and Social Services shows that people in the lowest income group — those with an annual income of $15,000 or less — had the highest incidence of diabetes at 13 percent. Only 5 percent of those earning $50,000 or more had diabetes, the survey found.

People with lower incomes are also more likely to have higher cancer rates. The largest group of cancer patients, 14 percent, earned less than $15,000 in 2005. Missouri residents with lower income are also more likely to have high blood pressure and coronary heart disease.

Recent reports from the Columbia/Boone County Department of Public Health and Human Services and the Missouri Office of Minority Health point out the harsh reality of health disparities at both the county and state level.

When it comes to health disparities along racial lines, those disparities are widening in some cases. The 2008 Community Assessment shows a significant increase in incidence of diabetes among blacks in Boone County from 1997 to 2005.

"Studies have shown that after controlling for economic and demographic factors, African-Americans still receive less treatment," the Missouri Health Disparities report, published earlier this year, said. "This may have a number of causes itself, including different help-seeking behaviors by African-Americans as well as the negative attitudes of some health care providers that poor people and minorities have reported. Another factor is that some aspects of poorer health are still not well understood."

The reasons behind health disparities are diverse and include a lack of affordable and accessible health care, language barriers and communication between providers and clients.

"There may be a difference in the delivery of health care by providers among minority and majority populations," Cheryl Avant, chief of Missouri Office of Minority Health, said. "Some root causes could be individual factors such as socioeconomic status; provider factors such as providers' perceptions about patients or clients; and system factors, such as how patients or clients are treated by health care providers."

Some individuals may also find it difficult to ask questions of health-care professionals, Avant said, "They may be afraid to question directives given by the health-care provider and, in addition, they may not understand their prescription instructions which is considered a health literacy issue."

The role of race and socioeconomic status as factors in health were the focus of four recent study circles sponsored by the Department of Public Health and Human Services. The centerpiece of those conversations was a documentary aired on PBS called "Unnatural Causes: Is Inequality Making Us Sick?"

Larry Adelman, executive producer of the series, said that class status is the strongest predictor of health. "But in every level on the class pyramid there are some populations that often do even worse," he said. "And this has to do with the added burden of race."

Racism operates on several levels: "Institutional, interpersonal and internal racism all contribute to health inequities," Adelman said. He prefers the term "inequities" over "disparities" when talking about "those differences in population health that are systemic, preventable and avoidable, and thus unjust."

Historically oppressed populations such as blacks, Native Americans or Aborigines show higher rates of health disparities than others, he said.

The documentary makes the case that tax cuts for the rich, deregulation and other economic policies widened the gap between rich and the rest of the Americans since the early 1980s, and health gaps have widened, too.

"The top 1 percent of Americans now own as much wealth as the bottom 9o percent combined," Adelman said. "But the health gaps narrowed between 1960s and 1980s. With the War on Poverty and the civil rights movement, there was a narrowing of inequalities."

Social policies play an important role in health.

"The wages and benefits we're paid, the neighborhoods we live in, the schools we attend, our access to resources and even our tax policies are health issues every bit as critical as diet, smoking and exercise," Adelman said.

Economic inequalities affect health because economic power determines the resources neighborhoods offer, the amenities accessible — even the foods available, the documentary says. For example, people with lower incomes sometimes live in neighborhoods that have few grocery stores and fewer safe or inviting places to walk.

Income, too, is a factor in how much leisure time a person has for physical activities. In Missouri, 46.9 percent of those earning less than $15,000 a year did not have leisure time for physical activity, the 2007 state survey found. The rate was much lower — 15 percent — for people earning $50,000 or more.

"More African-Americans live in neighborhoods where it is difficult to get fresh vegetables and fruits," Adelman said.

Kristofer Hagglund, associate dean and professor with the MU School of Health Professions, said race, per se, is not the only factor that gives rise to health disparities.

"Racial background accounts for very few and isolated differences (in health care). It's the social determinants associated with race that we need to address," he said.

Based on the local Health Department's conclusions from emergency room visits by blacks and whites, Hagglund said, "We can speculate that there is a difference in income that gives rise to a higher incidence of diabetes and also that more African-Americans are visiting the ER because they have no access to primary health care."

In 2007, 34 percent of Missourians earning less than $15,000 a year were without health coverage.

The local Health Department's efforts to reverse health disparities, such as high prevalence of diabetes among blacks, include promoting good nutrition and increased activity.

