Full text of "Report of the Secretary's Task Force on Black and Minority Health: Volume I: Executive Summary"

See other formats

Volume I:
Executive Summary

Report of the
Secretary's Task
Force on

Black &

Minority

Health

Margaret M. Heckler

Secretary

U.S. Department of Health and
Human Services

Volumel: J^l ^ _ i? J.1^ ^ (^W\0D9W

Executive Summary

Report of the
Secretary's Task
Force on

Black &

Minority

Health

Margaret M. Heckler

Secretary

U.S. Department of Health and
Human Services

August 1985

SECRETARY'S TASK FORCE ON BLACK AND MINORITY HEALTH

MEMBERS

Thomas E. Malone, Ph.D., Chairperson
Katrina W. Johnson, Ph.D., Study Director

Wendy Baldwin, Ph.D

Betty Lou Dotson, J.D.

Manning Feinleib, M.D., Dr.P.H.

William T. Friedewald, M.D.

Robert Graham, M.D.

M. Gene Handelsraan

Jane E. Henney, M.D.

Donald R. Hopkins, M.D.

Stephanie Lee-Miller

Jaime Manzano

J. Michael McGinnis , M.D.

Mark Novitch, M.D.

Clarice D. Reid, M.D.

Everett R. Rhoades , M.D.

William A. Robinson, M.D. ,

James L. Scott

Robert L. Trachtenberg

T. Franklin Williams, M.D.

M.P.H.

ALTERNATES

Shirley P. Bagley, M.S.
Claudia Baquet, M.D. , M,
Howard M. Bennett
Cheryl Damberg, M.P.H.
Mary Ann Danello, Ph.D.
Jacob Feldman, Ph.D.
Marilyn Gaston, M.D.
George Hardy, M.D.
John H. Kelso

P.H.

James A. Kissko
Robert C. Kreuzburg, M.D.
Barbara J. Lake
Patricia L. Mackey, J.D.
Delores Parron, Ph.D.
Gerald H. Payne, M.D.
Caroline I. Reuter
Clay Simpson, Jr., Ph.D.
Ronald J. Wylie

For sale hy the Superintendent o£ Documents, U.S. Government Printing Office
Wasliincton. D.C. 20402

TABLE OF CONTENTS

Letter of Transmittal vii

Secretary's Foreword and Charge to the Task Force ix

Tables and Figures xi

INTRODUCTION AND OVERVIEW 1

RECOMMENDATIONS OF THE TASK FORCE

Health Information and Education 9

Health Services 15

Health Professions Development 21

Cooperative Efforts 25

Data Development 31

Research Agenda 37

ACCOUNTING FOR THE HEALTH STATUS DISPARITY

Social Characteristics of Minority Populations 47

Mortality and Morbidity Indicators 63

Subcommittee Summary Reports

Cancer 87

Cardiovascular and Cerebrovascular Diseases 107

Chemical Dependency 129

Diabetes 149

Homicide, Suicide, and Unintentional Injuries .... 157

Infant Mortality and Low Birthweight 171

Health Services and Resources for Minorities 187

Inventory of DHHS Program Efforts 197

Survey of Non-Federal Organizations 205

APPENDIX

Task Force Members and Alternates 215

Task Force Subcommittees 219

Task Force Staff 227

Commissioned Papers 229

Acknowledgments 237

Key to Abbreviations 239

^«S!«l.„.,^

DEPARTMENT OF HEALTH AND HUMAN SERVICES 1?®'^/°'^.?," -^ ^ uu

Black and Minonty Health

The Honorable Margaret M. Heckler
Secretary, Department of Health

and Human Services
Washington, D.C. 20201

Dear Madam Secretary:

National Institutes of Health
Bethesda, Maryland 20205
(301) 496^177

On behalf of the Task Force on Black and Minority Health, I am
pleased to submit the report and recommendations of the Task Force for
your review and consideration. The report consists of an executive
summary volume presenting our major findings and recommendations , and
additional volumes containing extensive background information and
analyses supporting and extending the executive summary. These will be
extremely useful to those who wish to become familiar in greater depth
with selected aspects of the issues we have analyzed.

I believe this report is a landmark effort in analyzing and
synthesizing the present state of knowledge of the major factors that
contribute to the health status of Blacks, Hispanics, Asian/Pacific
Islanders, and Native Americans. It represents the first time the
Department of Health and Human Services (DHHS) has consolidated minority
health issues into one report. This report should serve not only as a
standard resource for departmentwide strategy, but as the generating
force for an accelerated national assault on the persistent health
disparities which led you to establish the Task Force a little more than
a year ago.

It would be a disservice to the Task Force members, staff and
consultants who worked so diligently on this project during the past
year, to understate the complexity of the task we undertook. The issues
identified during our deliberations and presented in this report are of
major importance, but must not be regarded as the final word on the
subject. Just as individual well-being is not static, the health needs
of minority populations are changing. They are influenced by a diverse
set of factors of which disease is but one aspect. The report, then,
must continue to be updated and revised as new data and information
become available.

In accordance with your charge, we have examined the impact of a
broad range of behavioral, societal, and health care issues on the
current departmental program areas. Our recommendations are consistent
with the objectives for the Nation in disease prevention and health
promotion for the year 1990. The six topics we have identified as
priority areas merit intensive action and study in themselves, as do
various issues such as nutrition and development of health professionals
that cut across all health problem areas. We encourage the Department
to continue to take the lead in implementing such activities.

Page 2 - The Honorable Margaret M. Heckler

The Task Force accomplished this monumental effort during the
course of one year only by mobilization of resources across the DHHS
agencies and by the dedicated contribution of all the Department staff
who served on Subcommittees, responded to our inquiries, and provided
supporting documentation necessary for us to arrive at these conclusions
and recommendations. In addition, many health professionals and
researchers outside the Federal government contributed to the Task Force
efforts by educating the Task Force members, providing information, and
enhancing our knowledge in ways we could not have accomplished on our
own in the time available to us.

The report has already had an extraordinarily beneficial effect.
The levels of awareness and sensitivity to the issues surrounding
minority health have been greatly heightened among the individuals
serving on the Task Force and through them, within the agencies,
divisions, and programs of the Department. Many of the specific
activities proposed by the Subcommittees of the Task Force are being
integrated into the program plans of the agencies represented on the
Task Force. Moreover, we have had the opportunity to share expertise
and cultivate working relationships that will last beyond this
particular effort. As a result, we are better prepared to serve as
emissaries for positive action within the Department, our communities,
and professional organizations.

The Task Force encourages you to identify the appropriate
mechanisms whereby our recommendations can be incorportated into the
body of the Department's programs and activities. If these
recommendations can be implemented with the same spirit as their
genesis, we will advance as a Department and as a Nation toward
improving the health status of minority Americans today, with the
assurance that we will all be healthier Americans tomorrow.

Sincerely yours.

Thomas E. Malone, Ph.D.
Chairman

THESECHETARV OF HEALTH AND HUMAN SERVICES

WASHINGTON. D C 20201

In January 1984 — ten months after becoming Secretary of Health and
Human Services — I sent Health, United States, 1983 to the Congress.
It was the annual report card on the health status of the American
people.

That report — like its predecessors — documented significant progress:
Americans were living longer, infant mortality had continued to
decline — the overall American health picture showed almost uniform
improvement .

But, and that "but" signaled a sad and significant fact; there was a
continuing disparity in the burden of death and illness experienced
by Blacks and other minority Americans as compared with our nation's
population as a whole.

That disparity has existed ever since accurate federal record keeping
began — more than a generation ago. And although our health charts do
itemize steady gains in the health status of minority Americans, the
stubborn disparity remained — an affront both to our ideals and to the
ongoing genius of American medicine.

1 felt--passionately — that it was time to decipher the, message inherent
in that disparity. In order to unravel the complex picture provided by
our data and experience, I established a Secretarial Task Force whose
broad assignment was the comprehensive investigation of the health
problems of Blacks, Native Americans, Hispanics and Asian/Pacific
Islanders.

The Task Force under the insightful direction of the distinguished
Thomas E. Malone, Ph.D. , Deputy Director of the National Institutes
of Health and with the invaluable contribution of experts from
throughout the department, has met its challenge. Brilliantly.
First: by a review of departmental programs to determine how the
health problems of minorities have been addressed; followed by a
careful analysis of the range of health care resources and information
available; and then — by a critique of the health status of Blacks,
Native Americans, Hispanics and Asian/Pacific Islanders. The Task
Force was further charged with finding ways for our department to
exert leadership, influence and initiative to close the existing gap.
The report is comprehensive. Its analysis is thoughtful. Its thrust
is masterful. It sets the framework for meeting the challenge — for
improving the health of minorities.

It can — it should — mark the beginning of the end of the health disparity
that has, for so long, cast a shadow on the otherwise splendid American
track record of ever improving health.

%^^.ta'9^:4^^^e£^

Margaret M. Heckler
Secretary

TABLES AND FIGURES

TABLES

Table 1. Average Annual Total and Excess Deaths in Blacks,

Selected Causes of Mortality, 1979-1981 5

Table 2. Percent Distribution of Persons by Ethnic/Racial
Background and Sex, Age, and Geographical Area,
United States, 1980 48

Table 3. Percent Distribution of Persons of Nonminority

and Minority Background by Number, Sex, and Geographic
Distribution, United States, 1980 49

Table 4. Occupational Distribution of Minority Groups, Ratio of

Nonminority to Minority 50

Table 5. Age-adjusted Death Rates by Selected Cause, Race,

and Sex, United States, 1980 67

Table 6. Blacks: Average Annual Number of Deaths by Disease

Category, United States, 1979-1981 71

Table 7. Hispanics : Average Annual Number of Deaths by Disease

Category, United States, 1979-1981 77

Table 8. Native Americans: Average Annual Number of Deaths by

Disease Category, United States, 1979-1981 80

Table 9. Relative Risk of Death for American Indians by Cause .... 81

Table 10. Asian/Pacific Islanders: Average Annual Number of Deaths

by Disease Category, United States, 1979-1981 82

Table 11. Proportion of Cancer Deaths Attributed to Different

Factors 88

Table 12. Cancer Incidence Rates

Primary Site and Racial/Ethnic Group 91

Table 13. Cancer Mortality Rates

Primary Site and Racial/Ethnic Group 93

Table 14. Five Year Cancer Survival Rates; 1973-1981 95

Table 15. Childbearing Patterns among Racial/Ethnic Groups,

1982 176

FIGURES

Figure 1. Average Annual Age -Ad jus ted Death Rates for All

Causes, 1979-1981 ' 65

Figure 2. Life Expectancy at Birth by Race and Sex, United

States, 1950-1983 66

Figure 3. Average Annual Excess Deaths for Blacks, 1979-1981 69

Figure 4. Average Annual Excess Deaths for Black Males,

1979-1981 72

Figure 5. Average Annual Excess Deaths for Black Females,

1979-1981 73

Figure 6. Average Annual Age-Adjusted Death Rates for Cancer,

1979-1981 90

Figure 7. Average Annual Age-Adjusted Death Rates for Heart

Disease, 1979-1981 108

Figure 8. Average Annual Age-Adjusted Death Rates for Heart

Disease, for Persons under 45 Years of Age, 1979-1981 . . . 109

Figure 9. Average Annual Age-Adjusted Death Rates for Stroke,

1979-1981 Ill

Figure 10. Average Annual Age-Adjusted Death Rates for Chronic

Liver Disease and Cirrhosis, 1979-1981 130

Figure 11. Percent of People in the Most Obese Group, 1976 151

Figure 12. Death Rates from Unintentional Injury, Suicide, and

Homicide by Race, 1977-1979 158

Figure 13. Average Annual Age-Adjusted Death Rates for Homicide for

Persons Under 45 Years of Age, 1979-1981 159

Figure 14. Infant Mortality Rates, 1950-1982 (Blacks and Whites). . . . 172

Figure 15. Neonatal and Postneonatal Mortality Rates, 1950-1982 .... 173

Figure 16. Low Birth Rate Ratios According to Race and Ethnicity,

United States, 1982 175

Xll

INTRODUCTION AND OVERVIEW OF THE
TASK FORCE ON BLACK AND MINORITY HEALTH

Perspective of the Task Force Study

Despite the unprecedented explosion in scientific knowledge and
the phenomenal capacity of medicine to diagnose, treat, and cure
disease, Blacks, Hispanlcs , Native Americans, and those of
Asian/Pacific Islander heritage have not benefited fully or equitably
from the fruits of science or from those systems responsible for
translating and using health sciences technology. With full
cognizance of this tragic dilemma in the United States, the Secretary
of Health and Human Services, Margaret Heckler, established the Task
Force on Black and Minority Health. ,

Since the turn of the century, the overall health status of all
Americans has improved greatly. In 1900, the life expectancy for the
United States population at birth was 47.3 years; for Blacks it was
much lower--33 years. In little more than three generations,
remarkable changes have occurred in health care and biomedical
research. As pointed out by the Surgeon General in the 19 79 report,
Healthy People, the leading causes of death in 1900 were influenza,
pneumonia, diphtheria, tuberculosis, and gastrointestinal infections.
In the first half of the century, improved sanitation, better
nutrition, and immunizations brought a drastic decline in infectious
diseases. Today, these diseases cause a relatively small percentage
of deaths compared to 1900.

'^ Knowledge about life processes in health and disease is being
acquired at an incredible pace. Because of one spectacular
achievement after another, it is predicted that many of the diseases
not now curable, will.be controlled by the year 2000. This
i"biological revolution" has placed into the hands of health
professionals effective medications, new and complex diagnostic
instruments, and treatment modalities not dreamed of in 1900.

V Since 1960, the United States population has experienced a steady
decline in the overall death rate from all causes. Remarkable
progress in understanding the causes and risks for developing diseases
such as heart disease and cancer have important implications for the
health of all Americans. The decline in cardiovascular disease
mortality from 1968 to 1978 alone improved overall life expectancy by
1.6 years. Advances in the long-term management of chronic diseases
mean that conditions such as hypertension and diabetes no longer
necessarily lead to premature death and disability.

Concomitantly, advances in social and behavioral sciences
research and methodology have elucidated relationships among
biological, behavioral, and social factors that affect health and
illness. The link among these factors is critical to understanding

the behavioral underpinnings of health, identifying effective
strategies for disease prevention, maintaining treatment regimens, and
suggesting ways to change behavior for more healthful living habits.

[^Although tremendous strides have been made in improving the
health and longevity of the American people, statistical trends show a
persistent, distressing disparity in key health indicators among
certain subgroups of the populatiorT^ In 1983, life expectancy reached
a new high of 75.2 years for Whites and 69.6 years for Blacks, a gap
of 5.6 years. Nevertheless, Blacks today have a life expectancy
already reached by Whites in the early 1950s, or a lag of about 30
years. Infant mortality rates have fallen steadily for several
decades for" both Blacks and Whites. In 1960, Blacks suffered 44.3
infant deaths for every 1,000 live births, roughly twice the rate for
Whites, 22.9. Moreover, in 1981, Blacks suffered 20 infant deaths per
1,000 live births, still twice the White level of 10.5, but similar to
the White rate of 1960.

I The Task Force on Black and Minority Health was thus conceived in
/ response to a national paradox of phenomenal scientific achievement
/ and steady improvement in overall health status, while at the same
^time, persistent, significant health inequities exist for minority
C^Americaris^ As the Task Force came into being in April 1984, it was
evident that to bring the health of minorities to the level of all
Americans, efforts of monumental proportions were needed.

Task Force Activities

Secretary Heckler appointed Dr. Thomas E. Malone, Deputy Director
of the National Institutes of Health, the Government's chief agency
for supporting biomedical research, as Chairperson of the Task Force.
After careful review of programs and staff of the Department, 18
senior scientists and officials were selected as primary members of
the Task Force. These individuals not only had expertise and
experience in the areas proposed for study, but had the programmatic
authority affording direct possibilities for implementing
recommendations of the Task Force. The Task Force members and
alternates are listed in the appendix to this volume. The Task Force
was assured the necessary resources to carry out its mandate and was
supported by a staff that included a wide range of health
professionals and technical staff from throughout the Department of
Health and Human Services (DHHS) .

The Task Force on Black and Minority Health was a unique and
historic assemblage in its own right. While DHHS has many programs
that have significant impact on improving the health status of
minorities, this was the first time that representatives of these
programs were joined in a common effort to carry out a comprehensive
and coordinated study to investigate the longstanding disparity in the
health status of Blacks, Hispanics , Asian/Pacific Islanders, and
Native Americans compared to the nonminority population.

The Task Force members developed a broad, multidimensional
approach to characterizing the health problems of minority Americans.
The approach was based on analyses of mortality data to define the
extent of the health disparity, intense examination of the major
health issues found in the analyses to explore why the disparity
persists, and consultations with experts in minority health issues from
the non-Federal community.

The findings and recommendations generated by the Task Force
within the confines of a little more than a year's time are summarized
in this volume. More detailed information supporting the findings
will appear in subsequent volumes.

Data Review and Analysis

In its initial meetings, the Task Force carefully reviewed
existing health status information for minority and nonminority
populations available in Health, United States, 1983 and other
supplementary data sources. After analyzing national mortality data
for more than 40 disease categories, the approach adopted by the Task
Force that best defined the disparity was the statistical technique of
"excess deaths"; that is, the difference between the number of deaths
observed in minority populations and the number of deaths which would
have been expected if the minority population had the same age and
sex-specific death rate as the nonminority population. This method
quantified the number of deaths that would not have occurred had
mortality rates for minorities equalled those of nonminorities .

Because of the paucity of data relating to the health needs and
mortality of Asian/Pacific Islanders and Hispanics in the United
States, the Task Force assembled an Asian/Pacific Islander advisory
group and an Hispanic advisory group. Each group provided the Task
Force with data and other information on health problems within the
diverse ethnic groups .that make up the aggregate population and
initiated special data reviews to supplement inadequate national
information.

Native Americans include American Indians, Alaska Natives, and
Native Hawaiians. -Most statistics cited in this report, however,
refer specifically. to American Indians and Alaska Natives. Where data
on Native Hawaiians are available, they are treated separately.

Identifying the Major Contributors to the Disparity

In analyzing mortality data from 1979 to 1981, the Task Force
identified six causes of death that together account for more than 80
percent of the mortality observed among Blacks and other minority
groups in excess of that in the White population. Although the
ranking of health problems according to excess deaths differs for each
minority population, the six health problems became priority issue
areas for Task Force study. Listed in alphabetical order, they are:

• Cancer

• Cardiovascular disease and stroke

• Chemical dependency, measured by deaths due to cirrhosis

• Diabetes

• Homicide and accidents (unintentional injuries)

• Infant mortality

Table 1 presents the leading causes of excess mortality and the
percentage that each cause contributed to the total excess deaths in
Blacks for the years 1979 to 1981. For Black males and females
combined, excess deaths accounted for 47 percent of the total annual
deaths in those 45 years old or less, and for 42 percent of deaths in
those aged 70 years or less. More detailed analyses of excess mortality
appear in the section "Mortality and Morbidity Indicators."

In addition to measures of excess deaths, special analyses of
morbidity and health status indicators for minorities were developed
by the Task Force. These indices included prevalence rates of
selected chronic and infectious diseases, hospital admissions,
physician visits, limitation of activity, and self -assessed health
status. Prevalence of arthritis, digestive diseases, dental problems,
and respiratory disease among minorities is poorly documented and data
were virtually unavailable. Additional mortality indices included
person-years of life lost, life expectancy, and relative risk of death
by cause. A summary of these findings is included in the section
entitled "Mortality and Morbidity Indicators."

Some factors contributing to minority health status are not
disease-specific but have bearing on the overall health needs of each
minority group. Among those that the Task Force reviewed are
demographic data characterizing the four minority groups, minority
needs in health education, health professionals, and health care
services and financing. A summary of issues that cut across health
problem areas appears in the sections of this report entitled
"Social Characteristics of Minority Populations" and "Health
Services and Resources for Minorities.

Subcommittee Activity

For each of the six causes of death identified as a priority
area, a Subcommittee was formed to explore why and to what extent the
disparity exists and what DHHS can do to reduce it. The Subcommittees
were charged with investigating the physiological, cultural, and
societal factors that, in combination, perpetuate health inequities
for minorities. They sought to understand the etiology of selected
conditions for different minority groups, explore potential means for
improving the effectiveness of treatment, and identify possible
intervention strategies to prevent excess death and injury in minority
groups. Because of the differences among minority groups, the
Subcommittees addressed each issue with special attention to the
cultural milieu of that population group.

Tkble 1

Average Annual Total and Excess Deaths in Blacks
Selected Causes of Mortality,
United States, 1979-1981

Excess Deaths
Males and Females
Cumulative to Age 45

Excess Deaths
Males and Females
Cumulative to Age 70

Number

Percent

Number

Percent

Causes of Excess Death

Heart Disease and Stroke

3,312

14.4

18,181

30.8

Homicide and Accidents

8,041

35.1

10,909

18.5

Cancer

874

3.8

8,118

13.8

Infant Mortality

6,178

26.9

6,178

10.5

Cirrhosis

1,121

4.9

2,154

3.7

Diabetes

223

1.0

1,850

3.1

Subtotal

19,749

86.1

47,390

80.4

All Other Causes

3,187

13.9

11,552

19.6

Total Excess Deaths

22,936

100.0

58,942

100.0

Total Deaths, All Causes

48,323

138,635

Ratio of Excess Deaths to Total Deaths

47.4%

42.5%

Percent Contribution of
Six Causes to Excess Death

86.1%

80.4%

The Subcommittees reviewed existing data and literature and
consulted with experts and organizations within and outside the
Federal government. When scientific information for a particular
issue was not readily available, research papers were commissioned to
review recent data in each Subcommittee's area. Material from most of
the commissioned papers was incorporated into the Subcommittee
reports. Many of the authors contributed new analyses that augmented
national information already available to the Task Force.

Interaction With the Non- Federal Community

In order to supplement its knowledge of minority health issues,
the Task Force had extensive interaction with individuals and
organizations outside the Federal system.

Presentations . The Task Force and its Subcommittees heard
presentations by experts in several issue areas . Presentations
included public health aspects of homicide and homicide prevention;
special problems concerning the health status of Asian/Pacific
Islanders, and American Indians and Alaska Natives; the political
history, demography, and health-related conditions of Hispanics ;
and the use of traditional folk medicine and healers by various
minority groups .

Outreach. Task Force members and staff attended national meetings
of non-Federal professional organizations to inform their
membership of the work of the Task Force and to solicit their views
on health priorities and model intervention programs.

Non-Federal community survey. The Task Force surveyed more than
350 non-Federal organizations and individuals concerned with
minority health issues. The survey requested opinions about
critical factors affecting the health status of minorities, and
requested examples of successful programs and suggestions for ways
that DHHS might better address minority health needs. This survey
may help to initiate cooperative efforts between the Federal and
private sectors for improving minority health. A summary of the
survey results appears in the section of this report entitled
"Survey of Non-Federal Organizations."

Program Inventory

The Task Force conducted an inventory of health care, research,
and prevention programs sponsored by DHHS that specifically affect
minority populations. The inventory of DHHS programs and projects is
the first such compilation describing existing programs oriented
toward minority health in DHHS . An index to the inventory is found in
the section "inventory of DHHS Program Efforts in Minority Health.

Task Force Report

The first volume of the Task Force Report summarizes the
information and data compiled on specific minority health problems,
special reports developed on cross-cutting minority health issues, and
recommendations proposing activities for a coordinated effort by which
DHHS may redirect its resources to address the demonstrated disparity
in health status between minority and nonrainority populations. For
greater understanding of the urgency and complexity of the issues
around which the recommendations were developed, all sections of the
report should be examined.

