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.
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.