POVERTY, CULTURE AND SOCIAL INJUSTICE: DETERMINANTS OF HEALTH DISPARITIES

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POVERTY, CULTURE AND SOCIAL INJUSTICEDETERMINANT
S OF HEALTH DISPARITIES

• The University of Iowa
• College of Public Health
• Distinguished Visiting Professor Seminar Series
• Iowa City, Iowa
• March 24, 2008

Harold P. Freeman, M.D. President and Founder of
Ralph Lauren Cancer Center New York, NY
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Life Expectancy at Birth USA (1970-2003)(CDC/N
ational Center for Health Statistics Report 2006)
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Chronic Disease and Related Risk FactorsMost
Common Causes of Death, U.S., 2003Percentage of
Total Deaths, age-adjusted
National Vital Statistics Report, 2006
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Chronic Diseases and Related Risk FactorsActual
Causes of Death, U.S., 1990 and 2000
McGinnis JM, Foege WH, Actual causes if death
in the United States. JAMA 1993 2702207-12.
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Cancer Incidence Rates by Race and Ethnicity,
1999-2003
Rate Per 100,000
Age-adjusted to the 2000 US standard
population. Person of Hispanic origin may be of
any race. Sources Howe HL, et al. Annual report
to the nation on the status of cancer 1975-2003
SEER, 1975-2003, Division of Cancer Control and
Population Sciences, National Cancer Institute,
2006.
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Cancer Death Rates, by Race and Ethnicity,
US,1999-2003
Rate Per 100,000
Per 100,000, age-adjusted to the 2000 US
standard population. Persons of Hispanic origin
may be of any race. Source Surveillance,
Epidemiology, and End Results Program, 1975-2003,
Division of Cancer Control and Population
Sciences, National Cancer Institute, 2006.
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• Disease always occurs within a
• Context
• of human circumstances
• including economic status social
• position, culture, and environment.
• These human circumstances are
• determinants of
• survival, and quality of life.

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The Discovery-Delivery Disconnect
Delivery
Discovery
Development
Critical Disconnect
This discovery to delivery disconnect is a key
determinant of the unequal burden of disease.
Voices of a Broken System Real People, Real
Problems, Presidents Cancer Panel, Freeman,
September 2001
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Causes of Health Disparities
Poverty/Low EconomicStatus
Culture
Social Injustice
Possible Influence on Gene Environment Interaction
Post Treatment/Quality of Life
Survival and Mortality
Early Detection
Diagnosis/Incidence
Prevention
Treatment
Freeman, H.P., Cancer Epidemiology Biomarkers
Prevention, April 2003 (modified)
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POVERTY
CULTURE
Risk-promoting lifestyle, attitude, behavior
Inadequate physical and social environment
Inadequate information and knowledge
Diminished access to health care
DECREASED SURVIVAL
Freeman, HP, Cancer in the Economically
Disadvantaged, CA, July 1 Supplement, 1999.
Presented at the American College of
Surgeons/American Cancer Society Workshop on
Quality Assurance in Cancer Care, 1988, published
Cancer, 1989
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• There is a need to distinguish
• between the meanings of
• Class (economic status)
• Culture
• Race
• Social Injustice

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The Meaning of Poverty

• Substandard housing
• Inadequate information and knowledge
• Risk-promoting lifestyles, attitudes, and
  behaviors
• Diminished access to health care

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Who are the poor?
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Poverty Rates by Race and Hispanic Origin
2-Years 2004 and 2005
U.S. Census Bureau, 2003 to 2005 Annual Social
and Economic Supplements Income, Poverty, and
Health Insurance Coverage in the U.S. 2005
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FY 2005 Below Poverty Level
Based on Total Population 287.3 Million
U.S. Census Bureau, 2003 to 2005 Annual Social
and Economic Supplements Income, Poverty, and
Health Insurance Coverage in the U.S. 2005
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2005 Poverty Levels by Race/Ethnicity
White Percent in Poverty 9.0 Number in
Poverty 17.4M Number in Total Population
192.0M
Black Percent in Poverty 25.6 Number in
Poverty 9.0M Number in Total Population 34.8M
U.S. Census Bureau, 2003 to 2005 Annual Social
and Economic Supplements Income, Poverty, and
Health Insurance Coverage in the U.S. 2005
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Who is uninsured?
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Percent of People Without Health Insurance
Coverage by Race and Hispanic OriginThree-Year
Averages 2003-2005
Health Insurance Coverage in the U.S. 2002, U.S.
Census Bureau, 2003 U.S. Census Bureau, 2005 and
2006 Annual Social and Economic Supplements
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The Meaning of Culture