Subsequent volumes of the report contain the complete text
prepared by the Subcommittees that support their findings and proposed
intervention strategies. They are excellent reviews of research and
should be regarded as state-of-the-art information on specific problem
areas in minority health. Subsequent volumes also contain the
complete inventory of DHHS programs and projects that benefit
minorities, and an annotated bibliography listing selected topics
related to Hispanic health issues.

The report of the Task Force looks to the future. It
concentrates on specialized activities that should have a direct and
timely impact on the problems of minority health. Apart from the
descriptions of DHHS programs referenced in the program inventory, the
report does not analyze or examine the many departmental activities
and services that benefit all Americans, including minorities, such as
the extraordinary advances in biotechnology and molecular biology.

In compiling its data, the Task Force tapped a broad range of
sources. Much information is based on the data systems of the
National Center for Health Statistics. Some data resulted from
special analyses conducted for the Task Force or studies from other
sources. Data comparisons are generally made between minority and
nonminority groups except in those situations where study data
specified White populations or aggregate (all races) populations.
Because the report was assembled during a year's time, more recent
data on some topics may now be available.

Context for the Task Force Recommendations

The Task Force acknowledged that the factors responsible for the
health disparity are complex and defy simplistic solutions. Health
status is influenced by the interaction of physiological, cultural,
psychological, and societal factors that are poorly understood for the
general population and even less so for minorities.

Even though the shared characteristic of economic disadvantage among
minorities suggests the possibilities of common approaches for
achieving improved health, diversity within and among minorities
necessitates activities, programs, and data collection tailored to

meet their health needs. The Task Force further observed that since
minorities are underrepresented as beneficiaries of the predominantly
nonminority health care establishment, efforts by all sectors must
proceed vigorously in areas in which current knowledge can suggest
action.

Recommendations were developed to emphasize the following
principles: incorporate minority health initiatives into existing
DHHS program areas in order to address health conditions amenable to
immediate improvement, press for greater public and private
involvement in a common effort to eliminate the health disparity,
resolve unanswered questions through a concerted program of research
and data collection, and seek new strategies to ameliorate health
inequities between minorities and nonminorities .

In the context of these general observations and with information
obtained from a broad range of experts in the field and its own
deliberations, the Task Force began the long and arduous
recommendation development process.

Early in the process, the Task Force recognized that many
activities of major importance to minority groups were already in
progress within DHHS. Therefore, the Task Force decided to emphasize
new directions for departmental activities in its efforts to reduce
the minority health disparity. Many of these activities are indicated
within the recommendations that follow. The Subcommittees, however,
proposed many other opportunities that relate more specifically to the
health priority areas. They appear in the Subcommittee reports as
"Opportunities for Progress." The reader is urged to consider them as
extensions of the recommendations.

The recommendations are organized into six categories. They
emphasize areas in which the Task Force members believe further
improvements were urgently needed. The categories are:

• Health information and education

• Delivering and financing health services

• Health professions' development

• Cooperative efforts with the non-Federal sector

• Data development

• Research agenda

The Task Force joins with all concerned citizens in acknowledging
the stark reality of the continuing, significant differences between
the health of racial/ethnic minorities in the United States and the
general population and proposes recommendations for DHHS and others in
the public health community to address these problems.

Recommendations
of the Task Force

HEALTH INFORMATION AND EDUCATION

Introduction

The ability to make informed decisions plays a significant role
in influencing the overall health status of Americans. Though not a
panacea, health education has been effective in increasing public
awareness about actions individuals and communities can take to
enhance personal health. The disparity in the death rate between
nonminority and minority populations in the United States (Blacks,
Hispanics, Asian/Pacific Islanders, and Native Americans) is a
compelling reason to investigate how health education can contribute
toward reducing this disparity. Because many of the identified
behavioral and environmental risk factors associated with the causes
of excess deaths among minorities can be controlled, more work is
needed to educate minority populations about the risk factors for the
six areas identified as having the greatest impact on minority health:
cancer; cardiovascular disease; chemical dependency; diabetes;
homicide, suicide, and unintentional injuries; and infant
mortality.

RECOMMENDATION 1: AN OUTREACH CAMPAIGN

The Department should launch an outreach campaign to disseminate
health information and education materials and program strategies
specifically designed for minority sectors of the population,
including Blacks, Hispanics , Asian/Pacific Islanders, and Native
Americans. The campaign should strengthen and expand present
departmental health promotion efforts emphasizing preventive aspects
of those public health areas identified by the Task Force which have
the greatest impact on death and disability among minority
populations : cancer; cardiovascular disease; chemical dependency;
diabetes; homicide, suicide, and unintentional injuries; and infant
mortality.

Access to Health Information

The Task Force has reviewed data suggesting that minority
populations may be less knowledgeable or aware about some specific
health problem areas than nonminorities . This situation is
particularly critical in those areas where minorities suffer a greater
burden of illness than nonminorities. For example. Blacks and
Hispanics have less information about cancer and heart disease than do
nonminority groups :

• Blacks tend to underestimate the prevalence of cancer, give
less credence to the warning signs, get fewer screening tests,
and are diagnosed at later stages of cancer than nonminorities.

• Hispanic women have less information about breast cancer than
do nonminority women. Hispanic women were less aware that
family history is a risk factor for breast cancer, and only
25 percent of Hispanic women have heard of breast
self-examination.

• Many professionals and lay persons, both minority and
nonminority, do not know that heart disease may be as common in
Black men as in nonminority men or that Black women die from
coronary disease at a higher rate than nonminority women.
Hypertensive Japanese women and younger men (18 to 49) are
less aware of their hypertension than are the nonminority
subgroups, according to a 1979 survey. Among Mexican Americans,
cultural attitudes regarding obesity and diet are often
barriers to achieving weight control.

Programs to increase public awareness about health problems have
been well received in several areas. For example, the Healthy
Mothers/Healthy Babies Coalition, which provides an education program
in both English and Spanish, has contributed to increased awareness of
measures to improve health status of mothers and infants. Also,
increased knowledge among Blacks of hypertension as a serious health
threat is one of the accomplishments of the National High Blood
Pressure Education Program. The success of these efforts indicates
that carefully planned programs have a beneficial health effect; but
the job is not complete and efforts must continue.

Planning Health Information

Sensitivity to cultural factors is often lacking in health care
of minorities. Although DHHS has considered cultural orientation in
many of its health information programs, improvement is needed.
Experience has shown that\ key concepts to consider in designing a i| J ,\-j
health information campaigrnhclude: meeting the language and ir\W*
cultural needs of each identified minority group, using \j)

minority-specific community resources for tailoring educational
approaches, and developing materials and methods of presentation
commensurate with the educational level of the target populatioir?>
Furthermore, because of the powerful influences of cultural factors
over a lifetime in shaping people's attitudes toward health behaviors,
health information programs must be sustained over a long period of
time. Examples of how these concepts might be interwoven into health
promotion efforts follow.

• Channel efforts for Black, Hispanic, Asian/Pacific Islander,
and Native American communities through local leaders, who
could represent a powerful force for promoting acceptance and
reinforcment of the central themes of health promotion messages,

• Data suggest that health messages are more readily accepted if
they do not conflict with existing cultural beliefs. Where
appropriate, messages should acknowledge existing cultural
beliefs .

• Involve family, churches, employers, and community organizations
as a support system to facilitate and sustain behavior change

to a more healthful lifestyle. For example, although
hypertension control in Blacks depends on appropriate medical
therapy, blood pressure control can be improved and maintained
by family and community support of activities such as proper
diet and exercise.

• Language barriers, cultural differences, and lack of adequate
information on access to care complicate prenatal care for
Hispanic and Asian women who have recently arrived in this
country. A model program in Hartford, Connecticut, uses volunteer
minority lay health workers to organize community support networks
to promote perinatal care by disseminating culturally appropriate
health information to Hispanic women.

• Homicide is the leading cause of death for young Black men and
one of the leading causes of death for Hispanic men and Black
women. It is a major contributor to the disparity in mortality
rates between these groups and nonminorities . Homicide
prevention activities should include strategies such as
behavioral modification interventions for handling anger and
community-based programs that call attention to the extent and
consequences of violence in Black and Hispanic communities.

• Task Force data suggest that the health of some young Hispanic
and Native Americans may be seriously threatened by the emerging
use of inhalants. Communities where young people are at risk
because of increasing use of such substances would benefit

from an appropriate and culturally sensitive health education
campaign to address this problem at the community level.

DEPARTMENTAL ACTIVITIES

In carrying out an outreach campaign to meet the health information
needs of minority populations, DHHS should initiate the following
activities :

• Assess existing departmental materials to ascertain whether
health information materials available to minority populations
are sensitive to their culture and appropriate to their language
and reading level. Reorient existing health information
materials as necessary.

• Review the accessibility of health information and educational
materials available to identified minority populations.

• Develop new health information and educational materials, suitable
for specific minority groups, where none already exist. New
materials should be formulated to be acceptable to the cultural
and language needs of each targeted population.

• Develop media-based messages in different languages at
appropriate reading levels, including culturally relevant verbal
and print messages, to increase awareness and provide knowledge
of health issues, and promote behavior change to a more healthful
lifestyle.

• Test improved or new materials before general distribution to
determine if the materials are both culturally acceptable and
useful to the target audience.

• Enlist the participation and counsel of professional and lay
members of each minority group to assess the suitability of
existing departmental health information materials, reorient
materials to specific minority groups, develop new materials,
and distribute the materials through the appropriate
minority-specific networks.

• Encourage private organizations such as religious and community
organizations, clubs, and schools, to participate in developing
minority support networks and other incentive techniques to
facilitate the acceptance of health information and education.

• Emphasize information and educational materials in those areas
where the health problems are identified as most severe, the
target population is at highest risk, and interventions are
likely to result in improved health status.

• Distribute health information through the established
communication networks, public and private, within minority
communities .

• Evaluate the impact of these efforts on health-related behavior
and, where appropriate, on morbidity and mortality.

Patient Education

The benefits of health education for overall health promotion
require a relatively long period of time to be realized. Patient
education is a component of health education that requires a much
shorter time for its benefits to be observed. Patient education
includes increasing a person's knowledge about identified health
problems and strengthening the ability to care for that condition.

Knowledge of appropriate self -care, treatment regimens, or beneficial
behavioral changes can influence an individual's health status
significantly and alter the probability of adverse health outcomes.

RECOMMENDATION 2: PATIENT EDUCATION

The Department should ensure that its materials , programs , and
technical assistance for patient education are responsive to minority
population needs, especially those provided in specific health care
service settings such as medical, community-based , school and
worksite locations . Emphasis should be given to those public health
topics that have the greatest impact on death and disability in
minority populations . Concomitantly , attention should be given by the
Nation' s schools and universities to training health care providers
and educators to be sensitive to minority cultural and language
needs .

Patient Education Is Interpersonal

Patient education is often linked to the delivery of medical care
or a specific health problem and frequently takes place in special
settings, such as hospitals, schools, communities, homes, or the
worksite. Although printed materials and information contribute to
the educational process, patient education is inherently
interpersonal. The success of the educational effort is often
determined by the credibility of the source of patient education and
is highly dependent on the skill and sensitivity of the health care
provider.

Task Force data suggest that physicians, often seen in clinics or
emergency rooms, are the primary source of health information for
Black and Mexican American patients. In addition, Mexican Americans
regularly seek advice from family members on health matters. American
Indians and Alaska Natives living on reservations rely on Public
Health Service health practitioners or community health
representatives for information. Some Asian/Pacific Islanders may
use traditional healers in combination with physicians. These
differences among the minority groups need to be given due recognition
in the design and delivery of patient education services.

Patient education programs are particularly critical and needed
for several health problems where the impact on minority health is
greatest, such as hypertension, obesity, and diabetes.

Patient Education Is Cost Effective

Task Force data suggest that patient education is effective in
reducing the cost of health care. For diabetics, it has been estimated
that improving self-management skills through education could reduce
the complications of diabetes--ketoacidosis , blindness, and amputations-
by up to 70 percent, preventing about 50,000 hospitalizations a year.

Costs for prenatal education of pregnant women fall far short of the
estimated $15,000 required for medical services for each low birth
weight infant.

Hospitals in Memphis and Atlanta have had projects lasting more
than a decade that offered prevention-oriented education programs
geared to early detection, therapy, and continuing follow-up care for
diabetics, on the assumption that prevention is effective both in
therapeutic effects and in cost. The results have supported this
assumption. The Atlanta program has saved an estimated $11 million in
costs, and the Memphis program, similarly cost effective, has seen
reductions in hospitalizations and diabetic complications. Given the
high prevalence of diabetes among Blacks, Hispanics , American Indians,
and some Asians, the potential for further savings in dollars and
suffering is considerable.

DEPARTMENTAL ACTIVITIES

Departmental activities to ensure that patient education materials
and programs are available and suitable to specific minority groups
should include the following recommendations:

• Review and assess existing patient education materials, messages,
and media in the Department to determine their applicability

and suitability to specific minority groups. Minority group
representatives should participate in planning and evaluating
the appropriateness of materials, messages, and media
addressing the major health problems confronting the
minorities .

• Develop new patient education materials, messages, and media as
needed, tailored to the specific needs of minority populations
and designed for use in specific health care settings.

• Encourage health professions' training institutions to develop
training programs so that health care providers such as
physicians, dentists, nurses, social workers, health educators,
lay counselors, allied health professionals, and volunteers may
gain increased awareness of and sensitivity to the health problems
and health attitudes, beliefs, and concerns of minority
populations .

• Ensure that minority-specific patient education programs
incorporate culturally relevant reasons why patients should
comply with the necessary medical regimen. Mechanisms for
involving minority organizations and disease-specific voluntary
organizations should be explored.

DELIVERING AND FINANCING HEALTH SERVICES

Introduction

The Task Force has reviewed data that indicate low income and
lack of health insurance coverage are among the most serious barriers
to seeking health care. Minorities are disproportionately represented
among impoverished Americans. The Department can serve as a catalyst
to promote action by private and public entities to address these
problem areas more effectively.

RECOMMENDATION 3: DELIVERY AND FINANCING OF HEALTH SERVICES

The Department should continue to investigate , develop, and
implement innovative models for delivery and financing of health
services , based on current departmental authorizations . The major
objectives of the models should be to increase flexibility of health
care delivery , facilitate access to services by minority populations ,
improve efficiency of service and payment systems, and modify services
to be more culturally acceptable .

Traditional Measures of Health Care Services

The most commonly used indicators of the adequacy of health
services for a population include distribution of physicians,
percentage of a specified population who did not see a physician
during the past year, and average number of visits to a physician.
For these gross indicators, data are lacking for some minority groups.

These data do suggest that, in general, availability of health
care professionals and utilization of health services for all
Americans have increased:

• The rate of increase in the number of physicians in the United
States has more than kept pace with the growth of the American
population. During the period from 1970 to 1982, the American
population grew by 11 percent, while the number of physicians
grew by 51 percent. With the exception of Native Americans,
most minority populations live in geographic areas where
physicians are present. Little is known, however, about the
practice patterns of medical specialists and the extent to
which they treat minorities.

• In 1970, the percentage of people who had not seen a
physician in the past 12 months was 30 percent for Whites and
42 percent for non-Whites (■'•) . During the period from 1978 to

The Census definitions of White and non-White were used in 1970.
People of Mexican or Spanish descent were coded "White," and Native
Americans, Asian/Pacific Islanders, and Blacks were coded "non-White."

1980, these percentages were 23 percent for Whites, 24 percent
for Blacks, 33 percent for Mexican Americans, and 20 to 24
percent for other Hispanic groups .

• In 1970, the average annual number of visits to a physician per
year was 4.1 for Whites and 3.6 for non-Whites. During the
period from 1978 to 1980, the average number of physician visits
rose to 4.8 for Whites, 4.8 for Blacks, 4.3 for Mexican
Americans, and from 5.1 to 6.1 for other Hispanic groups.

No absolute standards are available for measuring adequacy of
health services. Data for nonminorities, however, provide a base
against which to compare the use of health services by minorities . In
sum, gross indicators of access to and utilization of health services
show improvement for the Nation as a whole and for those minorities
for whom data are available.

Traditional Measures Are Incomplete

The narrowing of the disparity in reported use of health services
between minorities and nonminorities is an encouraging trend. The
data, however, are lacking for many of the minorities. Moreover, the
indicators themselves do not reflect delays between the onset of
problems and the seeking of medical attention, severity of the problem
when care is sought, quality of the care received, and whether
appropriate referrals are made to specialists.

Information provided to the Task Force from a variety of
non-Federal sources, including health professional and minority
organizations, and the Tasks Force's professional judgment indicate
problems relating to health services persist for minorities. The
following exemplify such problems:

• The disparities in death rates between minorities and
nonminorities remain despite overall increases in access and
utilization that have been noted.

• Language problems hamper refugees and immigrants when

they seek medical care and try to explain their symptoms to
providers .

• Blacks with cancer tend to postpone seeking diagnosis
of their symptoms longer than do nonminorities, and
delay initiation of treatment once diagnosed.

•

A smaller proportion of Black women than White women begin
prenatal care in the first trimester of pregnancy (63 percent
versus 76 percent in 1980) , a factor related to the high Black
infant mortality rate. The 1990 health objective for prenatal
care states that a minimum of 90 percent of mothers in any racial
or ethnic group should begin care in the first trimester of
pregnancy.

• The postneonatal death rate, which constitutes the bulk

of infant mortality for American Indians and Alaska Natives,
remains high. Postneonatal mortality implies an adverse milieu
for the infant and is thought to result from such problems as
infectious diseases, unintentional injuries, and a lower use of
health care for these acute problems.

Continuity of Care

Continuity of care is associated with improved health outcomes
and is presumably greater when a patient is able to establish an
ongoing relationship with a particular provider. The issue is central
because many of the major killers of minorities, such as cancer,
cardiovascular disease, and diabetes, are chronic rather than acute
problems and require repeated visits and extended treatment
regimens .

• A higher percentage of Blacks and Hispanics than Whites
report that they they have no usual source of medical care (20
and 19 percent versus 13 percent) .

• Proportionately fewer Blacks and Hispanics than Whites report
that they use a physician's office as their usual source of care
(46 and 54 percent versus 70 percent) .

• Proportionately twice as many Blacks and Hispanics than
Whites report they use hospitals and health clinics as their
usual source of medical care. In 1980, more than 25 percent of
all visits to physicians made by Blacks occurred in hospital
clinics or emergency rooms compared to 11 percent by Whites.

• Refugees are eligible for special refugee medical assistance
during their first 18 months in this country. After this,
however, refugees who cannot afford private health insurance and
who are ineligible for Medicaid or state medical assistance may
become medically indigent.

• Many American Indians and Alaska Natives live in areas where
the availability of physicians is half the national average,
and the Indian Health Service may not be able to provide
coverage.

Financing Problems

Many of the minorities tend to rely on Medicaid and charity care
for their medical treatment because they have no other sources of care
or ways to finance that care. Elderly minority people are less likely
than Whites to supplement Medicare with additional private
insurance.

• Proportionately three times as many Native Americans, Blacks,
Hispanics, and certain Asian/Pacific Islander groups as
nonminorities are impoverished (29 percent to 35 percent versus
11 percent) .

• Proportionately twice as many Blacks and three times as many
Hispanics as nonminorities have no medical insurance whatsoever
(18 percent and 26 percent versus 9 percent).

• Of those who had no insurance, 35 percent did not see a physician
during the past 12 months compared to 22 percent for those who did
have insurance.

The problem of how to apportion fairly the costs associated with
uncompensated hospital care is a major concern. The traditional
practice of paying for this care through increased charges to other
individuals and third party payers has become increasingly
unacceptable as price competition among hospitals has heightened.

Public and private, not-for-profit, inner city hospitals bear the
greatest share of the uncompensated care burden and are not likely to
offset these expenses by attracting more paying patients. Unless
solutions to the uncompensated care problem are found, the financial
viability of these institutions may be in doubt. Access to health
care is predicated upon the ability of both individual providers and
institutions to meet the needs of the populations they serve.

Many States are now exploring the issue of uncompensated care
through task forces or commissioned studies.

The composition of each State s medically indigent population
varies according to its employment patterns, degree of unionization,
structure of its Medicaid program, and other factors which differ
among States. It is important, therefore, to encourage the States to
undertake their own data collection efforts to define their medically
indigent populations and devise policy initiatives that meet their
particular needs. The DHHS can provide a clearinghouse function in
these endeavors by providing baseline information, making available
the results of other States' inquiries and initiatives, and providing
technical assistance on questions of methodology.

Implications of Diversity

America is rich in the diversity of its minorities. There are
more than 500 federally recognized American Indian tribes, 23
different countries of origin for Asian/Pacific Islanders, and three
major places of origin for Hispanics. This diversity among
populations is reflected in language difficulties, in cultural
practices and beliefs with respect to illness and health, in

differences in their birth rates, in differences in the afflictions
which kill them, and in differences in their needs for types of
services and the duration of health care.

DEPARTMENTAL ACTIVITIES

The following activities should be pursued by the Department in
the area of delivering and financing health services.

• Serve as a resource to States as they study the problem of
health care for the medically indigent. Encourage States to
include consideration of minority subgroups in their research.
Place a particular focus on the employed uninsured.

• Evaluate the changes taking place in the health care
environment to assess their effect on uncompensated care and,
in particular, on public hospitals. Resulting actions could
lead, for example, to the formation of risk or revenue pools by
the States .

• Emphasize prevention and primary care and promote, through
existing program authorities, the concept of community-oriented
primary care in those areas where problems of access appear to
predominate.

• Target Federal categorical initiatives to trouble spots
identified through the mid-course review of progress toward the
1990 Health Promotion/Disease Prevention objectives.

• Continue and expand the Department's participation in the
Healthy Mothers/Healthy Babies Coalition, which has proven
successful in addressing the issue of prenatal and perinatal
care for low income women.

• Expand prenatal care Medicaid benefits, within existing
program authorities, for high-risk pregnant women to include:
nutrition supplements, psychosocial and health education classes,
birth education classes, prenatal vitamins, and other health care
upon authorization by the woman's physician.

• Use the established communication networks of organizations
within minority communities as conduits for the dissemination
of information about health promotion, disease prevention, and
the use of health services.

HEALTH PROFESSIONS DEVELOPMENT

Introduction

Health care professionals are essential to any program that aims
to improve the health status of minorities, since they are the
providers who assist in preventing illness and restoring health. The
Task Force recognizes this centrality and believes the Department must
forge a partnership with the health professions' community and others
to address jointly the health issues confronting minorities. The Task
Force presents recommendations for developing health professionals
both outside and within the Federal Government.

RECOMMENDATION 4: DEVELOPING STRATEGIES OUTSIDE THE

FEDERAL SECTOR

The Department should initiate discussions with minority and
nonminority health professional organizations , academic institutions.
State governments and health departments , and other entities from the
public and private sectors , to develop strategies to improve the
availability and accessibility of health professionals to minority
communities .

Considerations for Discussion

Analyses of data on the availability of health professionals have
provided some insight into the issue of the persistent disparity in
the health status of minorities. Several factors, however, require
further investigation concerning minority and nonminority health
professionals and their roles in minority communities.

• Minorities (and nonminorities) live in communities that do
not generally conform to the specific geographic boundaries

of political jurisdictions (states, counties, wards, districts,
etc.). Minority communities are not evenly distributed and
frequently cross over these geographic boundaries. In contrast,
record-keeping and other processes for monitoring (and
potentially influencing) the availability of health professionals
and resources are generally determined by and restricted to these
political boundaries.

• The size of a minority group, number of cultural subgroups,
and demographic features such as pattern and distribution of
minority communities are factors that influence the number of
health professions' students that each group might be expected
to generate and the degree to which a minority group can
support a cadre of health professionals in their communities.
With few exceptions, minorities are underrepresented as
students and practitioners of the health professions. For

example, the percentage of Blacks (11.5 percent of the population)
in medical schools has decreased from a high of 6.3 percent
(1974-75) to 5.5 percent (1983-84).