Linda Cooperstock, public health planner at the Health Department, said the community is involved in several grants on this front including Healthy and Active Communities under the Missouri Foundation for Health and Healthy Eating by Design financed by the Robert Wood Johnson Foundation.

"We are involved with several other community groups interested in increased physical activity and improved nutrition, such as PedNet Coalition, University of Missouri's Obesity Summit, and the Health Policy Committee of Columbia Public Schools," she said.

To reduce disparities in health care, the department offers services regardless of race and ethnic background.

"We participate in screenings and education for diabetes, hypertension, breast cancer, and others," Cooperstock said. "We partner with numerous social services agencies, including United Way and 211," a social service referral line.

The Health Department can influence local policies, but it is state and federal policies that can have the most influence in creating downward trends in chronic diseases and disparities, she said.

"One consideration is economics," Cooperstock said. "Tax revenues are low throughout the state and the country, so less and less money is being spent to deliver health care to those who have no insurance."

Missouri has the lowest state tax on tobacco, she said, which contributes to numerous chronic diseases. It is known that if the cost of tobacco is increased by 10 percent the use goes down by about 10 percent, she said. Missouri uses "very little" of the $25 million it receives under a settlement with four major tobacco companies for health and prevention, she said.

Other policies that could reduce disparities are uniform health insurance for all; easy access to low-cost, healthy food; providing screening in schools; removing pre-existing stipulations from insurance policies; and economic incentives for all employers, including small businesses, to provide health insurance for employees.

"Currently some employers won't let people work more than 50 percent or 75 percent so they don't have to provide benefits, including insurance," Cooperstock said.

Steve Hollis, manager of the Community and Social Services at the local Health Department, said he hoped that some of the issues raised in the documentary would also be raised in local planning.

"I hope that people walked away from the screening with more awareness about the social determinants of health, such as neighborhoods, environment, economic opportunities and stress caused due to racial issues, which are not necessarily viewed as traditional health issues," he said.

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Ray Shapiro December 26, 2008 | 11:13 a.m.

This is one "mish-mosh" of an article which also omits other contributing factors to why statistics indicate racial health disparities, where "wealth issues" tag along for the ride.
After the headline, I see three graphs. So what? They don't prove that "wealth" is the factor. These graphs are nothing more than "hospitalization and infant death rates."
If blacks are hospitalized more for diabetic reasons, heart disease and infant deaths are higher among blacks than whites, are there better reasons to explain this than lack of wealth? (Being in the hospital is pretty expensive and apparently access to these hospitalizations is not just limited to the wealthy and does a natural occurrence, like having a baby mean that your baby dies due to your lack of cash?)

I propose the following several factors other than financial wealth for blacks to address:
1. Genetics:
Research scientist Dr. Ramkumar Menon believes that the disparity between races is too large to attribute to social, health or environmental factors alone. He is among a growing number of investigators who are convinced that genetics is a contributing factor in infant mortality.

"We've blamed it on socio-economic factors. We've said African-Americans are more likely to be poor," said Menon, a researcher at Centennial's Women's Hospital and a reproductive health research advisor for the World Health Organization. "Really that is not true. If you control for those factors, African-Americans still have a higher infant mortality rate."

2. Based on new ideas, as mentioned above, genetics is a major factor. Given that , what also do you need to do to improve your possible plight? How about improving your lifestyle. If illegal street drugs, alcohol/substance abuse, feeding your kids "junk food," not attending 12 step recovery programs, men not staying with their families, the life of a criminal, promiscuity, living the "hedonistic" life, affects your health, then maybe you could get some good health education and parenting skills classes, use what you learn at these classes to improve your lifestyle and get preventative care and monitoring, utilize the health and social service programs, government programs, nonprofit 501c3 services, church-related and family resources that are out there.
And remember, cash in your pocket does not neccessarily mean that you are going to be any healthier than you are right now.
(If you don't believe that, then stupidity must be genetic as well.)

(Report Comment)
Ayn Rand December 26, 2008 | 11:36 a.m.

Ray, regarding No. 2, if such lifestyles result in one being homeless and jobless, should society be obligated to support those people? Should society pay the medical and other bills of diabetics who lose a limb and thus qualify for disability? Should society pay for a diabetic's expensive medical treatment after that person refuses to exercise and eat healthy (e.g., )?