• Shared communication system
• Similar physical and social environment
• Common beliefs, values, traditions, and world
  view
• Similar lifestyles, attitudes, and behaviors

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Race Perhaps the single most defining issue in
the history of American society
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Who is Black?
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Evolution and Migration
Evolutionary history indicates that man
originated in East Africa 100,000 years ago and
later migrated to the rest of the world.
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Impact of Racialization on Social History,
Science, and Health Care
RACIALIZATION
Human Evolution Migration Population
Genetics Genomics
Medical Standards and Systems
Scientific Assumptions and Hypotheses
Scientific Studies and Findings

Social History
Classification
PatientOutcomes
Social Injustice
Differentially Applied Standards/Biased Care
Hypothesesfor FutureResearch
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Historical Timetable

• 1492 Columbus discovered America
• 1619 First African Slaves arrive in America
• 1776 Declaration of Independence
• 1857 Dred Scott Decision
• 1861-65 Civil War
• 1863 Emancipation Proclamation
• 186577 Reconstruction
• 1866 14th Amendment
• 1896 Plessy v. Ferguson
• 1954 Brown v. Board of Education
• 1960s Civil Rights Movement

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• Bach, NEJM, 1999
• Black patients were substantially less likely
  than white patients to have their non-small cell
  lung cancers surgically removed. (The rate of
  surgery was 12.7 percentage points lower for
  black patients than for white patients)fiveyear
  survival for blacks was 26.4 vs. 34.1 percent
  for whites

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80 of Black patients receive care from one-fifth
of all physicians.Black patients were less
likely to have access to board-certified
specialists.Black patients face obstacles in
accessing tertiary treatment centers.
Bach, 2005
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• Geographic Areas of Excess Cancer Mortality
• Cancer Hot Spot

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An Analysis of Excess Cervical Cancer Mortality
A Marker for Low Access to Health Care in Poor
Communities
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Cervical Cancer as a Marker

• High rates of cervical cancer are a sentinel
  marker indicating larger, systemic health care
  issues that need to be addressed.

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1986 American Cancer SocietyReport on Cancer
in the Economically Disadvantaged

• Black and White differences in cancer outcomes
  are primarily a function of economic status.

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Report to the Nation on Cancer and the Poor,1989

• Findings
• Poor people meet significant barriers when they
  attempt to seek diagnosis and treatment of
  cancer.
• Poor people often do not even seek care if they
  cannot pay for it.
• Poor people experience more pain, suffering, and
  death because of late stage disease.

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Report to the Nation on Cancer and the Poor,1989

• Findings
• Fatalism about cancer is prevalent among the poor
  and prevents them from seeking care.
• Poor people and their families must make
  extraordinary and personal sacrifices to obtain
  and pay for care.
• Current cancer education programs are culturally
  insensitive and irrelevant to many people.

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• Related to these findings the first Patient
  Navigation program was conceived and initiated
  in 1990 at Harlem Hospital Center

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The Harlem Experience
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Central Harlem Community Characteristics

• Ethnicity is predominantly African-American.
• Median household income in Central Harlem is
  22,367/year.
• Median years of school completed is 12.
• 11 less than high school
• 47 high school, no diploma
• 17 high school graduate
• 18 some college
• 8 4 yrs. of college

Source National Cancer Institute INFORUM database
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• Patient Navigation

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• There is a very critical window of opportunity to
  save lives from cancer between the point of an
  initial suspicious finding and the resolution of
  the finding by further diagnosis and timely
  treatment.