• Differences in the availability of health personnel resources
to minority communities are apparent regardless of the minority
group being considered. Communities located in urban/metropolitan
counties appear to have significantly more professional resources
available. Some of these professionals, however, are committed as
faculty, administrators, and researchers, thus making their
patient care contributions difficult to evaluate. The
aggregate number of health professionals in cities overstate

the actual availability of practitioners for patient care.

• The availability and accessibility of health personnel are
separate but related issues. The first is a critical initial
measure of resource potential, but is not an effective measure
of health care capability unless the latter is also considered.
Both of these critical issues must be addressed in planning for
the future.

In addition to these considerations, increasing health personnel
resources must involve interaction among the several groups that
influence the health professions. Most of the health disciplines
which collect data on their professional members do so on a national
basis. Licensure of practitioners is accomplished at the State level,
while accreditation of training institutions and certification of many
allied health professionals is done by national and State bodies.
Interests should be discussed and coordinated between those who
influence the numbers and types of health personnel and those who
wish to increase the numbers of health professionals in specific
geographic areas .

Data on the participation of each minority group and subgroup in
the various health professions is a prerequisite to determining how
these personnel contribute to improving the health status of minority
communities. Data on students are more readily available than
data on practitioners, but even these are not available for many
health disciplines and/or for many minority subgroups.

DEPARTMENTAL ACTIVITIES

The following activities recommended for DHHS would provide a
mechanism for sharing the Task Force's findings with the health
professions community, and concurrently provide a forum for dialogue
between interested and involved parties at all levels. Discussions
with the non-Federal sector should:

• Provide for a better integrated system for the collection
and analysis of data on: the numbers of health
professionals providing health care within minority
communities; the practice patterns and demographic features of

providers who serve these communities; and the numbers of
minority health professional students in training by-
discipline.

• Identify implementation strategies to address critical health
professions' educational issues, such as: increasing minority
participation in the various training areas; strengthening
training program curricula by making them more culturally
sensitive to minority patients and minority health problems as
identified in this report; and providing continuing education
programs for training on minority health issues.

Activities Witiiin the Federal Government

Development of a partnership for action with health professionals
outside the Federal Government should be supplemented with coordinated
action within the Federal Government. The Federal Government
maintains a substantial health professions' resource within the
Department and other elements of the Executive Branch. This resource
can and should be provided with the findings of this report so that a
cohesive approach may be developed with respect to the availability
and accessibility of health professionals to minority communities.

RECOMMENDATION 5: DEVELOPING STRATEGIES WITHIN THE

FEDERAL SECTOR

The Department should conduct both intra- and interdepartmental
reviews to identify and provide for collaboration between the various
activities currently being supported within the Department and other
elements of the Executive Branch, respectively . The reviews should
focus on programs that have impact on the actual or potential
availability of health professionals to minority communities.

Coordinated Effort

The Federal Government maintains a substantial health professions
resource. For example, it employs more than 18,000 physicians engaged
in a variety of activities which affect the health care of the Nation.
Within DHHS , the Public Health Service supports a number of programs
designed to address shortages of minority health professionals (as
practitioners and researchers) and place health professionals in
medically underserved areas. These resources should not duplicate
actions taken by other entities within DHHS or by other Federal
agencies .

DEPARTMENTAL ACTIVITIES

As part of the proposed reviews, discussions and dialogue between
responsible program officials should be stimulated to enhance DHHS
ability to address the persistent problems of providing health
professionals for underserved minority communities. Examples of
activities which DHHS could undertake follow:

• Sponsor a series of conferences, directed toward practitioners,
to promote the findings of this report and to develop health
education and health promotion techniques for minority
populations. The seminars should be made available to those
practitioners within the National Health Service Corps, the
Indian Health Service, and practitioners working under
DHHS grants, to identify areas where the impact of their
respective resources on minority communities might be
enhanced.

• Encourage other Departments and agencies of the Executive Branch,
especially the Veterans' Administration, to conduct training seminars
on health education and health promotion techniques for minority
populations. The seminars should foster interdepartmental support

to improve the health of minorities.

• Collaborate with other agencies in the Executive Branch, such
as the Department of Education, the National Science
Foundation, and others, to encourage more minority researchers
to apply for Federal research grants, and to encourage more
minority science faculty appointments to health and
health-related training institutions. A model program that
addresses the problem is the National Cancer Institute's
Minority Investigator Supplement to Investigator Initiated
Awards, which provides a means for entering into research grant
programs and the opportunity to utilize the research skills of
the minority investigator.

• Examine ways to increase minority representation in
preventive medicine, public health, health education,
communications, and other health professions.

COOPERATIVE EFFORTS WITH THE NON-FEDERAL SECTOR

Introduction

Activities to improve minority health cannot be confined solely
to the Federal Government. The participation of organizations at all
levels --National, State, municipal, and community-is vital to achieve
improved health for minority individuals. State and municipal
agencies are increasingly aware of the unique needs of their minority
residents. Many localities, in fact, have developed plans to meet the
national 1990 objectives for their health care needs.

The private sector can often be a very effective channel for
programs targeted to minorities. National organizations concerned
with minorities such as the National Urban League and the Coalition of
Hispanic Mental Health and Human Services Organizations (COSSMHO)
include health-related issues in their national agendas and are
actively seeking effective ways to improve the health of minorities.
Organizations such as these have a powerful potential for effecting
change among their constituencies because they have strong
community- level , "grass roots" support.

Changes in health behavior frequently depend on personal
initiative and are most likely to be triggered by health promotion
efforts originating from locally-based sources. Indeed, community
involvement in developing health promotion activities can contribute
to their success by giving credibility and visibility to the
activities, and by facilitating their acceptance. By addressing
health problems that occur within their own communities, minority
residents can empower themselves to press more actively for adequate
and comprehensive efforts aimed at improving the health of individuals
and the community.

Not all minority communities, however, have the ability to
identify their own health problems and initiate activities to address
them. It is here that the Federal Government's knowledge and
expertise in health can join with community and other non-Federal
groups to strengthen minority-related health activities.

RECOMMENDATION G: BUILD THE CAPACITY OF THE NON-FEDERAL

SECTOR TO ADDRESS MINORITY HEALTH
PROBLEMS

DHHS should increase its involvement with State, local, and
community agencies and organizations to encourage efforts
specifically oriented toward meeting minority health needs.
Recognizing that communities have unique insights into their own
health problems , DHHS should undertake activities to increase
awareness by minority communities of the Federal ability to provide an
overview of health problems and to provide technical assistance .

Through departmental efforts in assisting communities to define local
health goals, objectives , and priorities, develop strategies for
resolving health problems, and set action plans into operation,
localities can build an internal capacity for meeting the health needs
of local minority populations.

Overview Position of DHHS

The Federal Government, through DHHS, is in a unique position to
serve as a knowledgeable resource to State and local agencies and to
private health-related organizations. Through its efforts in data
collection, surveillance of health indicators, research programs on
specialized health topics, and delivery of model health services, DHHS
retains a national overview of the health problems and demographic
descriptors of minority populations in the United States. Examples of
these resources include:

• National surveys of health status and health services utilization
conducted by the National Center for Health Statistics (NCHS) .

• Specialized survey research, such as the National Drug Abuse
Survey conducted by the National Institute on Drug Abuse (NIDA) ,
and the National Survey on Physical Violence in American
Families funded by the National Institute of Mental Health (NIMH)
and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) .
Both surveys are oversampling Blacks and Hispanics in their 1985
cycles .

• The research and surveillance role played by the Centers for
Disease Control (CDC) in areas of infant mortality, homicide
and suicide, and diabetes.

• Model information and educational programs in each of the six
priority areas carried out by almost every agency.

• Demonstration programs, such as those sponsored by the

National Institutes of Health (NIH) that introduce proven preventive
and therapeutic regimens and health care delivery advances to
the public.

Special community needs often can be identified very effectively
at national and local levels by organizations concerned with specific
minority subgroups. Plans for intervention will be stronger and more
effective if they are initiated by groups that are familiar with a
community's culture, traditions, and languages and that can mobilize
local resources and networks for resolving particular health problems.

Some minority communities, however, do not have sufficient
information to define their greatest health needs and to develop
community strategies and constructive approaches for resolving these
problems. Where it is fitting and appropriate, DHHS can provide

states, municipalities, or communities with a national overview of
their place within a larger context, and share the benefit of
experience gained from programs that have proven successful in other
localities. The Model Standards for Community Preventive Health
Services project, a collaborative effort of CDC, the American Public
Health Association, and associations of State, territorial, county,
and city health officials, is a prime example of this kind of program
activity.

Providing Technical Assistance

The Department can provide technical assistance to State and local
health agencies, community- level organizations, business and industry,
professional and voluntary health associations, and other private sector
groups. Serving in a consultative or advisory role, DHHS experts can
assist the states in addressing problems that lie within the state's
jurisdiction (e.g., infant mortality, homicide, school health) by:

• Providing specific information to allow the health community
to take prudent action.

• Identifying special health problems and needs.

• Organizing and planning minority-relevant intervention approaches.

• Suggesting mechanisms for implementing plans.

Cooperative Efforts

The following examples demonstrate ways the Department has worked
with States, communities, and other organizations to build local capacity
to meet health problems .

Teclinicai Assistance to States. Upon request of State health author-
ities, the Low Birth Weight Prevention Work Group will send Infant
Mortality Review Teams (IMR teams) to conduct geographically focused
infant mortality reviews and investigate conditions associated with
high or changing infant mortality. The IMR teams, composed of experts
from the public and private sectors, serve as consultants and assist
State health departments in gaining a better understanding of local
difficulties in reducing infant mortality, in gathering precise
information regarding local maternity and infant health care systems,
and in developing strategies that will provide opportunities for
ameliorating local problems.

Specialized Community Health Services. The On Lok Senior Health
Services is a community-based, long-term care organization serving the
frail elderly, many of whom are Asian. On Lok began as a
federally funded research and demonstration project in 1972, and was
able to assume its own financial responsibility by 1984. Services
include hospitalization for acute conditions, a nursing home, a
pharmacy, professional services (dentistry, optometry, podiatry, and

other subspecialty medical services), home health services, nutrition
programs, housing for the elderly, and transportation to medical care.
Similar specialty services have been developed in other communities
based on the On Lok model, such as women's health, substance abuse
programs, and youth programs. The On Lok experience indicates that it
may be more feasible to develop specialty services in a particular
community rather than a more comprehensive health program.

Community Efforts. Results from research sponsored by DHHS are freq-
uently disseminated to the general public or to target populations with
the cooperation of national and local media, and community networks.

The National Cancer Institute launched a special cancer
prevention awareness program for Black Americans., It began with a
mass media effort aimed at increasing awareness among Black citizens
that everyone can do something to reduce the personal risk of cancer.
The mass media effort will be followed by national and community -based
educational activities that rely on strong involvement of
traditionally Black organizations.

The National High Blood Pressure Education Program has worked
successfully with communities. State and local health departments,
industry, and professional and voluntary health organizations to
increase health professionals' and the public's awareness about the
risks associated with untreated hypertension and the opportunities for
effective treatment.

The National Institute on Drug Abuse (NIDA) has encouraged Black
organizations to incorporate drug and alcohol abuse prevention
activities into their national agendas. NIDA has also provided
guidance and support in the development and promotion of national
multicultural networks among Black, Hispanic, Asian, and Native
American families. One outcome is the development of a network among
Black parents and community organizations to stimulate community-based
prevention programs in drug and alcohol abuse. This model for a
"grass roots" prevention program is being replicated in a select
number of cities across the country.

Business and industry. A number of agencies within DHHS provide
technical assistance to individuals and organizations in business and
industry. The Office of Disease Prevention and Health Promotion (ODPHP)
is working with the Workplace Health Fund, a component of AFL-CIO, to
develop worksite health promotion programs through unions. ODPHP also
assists businesses in planning health promotion programs for the future
by identifying trends that influence work and health.

The National Heart, Lung, and Blood Institute (NHLBI)
cosponsored a conference with several major corporations to examine
positive outcomes derived from worksite health promotion programs.
NHLBI also developed the Cardiovascular Primer for the Workplace to

assist private industry in developing cardiovascular risk reduction
activities. At present, NHLBI is examining ways of working with small
businesses to develop health promotion programs.

Health Care Settings. A leader in the field of preventive
interventions for victims of domestic violence has been the Harborview
Medical Center in Seattle. The Center developed a comprehensive
intervention model that addresses the needs of victims of spouse
abuse, child sexual abuse, rape, elder abuse, and assaults by
strangers. A model emergency room protocol for identifying adult
victims of domestic violence has been developed for hospitals in New
York State and can be adapted for use elsewhere. Efforts based on
these models need to be introduced and tested further in similar
health care settings.

DEPARTMENTAL ACTIVITIES

Activities in which DHHS can take a leadership role in initiating
cooperative efforts with the non-Federal sector to improve the long-term
health status of minority groups include:

• Support development, testing, and dissemination of model programs
suitable for minority community-based efforts for disease
prevention and health promotion, especially in the six priority
health areas.

• Provide technical assistance in the implementation of State and
local prevention programs that focus on the special needs of
minority populations.

• Increase collaborative efforts with State and local governments,
professional associations, and health-related voluntary and private
organizations, to develop their capacity to identify health
objectives, set priorities, and implement strategies to improve
the long-term health status of minority populations . This
collaborative effort should include:

--encouraging States to conduct reviews of their efforts to
address the health needs of minority populations.

--strengthening State, municipal, and local community capacities
to develop prevention initiatives aimed at the high incidence
of adverse health events such as drunk driving, family
violence, and drug abuse.

--advising States of Federal data on minorities relevant to
their localities and encouraging the States to develop data
on avoidable mortality by locality.

--conducting forums through the PHS regional health offices
where communities can present model health programs targeted
to a particular minority health effort. A manual of these

initiatives could serve as a resource to other communities
seeking information on effective prevention programs and
how to apply them in different communities,
--strengthening private and public efforts in addressing

minority health issues by convening meetings of groups, such
as leading private sector minority organizations, State
health agency officers, major voluntary organizations, and
professional organizations, to define specific minority
health issues and to discuss mechanisms for dealing with
them.

--encouraging organizations concerned with minority issues to
develop and promote health education materials that are
appropriate to the culture and the language of the minority
groups they serve.

• Encourage the development of outreach programs that evaluate
high-risk subsets of minority groups.

• Initiate meetings with other departments in the Executive Branch
to address health problems of mutual interest oriented to
building the capacities of local communities. Appropriate
topics and agencies include:

--developing a combined strategy for prevention of homicide
with the Department of Justice.

--improving housing and reducing environmental hazards for
populations at high risk for injuries with the Department of
Housing and Urban Development.

--coordinating smoking cessation programs and other health
promotion programs under other Departments' sponsorship,
such as the Departments of Defense and Education.

DATA DEVELOPMENT

Introduction

The Task Force believes that data issues are a major area for
recommendations and suggests that more extensive minority health and
illness data are needed to improve the information available to DHHS
and the private sector for making program and policy decisions.
Examples of why this is so include:

• National data on mortality rates for Hispanics are lacking.

• The accuracy with which ethnic group membership is described
on death certificates, especially for Hispanics, is variable.

• Studies based on diabetes mortality rates in minorities fail

to consider differences in incidence, age of onset, availability
of medical care, education, socioeconomic status, and
interaction with hypertension.

• Population-based cancer registries often lack comparability
with information from the National Cancer Institute's
Surveillance, Epidemiology, and End Results (SEER) program.

• The incidence of sudden cardiac death in Blacks in relationship
to coronary heart disease has been examined, but no firm
conclusion is possible because of lack of data.

Reliable data are central to measuring progress in public health,
and are the key to assessing the current health status of the Nation
and measuring health status trends; recognizing both sources of and
solutions to problems; identifying health disparities between segments
of the population; and targeting efforts directly to specific needs.

The data available in the Task Force review and other reports have
pointed to disparities in death rates, health status, and health care
utilization between minorities and nonminorities , but more detailed
data are needed to enhance our understanding of the processes underlying
the disparity and to provide a better basis for rational program
planning, implementing, and monitoring. The effort to obtain reliable
data is especially challenging because minority populations are growing
rapidly, changing rapidly, highly mobile, and, therefore, difficult
to track yet have greater health problems than nonminorities.

RECOMMENDATION 7: IMPROVING AND FULLY USING AVAILABLE

SOURCES OF DATA

DHHS should undertake activities , which would improve existing
sources of health data, such as: enhancing cooperative efforts with the
States in recording vital statistics , incorporating specific

racial/ethnic identifiers in data bases, and oversampling selected
minorities in national surveys. Furthermore, DHHS should support
innovative uses of currently available data consistent with the
Privacy Act and confidentiality constraints . Analyses such as
cross-comparisons from different data sets and specialized studies
should be encouraged because they can contribute to understanding the
health status and needs of minority populations .

Steps to Better Understanding

Gaining better understanding and knowledge of the health of
minority populations requires improving the collection of quantitative
data on the incidence and prevalence of health problems in these
populations. Analysis of health status data with specific minority
identifiers will allow elucidation of relationships between factors
that may be responsible for the disparity in death rates. For
example, the Task Force has concluded that data on the incidence of
chronic heart disease in Black populations are inadequate because
relatively few studies include significant numbers of Blacks.
Recognition of these needs has led to some efforts to obtain more
data, such as the surveillance of chronic heart disease events in a
predominantly Black community being performed under the sponsorship of
NHLBl. Similarly, the Hispanic Health and Nutrition Examination
Survey (HHANES) will advance knowledge of health and nutritional
status among Americans of Mexican, Puerto Rican, and Cuban origin
through special data collection efforts. Until this survey, data on
the health status of Hispanics were limited to self-reports such as
those compiled in the National Health Interview Survey (NHIS) .

Sources of Health Data

DHHS receives health data on a variety of topics from a wide
range of sources. Vital statistics data on births, deaths, marriages,
and divorces are provided by the States to the National Center for
Health Statistics (NCHS) , the Nation's chief health data collection
agency. NCHS also conducts national surveys based on samples that are
representative of the total U.S. population. These surveys include
NHIS, the National Health and Nutrition Examination Survey (NHANES) ,
the National Ambulatory Medical Care Survey (NAMCS) , the National
Hospital Discharge Survey (NHDS) , and other data collection activities
that document the health characteristics of the United States
population. Other data on health status and health care utilization
are furnished by States and local sources to the Centers for Disease
Control (CDC) , to the Health Care Financing Administration (HCFA)
through its Medicaid and Medicare programs, to the Social Security
Administration (SSA) , and to various programs within the Department
that may be studying health problems within specific populations.

Problems with Existing Sources of Data

The data now collected by the Department comprise a useful base
for health-related study and analysis. The Task Force, however, has
identified a number of problems with existing data relating to the
health of minorities.

One problem is the lack of common practices among the States in
recording ethnicity identifiers in their reported data. Few States
require a Hispanic identifier on death certificates, and the quality
of the identifications that are made is variable. Furthermore,
individuals who fill out death certificates may do so inadequately
because of insufficient training and understanding of the importance
and uses of the information.

When race and ethnicity are recorded in Federal data collection
efforts or for administrative record keeping, the Office of Management
and Budget (0MB) provides minimum requirements for the categories to
be recorded. The Office of Federal Statistical Policy and Standards
Directive Number 15 classifies race as: 1) American Indian or Alaska
Native, 2) Asian or Pacific Islander, 3) Black, and 4) White.
Ethnicity is defined as: 1) Hispanic origin, or 2) Not Hispanic
origin.

Although these categories, as mandated, are too broad to permit
delineation within subgroups, the greater difficulty is that many DHHS
statistical files and data bases fall short of meeting even the OMB
requirement, particularly administrative records, self-reported
hospital forms, and some social security claims. Furthermore, some
DHHS data bases that originally contained data specifying minority
group status have aggregated that data into a category labeled
other", thus losing the racial/ethnic integrity of the data.

Another problem relates to data collected from national surveys.
Current surveys provide a good indication of the health picture of the
Nation as a whole, as they are designed to do, but only limited
information is available from them for many minority populations.
Surveys usually sample minorities in proportion to their presence in
the U.S. population. More data exist on Blacks, as the
largest minority group and, indeed, NCHS has data on Blacks going back
to the 1960's, the earliest period for which tapes are available.
Smaller groups, such as Native Americans or Asian/Pacific Islanders,
are represented by far fewer households. National surveys may include
too few minority individuals to permit reliable analyses of health
data for a particular group.

The Task Force has concluded that inconsistencies in data
collection practices among the States, such as inadequate recording of
some ethnic identifiers, overaggregation of minority data, and
insufficient representation of minorities in national surveys are
areas needing improvement .

strategies for Improving Data

Two strategies for improving data on minorities are oversarapling
and targeted studies . Both approaches have advantages and
disadvantages that need to be weighed when planning data collection
efforts .

Oversampling of minorities offers the advantages of improving the
precision of the data and allowing comparison with other groups for
which data were collected contemporaneously. Oversampling in national
surveys, however, presents the problem of developing valid and
reliable procedures to select a randomized, representative sample of
minorities. Moreover, additional costs are involved in oversampling
in a national survey. Thus, there is a trade-off between costs and
precision of information.

Another strategy for obtaining improved data is to mount targeted
studies of specific minority populations or geographical areas. This
technique would enhance knowledge of an identified group without the
cost and difficulty of a national sample. By virtue of their targeted
focus, however, such studies yield data that may not necessarily be
comparable to other populations. Thus, careful planning is necessary
to ensure that meaningful comparisons can be made.

The choice of sampling strategy is influenced by the issue being
addressed, the needed degree of oversampling and its attendant costs
and complexity, the geographic concentration of minority groups, and
other considerations. Although oversampling or targeted studies may
correct deficiencies in national surveys, the technique selected must
be tailored to the particular data-gathering effort.

Using Existing Data

Many agencies in DHHS and other Federal Departments routinely
collect information for administrative and other programmatic purposes
that may contain health or ethnic identifying data. Presently,
legislative restrictions that protect the privacy of individuals
prohibit the exchange of administrative data for statistical research
purposes. A solution to this dilemma is to establish conditions for
the greater linkage of records among agencies to be used only for
statistical research purposes. The rights of individuals to privacy,
however, must be protected. Record linkage is one effective way to
obtain needed information on small populations without great cost.

Record linkage has been supported consistently by DHHS in the
past. Because of the tremendous wealth of information on minority
health that could be gleaned from administrative records in this and
other Departments, an appropriate resolution should be explored.

DEPARTMENTAL ACTIVITIES

To enhance the opportunities for more effective data collection
relating to minorities in the United States, DHHS should pursue the
following activities:

• Assign high priority to cooperative efforts between DHHS and the
States directed at developing standardized Hispanic identifiers
in vital statistics records (death, birth, marriage, and divorce
certificates) .

• Strengthen and expand efforts between the Department and the
States to develop a national data base of linked birth and
death records for analyzing infant mortality.

• Strengthen and expand cooperative efforts to train personnel to
complete vital statistics records accurately (particularly with
regard to correct coding of causes of death and racial/ethnic
identifying items).

• Establish a mechanism to evaluate the quality of information on
death certificates to determine if guidelines for completing the
items on the certificate are followed.

• Require all DHHS agencies that collect health data from in-
dividuals to include race and ethnic identifiers, as defined by 0MB.
Where possible and desirable, further breakdown within racial and
ethnic categories should be recorded, e.g., national origin of
Hispanics and Asian/Pacific Islanders.

• Maintain specific racial/ethnic identifiers when processing
original data. For those data collected cooperatively from
the States by agencies such as CDC and NCHS, efforts should be
increased to overcome barriers to obtaining data with standardized
race/ethnicity identifiers.

• Oversample selected minorities in national surveys of health
indicators or conduct targeted studies on minority health
problems, as appropriate.

• Work with the Census Bureau to improve health-related, minority-
specific data collection for the 1990 census.