Where do we draw the line?

With freedom (to live the life you choose) comes responsibility (to deal with the consequences on your own rather than expecting others to support you).

(Report Comment)
Charles Dudley Jr December 26, 2008 | 12:19 p.m.

How about we also look at the Mental Health Issues some people may have had or do have since birth when looking at all of this picture.

Many times a family with a child or children who could possibly suffer some form of a Mental Illness do not often times or rarely never become diagnosed until adulthood due to family denial,school teacher denial or lack of time,grandparent denial and even friends of the family denial or lack of true concern.

Are all children to be diagnosed with a Mental Illness? No but something must be at the very root of this issue in the very beginning of their lives to have effected them as they grow up into adulthood.

There also most often times too are issues with the parents that also lead to these underlying issues either being ignored as that child develops from a very young impressionable age up into adulthood. Remember as a child grows up it's role model is it's parents or at least in the ideal world it is supposed to be that way.

In our world today the new role models are fast food,movies,violent video games,rap music,promiscuous videos on TV and more things that turn even the most smartly and properly raised child away from the path it's parents wished it to follow.

In looking at this and all issues there is always another side,another angle of view that needs to be looked at but in order to fix what is obviously broken we must first find the base roots of all of the underlying issues before true and long lasting treatment and recovery of the citizen(s) in question.

(Report Comment)
Ayn Rand December 26, 2008 | 12:37 p.m.

How many kids diagnosed today with ADD, ADHD, ODD, etc. simply don't know, and were not taught, how to control themselves? "Disabilities" are only as disabling as one wants or lets them be. Case in point: Brad Cohen, who did not let a Tourette diagnosis stop him from becoming a teacher -- an accomplishment profiled in the movie Front of the Class, which debuted earlier this month.

(Report Comment)
Charles Dudley Jr December 26, 2008 | 12:49 p.m.

Ayn Rand you neglect to mention here though did the case individual in point have parental back up,family backing,backing of friends and teachers.

Many to most often times alot if most all of the cases that slip through the cracks in the system or are lost or shuffled about in the system do not have any support at all and they far outnumber world wide the single case you present here millions of times over going back into history as long as we can look back that these types of issues have been documented.

Nobody can use only or absolutely one case to try and prove an over all point of view if they are not willing to look at the entire picture as it is cut up into pieces just like a statistical graph with all numbers,categories in place or all people are really doing is presenting a single self centered side to the issue you bring into question.

(Report Comment)
Ayn Rand December 26, 2008 | 1:04 p.m.

Chuck, Brad had both backing and adversity. It's ridiculous to make excuses and say, "Oh, this poor person should get a free ride because he/she has ____ or didn't get ____." In the end, it's up to the individual to make the most -- or least -- of life.

(Report Comment)
Charles Dudley Jr December 26, 2008 | 1:43 p.m.

I'm sorry to say you seem to be missing the point Ayn Rand that not all people can do that as you seem to be trying to present here or we would all be living in the perfect world wouldn't we were all is happy and joyous and bright were nobody would want for anything nor would there be war nor famine nor disease,mental illness,health problems and no prejudices against all of the above by those of the uneducated variety of citizen.

Well I took off and threw away my cute little dime store "Rose Colored Glasses" at the tender age of 5 years old when I first realized this world that was ahead of me at that time was not going to be very pretty at all.

It still is not a pretty place today either and does not look to be any prettier in the future by far.

(Report Comment)
Ayn Rand December 26, 2008 | 2:05 p.m.

Now imagine if Brad or Missouri Supreme Court Justice Teitelman had thrown up their hands at age 5. But they didn't. Instead, they went out and staked their claim in life.

(Report Comment)
Charles Dudley Jr December 26, 2008 | 2:18 p.m.

You only present the tiniest piece of the entire issue here.

The picture is so much bigger than the itsy bitsy bread box politicking you are trying to present here.

(Report Comment)
Ayn Rand December 26, 2008 | 2:57 p.m.

Nope. "Disabilities" are only as disabling as one wants or lets them be. I am not the only one saying this. For example, go read Marcie McShane's posts. Many of us are not content to whine, "Woe is me."

(Report Comment)
Charles Dudley Jr December 26, 2008 | 3:17 p.m.

Ayn Rand disabilities whether mental or physical by nature can lead into further depths than what you perceive by far.

