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ScienceWeek
PUBLIC HEALTH: HISPANICS AND HEALTH DISPARITIES
The following points are made by the US Centers for Disease Control (Morb. Mort. Wkly. Rep. 2004;53:935-937):
1) In the 2000 census, 35.3 million persons in the US and 3.8 million persons in the Commonwealth of Puerto Rico identified themselves as Hispanic (i.e., Hispanic, Spanish, or Latino; of all races). Hispanics constituted 12.5% of the U.S. population in the 50 states; by subpopulation, they identified as Mexican (7.3%), Puerto Rican (1.2%), Cuban (0.4%), and other Hispanic (3.6%).[1]
2) For certain health conditions, Hispanics bear a disproportionate burden of disease, injury, death, and disability when compared with non-Hispanic whites, the largest racial/ethnic population in the US. The leading causes of death among Hispanics vary from those for non-Hispanic whites.
3) In 2001, Hispanics of all races experienced more age-adjusted years of potential life lost before age 75 years per 100,000 population than non-Hispanic whites for the following causes of death: stroke (18% more), chronic liver disease and cirrhosis (62%), diabetes (41%), human immunodeficiency virus (HIV) disease (168%), and homicide (128%); in 2000, Hispanics had higher age-adjusted incidence for cancers of the cervix (152% higher) and stomach (63% higher for males and 150% higher for females).[2] During 1999-2000, Mexican Americans aged 20-74 years reported higher rates of overweight (11% higher for males and 26% higher for females) and obesity (7% higher for males and 32% higher for females) than non-Hispanic whites[3]; Mexican-American youths aged 12-19 years also reported higher rates of overweight (112% higher for males and 59% higher for females).[3]
4) Socioeconomic factors (e.g., education, employment, and poverty), lifestyle behaviors (e.g., physical activity and alcohol intake), social environment (e.g., educational and economic opportunities, racial/ethnic discrimination, and neighborhood and work conditions), and access to preventive health-care services (e.g., cancer screening and vaccination) contribute to racial/ethnic health disparities. Level of education has been correlated with prevalence of certain health risks (e.g., obesity, lack of physical activity, and cigarette smoking). Recent immigrants also can be at increased risk for chronic disease and injury, particularly those who lack fluency in English and familiarity with the US health-care system or who have different cultural attitudes about the use of traditional versus conventional medicine.
5) For Hispanics in the US, health disparities can mean decreased quality of life, loss of economic opportunities, and perceptions of injustice. For society, these disparities translate into less than optimal productivity, higher health-care costs, and social inequity. By 2050, an estimated 102 million Hispanics will reside in the US, nearly 24.5% of the total US population. If Hispanics experience poorer health status, this expected demographic change will magnify the adverse economic, social, and health impact of such disparities in the US.[4,5]
References (abridged):
1. Grieco EM, Cassidy RC. Overview of race and Hispanic origin: census 2000 brief. United States census 2000. Washington, DC: US Department of Commerce, US Census Bureau; 2001. Available at http://www.census.gov/prod/2001pubs/c2kbr01-1.pdf
2. CDC. Health, United States, 2003: table 30. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2003. Available at http://www.cdc.gov/nchs/data/hus/tables/2003/03hus030.pdf
3. CDC. Health, United States, 2003: table 68. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2003. Available at http://www.cdc.gov/nchs/data/hus/tables/2003/03hus068.pdf
4. US Department of Health and Human Services. Data 2010: the healthy people 2010 database. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2004. Available at http://wonder.cdc.gov/data2010/focus.htm
5. Hutchins SS, Jiles R, Bernier R. Elimination of measles and of disparities in measles childhood vaccine coverage among racial and ethnic minority populations in the United States. J Infect Dis. 2004;189(Suppl 1):S146-S152
Centers for Disease Control and Prevention http://www.cdc.gov
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PUBLIC HEALTH: RACIAL/ETHNIC DISPARITIES IN NEONATAL MORTALITY
The following points are made by S.L Lukacs and K.C. Schoendorf (Morb. Mort. Wkly. Rep. 2004 53:655):
1) Neonatal mortality (i.e., death at age less than 28 days) accounts for approximately two-thirds of infant deaths in the US. During 1989-2001, neonatal mortality rates (NMRs) declined. However, 2002 preliminary data indicated an increase. To characterize trends in neonatal mortality by gestational age and race/ethnicity, the Centers for Disease Control and Prevention (CDC) analyzed linked birth/infant death data sets for 1989-1991 and 1995-2001 (2002 linked data were not available).
2) Results indicated that (a) extremely preterm infants (i.e., born at less than 28 weeks gestation) accounted for 49%-58% of neonatal deaths during 1989-2001 and (b) racial/ethnic disparities persisted despite NMR declines among infants of all gestational ages.(1,2)
3) The findings document a considerable decline in neonatal mortality among infants of all gestational ages and racial/ethnic populations during the 1990s; despite this decline, racial/ethnic disparities persisted. Implementation of new therapies and recommendations likely contributed to the decline; however, the effects of these advances might differ within racial/ethnic populations. The medical advances include (a) surfactant therapy, which improves infant lung maturity, resulting in a decreased risk for death for high-risk preterm infants(3); (b) folic acid consumption by women of childbearing age to reduce the risk for neural tube defects(4); and (c) intrapartum antimicrobial prophylaxis for women colonized with or at high risk for maternal-infant transmission of group B streptococcal infection.(5)
4) In 2001, blacks continued to have the highest overall NMR, more than twice that of any other racial/ethnic population. The high rate among this population is likely attributable to a combination of high mortality among black infants born at 37 weeksĘ gestation (full-term infants account for approximately 90% of all births) and a high proportion of preterm births (17.6% black preterm births versus 10.8% white preterm births).