• Analyze and highlight minority health issues, especially in the
six health priority areas, that result from improved minority
identifiers in data collection.

Develop mechanisms for matching individual records from among
government data sets, within and between Departments, for
health and statistical research purposes. DHHS should
encourage and support legislative changes to allow such
matching to occur with the appropriate safeguards.

Investigate, in the absence of legislation permitting data
linkage across DHHS agencies, mechanisms whereby the minority-
specific, health-related data collected by each agency can be
analyzed and published.

RESEARCH AGENDA

Introduction

The Task Force has reviewed a considerable body of scientific
knowledge related to the disparities in health status between minority
and nonminority populations in the United States. It is evident that
most of the disparity can be attributed to six areas identified as
major contributors to excess mortality among minorities. Although the
Task Force Subcommittees have explored physiological, cultural, and
societal factors that may be responsible for the health disparity,
many unanswered questions remain. Resolving these questions will
require continued research and analysis to increase the base of
scientific knowledge and to elucidate factors that put minorities at
greater risk for illness and death.

The research activities recommended by the Task Force refer
primarily to needed minority-specific health issues. The huge volume
of ongoing research, particularly basic research already conducted
through DHHS, applies to all populations, including minorities.
Research into the etiology of diseases, treatment of diseases, and
improved health service delivery will continue to benefit all
Americans. The research proposed by the Task Force, however, is of
major importance to minority health because it specifically aims at
understanding the reasons underlying the longstanding disparity of
health status in the United States. It offers the means to prevent or
reduce much of the illness and death experienced by minorities in
disproportion to their representation in the American population. The
spectrum of suggested activities includes research into the etiology
of diseases, research in behavioral and social sciences, clinical
studies of treatment and treatment outcomes , research on the dynamics
of health care and its impact on disease, and appropropriate
interventions for disease prevention and health promotion.

The research agenda presents examples of priority areas for
immediate investigation. The Subcommittee reports provide a rationale
and fuller elaboration of the recommended research activities. By no
means do they exhaust the range of activities needed for further
research into minority health.

In addition to research into the reasons for the disparity,
separate studies need to evaluate the impact of DHHS and other Federal
programs on the health of minorities. Such studies are needed to
coordinate departmental policies and programs, to identify areas where
program efficiency can be improved and costs reduced, and to provide a
measure of the extent to which policies and programs are achieving
their objectives. Recognizing this, the Task Force includes
evaluation studies as an integral part of the research agenda.

The Task Force suggests that each agency of DHHS review its
portfolio of federally supported research and its applications for
research funding to ensure that minority health issues are included.

RECOMMENDATION 8: RESEARCH AGENDA

The Department should adopt and foster a research agenda to
investigate factors affecting minority health and should incorporate
appropriate research activities on minority health into ongoing
research programs consistent with the referral guidelines of each DHHS
agency. The Task Force considers the following areas to be of major
Importance for research :

• Risk factor ident if icat ion

• Risk factor prevalence

• Health education interventions

• Preventive services interventions

• Treatment services

• Sociocultural factors and health outcomes

DEPARTMENTAL ACTIVITIES

I. Research into Risk Factor Identification

Risk factors are the characteristics of individuals that are
associated with the occurrence of health problems . Their identification
is important to elucidate possible etiologic factors for a disease,
to identify individuals or populations likely to experience health
problems, to institute early preventive measures, and to identify groups
on whom preventive or educational interventions can be concentrated.

More information is needed to clarify whether risk variables that
contribute to the occurrence of disease in White populations contribute
to disease differently in minority populations. For example. Black
males have a higher prevalence of hypertension than Whites but experience
a similar rate of mortality from coronary heart disease (CHD) as White
males. Similarly, some Hispanic subgroups, specifically Mexican Americans,
have a higher prevalence of diabetes, another risk factor for CHD, but
exhibit lower mortality rates from CHD than Whites.

For the most part, identifying risk factors, defining risk status
(whether a person is at high or low risk for a health problem) ,
establishing risk profiles (distribution of risk status in a
population), and following trends in risk patterns can be accomplished
by well-designed epidemiologic studies. The impact of behavioral,
physiological, and environmental factors also can be assessed in such
studies .

Certain minority groups, such as second-generation Chinese, have a
more favorable health status for certain conditions or have reduced
all-cause mortality. Studies of populations at low risk for certain

diseases also will add to understanding the relationship of risk
factors to disease. DHHS activities to identify risk factors for the
major health priority areas include:

• Identify and quantify, where possible, behavioral, physiological,
and environmental risk factors for CHD, cancer, and diabetes in
each minority group. Determine if the risk factors for CHD
identified for White populations act similarly in the minority
groups or if other risk factors, not yet identified, contribute
to CHD in minority groups.

• Identify behavioral, physiological, and environmental
characteristics of minority groups that place them at higher
risk for any of the six health priority areas.

• Assess the impact of hypertension as a risk factor for morbidity
and mortality in all minority groups.

• Identify the determinants of smoking behavior, cessation, and
cessation maintenance in minority populations, particularly
among pregnant minority women. Blacks, Hispanics, and Native
Americans who may suffer the delayed effects of increasing
rates of smoking.

• Determine the relationship of high rates of obesity found in
Black females to their consequent excess mortality from CHD.

• Investigate the role of high-density lipoprotein (HDL) levels
in influencing CHD outcome in Black and other minority males.

• Investigate links between dietary potassium and sodium intake
(and other electrolytes) and hypertension in Blacks and other
minorities .

• Study variables such as income, employment, school truancy, drug
and alcohol problems, educational attainment, and accessibility
of handguns as possible risk factors for homicide, particularly
among Black and Hispanic males.

• Support improved studies of situational correlates of homicide and
nonfatal assaults aimed at identifing high-risk situations for
which preventive interventions are needed.

• Support studies on risk factors for deaths from unintentional
injuries, suicide, and homicide among Native Americans and
other minorities.

• Support studies on risk factors for suicide among Asian women,
particularly those of age 45 and older.

• Investigate generational factors related to birthweight since
the birthweight of the offspring appears to be correlated with
the weight of the mother at her birth. Investigate racial/ethnic
differences and socioeconomic resources related to differences

in birthweight.

• Elucidate the role of physiological, social, psychological,
and environmental stress on pregnancy outcome in different
racial/ethnic groups, for example, the effects of unplanned
pregnancy, unmarried status, low economic status, and employment
in physically stressful jobs.

• Study the influence in Black women of nutrition as a risk
factor for cancer, cardiovascular disease, and low-birthweight
offspring.

• Conduct studies to understand dietary and exercise patterns more
thoroughly in the four minority groups .

• Focus research efforts on the preventable causes of postneonatal
mortality, including causes of accidental death. Research should
encompass the interrelationship of individual and family
behaviors, and health care delivery factors that influence the
use of well and sick baby care, and immunization of babies.

• Initiate descriptive studies to identify occupational risks
associated with the leading causes of death and disability in
minority populations.

• Investigate minority status as a risk factor for safety in the
workplace, including monitoring excessive exposure to contaminants
from occupational sources and environmental pollution.

• Assess factors contributing to excess deaths due to cardiovascular
disease in Native American men aged 35-39 years old.

II. Research into Risk Factor Prevalence

Disease patterns may be shared by an entire minority population, a
subset of that population, a certain age group or gender, or geographic
grouping of the minority population. Risk factor prevalence in such
groups which share a health status trait warrant careful investigation,
not only in cases where a clear disease burden is evident but also for
diseases in which a subgroup displays better health. Activities to
study risk factor prevalence for the major health priority areas should
include :

• Continue to support large-scale, population-based prospective
studies of coronary heart disease, similar to the Framingham
studies and/or community-based studies for minority
populations. Among the many Hispanic subgroups, Puerto Ricans

and Cubans living in the United States have not been studied
extensively and particularly warrant such research. Sudden
death rates from CHD among Blacks need to be investigated by
age and gender. Surveillance of the offspring of individuals
studied is needed to understand coronary disease trends and to
elucidate familial contributions to the incidence and disease
process in these population groups.

• Study serum lipid levels, dietary risk reduction information,
interventions, and behaviors for Puerto Rican, Cuban, and
other Hispanic populations.

• Assess the relationship between dietary patterns in minority
groups and the development of diabetes, cancer, and cardio-
vascular disease (CVD) . Strengthen nutritional status surveillance
of low income minority populations.

• Design epidemiologic studies to evaluate differences in the
distribution of diabetes in minority groups and the

impact of physiologic variables on these differences. Study
etiology of diabetes using diabetes blood group analysis,
particularly for American Indians.

• Support cohort studies to gain more insight into the etiology
of drug abuse among minorities.

• Examine smoking prevalence and industrial exposures as contributing
to CVD and the rapid rate of increase in lung cancer in Blacks.

• Examine factors associated with unplanned pregnancies, including
both nonuse and inadequate use of contraceptives, in high-risk
minority women and teenagers. Unplanned pregnancies are
associated with worse patterns of prenatal care and higher
rates of low birthweight.

• Investigate the prevalence of multiple risks (e.g., smoking
and drug abuse) among different minority populations to
understand possible synergistic effects on pregnancy outcome.

• Initiate prospective studies on perinatal outcome (low birth-
weight and infant mortality) .

III. Research into Health Education Interventions

Health education interventions are directed at improving the
awareness of individuals and communities about controllable risk
factors associated with the causes of excess death and disability.
Components of the major health problems facing minorities that are
amenable to health education efforts include the misuse of alcohol
and drugs, use of tobacco, dietary habits, exercise, stress
management, compliance with medical regimens, and appropriate use of
preventive services. It is not always clear, however, which type of

intervention is best suited to the target audience and what kinds of
outcomes should be expected from efforts to promote intervention
strategies for minorities. Activities for investigating health
education interventions include:

• Develop health education techniques appropriate to particular
minority groups that will facilitate the adoption of specific
interventions for risk factors, especially among groups at
high risk for cardiovascular disease, cancer, diabetes, and
homicide. Such research should recognize different cultural
sensitivities and attitudes toward health behaviors related to
these problems.

• Support research to develop and validate effective stress
reduction and behavior modification strategies for treatment of
coronary heart disease and its risk factors in minority
populations .

• Develop model programs for use in community-based efforts to
prevent homicide and improve delivery of services to victims
of violence, such as the House of Umoja.

• Support studies among minority groups to identify existing
health beliefs and practices more accurately.

• Analyze factors associated with positive perinatal health
outcomes among Asian Americans to help identify ways to avoid
adverse outcomes for other minority populations.

• Identify effective health education interventions for minority
groups in the areas of dietary risk factor reduction,
nutritional counseling, exercise, and smoking cessation.

• Support impact .and outcome evaluations of minority health
education interventions to help plan or modify interventions
and to justify the allocation of resources to such projects.

• Elucidate specific characteristics of minority populations that
may influence the dissemination of health information.

• Examine different methods of approaching minority populations,
through schools or worksites, to effect behavior change for
developing positive coping strategies. Explore differences

in coping strategies between males and females.

IV. Research into Preventive Services Interventions

Maintenance of health and prevention of disease are major
challenges to both the individual and the health community. To meet
the challenge, rigorous prevention-oriented research should be
initiated commensurate with the levels of need and representation of
minority populations. Components of effective disease prevention and

health promotion interventions that address minority health concerns
and methods that build on the strengths of both urban and rural
families and communities are among the activities stressed in this
section. Research activities include:

• Assess the factors influencing compliance/noncompliance to
antihypertensive medication regimens, especially in Filipino
women. This group contrasts with other ethnic minority groups
in the United States in which women generally have better blood
pressure control than men.

• Design and support studies to develop prevention methodologies
especially in the areas of alcohol and drug abuse as well as in
each of the health priority areas. Assess the success of
prevention and treatment strategies for alcohol and drug abuse
in minority populations.

• Conduct evaluation studies to assess the impact of innovative
approaches to prevent adverse pregnancy outcomes, especially
for minority women. Sociological, behavioral, and biological
variables should be controlled.

• Investigate the usefulness of expanded screening programs among
minority groups, e.g., blood glucose screening in those over
age 50 for diabetes, hepatitis B screening for pregnant Asian
women, screening newborns for sickle cell disease, and sonography
for Black women at increased risk for multiple gestations.

• Determine the mechanisms by which pregnancy planning influences
prenatal care, birth outcomes, and infant well-being.

• Track victims of serious nonfatal violence (e.g., child abuse,
spouse abuse, assault) because these may be events preceding
homicide.

• Explore mechanisms for reimbursing counseling and patient
education services provided under Medicare and Medicaid programs.
Continue to develop demonstration programs, particularly those
that serve minority populations, to identify the best means

for reimbursing health education programs provided in clinical
settings .

• Assess usefulness of clinical settings to offer counseling to
minorities for key health behaviors.

• Support studies to identify beliefs, awareness, and prehospital
behavior that might potentially delay diagnosis and treatment of
cardiovascular disease, cancer, diabetes, and other conditions
in minority patients.

V. Research into Treatment Services

Favorable health outcomes are related to accurate diagnosis,
appropriate and timely therapy, and follow-up. Understanding the
factors in primary health care settings that influence diagnosis and
treatment of minorities is important in developing intervention
approaches. Research is needed into the factors that operate in
medical care settings including: the dynamics of the patient-provider
relationship; the behavior, beliefs and attitudes of minority patients
and health care providers; and patterns of treatment/medical care
provided to minorities. Specific research activities follow:

• Assess determinants of physician behavior that influence
patient interaction, follow-up, and the adoption of innovative
techniques for prevention, early detection, and treatment.

• Determine how specific patterns of increased risk factors or
preexisting conditions determined to be more common among
minorities influence treatment approaches.

• Develop methods to monitor coronary heart disease events that
occur in the community, such as: sudden death, hospital admissions
and discharges of patients diagnosed as having heart disease,

and emergency room visits for patients with chest pains and
related complaints.

• Evaluate the long-term efficacy and safety of antihypertensive
medications, particularly in Blacks.

• Identify delivery systems to facilitate the recruitment of
hard-to-reach pregnant women into early care programs.

• Continue to evaluate the effect on perinatal outcomes of major
programs such as Maternal Infant Care, Improve Pregnancy Outcome,
and Supplemental Food Programs for Women, Infants, and Children.

• Elucidate how health service patterns and individual behavior
during illness affect cancer incidence, survival, and mortality
of minorities.

• Develop model programs to foster participation of State and
Federal efforts in diabetes control.

• Study the specific components of prenatal care that have the
greatest potential for preventing untoward perinatal complications.

VI. Research into Sociocultural Factors and Health Outcomes

Sociocultural factors play an important role in the maintenance
of health, perception of illness, and/or the pattern of treatment
sought by the individual. Many factors such as cultural heritage,
socioeconomic status (SES), social support, knowledge attitudes,
and health practices interact to affect health status. Furthermore,
sociocultural factors may vary over time with other factors such as
acculturation, economic and employment changes, age, or immigration
patterns that affect either an individual or an entire group. These
complex interrelationships can only be addressed through
multidisciplinary research that investigates factors beyond those
in a traditional biomedical model. Specific research activities
include:

• Develop valid and reliable measures of acculturation and socio-
cultural indices that are sensitive to shifts in beliefs, values,
and behavior patterns that might increase CHD risk in Native
Americans. Similar measures should be developed for other
diseases for which other minority populations have an increased
risk of mortality.

• Study tribal variations in diabetes among middle-aged and
older American Indians.

• Investigate SES as a risk factor for CHD, hypertension, stroke,
hypertension-related end-stage renal disease, and cancer in
all minority groups. Investigate minority subgroups who appear
to have higher risk profiles and who actually display lower
CHD mortality rates.

• Continue research on the association of social mobility and social
status with CHD and other disease categories in minority populations,

• Focus studies on the link between economic conditions and infant
mortality, including sociocultural factors that may help to
explain the relatively good outcomes in infant mortality seen

in the Asian, American Indian, and Alaska Native populations.

• Support research to characterize the experiences, attitudes, and
beliefs among minority women who tend not to seek or continue
prenatal medical care.

• Conduct research into the role of traditional folk medical
practices among minority populations and its effect on health
outcomes .

• Conduct descriptive studies to examine the relationship between
level of acculturation, the influence of cultural beliefs,
values, and behavior patterns in the maintenance of health,
development of illness, and pattern of treatment in minorities.

Accounting For the
Health Status Disparity

SOCIAL CHARACTERISTICS OF MINORITY POPULATIONS

Introduction

Among the many factors presumed to influence minority health
status in the United States today, four social characteristics are
believed to be especially significant: (1) demographic profiles, (2)
nutritional status and dietary practices, (3) environmental and
occupational exposures, and (4) stress and coping patterns.

The demographic profiles of Blacks, Hispanics , Asian/Pacific
Islanders and Native Americans differ considerably from those of the
nonminority populations (see Tables 2, 3, and 4). Marked differences
also exist among the four groups and within each group. For example,
native-born versus foreign-born status, age at time of immigration,
and degree of acculturation are important variables within the
Hispanic and Asian American populations. Dietary patterns and
practices are similarly group-specific and fluctuate with the extent
to which immigrants have adopted nonminority eating habits and food
preferences .

Because high percentages of minorities are city dwellers, with
high concentrations living in the inner cities, they are exposed to a
relatively greater number of environmental hazards, including
pollution, traffic hazards, substandard and overcrowded housing, and
crime. Occupational risks faced by minorities are higher than those
confronting nonminority group members because a higher proportion of
minority individuals are employed in positions that potentially
present greater levels of exposure to environmental risks, such as
physical and mental stressors, and toxic substances.

Finally, the unique patterns of exposure to stressors and ways of
dealing with stress and adversity in minority groups may play a
crucial role in health outcome. An increasing body of research
suggests that the ways an individual copes with stress and the
resources available to resolve stressful situations, rather than the
stressor itself, play the more important role in health outcome. In
some minorities, traditional folk beliefs and culturally specific
family patterns may affect their ability to withstand social,
economic, and psychological stressors.

The following sections outline some of the demographic data,
nutritional and dietary patterns, environmental and occupational
risks, and behavior patterns that may influence the health status of
minorities in the United States. Although the data on social
characteristics of minorities are compared with those of
nonminorities , each minority is discussed separately with few
comparisons to the other minority populations.

Table 2

Percent Distribution of Persons by Ethnic/Racial
Background and Sex, Age, and Geographical Area
United States, 1980

Characteristic

Ethnic/Racial

Background

White

Black

Hispanic
Origin

Other

Total

79.6

11.5

6.4

2.5

226,545,805

Sex

Male

79.7

11.2

6.6

2.5

110,053,161

Female

79.5

11.8

6.3

2.4

116,492,644

Age

Median Age*

31.6

24.9

23.2

26.5

30.0

Under 15**

73.0

15.0

9.0

3.0

51,290,339

15-44**

79.0

12.0

7.0

3.0

105,203,337

45-64**

84.0

9.0

4.0

2.0

44,502,662

65 -h**

88.0

8.0

3.0

1.0

25,549,427

Geographic Area

Region

North East

83.4

9.6

5.3

1.7

49,135,283

North Central

87.5

9.0

2.2

1.3

58,865,670

South

74.3

18.4

5.9

1.3

75,372,362

West

73.5

5.1

14.5

6.9

43,172,490

Urban

76.1

13.3

7.9

2.8

167,050,992

Rural

89.4

6.5

2.5

1.6

59,494,813

SOURCE: General Population Characteristics, United States Summary, 1980 Census of Population. U.S. Department of
Commerce, Bureau of the Census. Issued May 1983.
♦Note that the median age is given in years for each racial/ethnic group (and total) and is not a percent distribution.
**Percent distribution is rounded to nearest whole number.

Table 3

Percent Distribution of Persons of Nonminority and

Minority Background by Number, Sex, and Geographic Distribution,

United States, 1980

Characteristic

Total
Male
Female

Ethnic/Racial Background

Nonminority

79.6
79.7
79.5

Minority

20.4
20.3
20.5

Total

226.5
110.0
116.5

Geographic Area
Region
Northeast
North Central
South
West

83.4
87.5
74.3
73.5

16.6
12.5
25.6
26.5

49.1
58.9

75.4
43.2

Urban
Rural

76.1
89.4

24.0
10.6

167.1
59.5

NOTE: Percent distribution is rounded to nearest tenth.

SOURCE: General Population Characteristics, United States Summary, 1980 Census of Population. U.S. Department of
Commerce, Bureau of the Census. Issued May 1983.

Table 4

Occupational Distribution of Minority Groups
Ratio of Nonminority to Minority*

Occupation

Sex:

Black

Asian

Native
American

Hispanic

White Collar

1.39 1.59 1.03 .96 1.50 2.04 4.70

Blue Collar

.77 .85

.88 1.42

.68

.77 1.54

Farm

1.56 1.08 1.20 1.03

.78

.66

Service

.56

.49 1.03

.35

.57

.13 -

Employed

1.08 1.07 1.90 1.39 2.95

1.82

SOURCE: Department of Commerce: A Statistical Analysis. Women in the United States. Series P-23, No. 100.
Washington, D.C.

*Represents the ratio of nonminority to minority. For example, 39 percent more nonminority males are in white collar
occupations than are Black males.

Social Characteristics of Blacks

The 1980 report of the Bureau of the Census indicates that one
out of every five persons in the United States is a member of a
minority group. Blacks are the single largest minority group,
constituting 11.5 percent of the total population of the country. The
number of Blacks in 1980 was 26.5 million, an increase of
approximately 17 percent over 1970 Census figures. The distribution
of Blacks compared with Whites is different within age categories. At
age 15 or under. Blacks constitute approximately 15 percent of the
total population, while by age 64, their relative proportion has
declined to 8 percent.

Nearly 59 percent of all Blacks lived in the central cities in
1980, although increasing numbers were living in nonrural areas
outside these cities. Cities with the largest number of Blacks are
New York, Chicago, Detroit, Philadelphia, and Los Angeles. Migration
of Blacks from the South not only slowed but slightly reversed during
the 1970's; nonetheless, 53 percent of all Blacks still reside in the
southern region of the country.

The median age of Blacks is 24.9 years. The life expectancy in
1983 was 65 years for men and 74 years for women, contrasted to 72
years and 79 years for White men and women, respectively. The
age-adjusted mortality rate per 1,000 population for Blacks is 7.7;
for Whites , 5.3.

Black families are on the average slightly larger than
nonminority families, with the average Black family comprised of 3.7
members. Although total birth rates among all groups have dropped
since 1970, the overall rate of childbearing is still higher among
Black women than among women of nonminority groups, currently
averaging 2.3 births per woman for Blacks and 1.7 for nonminority
women. The percent of Black households headed by women (37.7 percent)
is more than three times higher than that of nonminority households
headed by women (10.9 percent).

Seventy-nine percent of Blacks have completed a high-school
education, and 13 percent are college graduates. The median income of
Black families in 1981 was $13,270; nonminority median family income
was approximately $10,000 higher. One of every three Blacks (34
percent) lived below the poverty level in 1981. This rate was
consistent with that of Hispanic and Native Americans but
substantially higher than that of nonminorities, among whom the rate
was 11 percent. Unemployment among Blacks in 1982 was 18.9 percent.
This was more than double the nonminority unemployment rate of 8.6
percent .

There is no single dominant dietary pattern among Black
Americans. Generally, dietary patterns may be subdivided into
southern versus nonsouthern, urban versus rural, native-born versus

foreign-born, and Christian versus Muslim. Many of the unique dietary
patterns among Blacks are influenced by historical and regional food
availability and food preparation practices. For example, among
Blacks living in the southern region of the United States, diets may
include a preference for vegetables, grain and grain products high in
carbohydrates, and organ meats high in cholesterol.