Physical disabilities almost always bring on more trying mental disabilities and sometimes visa versa too.

This is a fact any doctor of medicine will confirm.

Not always can everybody overcome those obstacles as you present here as the only view. Alot never do and that is a fact.

You only look at the tiniest part of the picture by all of your postings presented here of your views while there those who really know how it is out in the real world.

I am not saying you are not entitled to your views but you are not representing nor presenting the entire picture in it's true form thus giving total injustice to the issue and showing a wanton prejudiced towards the disabled community as a whole.

(Report Comment)
Ayn Rand December 26, 2008 | 3:32 p.m.

"Ayn Rand disabilities whether mental or physical by nature can lead into further depths than what you perceive by far."

Or people can rise above them, as many do. Examples include Brad Cohen, Justice Teitelman, Chuck Graham, David Beckham, Howie Mandel, Bob Pund and Stephen Hawking, to name just a few well-known ones. There are also millions of everyday people who refuse to let a disability disable them.

"A wanton prejudiced [sic] towards the disabled community as a whole" would be to say that the nothing should be expected from the disabled because they are helpless. I'm saying just the opposite, and I'm backing it with example after example of people who refuse to let a disability disable them.

(Report Comment)
Charles Dudley Jr December 26, 2008 | 3:49 p.m.

>>> would be to say that the nothing should be expected from the disabled because they are helpless. I'm saying just the opposite, and I'm backing it with example after example of people who refuse to let a disability disable them. <<<

This might be so but that is not the way you come across to me by far. You come across to me and to others I do talk to who do not post here as somebody who has a serious prejudice towards the disabled and especially the Mentally Disabled.

Your views are usually always presented as a one way view that is only to be viewed through your eyes only by everybody here.

When you truly present the entire issue then maybe we can communicate better on this site but until that time I will keep calling you up on this issue.

(Report Comment)
Ayn Rand December 26, 2008 | 4:02 p.m.

Chuck, you have this narrow, chronic-malcontent view of the world, one that causes you to decry anyone who presents alternatives as "uneducated," to use just one of your favorite slurs. You refuse to acknowledge that there are people who are living refutations of your views.

(Report Comment)
Mark Foecking December 26, 2008 | 4:29 p.m.

Chuck sez:

>>>Your views are usually always presented as a one way view that is only to be viewed through your eyes only by everybody here.<<<

And yours aren't?


(Report Comment)
Charles Dudley Jr December 26, 2008 | 4:29 p.m.

Ayn Rand you refuse to even accept the realities of this issue.

(Report Comment)
Ayn Rand December 26, 2008 | 4:56 p.m.

Chuck, obviously I am stating the real facts as they truly are.

(Report Comment)
Charles Dudley Jr December 26, 2008 | 5:01 p.m.

Ayn Rand and so are mine which you are in denial of and do not accept.

(Report Comment)
Ray Shapiro December 26, 2008 | 11:20 p.m.

The article you and Chuck are discussing, (the one you directed me to), is dated January, 2007. It has nothing to do with "race and wealth health disparities." (Chuck does make a good point about that article implying that this lack of healthy behavior may be a sign of an undiagnosed mental illness.) However, considering that the article has nothing to do with the one I have commented on here, and considering that no one ever posted a comment on the one you are referring me to, why should I care to answer your questions here and now? I suggest you post your questions to me on that article's comment portion, (which is about some 54 year old white guy who did have a job and now has about a year to live.) I will try to answer your questions after you post on that January, 2007 article. You can be the first. No one has cared enough to do so since almost 2 years ago.

(Report Comment)
Ayn Rand December 27, 2008 | 8:20 a.m.

Ray, go back through this thread and you'll see why I posted it after the thread evolved. Feel free to copy and paste my quote from December 26 @ 11:36 a.m. in order to start a thread for the other article.

(Report Comment)
Ray Shapiro December 27, 2008 | 10:04 a.m.

You posted on 12/26, "With freedom (to live the life you choose) comes responsibility (to deal with the consequences on your own rather than expecting others to support you)."

I agree with the gist of this statement. Expecting others to "fix" the results of your bad choices is not the best answer. I see nothing wrong with people seeking help and using the help they are given to improve their situation and then, in some way, "give back" to society. This doesn't always have to be about money, sometimes it has to do with behavior. This may be no more than being a good neighbor or a good parent. That too can be considered a "give back."

(Report Comment)

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