5) Preterm white infants had higher NMRs in 2001, compared with other racial/ethnic populations, despite a greater rate of decline in mortality. Although black preterm infants had lower NMRs in 2001, the annual rate of decline was lower than among other racial/ethnic populations. The narrowing gap in mortality between preterm white infants and preterm black infants might reflect the widened distribution of neonatal intensive care in the 1990s beyond urban tertiary-care centers and a possible difference in benefit from surfactant therapy between black and white infants.
6) Differences in neonatal mortality trends among racial/ethnic populations also might be explained by changing patterns in the occurrence of multiple births. The rate of multiple births has increased substantially over the preceding decade, and trends vary among infants of different races/ethnicities.
References (abridged):
1. National Center for Health Statistics. National Center for Health Statistics linked birth/infant death data set: 1989-91 cohort data, 1995-2001 period data. Hyattsville, Maryland: U.S. Department of Health and Human Services, CDC, National Center for Health Statistics, 2003
2. Alexander GR, Himes JH, Kaufman RB, Mor J, Kogan M. A United States national reference for fetal growth. Obstet Gynecol. 1996;87:163-168
3. Horbar JD, Wright EC, Onstad L, National Institute of Child Health and Human Development Neonatal Research Network. Decreasing mortality associated with the introduction of surfactant therapy: an observational study of neonates weighing 601 to 1,300 grams at birth. Pediatrics. 1993;92:191-196
4. Mathews TJ, Honein MA, Erickson JD. Spina bifida and anencephaly prevalence--United States, 1991-2001. MMWR Recomm Rep. 2002;51(RR-13):9-11
5. CDC. Prevention of perinatal group B streptococcal disease: a public health perspective. MMWR Recomm Rep. 1996;45(RR-7):1-24
Centers for Disease Control and Prevention http://www.cdc.gov
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PUBLIC HEALTH: CLASS AND NATIONAL HEALTH
The following points are made by S.L. Isaacs and S.A. Schroeder (New Engl. J. Med. 2004 351:1137):
1) The health of the American public has never been better. Infectious diseases that caused terror in families less than 100 years ago are now largely under control. With the important exception of AIDS and occasional outbreaks of new diseases such as the severe acute respiratory syndrome (SARS) or of old ones such as tuberculosis, infectious diseases no longer constitute much of a public health threat. Mortality rates from heart disease and stroke -- two of the nation's three major killers --have plummeted.(1)
2) But any celebration of these victories must be tempered by the realization that these gains are not shared fairly by all members of our society. People in upper classes -- those who have a good education, hold high-paying jobs, and live in comfortable neighborhoods -- live longer and healthier lives than do people in lower classes, many of whom are black or members of ethnic minorities. And the gap is widening.
3) A great deal of attention is being given to racial and ethnic disparities in health care.(2-5) At the same time, the wide differences in health between the haves and the have-nots are largely ignored. Race and class are both independently associated with health status, although it is often difficult to disentangle the individual effects of the two factors.
4) The authors contend that increased attention should be given to the reality of class and its effect on the nation's health. Clearly, to bring about a fair and just society, every effort should be made to eliminate prejudice, racism, and discrimination. In terms of health, however, differences in rates of premature death, illness, and disability are closely tied to socioeconomic status. Concentrating mainly on race as a way of eliminating these problems downplays the importance of socioeconomic status on health.
5) The focus on reducing racial inequality is understandable since this disparity, the result of a long history of racism and discrimination, is patently unfair. Because of the nation's history and heritage, Americans are acutely conscious of race. In contrast, class disparities draw little attention, perhaps because they are seen as an inevitable consequence of market forces or the fact that life is unfair. As a nation, we are uncomfortable with the concept of class. Americans like to believe that they live in a society with such potential for upward mobility that every citizen's socioeconomic status is fluid. The concept of class smacks of Marxism and economic warfare. Moreover, class is difficult to define. There are many ways of measuring it, the most widely accepted being in terms of income, wealth, education, and employment.
6) Although there are far fewer data on class than on race, what data exist show a consistent inverse and stepwise relationship between class and premature death. On the whole, people in lower classes die earlier than do people at higher socioeconomic levels, a pattern that holds true in a progressive fashion from the poorest to the richest. At the extremes, people who were earning $15,000 or less per year from 1972 to 1989 (in 1993 dollars) were three times as likely to die prematurely as were people earning more than $70,000 per year. The same pattern exists whether one looks at education or occupation. With few exceptions, health status is also associated with class.
References (abridged):
1. Institute of Medicine. The future of the public's health in the 21st century. Washington, D.C.: National Academies Press, 2003:20.
2. Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, D.C.: National Academy Press, 2003
3. Steinbrook R. Disparities in health care -- from politics to policy. N Engl J Med 2004;350:1486-1488
4. Burchard EG, Ziv E, Coyle N, et al. The importance of race and ethnic background in biomedical research and clinical practice. N Engl J Med 2003;348:1170-1175
5. Winslow R. Aetna is collecting racial data to monitor medical disparities. Wall Street Journal. March 5, 2003:A1
New Engl. J. Med. http://www.nejm.org
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