Although there is a relatively high rate of meal skipping and a
lower use of vitamin and mineral supplements among the Black
population, there are no data that suggest major differences between
Blacks and nonminorities today with regard to the proportion of
calories consumed from carbohydrates, proteins, and saturated and
unsaturated fats. Generally, Black diets are rich in sources of
vitamin A, predominantly from green leafy vegetables, and in protein
derived from poultry, fish, and dried beans. Blacks tend to consume
fewer dairy products than do nonminority group members, possibly
related to a higher rate of lactose intolerance among Blacks than
Whites. Salt consumption is high; however, excessive salt intake is
also a dietary risk factor in the diet of nonminority groups.

Breast feeding is less common among Black women than among
nonminority women, with the exception of women from the Caribbean
countries among whom breast feeding is more common. Some research has
shown that pica (a craving for nonfood substances such as clay) is
fairly common in Black women of the rural South. A significant
nutritional risk among Blacks is the marked prevalence of obesity
among Black women compared with nonminority groups. There is no
evidence of extensive prevalence of growth stunting among Black
children.

In general, Blacks have higher rates of morbidity and mortality
from unintentional (accidental) injuries such as poison ingestion,
asphyxiation resulting from faulty heaters, and drowning than do
nonminority members. Blacks also have a much higher death rate from
housefires than do nonminority group individuals. Differences in
nondisease mortality and morbidity rates, however, are diminished with
adjustment for income.

Black women have approximately the same rate of participation in
the work force as nonminority women, while the rate for Black men is
slightly lower than that of nonminority men. Black women have a 39
percent greater chance of sustaining job-related disease and serious
work-related injuries than nonminorities. Blacks have a 25 percent
greater chance of dying from such causes than nonminorites . Blacks in
the work force are highly concentrated in three of the six major
occupational groups: operators, fabricators, and laoorers (27
percent); technical, sales, and administrative support (24 percent);
and service occupations (23 percent) . Blacks are consistently
underrepresented in managerial and professional specialty occupations,
where they constitute 6 percent of the work force.

A review of the family and behavior patterns of Blacks reveals
that among the Black populations, kinship and family ties are
extremely important. These ties often form the basis of a network of
mutual support that can provide material, emotional, and social
resources to family members in distress. Also, the church is a
powerful source of emotional strength for many Blacks and their
families. Folk beliefs about health and illness may have have varying
effects on how an individual reacts to signs and symptoms of poor
health. However, little is known about folk beliefs among Blacks or
the extent to which Blacks rely on folk remedies. Research on the
relationship between health beliefs and illness behavior suggests that
such differences may assist in explanation of patterns of health care
for some minorities.

Social Characteristics of Hispanic Americans

Hispanic Americans numbered 9.1 million in 1970 and 14.6 million
in 1980, a 61 percent increase within the decade. By 1983, the
Hispanic population in the U.S. had reached 15.9 million. Mexican
Americans constituted nine million, or nearly two-thirds of this
total, followed by Puerto Ricans (two million), and Cubans (one
million). All told, Hispanic Americans constitute 6.4 percent of the
population of the United States. The more than three million Puerto
Ricans residing in Puerto Rico are not included in these figures,
since they are treated separately by the Census Bureau.

Sixty percent of all Hispanics live in Arizona, California,
Colorado, New Mexico, and Texas. Half of the total live in two states,
California and Texas. The Hispanic population showed signs of greater
geographic dispersion during the 1970s, most notably to New York,
Illinois, and Florida. Half of all Cuban Americans live in Florida.
One out of two Hispanic Americans lives in the inner city of
metropolitan areas, and they are heavily concentrated in the larger
cities, i.e., those with a population of one million or more.

Hispanics are generally a youthful population. In 1980, 20
percent were less than ten years of age, contrasted to 14 percent for
the country as a whole. Conversely, only 3 percent of Hispanics were
more than 70 years of age, as opposed to 7.7 percent of nonminorities .
The median age of Hispanic Americans is 23 years.

Hispanic Americans have a relatively high fertility rate; the
number of children per family is 2.3. Twenty-three percent of
Hispanic households are headed by women; among Puerto Rican families,
the rate is 40 percent. Forty-nine percent of Hispanic women are in
the work force. Fifty-eight percent of Hispanic Americans have
completed a high-school education; this number is more than 20
percentage points lower than that of the Black population. One out of
every ten Hispanic Americans holds a college degree.

The median family income for Hispanic Americans in 1981 was
$16,228. Thirty percent of all Hispanics were living below the
official poverty level in 1982, and 13.8 percent were unemployed.

The variation in dietary practices among Hispanic Americans
reflects the diversity of backgrounds among this subset of the
population. Certain similarities, however, may be seen; these include
a relatively higher reliance on vegetable protein sources rather than
on meat sources. Grains and grain products are dietary staples.
Green leafy vegetables are not a typical part of the diet.
Consumption of dairy products is relatively low.

Food consumption and preparation practices common among Hispanics
of Mexican, Puerto Rican, and other backgrounds are generally adequate
to provide all needed nutrients. Fiber consumption is high. Animal
fat content is substantial, but it is roughly equivalent to that of
the typical nonminority diet.

Several authors have reported concern over the high sodium and
high carbohydrate content of many Hispanic diets . Studies also have
shown an excessive prevalence of growth stunting in Hispanic children,
especially among those two to five years old. This problem is more
severe among children not born in the United States than it is among
native-born Hispanic children. Growth stunting is also more prevalent
among children of lower income families. It has been suggested that
the incidence of chronic disease such as diabetes mellitus is related
to overnutrition and obesity in Hispanics.

A large proportion of Hispanics work in blue collar, service, or
agricultural occupations. The shift from rural, unskilled labor to
blue collar work has not been accompanied by a rise in socioeconomic
position. Hispanic Americans are overrepresented in positions in the
manufacturing and construction industries, which report the first and
second greatest number of work-related injuries, respectively. They
also are overrepresented in farming and in metal mining, two
additional high-risk employment areas. Data from the Social Security
Administration reveal that severe disability resulting from
work-related injury was almost twice as high among Hispanics as among
nonminority workers in 1980. It may be presumed that the impact of
occupational injury on Hispanics may be much higher because of the
number of migrants and undocumented workers who are not reported when
injured and who do not receive workmen s compensation benefits.

In 1982, Hispanics were classified in the employment category of
operators" almost twice as often as nonminorities (23 percent versus
12 percent) . Hispanics have lower rates of employment than
nonminorities as professional workers (9 percent versus 17 percent)
and in management positions (7 percent versus 17 percent). They have
higher employment rates as general laborers (7 percent versus 4
percent) and as farm laborers (4 percent versus 1 percent) .

Hispanic Americans have a very strong family and community
orientation. The church and parish community are an important focus
of family and social life for many Hispanics . In more rural settings,
some Hispanics view the community as an extension of the family and
feel that it has a protective and healing force that may be used to
reinforce an individual's own coping skills. However, regional
studies on naturalistic support systems indicate that the quality of
support, rather than the number of sources, has a greater impact on
the effectiveness of support systems in ameliorating stress. Little
research has been done to explore how family, church, and community
interact to provide support to a community member. Many Hispanics
accord their elders respect and authority and value their support in
times of distress.

Social Characteristics of Asian/Pacific Islanders

The number of Asian/Pacific Islanders in the United States grew
by 120 percent between 1970 and 1980. As of 1980, this group numbered
3.7 million and constituted 1.6 percent of the population.
Asian/Pacific Islanders have a far larger percentage of foreign-born
persons (58 percent) than any of the other United States minority
groups .

Asian/Pacific Islanders come from more than 20 different
countries. The three most common countries of origin are China
(812,000 persons), the Philippines (781,000), and Japan (716,000).
A distinct trend in Asian/Pacific Islander demographics of the past
decade has been the immigration of large numbers of Southeast Asians
under the Refugee Resettlement Program. However, data on social
charactistics of Asian/Pacific Islanders principally reflect
information from the three largest subgroups.

Asian/Pacific Islanders live predominantly in the western part of
the United States, although their concentration in this region has
begun to decrease noticeably. Fifty-six percent now live in the West,
compared with 70 percent at the time of the 1970 census. Four out of
every five of the country's recent Indochinese immigrants live in 16
states; one-third of the total live, in California, and one-tenth are
in Texas .

The median age of the Asian/Pacific Islander population is 28.7
years . This is higher than that of the other three largest minority
groups but still lower than the median age (31.3 years) of the
nonminority group. The age-adjusted mortality rate is 3.2 deaths per
1,000 population. Only 11 percent of Asian/Pacific Islander
households are headed by women; this is less than the nonminority
rate. Fifty-eight percent of Asian/Pacific Islander women are in the
workforce.

The median educational level of Asian/Pacific Islanders is quite
similar to that of the general population. Three out of four have
completed high school, and approximately one out of three holds a
college degree.

The median income level for Asian/Pacific Islander families, as
shown in the 1980 census, was $22,713. Median income among
Asian/Pacific Islander families is consistently higher than that of
any other group, including the nonminority group. Asian adults,
however, often share a household for reasons of exigency, thereby
inflating the reported "family" income. As a result, the true extent
of poverty among Asian/Pacific Islanders is often masked.

Moreover, income differs substantially among the Asian subgroups:
it is highest among those from Japan and lowest by far ($12,840) among
the Vietnamese. The unemployment rate shows similar variations. In
1979, the overall poverty rate for Asian/Pacific Islanders was 13.1
percent; the range was from 7 percent for the Japanese and Filipino
subgroups to more than 35 percent for the Vietnamese. The
unemployment rate for the overall Asian/Pacific Islander population
stands at 4.7 percent, which is nearly two percentage points lower
than the nonminority rate.

The primary source of calories for many Asian/Pacific Islanders
is rice. The varieties of rice used and the techniques of
preparation, however, are diverse. Prewashed or unenriched rice poses
risks of low vitamin B and mineral intake, although such deficiencies
may be overcome by adequate intake of pork or fish. Consumption of
vegetables, fruits, fish, and shellfish is relatively higher; but
intake of animal protein is relatively lower than that of the
nonminority population. Dairy products are used much less frequently;
however, the traditional sources of calcium in the Asian diet are from
soy bean curd, sardines, or green leafy vegetables. With
acculturation, adaptation of the traditional Asian diet to the foods
most readily available in the United States generally involves
increasing the proportion of caloric intake coming from animal
protein, fats, and refined sugar. Intakes of complex carbohydrates
and cholesterol increase, while fiber intake decreases. Such changes
are reflected in the higher weight and increased rate of coronary
disease among Asians in the United States compared with cohorts in
their countries of origin. Many foods in the Asian diet, such as
salted and pickled vegetables, soy sauce, meat and fish pastes, and
fermented soy bean curd, are high in sodium.

When all aspects of the Asian/Pacific Islander diet are taken
into consideration, an area of concern is possible growth stunting,
which may affect as many as one-third of the children between two and
five years of age. However, the data are insufficient to determine if
this is true and if it has health consequences for Asians/Pacific
Islanders. Low weight for height is not a problem. Obesity, a
notable health risk among other minority groups, is not common among
Asian/Pacific Islanders.

Information on occupational patterns and employment rates of
Asian/Pacific Islanders are most complete for the larger subgroups,
Chinese, Japanese and Filipinos. Although there are relatively larger
numbers of Asian/Pacific Islanders employed in white collar positions,
a disproportionate number of Asian/Pacific Islanders are engaged in
jobs that are substantially below their educational levels. Taking
into account both men and women, 19 percent of Chinese, 15 percent of
Japanese, and 14 percent of Filipinos have professional occupations,
compared with 13 percent for nonminorities . At the same time, 19
percent of Chinese, 17 percent of Filipinos, and 13 percent of
Japanese workers have service occupations, compared with only 11
percent of nonminorities.

Recently arrived Indochinese refugees constitute a specific
subset within the larger Asian population that may vary considerably
from the demographic patterns cuurently reported for more established
Asian groups. Their unemployment rate and poverty rate are much
higher than other Asian groups, and nonminorities. Furthermore,
because many of these newcomers speak little or no English, they often
are forced to seek employment in positions with a disproportionate
number of occupational hazards or in low-level service areas.

Many Asian/Pacific Islanders pride themselves on their
independence and self-sufficiency. Consequently, some are
particularly reluctant to seek health services, especially for mental
illness or for counseling. In some Asian countries, the ability to
control the expression of feelings is often felt to be a sign of
refinement. The family is very important to many Asians, and some
Asians believe that seeking help outside the family is a sign of
weakness. Although cultural patterns of family reliance often
strengthen an individual's social support resources, they also may
pose a barrier to care when it is truly needed. Some Asian/
Pacific Islanders consult traditional healers such as acupuncturists
and herbalists or use traditional remedies as supplements to other
western medical care sources. The extent of use and efficacy of
traditional medicine among Asian/Pacific Islanders is unknown.

Social Characteristics of Native Americans

Native Americans include American Indians, Aleuts, Alaska
Eskimos, and Native Hawaiians. Data reported here, however, refer
primarily to American Indians for whom information is most available.

American Indians are the smallest minority group in the United
States. In 1980, they numbered approximately 1.5 million, less than
one percent of the total population. The average American Indian
family has 4.6 members; this is larger than any other minority or
nonminority group. The birth rate among American Indians is nearly
twice that of other groups, and the average life expectancy is six

years less. The median age of American Indians --22 .4 years--is lower
than that of any other group. It is nearly nine years lower than that
of the nonminority population.

Nearly one out of every four American Indian households is headed
by a woman, and approximately half (48 percent) of American Indian
women are employed outside the home.

The overall educational attainment of American Indians is the
lowest of all minority groups. The 1980 census revealed that fewer
than one out of three (31 percent) have graduated from high school and
that only 7 percent hold college degrees.

Likewise, median family income is well below the national level.
In 1979, it was $15,900 per year, which is $7,200 below the level for
the nonminority group. Twenty-nine percent of American Indian
families lived in poverty in 1979; this is similar to the overall
poverty rate among Black and Hispanic minorities but substantially
higher than the poverty level of Asian/Pacific Islanders and of the
nonminority group. The unemployment rate among American Indians in
the civilian labor force in 1979 was more than 13 percent.

One-half of all American Indians live in the western or
southwestern United States. Twenty-four percent live on
reservations, and another 8 percent live on historic trust areas in
Oklahoma. Most of these reservations have fewer than 1,000 residents;
only one reservation has a population greater than 100,000.

Tribal variations are considerable in current diets of American
Indians. Factors contributing to dietary differences are food
availability, preference for nonminority food, and place of residence
(i.e., urban or reservation). In general, the diets of many
traditional American Indians today are high in refined carbohydrates,
fat, and sodium. They are low in meat, eggs, cheese, and milk; this
may indicate a potential problem with protein deficiency.

A relatively high percentage of American Indian women report that
they breast feed their infants, and the growth patterns indicating
adequate childhood nutition are not markedly different from that of
nonminority children. There is, however, a disproportionate incidence
of high weight for height among American Indian children that begins
in early childhood. Likewise, obesity is a problem for a large
proportion of American Indian adults and may be associated with the
high risk of diabetes mellitus in this population. Alcohol-related
disease is also a source of concern among the American Indian
population, and excessive alcohol consumption may interfere with
adequate nutritional intake.

Native Americans, along with Blacks, have the highest rates of
injury and death from nondisease causes. Motor vehicles are included
in nearly half of all accidental injuries, and the rate of such accidents
among Native Americans is higher than that of any group.

The unemployment status of a large number of American Indians
seems due to a combination of socioeconomic and cultural factors.
However, industrial firms attracted by tax incentives, low labor
costs, and an accessible labor force have begun moving onto some of
the Indian reservations. Although they provide a much needed source
of employment, many of these industries are of the type that produce a
number of occupational risks. This may increase the health risks to
American Indian workers. Because of traditional cultural beliefs, some
Native Americans are reluctant to use prescribed safety measures or
precautions. The National American Indian Safety Council (NAISC),
representing a cross-section of the Indian tribes, is working to
establish guidelines that may assist in reducing occupational hazards
for these workers .

The mores and cultural patterns of the nonminority population
imposed upon Native Americans have disrupted their traditional way of
life. A sense of powerlessness and hopelessness has often been
observed as a result and may be related to the high incidence of
alcohol abuse, suicide, depression, and obesity among this population.

The medical and socioeconomic consequences of alcoholism, which
is sometimes viewed as a way of coping with cultural disruption, are
extensive and tragic; they include death and injury from motor vehicle
accidents, assaults, family violence and disintegration, and
alcohol-related disease. Alcoholism also contributes to instability
of the work force.

American Indians, however, are also observed to draw upon
traditional sources of strength to cope with stressors. Traditional
strengths include the family, the tribe, and the land itself. Yet,
many American Indian children leave their homes today, most often to
go to boarding schools. Many of those who have studied the problems
of the American Indian family believe that this practice has weakened,
rather than strengthened, family stability.

It is recognized that traditional medicine men play powerful
roles in the health practices of this population. Health care and
social programs should be coordinated with these individuals, with the
awareness that treatment outcome is strongly influenced by the belief
system of the patient.

REFERENCES

1. Bureau of the Census. (1983). America's black population,

1970 to 1982: A statistical view. Washington, DC:
U.S. Department of Commerce.

2. Bureau of the Census. (1980). American Indian areas and

Alaska Native villages: 1980 census of the population.
(Supplementary report). Washington, DC: U.S. Department
of Commerce.

3. Bureau of the Census. (1984, January 8). American Indian,

Eskimo, and, Aleut populations. Washington, DC: U.S.
Department of Commerce.

4. Bureau of the Census. (1984, July). Asian and Pacific

Islander population. Washington, DC: U.S. Department of
Commerce.

5. Bureau of the Census. (1984, January 8). Asian and Pacific

Islander population. Washington, DC: U.S. Department of
Commerce.

6. Bureau of the Census. (1980). Asian and Pacific Islander

population by state: 1980 (Supplementary report) .
Washington, DC: U.S. Department of Commerce.

7 . Report of the Working Group on Health Education among Minorities.

Unpublished manuscript, Task Force on Black and Minority Health,
DHHS.

8. Bureau of the Census. (1983, May). General population

characteristics: 1980 census of the population (Chap. B,
Vol. 1, Pt. 1). Washington, DC: U.S. Department of
Commerce.

9. Haan, M. N. , & Kaplan, G. A. (1985). Socioeconomic position

and minority health. Unpublished manuscript. Task Force on
Black and Minority Health, DHHS.

10. [Demographic profile of the U.S. Asian/Pacific Islander population]

(1985). Unpublished raw data. Task Force on Black and Minority
Health, DHHS.

11. Keefe, S. E., Podilla, A. M. , &. Carlos, M. L. (1978). Emotional

support systems in two cultures: A comparison of Mexican
Americans and Anglo Americans. Los Angeles, CA:
UCLA Spanish-Speaking Mental Health Research Center.

12. Kumanyika, S. K. , & Helitzer, D. L. (1985, February).

Nutritional status and dietary patterns of racial
minorities in the United States . Unpublished manuscript,
Task Force on Black and Minority Health, DHHS .

13. National Institute for Occupational Safety and Health.

(1981, July). Issues affecting minority workers.
Proceedings of the National Conference on Occupational
Health and Safety. U.S. Department of Health, Public
Health Service, Centers for Disease Control. Cincinnati, OH.

14. Parron, Delores. (1985). Stress and Coping. Unpublished

manuscript. Task Force on Black and Minority Health, DHHS.

15. Subcommittee on Cancer in Minorities. (1985). [Demography and

health services' patterns]. Unpublished raw data, Task Force
on Black and Minority Health, DHHS.

16. Yu, E., Chang, C. F., Liu, W. T. , & Kan, S. H. (1984). Asian-White

mortality differences: Are there excess deaths?
Unpublished manuscript. Task Force on Black and Minority
Health, DHHS.

MORTALITY AND MORBIDITY INDICATORS

Introduction

Differences in life expectancy between minorities and
nonminorities strongly suggest the existence of health problems among
certain segments of the population. Although life expectancy
dramatically summarizes the overall differences in specific causes of
death and illness among various groups in the United States, Secretary
Heckler asked the Task Force to go beyond life expectancy data and
investigate more fully the magnitude of the disparity in health status
of minority groups compared with nonminorities, and its causes.
Consequently, the Task Force examined and identified appropriate
indices to measure the various disparities, identified the leading
causes of death and their ramifications within each minority, examined
other indicators of health status and morbidity for minority groups,
and reviewed the socioeconomic correlates of these factors. Based on
this investigation, the Task Force was to suggest approaches for
reducing the identified disparities.

Measures of Mortality

In addition to life expectancy, two other indices were used by
the Task Force to summarize mortality differentials: 1) excess
deaths, and 2) relative risk of death.

"excess deaths" expresses the difference between the number of
deaths actually observed in a minority group and the number of deaths
that would have occurred in that group if it experienced the same
death rates for each age and sex as the White population (1). "Excess
deaths" are sometimes referred to as "observed minus expected deaths
(when expected deaths are based on the death rate of the White
population) . Excess deaths can be calculated for each age and sex
group as well as for specific causes of death. When minority death
rates are higher than those of Whites, excess deaths will be a
positive number greater than zero; it will be zero when the rates are
the same as for Whites; and it will be a negative number when the
death rates for minorities are lower than for Whites .

The measure of excess deaths depends on differences in death
rates between the minority and nonminority populations and specifies
the actual deaths in a minority group attributable to these mortality
rate differences . The number of observed excess deaths also depends
on the size of the minority population and the number of total deaths.
Further analysis with this measure can identify excess deaths due to a
specific cause such as heart disease, affecting the greatest number of
people in a particular group.

To account for the differences in size of the population, the
"relative risk" of death is used. "RELATIVE RISK" is the ratio of the
minority death rate to the White death rate. Relative risk also can
be calculated for specific causes of death and for each age and
sex group. When the relative risk of death is greater than 1.0, it
indicates that the death rate is proportionally higher in the minority
group than in Whites; a value of 1.0 or less than 1.0 indicates that
the minority group has the same or lower death rate as Whites . A high
relative risk for a specific cause of death may be misleading if a
disease is rare and affects a small number of people. The relative
risk for a rare condition may appear to indicate a disproportionally
high risk for a problem that may not be serious in terms of excess
deaths because so few individuals are affected.

The Task Force used excess death as the primary indicator of the
disparity and used measures of relative risk to confirm and extend
findings of the excess deaths' index. Both excess deaths and
relative risk as applied by the Task Force are statistics which
present death rates for minority groups only as compared to the White
population.

The age-adjusted death rate for the United States, which takes
into account the age structure of different population groups, was
553.8 deaths per 100,000 population, and is estimated to be 549.6 for
1983 (2) . Figure 1 shows the average annual age-adjusted death rate
for several racial groups. Life expectancy at birth has been rising,
increasing from 74.6 years in 1982, to 74.7 years in 1983.

Despite these encouraging overall trends, differences in health
status indicators remain between minority groups and Whites, as seen
in Figure 2. Life expectancy at birth for White males in 1982 was 71.5
years; for Black males, it was 64.9 years. Since life expectancy is
not routinely available for other minority groups, special
calculations were commissioned by the Task Force. These data indicate
that life expectancy for Native American males was 70.4 years in
1979-81, and life expectancy for Asian males was about seven years
greater than that of Whites. Data on Hispanics are not available to
estimate comparable life expectancy. Minority and nonminority women
have a longer life expectancy than men; minority women, however,
experience similar disparities in health status compared to
nonminority women. Asian females have the highest life expectancy of
any group (3) .