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Patient Navigation Model
Patient Navigation
Rehabilitation
Outreach
Resolution
Abnormal Finding
Abnormal Results
Diagnosis
Treatment
ConcludeNavigation
Freeman, et.al., Cancer Practice, 1995.
Diagnosis
Treatment
Abnormal results
ConcludeNavigation
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Principal Barriers in Harlem

• Financial barriers
• Communication and information barriers
• Medical system barriers
• Fear and Emotional Barriers

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Patient Navigation across the Health Care
Continuum
Patient Navigation
Initial target in Harlem Model
Rehabilitation
Abnormal Results
Outreach
Diagnosis
Treatment
Resolution
Abnormal Finding
Post Treatment/Quality of Life
Early Detection
Diagnosis/Incidence
Survival and Mortality
Treatment
Prevention
Freeman, 2006.
Diagnosis
Treatment
Abnormal results
ConcludeNavigation
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Impact of Harlem Hospital Center Breast Cancer
Screening Program with Patient Navigation
Comparison of Stage at Diagnosis

• 1964-1986 1995-2000
• Stage 0 0 12
• Stage I 6 29
• Stage II 45 38
• Stage III 39 14
• Stage IV 10 7

Oluwole/Freeman, Journal of American College of
Surgeons, 2003
Comparison of 5-year Survival
Freeman HP, Wasfie TJ (1989). Cancer of the
breast in poor black women. Cancer, 63(12),
2562-2569.
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National Legislation
Signed into law June 29, 2005 "Patient Navigator
Outreach and Chronic Disease Prevention Act of
2005" P.L. 109-18
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• Recommendations

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We must apply what we know at any given time to
all people, irrespective of their ability to pay.
Freeman, HP, Cancer in the Economically
Disadvantaged, CA, July 1 Supplement, 1999.
Presented at the American College of
Surgeons/American Cancer Society Workshop on
Quality Assurance in Cancer Care, 1988, published
Cancer, 1989
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Provide universal access to health care.
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We must develop a comprehensive, unified approach
to improving conditions rooted in poverty.
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• Geographically and culturally defined areas of
  extreme excess mortality in America should be
  delineated.

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Such communities should receive funding for
Patient Navigation Programs, to provide personal
assistance in obtaining timely and adequate
diagnosis and treatment.
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• Provide culturally targeted education to promote
  healthy life-styles, particularly among young
  people, including access to tobacco cessation
  programs.

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Establish and implement systems for monitoring
treatment equity according to standards of care
to diminish bias in the provision of health care.
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Ensure that each individual, regardless of
economic status, share in the responsibility for
promoting his/her own health and well being.
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• Create a high level of awareness among medical
  trainees and professionals regarding their role
  in eliminating bias in medical care delivery.

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Final Thoughts
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Disparities in cancer are caused by the complex
interplay of low economic class, culture, and
social injustice, with poverty playing the
dominant role.
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• Residents of poorer communities, irrespective of
  race, have higher death rates from disease.
• Within each racial/ethnic group, viewed
  separately, those living in poorer counties have
  lower disease survival.

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• There is evidence that race, in and of itself, is
  a determinant of the level of health care
  received.

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In this nation we see, value, and behave toward
one another through a powerful lens of
race.This lens can create false assumptions
that may result in serious harm to members of
some racial and ethnic groups.
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• Health disparities exact an extraordinarily high
  human cost and a significant economic cost to
  this nation.

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Poverty should NOT be an offense which is
punishable by death.
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A New Paradigm
Biomedical Science
Civil Human Rights
Social Sciences History
Freeman, HP, 2005
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• Of all of the forms of inequality, Injustice in
  health is the most shocking and inhumane.
• Dr. Martin Luther King Jr.

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• The drive to reach
• Scientific Truth
• Must be wedded to concern for
• Social Justice

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What you see depends on where you stand.
Albert Einstein