The Task Force explored the disparity in death rates between
minorities and Whites by disease category, by analyses of relative risk
of death for the different disease categories (shown for Blacks in
Table 5) and by analyses of excess deaths. Based on these analyses,
the Task Force observed that four of every five excess deaths among
minorities result from six causes: cancer, heart disease and stroke,
infant mortality, diabetes, homicide and unintentional injuries, and
chemical dependency (primarily alcohol abuse as revealed by

2 uT

s ^

DDS

^ :■:■:

n yA

^^^^ri

^H 5 j 5 ^^^^^^^^^W

^^^^

hhmh

^HH

c
o

o
o

8 8 8

oo vo •*

■S

^c£2

■S

c«

J<!

o
S

r=-

• S o ca

■c
o
.5
S

■c

E
<

a
e

S
a

S (J

o "
c -S

S t:

o
• - S

■**

acn

■O
a

•1

JU>

•a

Table 5

Age-Adjusted Death Rates by Selected Cause, Race, and Sex
United States, 1980
(Rate per 100,000 Fbpulation)

Black White Relative Black White Relative

Male Male Risk Female Female Risk

Total Deaths
(All Causes)

1,112.8

745.3 1.5

631.1 411.1

1.5

Heart Disease

327.3

277.5

1.2

201.1

134.6

1.5

Stroke

77.5

41.9 1.9

61.7

35.2

1.8

Cancer

229.9

160.5 1.4

129.7 107.7

1.2

Infant Mortality

2,586.7 1,230.3 2.1

2,123.7 962.5

2.2

Homicide

71.9

10.9 6.6

13.7

3.2

4.3

Accidents

82.0

62.3

1.3

25.1

21.4

1.2

Cirrhosis

30.6

15.7

2.0

14.4

7.0

2.1

Diabetes

17.7

9.5 1.9

22.1

8.7

2.5

SOURCE: NCHS, Health: United States, 1983, Tables 9 and 15.

cirrhosis). Figure 3 illustrates the major contributors to excess
death for Blacks, in 1980, for those who died before age 45 or before
age 70. The data clearly depict that the bulk of excess deaths in
each age bracket are attributable to the six causes cited. Homicide
and accidents, infant mortality, and heart disease and stroke
contribute the greatest number of excess deaths before age 45 in
Blacks. Heart disease and stroke, and cancer increasingly contribute
to excess deaths in Blacks when deaths up to age 70 are examined. The
same six causes of excess death also apply to Hispanics , Asian/Pacific
Islanders, and Native Americans, although the ranking may vary.

Subcommittees were formed to investigate the reasons for
disparities due to these six causes of death. Suicide among
minorities was added to the charge to the Subcommittee on Homicide and
Unintentional Injuries based on the contribution of suicide to the
excess deaths of Native Americans. Detailed results are found in the
Subcommittee summary reports and in later volumes of this Task Force
report.

Other Health Status Measures

Morbidity and health status measures were also examined as
indicators of the disparities in health between nonminorities and
minorities in the United States. These measures were taken largely
from the NCHS National Health Interview Survey (NHIS), an annual
survey sampling 40,000 households nationally. Morbidity estimates are
based on prevalence rates from self-reports of the sample population
for a selected list of diseases. Health status measures include
self -assessed health, number of physician and dentist visits, and
number of hospital admissions. An analysis also was commissioned to
determine differences in ambulatory care use among minorities (4) .

The 1976 Survey of Income and Education (SIE) provided measures of
social characteristics related to self-assessed health status for
minorities. Additional information from the Health Care Financing
Administration End-Stage Renal Disease Program and from the DHHS
Office for Civil Rights reports of hospital admissions and emergency
room visits was examined. These sources proved to be severely limited
for the needs of the Task Force because of difficulty in identifying
minorities by age-sex group and health problem for comparison to
Whites .

Limitations of Data

A variety of measures of health status are needed to draw
conclusions about diferences in health status among minority
populations; single measures such as national mortality summaries may
not provide a complete enough picture. Although mortality data are
available by age, sex, and race for Blacks, Asian/Pacific Islanders,
Native Americans, and Whites, the Task Force noted that one of the
most serious data deficiencies is the lack of national mortality data

1/3

J? -P

u
Q

o\^

^ II

IT) —I

E« od

u.
u
■S

-a

c
•2

►5

3
e2

(-1

'la in

"/-^

"o
S

as §
IS

i6 X

■3 CI
g. g-

8 O

•S Q
-^

§ O

for Hispanics . These data are usually obtained from death
certificates but, for Hispanics, ethnicity is not uniformly recorded
in every State.

In addition, mortality data are usually not recorded for
subgroups within Asian/Pacific Islander and Native American
populations. Although mortality rates are believed to vary among
subpopulations , no information is available on a national basis from
which to analyze data for subgroups.

The Task Force also noted that the sample sizes of minorities,
other than Blacks, in surveys tend to be insufficient to obtain an
accurate picture of disparities in health compared to Whites . Data on
the health status of Native Americans and Asian/Pacific Islanders
compiled from surveys must be aggregated over time to obtain adequate
numbers to draw statistically valid conclusions. Despite these
limitations, the National Health Interview Survey (NHIS) does provide
sample coverage of Native Americans and Asian/Pacific Islanders.
Health information about American Indians and Alaska Natives on or
near reservations is available from the Indian Health Service.

As in the mortality data, the NCHS health survey statistics on
illness and disability do not generally distinguish subgroups within
the racial/ethnic groups as a whole. For example, recent immigrants
from Southeast Asia have more health problems than the more
established Asian/Pacific Islander groups, such as Chinese, Japanese,
and Filipinos, yet all data are aggregated into the Asian/Pacific
Islander minority group which, overall, has a greater life expectancy
than the White population (5).

The following sections present highlights of the mortality and
morbidity findings for Blacks, Hispanics, Asian/Pacific Islanders, and
Native Americans.

MINORITY HEALTH INDICATORS

Blacks

Of two million American deaths per year, roughly twelve percent
are Black. Between 1979 and 1981, an average of 227,000 Blacks died
each year. Of these, 139,000 Blacks were under the age of 70 years.
About 59,000 of these deaths among Blacks under age 70 would not have
occurred had Blacks experienced the same age-sex death rates as
Whites. These "excess deaths" represent 42.3 percent of all Blacks
who died before the age of 70. Table 6, based on death certificate
information, indicates the major causes of the excess deaths in Blacks
under ages 45 and 70; Figures 4 and 5 illustrate the contributors to
the average annual excess deaths for Black men and women.

The disparity between the death rates of Blacks and Whites
(excess deaths) affects certain age groups more than others. Compared
to Whites, Blacks have twice the rate of infant mortality. The

o u

on H

■3

c
o

D£

<2 o

Q
>

»o

u-1

•^

''"

.— (

' — '

c<^

t~ On 00

00 — VO

•* o ■*

« vo in

O OO "

CM U-l t^

OO VO -H

t^ ■* ro

—I On CS
^ "O O
On CM t^

t~- -^ ro
00 O 00
<o CN fn

NO O VD
<^ Tj- ON

CN m 00

_«

■^ -a

(U o a>

O W U

•9

,:ii
^

CM 00 O
CO 0\ (N
(N O CM

(N OO ■*
m On c*^
<N O -H

NO 00 00
OO CO ■*

NO 00 00

00 rn vo

00 Tj- "*

Tt m -H

u-i " NO

2 2' 00

On On i

•cf t^ r^

00 [^ O

O ON — '
Tt t^ NO

in NO 00

On O On
Tf (O -^
u-i — ■*

O NO Tt
On NO CS
t^ CO Tt

O ^ NO
On r- —
O NO rf

~0 -n

> -^ CA

tH O CA

CL> (D (U

cj o. o

5 X X

O W W

_ o.

O 00

t--^ cO_

tJ-'on"

00 Tt

^oT

c-T

O 00

r- iri^

■* On'

u-i

00 Tj

On tJ-

CnI — '

NO ON

m p- 00

CO cs o

ON <N t^

On NO CO
(N « rt
■^ CO "

O •* NO
On •* ^
— . in NO

(N m t^

OO NO •^
t^ Tt CO

NO Tj- CN
O ■* NO

[^ iri (N

— CO 00
" CO t^

w
o

_ *
« u

> *- CA

tH CJ CA

<D (U tU

5f :£ X X

•< O m m

a
a

^ cfl

t^ cs m

CO ON ■*
On^ co^ CO

co' o' co'

>0 CO (N

t^ (N U-l

CO On "cf
ON CO CD

co' o' fo'

<0 CO CN

r~ Tt CO

^H ^H O

00 NO (N

NO iri — '
On — 00
I^ ^ CO

On >n -^
CO O CO
t^ NO —

NO CO CO
00 00 o
[^ CO CN

O CON —
^ [^ NO
10 NO 00

IT) CO CN
CN 'O- 00

m t~ t^

NO [^ C3N
TJ- t^ NO

On NO (N

00 NO CN

00 1^ —H

t^ o t^

> S -

U O CA

oj d, (J

i X X

O W U

•a

E-

■0

i o

> -a

- .2-

.2 E 3 -o

■S 1= -5 -^ Q

U H crt a. c/3

■a

SVE^

u
Q

cs is ^
S;2^ II

■^ o —
S V F

5
o

§ .2

U Q

fc
u

a
e

•I .&

5
a

:„ CO

■s s

g °

S [£

^^ I

=5 I

^^i

0 i£

'e 3

C/l

IX!

.«u

,:^

OJO

c
u

^ 1/^ «

iS ^ o

m Vh

tg| II
■^ o -T^

PQ V H

■s
o

g
55

S 2
c

i|
■s S

a -g
g S

■s J

:^ CO
■3 =
S °

i-i

§. £•

3 'g

.=2 >

: -a

s =>

D
O

disparity is smaller through age 24, followed by a sharp rise in
excess deaths thereafter through age 64. Thus, for infants and adults
through middle age, the excess deaths are most pronounced.

In later life, minorities have lower death rates for many
diseases than do nonminorities . This "survivor effect", or mortality
crossover, has been attributed to hardiness among survivors in a
population that has a higher early-age death rate.

The excess death rates for Black males and females are similar across
age categories except that a greater percentage of males than females
died between the ages 25 to 44, but a greater percentage of females
than males died between the ages of 45 to 69.

Homicide was the major cause of these excess deaths occurring in
Blacks, aged 25 to 44 years. Homicide accounted for 38 percent of the
male excess deaths and 14 percent of the female excess deaths below
age 45. Excess Black deaths between the ages of 45 to 69 were due
mainly to cancer, heart disease, stroke, diabetes, and cirrhosis.

As seen in Figure 4, homicide and unintentional injuries are the
major contributors to excess deaths for Black males. Heart disease
and stroke and cancer assume greater importance with advanced age.
For Black females, as shown in Figure 5, death from heart disease and
stroke assume the same importance as homicide and unintentional
injuries do for younger Black males. Diabetes is increasingly
important in the excess deaths of older Black females. Though
diabetes itself accounts for less than 2 percent of male excess deaths
and 5 percent of female excess deaths (to age 70), it is a major risk
factor for heart disease and leads to other serious consequences,
including amputation and blindness, if uncontrolled.

Hypertension similarly has serious health consequences if left
untreated. It is the leading cause of kidney failure and
hypertension-related end-stage renal disease in Blacks and is a major
concomitant of heart disease and stroke. Hypertension itself accounts
for more than 5 percent of the excess deaths in Blacks. Cirrhosis
accounts for more than 3 percent of excess deaths in both Black males
and females (to age 70), and unintentional injuries account for 6
percent of the excess in males and 2 percent of the excess in Black
females (to age 70). to age 70. Many of the causes of excess deaths
in Blacks are amenable to reduction through preventive and public
health activities. Hypertension and diabetes, which relate to other
conditions, are controllable through proper treatment.

Relative risks for specific causes of death under age 45 are
disturbingly high among Blacks compared to the White population, and
further support the findings of excess death. Blacks under 45 years
of age have a relative risk of death from all causes nearly twice that
of Whites (1.96 for males and 1.93 for females). Relative risk does
not indicate the largest numbers of deaths; rather, it reflects the

comparative likelihood of dying from a particular cause. The
conditions for which relative risks of death are highest for Black
(compared to White) males and females under age 45 are:

Males Females

Tuberculosis

Hypertension

Homicide

Anemias

Deaths from tuberculosis (TB) and anemias, although not major causes of
death, occur at a higher frequency among Blacks and may be related to
socioeconomic conditions commonly associated with these diseases.

Morbidity data from NHIS substantiate the problems Blacks,
especially women, face with hypertension, diabetes, and anemia. Black
women ages 45-64 had a prevalence rate of hypertension 85 percent
higher than White women, with hypertension afflicting 43 percent of
the Black women sampled in the 1979-81 NHIS. More striking data also
appear. Black women ages 25-44 had a prevalence rate for hypertension
2.6 times greater than White women of the same age; diabetes rates in
Black women 45-64 were 2.7 times higher than those in Whites, and
anemia rates reported were higher at all ages, ranging from 6.7 times
in children ages 1-14 to 2.6 times higher in Black women 15-44. These
morbidity figures clearly show the health disparities in Blacks
surfacing early in life, and several health conditions responsible for
the disparities are known risk factors for cardiovascular disease.

Disability data from the 1976 SIE provides additional information
on health differences in Blacks. Blacks reported lower rates of
disabling heart disease than Whites at each income level. However,
because the rates decrease as income rises and there are proportion-
ally more Blacks among the lower income strata, the overall Black
rates of disabling heart disease are higher. Similar correlations can
be found between education and other diseases reported in SIE. The
main conclusion from this analysis is that income and education are
major factors influencing health status. Lack of income and education
must be recognized as risk factors for disease and death in Blacks.

Hispanics

Hispanics are the second largest minority group in the United States.
For many data collection purposes (e.g., birth and death certification),
Hispanics are classified as an ethnic rather than a racial minority and are
often noted in vital statistics' information as White.

The primary sources of mortality data for all racial groups are
death certificates recorded by the states and used by Federal agencies
such as NCHS in computing national mortality statistics. Because
uniform procedures for reporting Hispanic ethnicity have not been
adopted nationwide, such information is not captured on many documents
including death certificates.

One effect of the lack of uniformity in noting Hispanic ethnicity
is that national mortality statistics for Hispanics cannot be compiled
from existing data and are therefore not available. Many states with
large Hispanic populations, such as Florida and New Jersey, have no
mortality data on Hispanics because ethnicity information is not
required on death certificates.

To compensate for the lack of national data, the Task Force
undertook a series of activities to obtain Hispanic mortality and
morbidity information. The Task Force established a panel of Hispanic
advisors, brought in Hispanic experts to speak to and consult with the
Task Force, participated in COSSMHO and other national meetings of
Hispanic health professionals, and commissioned special studies where
data were available. For example, Spanish-surname data from Texas and
national data on death certificates listing either Mexico or Cuba as
the country of birth were used to generate information on the health
problems of Hispanics compared to non-Hispanic Whites . This
information provided the best indication of Hispanic health problems
available to the Task Force until national data on Hispanic mortality
can be collected and analyzed.

Excess deaths were calculated for three Hispanic populations:
the Texas Spanish-surname, the Cuban-born, and the Mexican-born
populations. Excess deaths were fewer than those found for Blacks in
the 1979 to 1981 period. In the Spanish-surname population of Texas,
14 percent of all deaths were excess deaths when compared to the White
non-Spanish-surname population of the State (6). Among persons of
Cuban birth who died in the U.S. between 1979 and 1981, excess deaths
amounted to 2.2 percent of all deaths; for the Mexican-born
population, excess deaths amounted to 7.2 percent of all deaths.

The causes of excess deaths among the three Hispanic groups
analyzed are similar. As seen in Table 7, homicide was the leading
contributor to the disparity among both Cuban-born and Mexican-born
Hispanics. No other major cause examined contributed to the excess
deaths in the Cuban-born. Unintentional injuries, heart disease and
stroke, cirrhosis, and diabetes appeared to be major causes of the
disparity in the Mexican-born. Among the Spanish-surname population
of Texas, external causes, especially motor vehicle accidents and
homicide, were the primary contributors to excess death. Some
differences among the three Hispanic groups may reflect the
limitations in the data bases used in the separate analyses. For
example, infant mortality is virtually eliminated when the analyses
are limited only to the foreign-born.

These data for selected Hispanic populations suggest that the
relative risks for deaths from the causes evaluated are generally
lower than those of Blacks. Yet, certain causes of mortality before
age 45 merit special attention. The most important of these is
homicide among both Cuban-born and Mexican-born Americans, an excess
also noted in the Spanish-surname data. The relative risk of death
from homicide is 6.4 in Cuban-born and 5.9 in Mexican-born males under

3 «

Q
>

Tt — Tt

— o\ oo
ao m cA

Tt — en
-- On (N
00 r<-) Tf

^ [^ m
lo <s r-
in t^ ^

00 I^ -H

■* ■* O
00 ^ p-

fS CT\ r<^

<N VO 1/^

r<^ [^ m

ts Tt tN

m en I

o o\ vo
en m

VD O <N
OO cs m

\o o ■*

00 ts en
es "n (N

OS t-~ 00
O IT) -*

m m 1

en en o
>r> en CM

en I

o
en

•a

iS ** 5

Tt fN 00
en <N 00
en \o es

in t^ es

00 ■* VO

m OS en

U U <u

« a. o
.£ X X
O W W

Tj-

u->

■*

«S

*
*

*
*
•a

C/5

«5

O W w

"rt

■* On OO
NO — • Tj-

■* On «-l
NO -" "n

O NO S

es es I

On -H 00
t-~ en 'S-

en ts On
•* r- fN

<N t^ >n

O — ' — '

es en —
en m eN

en r- •<*■
■* en On
CN en I

— O ON
>0 Tj- 00

m lo -H

T3 -a

> ■*-; «5

t- U v:

(L> 0) a>

to Q, O

£ X X

O W PP

.a «

5 IB U

00 — NO
" oo — '
<n 1^

00 -H en

— 00 NO

m t^ eN

eN 00 NO
O m >n

iri On NO

eN "

On NO r~-
m in —

On NO t^

■^ NO eN
— ' eN -^

>n t^ cN

-H O ON

eN en |

Tt 00 ■*

rt O ON
- <N I

u u

> ^ c«

V- O !«

<U 0) 1)

j; a. o

■£ X X

O pq W

■«

■3

■a

s g

2 €
2 S

•S p

U U

■s :5
P s.

g -s g

> fl rt

■o

o
B

? i-1

U f- W5

2P tu
g «
u O

Oh CO

age 45 compared to the overall White male population under 45. For
females, the comparable figures using the overall White female
populations as a base are 2.4 and 1.5, respectively, suggesting that
homicide is not solely a problem for young Hispanic males.

Deaths from unintentional injuries pose a risk to males who are
Mexican-born under age 45, but not for the Cuban-born. The relative
risk of death due to unintentional injuries for Mexican-born males
under age 45 is 1.7; for females it is 1.0 (the same as White
females). This result is explained to some extent by examining the
relative risk of death due to cirrhosis. Mexican-born males have a 40
percent higher risk of death from cirrhosis than the White population
(i.e., a relative risk of 1.4). Cirrhosis is associated with
alcohol abuse and suggests that alcohol abuse in Mexican-born males
may be a problem. Alcohol abuse is also suggested to play a role in
higher risk of death due to accidents. Again, analysis of
Spanish-surname data confirm that there are excess deaths from
unintentional motor vehicle injuries.

Tuberculosis carries the largest relative risk of death
under age 45 to the Mexican-born, 7.8 for males and 11.0 for females,
as well as being high in Cuban-born males, 8.0. For the major killers
(heart disease, stroke, and cancer), the risks of death for the
Hispanic groups are less than that of non-Hispanic Whites. Overall,
the risk of death under age 45 is 1.4 times greater in Mexican-born
males and 1.2 times greater in Cuban-born males than Whites; however,
risk of death for foreign-born Hispanic females is less than that for
females under age 45 in the general, nonminority population.

Morbidity rates and health status measures for Hispanics were
analyzed to investigate possible reasons for the health differences
revealed by the mortality data, as was done with Blacks. Trevino and
Moss (7) examined a number of health status indicators from the NHIS,
including physician and dental visits, hospital stays, disability
days, acute conditions, and activity limitations due to chronic
conditions, for Hispanics, Blacks, and non-Hispanic Whites in the
period 1978 to 1980. The size of the Hispanic sample in NHIS,
however, is too small to generalize to the Hispanic population when
age, sex, Hispanic origin (Cuban, Mexican, and Puerto Rican) and
health condition are taken into account, as must be done to get
results meaningful to the charge of the Task Force.

The only statistically significant results reported in the
analysis of the NHIS data are prevalence rates of digestive conditions
among Puerto Rican females ages 25-44, which are 2.2 times greater
than those in non-Hispanic Whites. Skin and musculoskeletal
conditions among Cuban females are twice as high as those among White
non-Hispanics . Other results suggest that Hispanics in the NHIS
sample suffer from a number of conditions with potentially serious
outcomes if left untreated, but the small sample sizes preclude

generalization to the entire Hispanic population group. A better
picture of the health of Hispanic Americans should be available when
analyses of the Hispanic Health and Nutrition Examination
Survey (HHANES) are published.

Native Americans

Table 8 shows a striking pattern of excess deaths, by age groups,
among American Indians. The excess death rate of Indians under age 45
is high, at 43 percent. Of all American Indians who die before age
70, 54 percent die before age 45. Excess deaths before age 70 amount
to one of every four deaths in American Indians. Eighty-seven percent
of the excess deaths in American Indians occur before the age of 45.
(The comparable figure for Blacks is 39 percent.)

Eighty percent of excess deaths occurring before age 45 and 99
percent of the excess deaths up to age 70 are due to six causes.
These six causes, in order of greatest contribution, are:
unintentional injuries, cirrhosis, homicide, suicide, pneumonia, and
diabetes. Conspicuously absent are heart disease and cancer which
have higher overall rates in the White population and which are
considered diseases of middle and later life.

Deaths from unintentional injuries account for 48 percent of
excess deaths for males and 40 percent of the excess deaths for
females (up to age 45). Cirrhosis accounts for 11 percent of the male
excess and 20 percent of the female excess deaths prior to age 45.
Homicide accounts for 9 percent and 8 percent of the excess among
American Indian males and females under age 45, respectively. From
these causes, it would appear that alcohol abuse is one of the most
serious contributors to premature deaths among young adult American
Indians .

The risk of death for American Indians under age 45 is 1.8 times
that of Whites for both sexes. Over age 45, relative risk of death
for Native Americans is equal to or slightly lower than for Whites.
The lower relative risk observed over age 45 might be due to a
"survivor effect" similar to that among older Blacks. Causes with
higher relative risks are seen in Table 9.

The extremely high relative risks of death for females due to
cirrhosis and tuberculosis in part reflect the low rates for
White females who are the basis of the comparison. Nonetheless, these
relative risks do convey the dimensions of the problem in this
population. These statistics further confirm the magnitude of alcohol
abuse among young American Indians of both sexes. The high risks of
TB , combined with relative risks of death above 1.0 for anemia and
hepatitis, probably reflect socioeconomic correlates of these diseases.

c/3

"3 M

o u

3 O

■i

•3

B
O

00 t-~ ro

fO OO 00

[^ Ov t~

00 t^ -^

m 00 m
1^ OS (^

t^ (^ O

00 00 o
m " CN

On O On

<N| NO NO

u-1 ^ ■*
-^ ITi NO

I^ ro r<1

c<^ ■* On
NO — ■*

ir^ NO OS

On -H t^

O CS (N

■* t^ en

t^ — NO

On 00 «

b *

(N ■* <N
1^ — 00

00 lO m

CN Tj- 00

r^ — >Ai

00 lo m

-H 00 m

t^ On t^

iri 00 [^
Tt — (N

(U U CU

a s a. o

S o w w

CN On m
iri o '^
cs ^ "

Tf Tl- o

On NO ro

rt NO >n

t^ t~- O

ON r<^ -^
■* r- cnI

in On NO

IT) <n --

U (U

> t^ «5

l-i O crt

(u a> (u

£ X x

O W W

t^ t^ 00

OS fs r^
o •* o

t^ t^ o

On <N t^
O ■* NO

rs) >o t-~

m m On

!~- ■* (N

OO O 00

in t^ 00

— ' (N OS
00 — NO
00 ■* -*

r- NO — '
m ra c<"i

ro ^ OS
NO — ^

O NO ^

— ' NO ^

lo OO en

<N NO '^
Cn) ^ CN

« NO m
t^ m NO
m t^ — ■

Ofl

3 £; o S

„ O 1) 1)

g O m w

C9 ™

Z 2

On t^ m

O fO t^

t~ cn u-i

On t^ fS

O CO 1^

[^ m CO

t^ m CM

OS -^ u-i

(N •* 00

O m NO
m — —

On tS t^
NO CN T)-

OS NO m
— NO >ri
(N — '

NO <N ^

in m CNi

NO OO CN
— ■ OS 00

<N m — ■

OO On --
OS — CN
cs tn I

« *

o. u

X X

O W tq

•a
E

-5 ci-

2 2

(D td

o o

s g

> M

1) .D E °

3 S

op la
o::

U H w a. w

Table 9

Relative Risk of Death for American Indians by Cause*

Cause Relative Risk

Male Female

Cirrhosis 6.1 11.1

Tuberculosis 8.5 9.8

Chronic Renal Disease 2.7 4.7

Unintentional Injuries 2.1 2.4

Drowning 2.8 2.4

Homicide 2.2 2.6

Diabetes 2.2 1.1

SOURCE: Duke University analysis commissioned for the Task Force, 1984.
*NCHS microdata mortality tapes and 1980 U.S. Census population at risk.

Too few Native Americans are sampled in the NHIS to derive
population-level prevalence estimates for selected diseases and
disability. The responses reported by the sample respondents tend to
reflect the mortality results, but it would be misleading to attempt
to extrapolate these to represent morbidity in Native Americans. The
Indian Health Service (IHS) provides statistics about the population
it serves, but these data are obtained from only 60 percent of the
total American Indian and Alaska Native population. The data that
are available, however, along with selected examples such as the high
rate of diabetes among Pima Indians, indicate the existence of serious
health problems. More reliable information on the Native American
population is needed. Clearly, more needs to be known about
environmental and psychosocial contributors to the widespread abuse of
alcohol by young Native Americans if the premature loss of life in
this minority population is to be prevented.

Asian/Pacific Islanders

The Asian/Pacific Island minority, in aggregate, is healthier
than all racial/ethnic groups in the United States, including Whites.
There are virtually no excess deaths, as seen in Table 10, when all
Asian ethnic groups are combined, and Asians have a greater life
expectancy than Whites. Yet, specific health problems do exist among
various subgroups of this population. The Task Force explored several
avenues to determine those health disparities that might be masked as
a consequence of combining the subpopulations . The Task Force
established an Asian advisory panel, commissioned papers from experts
in the field, and visited the Chinese Hospital in San Francisco and
consulted with the School of Public Health at the University of Hawaii.

3"!

O O

E
o

'u^

•^i

Q
>

,-H

oo (N

■*

00 O CN
^ ■* ON

« c^ I

■<:

■w

Tj- — r-

_: I

00 rt

fN O —

IT) VO O

«-i

■o

t~-

u-i

fN On

\o " >n
r^ CM •*

^ ^ B

NO On
t^ On
Tt- On

o <o >n

o o o

ro ■* '-

On — ■

en Tf —

t^ •* (^

00 m -^

C^ CN On
00 Tj- lO

R 1 'R

O
1^

V
DC

B '"

< S

NO
NO

<n o

NO «-> On
— ro rt
CN en rt

On (^

O m
en I

— c NO

cn On

(N (N O

en 00 m

NO -*

O — '
U-) On

> 2
= 2
>> "a

§ 1 1

J2 -S J^

gum

K Si H U.

-S -s a

J3 I*- O "

O 4J W5 1^

D 3 <« g

(U iS ^

3-S

•O. PJ

■ ■ u

2 o

The University of Hawaii is conducting a major study of the
health status of Americans in the Pacific. Preliminary results
indicate that, compared to Caucasians in Hawaii, Native Hawaiians
experience excess deaths for heart disease, cancer, diabetes, infant
mortality, and accidents. Cancers of the stomach and lung are
particularly high relative to Whites. Excess deaths due to accidents
are believed to result from the riskier occupations of Native
Hawaiians, relative to Whites.

The primary morbidity problems found in Native Hawaiians include
heart conditions, hypertension, diabetes, asthma, gout, and back
problems - results in keeping with the mortality findings. The
University of Hawaii study also applied "excess deaths" methodology to
the Pacific Island territories, but the vital statistics in those
territories were inadequate to report findings (8) .

The Task Force analysis of national mortality data for Asian/
Pacific Islanders under age 45 indicates that the relative risk of
death for almost every cause is low. Although the risk of death for
all causes is a third lower than that of Whites, Asian/Pacific
Islanders have higher rates for TB, hepatitis, anemia, and
hypertension. The importance of the increased risk indicated by
relative risk for hypertension, though not large (1.2 for males and
1.3 for females), cannot be ignored because of the impact of
hypertension on other diseases.

An analysis by Yu, Chang, Liu, and Kan (3) commissioned by the
Task Force provides results of excess death analyses for the three
major Asian subgroups: Chinese, Japanese, and Filipinos. The authors
emphasize the lack of data for other Asian/Pacific Islander subgroups,
such as Southeast Asians and Native Hawiians , whose health status is
believed to be poorer than that of those Asians for whom data are
available. The study found no "substantial amount of- excess deaths
for a majority of the causes of death. . . [with the only consistent
pattern being]... the high suicide rate of Chinese women vis-a-vis
White women." Differences in socioeconomic status, culture, and
lifestyle are hypothesized to explain the lower relative mortality of
Asian/Pacific Islanders in the United States. The extremely low
relative risks of death for causes generally associated with cigarette
smoking and alcohol consumption bolster this claim. The lower
mortality rates were analyzed separately for the Chinese, Japanese,
and Filipinos, with the same generally favorable outcome relative to
Whites for each.

Relative risks of selected causes of morbidity based on
prevalence rates from the NHIS are unavailable. Fewer than 5,000
Asian/Pacific Islanders were sampled in the period 1979 to 1981. When
age, sex, and cause of illness are examined, the number of responses
on which to base population estimates is insufficient.

Papers by True (9), Yu, Chang, Liu, and Kan (3), and by Yu, Liu,
and Kurzeja (10), commissioned for the Task Force, examine the health
problems of immigrant and ethnic groups within the Asian population
more closely. Cultural differences and language difficulties are
major barriers for immigrants and refugees for using existing health
services in the areas where they reside. Additionally, for almost
every age group, the death rates for foreign-born Chinese, Japanese,
and Filipinos are higher than for native-born Americans of these same
subgroups .

As a group, the Asian/Pacific Island population in the United
States is at lower risk of early death than the White population.
There are, however, specific diseases for which this population is at
higher risk. There are also significant subgroups in this population,
e.g.. Southeast Asians, other recent immigrants and refugees, and
Native Hawaiians and Pacific Islanders, who have specific health
problems that are not reflected in national data. These issues are
discussed in more detail in Subcommittee reports found in a later
volume of this report.

Summary

The data reviewed by the Task Force clearly show that Blacks have
the greatest disparity in mortality and morbidity among the minorities
as compared to Whites. This disparity is evident in life expectancy
at birth, and is reflected in excess deaths as well as other measures
of mortality and morbidity. Data for Hispanics cover only a limited
segment of this minority; they do, however, indicate disparities in
mortality. National mortality data, including the calculation of
excess deaths and relative risks, indicate major areas of disparities
between Native Americans and the White majority, perhaps most
prominently due to several causes related to alcohol abuse. When data
from many of the Asian/Pacific Islander subgroups are aggregated, a
negligible disparity only is evident. However, data from the
individual ethnic subgroups, when considered separately, suggest a
different picture--one of a range of health problems and disparities
in certain subgroups .

The data used in compiling other health indicators for minority
groups are uneven and far from complete. Nevertheless, the results
provide a basis from which further data collection efforts and
analyses may be made. Data on morbidity and other health status
indicators in the four minority groups are: the most complete and
accurate for Blacks; very limited for Asian/Pacific Islanders;
available for American Indians and Alaska Natives living on or near
reservations (through the Indian Health Service); and available on
Hispanics through the surveys of NCHS, primarily the NHIS and the
HHANES. The data currently available for Asian/Pacific Islanders and
Hispanics may be weighted toward the larger, more established,
healthier, ethnic groups within these minorities, rather than the less
settled, immigrant and refugee subgroups.

Homicide, unintentional injuries, and alcohol abuse, a precursor
to cirrhosis, stand out as primary causes of the disparity in
mortality that are amenable to health promotion and education
programs. Similarly, infant mortality rates in minorities may be
improved with increased availability of prenatal counseling and
services. Positive results of such services among the American
Indians are already reflected in IHS statistics on neonatal deaths,
although postneonatal deaths remain a problem.

Hypertension, a subject of major public health initiatives at
present, clearly is an area deserving continued emphasis in the
minority population. Diabetes is another significant health problem
for Blacks, American Indians, and Hispanics . The magnitude of the
diabetes problem is often underestimated because mortality statistics
understate the relationship of the disease to other health problems,
especially as a risk factor for cardiovascular disease. Yet, the
complications of diabetes can be controlled by intervention efforts.

Only limited information exists to determine the possible
association between health status and socioeconomic factors, such as
income and education. Greater awareness of this relationship would
make it possible to target existing resources more effectively toward
the areas of greatest need in the various minority populations at risk.

REFERENCES

1. Haynes , M. A. (1984, June 7). Presentation to the Task Force on

Black and Minority Health, DHHS .

2. National Center for Health Statistics. (1984). Final mortality

statistics, 1982. Hyattsville, MD: Author.

3. Yu, E., Chang, C-F., Liu, W. T. , & Kan, S. H. (1984, December 5).

Asian-White mortality differentials: Are there excess
deaths? Unpublished manuscript. Task Force on Black and
Minority Health, DHHS.

4. Haynes, M. A. (1985) Association of health problems with

ethnic groups as reflected in ambulatory care

visits. Unpublished manuscript, Task Force on Black and

Minority Health, DHHS.

5. Rumbaut, R. (1984) The politics of migrant health care:

A comparative study of Mexican immigrants and
Indochinese refugees in San Diego County. Unpublished
manuscript, University of California, San Diego.

6. Bradshaw, B. S., Frisbie, W. P., & Eifler, C. W. (1984). Excess

and deficit mortality due to selected causes of
death and their contributions to differences in life
expectancy of Spanish-surnamed and other White males:
1970 and 1980. Unpublished manuscript. Task Force on
Black and Minority Health, DHHS.

7. Trevino, F. M. , & Moss, A. J. (1984, September). Health

indicators for Hispanic, Black, and White Americans.

(DHHS Publication No. (PHS) 84-1576). Washington, DC: National

Center for Health Statistics.

8. Chung, C. S., & Michael, J. M. (1984). Analysis of mortality

and morbidity of native Hawaiians and the Pacific
Islanders . Honolulu: University of Hawaii School of
Public Health.

9. True, R. H. (1985, January 11). Health care service

delivery in Asian American communities. Unpublished
manuscript. Task Force on Black and Minority Health, DHHS.

10. Yu, E., Liu W. T., & Kurzeja P. (1985, January 11). Physical

and mental health status indicators for Asian/Pacific
Americans. Unpublished manuscript, Task Force on
Black and Minority Health, DHHS.

Accounting For the
Health Status Disparity

Subcommittee
Summary Reports

SUBCOMMITTEE ON CANCER
EXECUTIVE SUMMARY

Introduction

This report examines cancer mortality in minorities, with
particular emphasis on factors that contribute to excess mortality;
i.e., cancer incidence and survival, risk -factors/exposures , health
resources, and other factors. The report illustrates the complex
relationship among cancer incidence, survival, and mortality for
minorities and nonminorities .

Patterns of cancer distribution among U.S. population groups
vary according to racial and ethnic background. In examining these
differences, this report looks at information regarding incidence,
mortality, and survival; information relating to prominent factors
that are risks for cancer development; and information on knowledge,
attitudes, and practices regarding cancer that influence care-seeking
behavior. In short, differences in cancer experience among minorities
and factors that may contribute to the differences between minorities
and nonminorities are discussed.

Risk factors are discussed because they are critical to the
understanding of endogenous and exogenous conditions that may pre-
dispose a person to cancer development. Major risk factors--tobacco,
the combined effects of tobacco and alcohol, nutritional and dietary
factors, and occupation- -account for approximately 72 percent of
cancer mortality and 69 percent of incidence (1).

Socioeconomic status is also an important factor in
cancer incidence and survival and, therefore, mortality.
Socioeconomic status is related to a variety of factors which
influence cancer experience, including: nutritional status; smoking
patterns; distribution, quality, and use of health resources; and
knowledge, attitudes, and practices. Lower socioeconomic status has
been correlated with poorer survival from cancer (2,3). It is also
related to increased cancer incidence for cancers of the lung, breast,
and cervix (4) .

Most statistics relating to cancer incidence and survival rates
are derived from the Surveillance, Epidemiology, and End Results
(SEER) Program of the National Cancer Institute (5). The SEER Program
obtains cancer patient incidence and survival information from 11
population-based cancer registries that cover more than 13 percent of
the U.S. population. Within the racial and ethnic groups in the
United States, SEER data cover 12 percent of nonminorities, 12 percent
of Blacks, 27 percent of Native Americans, 32 percent of Chinese, 47
percent of Japanese, 38 percent of Filipinos, 12 percent of Hispanics,
and 31 percent of "other". The areas covered by SEER include five

states (Connecticut, New Jersey, New Mexico, Utah, and Hawaii), four
metropolitan areas (Atlanta, Detroit, San Francisco, and Seattle), and
the Commonwealth of Puerto Rico. SEER data on Hispanics in this
report, however, refer only to those Hispanics living in the United
States. Mortality data are derived from the National Center for
Health Statistics (NCHS) through the national vital statistics'
system. This system classifies Hispanics as Whites, and therefore no
death statistics on Hispanics are presented. Most of the indepth
analysis underlying this report is limited to Blacks and Whites. The
reason for this is that the number of cancer cases is too few in the
other minority groups to permit meaningful statistical analysis.

Risk Factors and Exposures

Risk factors and exposures are important in explaining and
accounting for the initiation and/or rise of cancers in minority and
nonminority populations.

The major risk factors/exposures that account for 72 percent of
all cancer deaths are tobacco, dietary/nutritional factors,
occupation, and ethanol, as seen in Table 11 (1). Of these, tobacco
the greatest risk factor for cancer for Blacks.

Table 11

Proportion of Cancer Deaths Attributed to Different Factors

Factors

Estimated

Percent of All Cancer Deaths

Tobacco
Alcohol
Diet
Occupation

30%

35%

SOURCE: Doll and Peto, The Causes of Cancer (1).

Tobacco-related cancers account for approximately 45 percent of
new cancer cases (incidence) in Black males, 25 percent in Black females,
and approximately 37 percent of cancer deaths in Black males and 20
percent in Black females.

Examination of tobacco use patterns indicates a higher prevalence
of smoking in Blacks compared to Whites. However, Blacks tend to be
lighter smokers (fewer pack years) than Whites. In view of these
patterns, the contribution of other risk factors (e.g., diet and
occupation and their combined effects with tobacco) gain added
importance, particularly in explaining excess lung cancer mortality in
Black males.

The contribution of occupational exposures to cancer etiology in
minorities may be even greater than the 4 percent listed in Doll and
Peto (1). Numerous occupational epidemiology studies document the
higher rate of assignment of Blacks to hazardous worksites compared
with rates for Whites. This fact, coupled with the excessive cancer
experiences of Blacks, suggests occupation may likely account for a
greater percentage of cancers in minorities than previously
appreciated (6) .

Knowledge, attitudes, and practices are important to
understanding factors that relate to people seeking care for cancer
(cancer screening, detection, treatment, and rehabilitation).
National surveys indicate that Blacks overestimate the deadliness of
cancer and underestimate cancer prevalence in their population.
Additionally, Blacks are less knowledgeable about cancer-related
warning signs and screening methods than Whites. Even with early
detection. Blacks are more pessimistic about the curability of cancer
than Whites (7). Such disparities in knowledge, attitudes, and
practices between Blacks and nonminorities may help to explain the
longer delay in seeking diagnosis and treatment among Blacks and thus
the greater prevalence of more advanced stages of cancer in Blacks
than in Whites (5). More advanced stages of cancer have unfavorable
prognosis for cancer survival.

Cancer in Minority Groups

Blacks are the largest minority population in the United
States and the one for which the most cancer data are available.
However, where relevant reliable information is available for other
minority groups - -Hispanics , Asian/Pacific Islanders, and Native
Americans--it will be presented. Blacks have the highest overall
age-adjusted cancer rates for both incidence and mortality of any U.S.
population group. Figure 6 illustrates the average annual mortality
rate for cancer, by sex and race.

Table 12 shows the average annual incidence rates (detecting new
sites of cancer) according to selected primary sites and racial/ethnic
groups. The most recent SEER cancer incidence data, 1978-81, show an
11 percent excess incidence of cancer among Black Americans compared
with nonminority Americans. The age-adjusted incidence rate is 25
percent higher among Black males compared with nonminority males, and
4 percent higher among Black females compared with nonminority
females. Black men showed the largest increase (8 percent) in cancer
mortality between 1973-77 and 1978-81.

--. o iJ

^s'y

•— O S3

^c£S

■4.
'A

u.y

I te

a E

z <

30 ^^^^^^^^^

i 1 1

■c

■a

-2

(«

z <

■o

s
S

■^ s

=5 S

§^

C/5

•id

■^

o
c

— '

Zs:

T? >^

-w

ffl

C/5

o r~ <N

c«^ — -^

[^ 00

vd — ^

t~~

-H

o
U

c
_o
"o
U

U-1

■*

l/^

—

m
■*

— — ' — ■ vo

On — <
od Tt

5 -

^ — ' vo -^

en O -H

vo
t^

u-i

v~,

>■

C<1

"•

1— 1

CL.

per

rveill

prog

Rates
E: Su
SEER

■■ l_> u

S^ = t"

Z i«

;2 s

tu Z

,o _o s
■2 ■§ X

Blacks experience greater age -adjusted incidence rates than
nonminorities for cancers of the cervix, esophagus, larynx, pancreas,
prostate, and stomach. Excess mortality exists for cancers of the
following sites: bladder, cervix, corpus uterus, esophagus, lung,
prostate, and stomach. Excess incidence and mortality are particularly
pronounced among Black males.

SEER data are available for 25 primary cancer sites. Blacks
have lower survival rates than nonminorities for 22 of those cancers (5)
Five-year relative survival for all cancer sites combined is 12
percent less in Blacks than in Whites (38 percent versus 50 percent,
respectively). Blacks survive less for cancers of the bladder,
breast, corpus uterus, prostate, and rectum.

Blacks

Table 13 shows average annual cancer mortality rates by selected
primary sites and race. The death rate for lung cancer is 45 percent
higher among Black males compared to nonminority males. The death
rate for both Black and nonminority females is about equal. For
cancer of the esophagus among Black males, mortality is three times
higher than for nonminority males. Mortality rates among Black women
are 2.5 times higher than for nonminority women. Age-adjusted
incidence rates of esophageal cancer are correspondingly high: 3.5
times higher for Black men compared with nonminority men, and almost 3
times higher in Black women than nonminority women. Mortality from
stomach cancer is more than 1.5 times greater among Blacks than among
nonminorities. Stomach cancer incidence is almost twice as high among
Blacks compared with nonminorities.

Age-adjusted mortality from prostate cancer is two times higher
among Black males than among nonminority males. The death rates
increased by 11.8 percent among Blacks and only 4.2 percent among
nonminorities between the periods 1973-77 and 1978-81. Incidence data
show that Black men have a 60 percent excess incidence of prostate
cancer compared with nonminority men in the United States .

Both mortality and incidence rates for cervical cancer are
approximately 2.5 times higher among Black females than among
nonminority females. Nonminority females showed a 20 percent decrease
in cervical cancer deaths between 1973-77 and 1979-81, while Black
females experienced a 27 percent increase during this same period.
Black females experienced a 33 percent excess death rate from cancers
of the corpus uteri compared with nonminority females.

The incidence of multiple myeloma is more than twice as high for
Blacks than for nonminorities. The incidence for Black men is 9.6 per
100,000 and for Black women it is 6.7. The rate for nonminority men
is 4.3, and for nonminority women it is 3.0.

'.a

U
CQ

c/5

s
2

c
a
a.

§1

Sri

k-r

CO a.

— ■

•rt

r-~

v£)

—

oo oo

IT)

■*

W-1

iri

•"^

00
00

—

■*

^-i

'T)

■o

— '

»Ci

— ■

1/-1

■*

r~~

oo ■

,—1

»— t

c« Z

u-i

fNl

'— '

^-1

u-i

o o

NO — ' «-!

^^ 00 m

00 -^

On O
NO <S

-1

Qs;

00 J2

3 ^

2 § E

■o

d) U CxO
8. £ £

2 ^^

cd OS

E: R

RCE

SEE

NOT
SOU
*The

E
<

2 o ■=

« o i

a. u X

2 "t3 .

There are striking differences in Black/nonminority survival for
cancers of certain sites. Table 14 shows relative 5-year survival
rates for selected sites of cancer. The 5-year relative all-site
survival rate for 1976-81 was 50 percent for nonminorities and 38
percent for Blacks. Of the 25 primary cancer sites for which survival
data were available, Blacks had better 5-year relative survival than
non-minorities for only three sites--ovary , brain, and multiple
myeloma--all relatively low-incidence cancers. Black patients had
better survival rates than nonminorities for ovarian cancer for all
stages combined and also within each stage category.

The breast cancer survival difference (Blacks, 63 percent;
nonminorities, 75 percent) was statistically significant. This was
partly related to the large number of Blacks who had lymph node
involvement or direct extension of tumors to adjacent tissue at the
time of diagnosis (stage III B). The difference in 5-year relative
survival rates for Blacks and nonminorities for all stages combined
for colon cancer and bladder cancer was significant, with Blacks
experiencing lower survival rates.

The scientific literature supports a hypothesis that the
differences in cancer experience between nonminorities and Blacks may
be largely attributable to social or environmental factors rather than
inherent genetic or biologic differences (4,8,9). This has major
policy ramifications for the accessibility, availability, utilization,
quality, and continuity of health resources, for example, state-of-the-art
cancer screening, detection, treatment, and rehabilitation. Other
possible contributors include: nutritional status and dietary
patterns; immune status and function; educational level and attitude,
and awareness of cancer preventive concepts and behaviors; and
acceptance of cancer as a real and potential threat.

When adjustments are made for stage at diagnosis in cancer
patient survival studies, survival differences decrease between Blacks
and nonminorities (10), and when adjustments for socioeconomic status
are made, the disparities between the two groups are further reduced
(2,3,8,11). Factors that may contribute to poor cancer survival in
Blacks include lower socioeconomic status (11), later stage at diagnosis,
delay in detection and treatment (10), treatment differences (12)
and biologic factors such as immune competence and response,
histologic patterns of tumors, and nutritional status (13).

Hispanics

Overall age-adjusted cancer incidence rates for Hispanics are
lower than for Blacks or nonminorities. Specific sites of excess
incidence among Hispanics are stomach, prostate, esophagus, pancreas,
and cervix cancers . Stomach cancer incidence in Hispanics is twice
that of nonminorities. Stomach cancer incidence has been correlated
with diets high in smoked, pickled, and spiced foods--especially those
high in N-nitroso compounds. Tobacco also has been suggested as a
risk factor in stomach cancer development. New Mexico Hispanics have

C
00

1/3

z <

C/5

? <N

I I

? I 2

•— 1

1 '^

•*

U-,

•*

t~~

I s

*0 -^ oo IT)

IT)

'— '

— *

C<)

•*

? " S

O m

V-)

U~l

iri

in Tf VO [^

0-.

— ' O ■* r~i

-H rt ^ VO

t^
^

I 2

VO 00 Tt
■* ^ ■*

, [

•<* — ' CM ov
— >0 in Tt

00
VO

c
o

■q

■U

(/)

•3 U OS

«
s

ov
VO

■a

o S

«! »-< G

E
_o
13
>^

-^ 3 ca -5^
& !S c ^

J (£ ^3 S

E
<

' >

OS S
W Z
u
on c

^^ CO

2 S

— rt

as u

0) u.

— oo -^
~ O fc,
U Jr O

e °- t:

■^ W -a

W c/5 ^

n E- C/D ■

r\ * *

pancreatic cancer rates that are higher than those of nonminorities .
An upward trend also is appearing for Puerto Rican females. Excess
risk for pancreatic cancer has been found among cigarette smokers.
Also, cervical cancer is twice as high among Hispanics as among
nonminorities. The incidence among Hispanics is, however, lower than
that for Blacks, Native Americans, and Chinese Americans.

The overall 5 -year relative survival rate of Hispanic males is
almost identical to that of nonminorities. Hispanic females have
somewhat lower survival rates than that of nonminority females.
Survival data are similar for Hispanics and nonminorities for all
sites except bladder cancer and Hodgkin's disease, where survival is
poorer for Hispanics, and ovarian cancer, where it is poorer for White
non-Hispanics (14).

Asian/Pacific Islanders

Cancer incidence varies widely among Americans of Chinese,
Japanese, Filipino, and Hawaiian descent. Rates of cancer incidence
among Hawaiians follow Blacks with the second highest in the U. S.
population. The rates for Chinese, Japanese, and Filipinos are less
than for nonminorities. There is, however, an upward trend in
incidence rates for both sexes of the Chinese population and for
Japanese males. Hawaiians have excess mortality for cancers of the
breast and lung. Japanese Americans have excess mortality for stomach
cancer. Chinese Americans have excess rates for cancer of the cervix
and for nasopharyngeal cancer. Among Chinese and Japanese, rates for
males are higher than those for females (15).

Stomach cancer incidence is 2.5 times higher for Japanese males
and 3.8 times higher for females than for nonminority males and
females. Esophageal cancer is also 2.5 times higher in Japanese males
compared with nonminorities. Migratory studies of Japanese point to
dietary practices as a cause in three major cancer sites: stomach,
breast, and colon. Japanese females are the only U.S. minority group
that does not have cervical cancer incidence rates above that of
nonminorities. However, Japanese females show a trend toward higher
rates .

Chinese Americans have an increased incidence of about 17
percent over nonminorities of multiple myeloma. Incidence of
esophageal cancer is higher for Chinese males and females than for
nonminorities. Most studies on the causes of esophageal cancer
suggest that the major risk factors are smoking and alcohol
consumption, with the combined use having a synergistic effect.
Consumption of hot beverages also has been implicated in esophageal
cancer. Pancreatic cancer incidence is about 20 percent higher among
Chinese females than among nonminorities, and an upward trend in
incidence exists for Chinese of both sexes. Excess risk for
pancreatic cancer has been found among cigarette smokers.

Filipinos have the lowest survival of all ethnic groups for
colon cancer (35 percent) and the highest for ovarian cancer (35
percent) . Hawaiians experienced comparatively high survival rates for
lung, breast, prostate, and cervix cancer and comparatively lower
survival rates for ovarian (38 percent) and corpus cancers (76
percent) .

SEER registry data (1973-79) indicate that for Chinese Americans
the 5-year relative survival for all sites was 35 percent in males and
50 percent in females compared with 40 percent and 55 percent in
nonminorities . In Filipino Americans, site-specific relative survival
rates vary widely, with some rates being the lowest of eight ethnic
groups and others being much higher. Survival rates for Hawaiians
also vary widely, as noted above.

Native Americans

Native Americans have the lowest rates of overall cancer
incidence and mortality of all U.S. populations (including
nonminorities) covered in the SEER program. Cause of death data
indicate that cancer, the second leading cause of death for the U.S.
population as a whole, is the third most common cause of death
(preceded by accidents and heart disease) among Native Americans. In
1975, the age-adjusted mortality for cancers was 39 percent lower for
this group than for the general U.S. population (16).

However, Native Americans generally had low survival rates
according to 1973-79 SEER data. Overall 5-year relative survival for
males was 26 percent compared with 40 percent for nonminority males,
and 39 percent for females compared with 55 percent for nonminority
females. Native Americans have rates below nonminorities for the most
common cancers --lung, colon, breast, and prostate cancer--and much
higher rates for cancers of the cervix, gall bladder, and kidney.
Differences in overall cancer mortality for Native Americans and
nonminorities are believed to be due more to cultural factors and
environment than to genetic factors.

The lung cancer mortality among Oklahoma tribes is nine times
greater than that of Southwest tribes . Environmental and cultural
factors, in this case, heavy smoking among Oklahoma Indians but not
among Southwest tribes, undoubtedly play a role in this discrepancy.
Indians of the Southwest, who seldom smoke extensively, have low rates
of squamous cell bronchogenic carcinoma--a common type of lung cancer
and the one associated with heavy smoking (16).

Native Americans show excess mortality for cancer of the gall
bladder. Indians of the Southwest have the greatest incidence as
compared with Oklahoma Indians. The excess incidence of cancer of the
gall bladder is frequently attributed to a genetic basis. Native
Americans also have excess mortality from cancer of the cervix. Alaska
Natives are reported to have increased incidence of cancer of the gall
bladder and excess mortality from primary liver cell cancers (17).

OPPORTUNITIES FOR PROGRESS

Many of these activities, proposed by the Subcommittee on
Cancer, are also applicable to the United States population in
general, not just to minorities.

Information and Education

Increase the public's knowledge of the health hazards of tobacco
through activities originating in the Office on Smoking and Health.

Design smoking cessation programs targeted specifically to the
underserved working population (migrant workers, recent immigrants,
part-time workers, shift workers).

Continue to publicize the risks of smoking and tobacco use through the
Office of Cancer Communications (and its Cancer Prevention Awareness
Program and other National Cancer Institute (NCI) programs).

Continue to inform the public, through the Cancer Information Service
(CIS) , about resources available to prevent and stop smoking and
tobacco use.

Assist and promote an increased role for the NCI-sponsored
Comprehensive Cancer Centers in prevention and cessation of smoking
and tobacco use.

Develop joint efforts between the Federal Government and industry to
develop diet and cancer programs that use mass media and other
high- techno logy communication approaches.

Target primary care physicians and other primary care health
professionals (for example, pharmacists, occupational nurses) for
educational campaigns about the importance of screening and early
detection. Specific educational messages for these groups should
include:

• The importance of comprehensive physical examinations to detect
cancers of the rectum and prostate (digital rectal examination) ,
breast (palpation and mammography), skin (physical examination),
cervix and uterus (pelvic examination and Pap smear) , and
endometrial sampling in high-risk females to detect uterine
cancer.

• The importance of identifying and closely monitoring: high-risk
individuals with aggressive follow-up where changes are apparent;
any history of nonmenstrual bleeding in women, with aggressive
follow-up; and family history to determine risk for breast
cancer and melanoma;

• The importance of early referral for diagnosis and treatment
planning.

• The fact that many forms of cancer are treatable and curable.

Emphasize through teachers' associations and appropriate clubs,
lay organizations, and churches the value of screening for cancer in
their efforts to inform and educate the public and their members.

Use radio and television and other media programs more
effectively to present information on the value of screening for
cancer. These program efforts should make special attempts to target
messages to high-risk groups, such as those exposed to known
carcinogens and those with a strong family history of cancer (breast
cancer, ovarian cancer, and melanoma). The messages should be
sensitive to the special cultural and social settings of the people
who need to be reached. All public education programs should
emphasize:

• The importance of early warning symptoms of cancer.

• The importance of comprehensive physical examinations.

• The appropriateness and importance both of seeking information
about treatment choices and seeking referrals when appropriate.

In educational efforts regarding cervical cancer, include informa-
tion on risk factors for the disease and on the importance of follow-up for
abnormal bleeding, as well as on the availability and usefulness of the Pap
test. The importance of pelvic examinations and follow-up for abnormal
bleeding should be emphasized in public education campaigns about uterine
cancers; such efforts should be targeted to postmenopausal women, especially
those with lower socioeconomic status.

Public information programs about colon, rectal, and prostate cancer
should emphasize:

• The high risk of these cancers for adults aged 50 and above.

• The importance of early recognition of symptoms.

Try innovative channels of communication, for example,
mailing information on colon, rectal, and prostate cancer with social
security checks to reach retired elderly persons, and distributing literature
at retail stores and pharmacies.

Strategies for disseminating information to professionals should
include all the traditional methods, such as professional meetings,
journals, special continuing medical education symposia and consensus
conferences, revised medical school curricula, and residency training.

Use the Physician Data Query (PDQ) system should be used as a
vehicle for disseminating up-to-date cancer treatment information to
physicians .

Capacity Building in the Non-Federal Sector

DHHS should work with the non-Federal sector in developing the
capacity to perform periodic surveys on the prevalence of smoking to
assess problems and progress.

Encourage state health agencies to develop and implement
statewide, health-risk appraisals/risk reduction programs that include
smoking as a risk factor.

Encourage state education departments to review and evaluate
elementary and secondary school health and home economics curricula
and training guides. Draw upon appropriate local and national experts
to upgrade curricula to reflect newer knowledge of diet and cancer
risks and strategies for risk reduction.

Encourage state and local governments to assist voluntary and
private sector groups in modifying existing health promotion programs
to include diet and cancer risk reduction components.

Encourage state and local agencies for agriculture, environmental
protection, health, and aging to coordinate program planning
activities to ensure that attention is given to reducing dietary risk
factors for cancer. One such activity would be to include education
and information on eating for better health and for avoiding cancer
risk, and to make use of innovative approaches to reach high-risk
groups .

Voluntary health organizations should continue to expand their
efforts to increase the utilization of screening for cancer and should
develop programs to overcome identified impediments to utilization.
These groups should be the focus of other prevention activities.

As appropriate, hospitals should consider adopting mechanisms
that would promote screening tests such as breast examination, the Pap
smear, the stool occult blood test, and rectal examination at some
time during admission or prior to completion of treatment in the
emergency room for most patients.

Financing Issues

Encourage employers to include screening for cancer according to
specified protocols as a component of their health care packages.

Health insurers should remind their clients about cancer
screening recommendations.

100

Life insurers should offer rate incentives to clients who
participate in recommended cancer-screening activities, and purchasers
of large amounts of insurance should be encouraged to request thsse
incentives .

Explore incentives that might offer health care providers
reimbursement for comprehensive diagnostic workups, adequate clinical
staging prior to treatment, appropriate multidisciplinary referrals,
and application of state-of-the-art detection, treatment, and
rehabilitation.

Health Professions Development

The curricula of medical students and ongoing education programs
for physicians and health care providers should include information
regarding the health consequences of smoking and tobacco use and
prevention and cessation methods. The collaboration of medical and
health professional associations (particularly associations of
minority physicians and other health professionals) in this process
would further facilitate this effort.

Physicians and other health care providers should be encouraged
to serve as role models by refraining from tobacco use.

Physicians and other health care providers should offer
interventions to heavy smokers; patients with lung disease, heart
disease, cancer, or alcohol dependence; and patients in occupations
with high risk for cancer.

Active cancer-screening programs for demonstration and teaching
purposes should be incorporated into the educational programs of
medical and other health professional schools.

Educational programs for health professionals and physicians in
residency training should promote cancer screening.

Educational messages to specialty physicians should emphasize the
importance of:

• Aggressive workups (radiology and endoscopy) for occult blood.

• Disease staging prior to treatment for all cancers, especially
rectal, colon, breast, prostate, small-cell lung, cervical,
uterine, ovarian, and skin (melanoma) cancer.

Professional oncology education should be enhanced by
institutions through the Physician Data Query (PDQ) system, oncology
nursing support, treatment guidelines, protocol participation, and
quality assurance requirements by the Joint Commission on
Accreditation of Hospitals.

101

Federal Leadership in Work with Other Sectors

Promote comprehensive health education, emphasizing avoidance of
smoking and other high-risk behavior, from kindergarten through
grade 12.

Make model smoking cessation programs available, through the
Office of Smoking and Health, to students, faculty, and staff of
interested educational institutions.

The establishment of a "peer corps ' of high-school seniors
interested in practicing health promotion should be encouraged; these
students could be given incentives such as scholarships and could play
a significant role in smoking prevention and cessation at the local
level.

Explore collaborative efforts between DHHS and such associations
as health maintenance organizations, the American Hospital
Association, and local hospitals to develop hospital-based cessation
and prevention programs. These organizations could participate in
efforts to discourage the sale of cigarettes in hospitals, nursing
homes, other health care facilities, and pharmacies.

Corporate and union leaders should collaborate to develop and
promote model nonsmoking standards as an integral part of worksite
health promotion and fitness programs.

Insurance companies should be encouraged to establish and expand
nonsraoker differential rates for health, life, and home insurance.

Schools and programs of occupational medicine should be
encouraged to include smoking cessation in their educational programs.

Federal meat and milk grading programs should work with producers
to expand production and marketing of leaner, low-fat products. For
example, the red meat industry has proposed new grading standards that
permit the choice and prime grades to be leaner, which would result in
less fat in American diets .

Senior citizen organizations should seek health care
organizations that provide low-cost but technically skilled screening
programs and should actively encourage their members to use these
screening programs.

Research Issues

Promote close collaboration in research by developing a network
among smoking intervention researchers funded by the NCI Smoking,
Tobacco, and Cancer Program.

102

Involve NCI -sponsored researchers of smoking interventions in NCI
year 2000 activities, especially the application of findings that come
from their research.

Intensify research on selective livestock breeding to produce
leaner food products .

Conduct research to enhance the quality and desirability of
fiber-rich foods, including cereals and breads.

The NCI should support research on cancer screening technology
and on utilization of screening techniques.

Data

To track progress in controlling cancer in all populations and
especially in the minorities, baseline information and monitoring on a
regular basis of the following indicators should be undertaken:
incidence, mortality, stage at diagnosis, and relative survival by
cancer site; percent of adults and children who smoke and for former
smokers, the time since quitting; the percent of fat and fiber in the
diet and the percent who are obese; the percent of eligible persons
who are screened for cancer; percent of cancer patients treated by
state-of-the-art methods; percent of workers exposed to carcinogens in
the workplace as well as the percent of those who are screened in the
workplace; and the percent of the population and ethnic groups with
particular knowledge, attitudes, and beliefs about cancer.

Improve surveillance and registration of occupational exposure.
Link registration to current cancer surveillance systems.

Improve the timeliness of mortality data reported by the NCHS so
that data for a given year will be available by the end of the
following year.

Obtain data on smoking habits on an annual basis and on knowledge
and beliefs about cancer on a biennial basis through the National
Health Interview Survey (NHIS).

NCI should take the lead in helping population-based cancer
registries achieve compatibility with SEER and help them to improve
data quality.

Augment existing national surveys rather than conduct new ones.

The Centers for Disease Control should explore the possibility of
using the Morbidity and Mortality Weekly Report or the 121 City
Mortality System for monitoring cancers that are amenable to
rapid intervention.

103

Continue the longitudinal study of the Current Population Survey
sample matched to the National Death Index.

Explore the possibility of NCI including additional items in SEER
such as detailed treatment information and socioeconomic status
information.

Install a data collection mechanism in SEER areas to obtain
additional information from medical records or through slide review as
specific questions arise.

Supplement ongoing population surveys (preferably the NHIS) with
questions on cancer screening.

Consider including one or more questions on smoking in the 1990
census .

Conduct special surveys, under the direction of NCI, to obtain
data on the general population in specific geographic areas.

Conduct population surveys to obtain detailed data for various
surveillance indicators in SEER areas or in other areas with
population-based cancer registries so that indicators can be
correlated with measures of outcome.

104

REFERENCES

1. Doll, R., & Peto, R. C1981). The causes of cancer. New

York, NY: Oxford University Press.

2. Linden, G. (1969). The influence of social class in the survival

of cancer patients. American Journal of Public Health,
59, 267-274.

3. Lipworth L. (1970). Socioeconomic factors in the prognosis of

cancer patients. Journal of Chronic Diseases, 23, 105-116.

4. DeVesa, S. S., & Diamond, E. L. (1980). Association of breast

cancer and cervical cancer incidences with income and
education among Whites and Blacks. Journal of the National
Cancer Institute, 65(3), 515-528.

5. National Cancer Institute. (1985). Cancer incidence and

mortality in the United States, 1973-1981 (NIH
Publication No. 85-1837). Bethesda, MD: U.S. Department
of Health and Human Services.

6. Miller, W. , & Cooper, R. (1982). Rising lung cancer death

rates among Black men: The importance of occupation and
social class. Journal of the National Medical
Association, 74(3), 253-258.

7. EVAXX, Inc. (1980). A study of Black Americans' attitudes

toward cancer and cancer tests . New York, NY: American
Cancer Society.

8. Dayal, H. H. , Power, R. N., & Chiu, C. (1982). Race and

socioeconomic status in survival from breast cancer.
Journal of Chronic Diseases, 35, 675-683.

9. Graham, S., &. Schotz, W. (1979). Epidemiology of cancer of the

cervix in Buffalo, New York. Journal of the National
Cancer Institute, 63(1), 23-27.

10. Wilkinson, G. S. (1979). Delay, stage of disease, and survival

from breast cancer. Journal of Chronic Diseases , 32,
365-373.

11. Berg, J. W. (1977). Economic status and survival of cancer

patients. Cancer, 39, 467-477.

12. Page, W. F., & Kuntz, A. J. (1980). Racial and socioeconomic factors

in cancer survival: A comparison of Veterans' Administration
results with selected studies. Cancer, 45, 1029-1040.

105

13. Savage, D., Lindenbaum, J., Osserman, E., Van Ryzin, J.,

& Garrett, T. (1981). Survival of Black and White patients
with multiple myeloma at two hospitals [Abstract].
Proceedings of the American Association of Cancer
Research, 22, 537.

14. Young, J. L. , Jr., Ries , L. G. , & Pollack, E. S. (1984). Cancer

patient survival among ethnic groups in the United States.
Journal of the National Cancer Institute, 73(2) ,
341-352.

15. Thomas, D. B. (1979). Epidemiologic studies of cancer in

minority groups in the Western United States. National
Cancer Institute Monographs, 53, 103-113.

16. Sievers, M. L. , Fisher, J. R. (1981). Diseases of North

American Indians. In H. Rothschild, & C. Chapman (Eds.),
Biocultural aspects of disease (pp. 191-252). New York, NY:
Academic Press .

17. Boss, L. P., Lanier, A. P., Dohan, P. H. , & Bender T. R. (1982).

Cancers of the gall bladder and biliary tract in Alaska
Natives. Journal of the National Cancer Institute,
69,(5), 1005-1007.

106

SUBCOMMITTEE ON CARDIOVASCULAR AND
CEREBROVASCULAR DISEASES

EXECUTIVE SUMMARY

Introduction

This report reviews cardiovascular and cerebrovascular diseases
in Black Americans and, to a lesser extent because of the paucity of
information, in Hispanics , Native Americans, and Asian/Pacific
Islanders. Heart diseases and stroke cause more deaths, disability,
and economic loss in the United States than any other acute or chronic
diseases and are the leading causes of days lost from work. This
observation is true, not only for the general population, but for each
of the four minority populations in this report (1,2,3). The data to
extend this statement to the many subgroups of each minority do not
exist, but cardiovascular disease (CVD) remains an unquestionably
important health issue for each.

Even though currently available data are insufficient for excess
deaths to be calculated for each minority population, average annual
death rates for heart disease are higher in Black men and women under
age 70 than in comparable Whites. Under 45 years of age, the rates
for Native Americans, as well as for Blacks, are higher than they are
for Whites, in both genders (Figures 7 and 8).

Dramatic differences exist between the levels of the various CVD
risk factors both when minority populations are compared with each
other and also when each is compared with the White population. The
leading treatable risk factors for cardiovascular disease in the White
population include hypertension, elevated blood cholesterol, cigarette
smoking, diabetes mellitus, and obesity. Although the data are
limited or frequently .nonexistent regarding these risk factors and
their importance in minority health, current wisdom suggests that a
major approach to improvement of cardiovascular and general health in
minorities should focus on these modifiable risk factors. Major
socioeconomic differentials also exist between minorities and Whites
that affect their respective life experiences, biological risk factor
distributions, and access to medical care. A comprehensive model that
takes into account the social context of disease is required to
clarify the causes of the observed CVD disparities, to develop
effective therapeutic approaches, and to enhance understanding of CVD
etiology.

Blacks

Coronary Heart Disease

The burden of coronary heart disease (CHD) can be evaluated by
several indices including: CHD mortality, prevalence (the proportion
of people alive at a point in time who have a history of CHD) , and

107

Q ^

;;;:;".vXxX

■

'^m

■

'*.

^^^^1

rj-

^^^^^^^^^^1

^^^^^^^^^^^^^^^^^^^^^^^^1

"eS

^^>M^y^^<MM

■

^^^^1

Males

1^1

^£2

1- <=

f )

crt

Z <

^
^

■g £■

J §

JS .S

I 1

o
in

i£

■c

E
<

, ,

•H

'■Si

-1

■^

■S

5
S

108

a> o

Isl

I
I

2
5

■c
o
.S
S

I i

3
C

-s

X I a

2 1 .9

109

incidence (the combination of fatal and nonfatal CHD events occurring
over a specified period of time in a population). Curiously, these
indices give different estimates of the magnitude of the problem in
Blacks. CHD mortality rates are similar in Black and White men, but
are greater among Black than White women (4). Incidence of CHD also
shows an excess among Black women, but in several studies in the
southern region of the United States, excess incidence was not found
in Black men (5,6). Interestingly, the prevalence rates of CHD in
Blacks and Whites appear similar (7). Finally, hospital admission
records of acute myocardial infarction (MI) indicate higher rates for
White than Black men which may result from higher rates of sudden
death in Blacks prior to hospital admission (8).

Hypertension

Hypertension is a major risk factor for heart disease and stroke.
Mean blood pressure levels are greater in Blacks than Whites with a
marked excess of hypertension in Blacks (9). However, progress has
been made. Between 1960-80, mean systolic pressures declined more in
Blacks than in Whites (5). By 1980, Black adults were more likely to
be aware of their elevated blood pressure than Whites (9).
Hypertensive Blacks were at least as likely as Whites of the same sex
to be treated with antihypertensive medication and nearly as likely to
have their blood pressure controlled. The improved control of
hypertension has almost certainly contributed to significant
improvement in CVD status, and thus to the general health, of Black
Americans. Despite this encouraging progress in awareness, treatment,
and control of high blood pressure, there remains significant excess
of hypertension in Black men and women.

Stroke mortality of Blacks declined 51 percent, and CHD mortality
in Blacks declined 42 percent from 1968 to 1982. Hypertension control
has certainly been one of the factors responsible for this improvement
in health.

Stroke and Hypertensive End-Stage Renal Disease

Stroke deaths are much higher among Blacks than Whites (see
Figure 9); a greater proportion of Blacks than Whites suffers nonfatal
strokes as well (10). End-stage renal disease (ESRD) , resulting from
hypertension, occurs more commonly in Blacks than Whites (11); Blacks
with hypertension are at much greater risk of developing ESRD than
Whites. Interestingly, Blacks with hypertensive ESRD who receive
treatment with dialysis have a more favorable cardiovascular mortality
outlook than Whites who receive treatment.

Other Cardiovascular Risk Factors

Mean total serum cholesterol levels in Black and White adults are
similar (12). High-density lipoprotein (HDL) cholesterol levels are
consistently higher in Black men than White men, but the same is not
true for women.

110

a» o

^;2

r-:

....■.■.■.■.■.■,

X;XxX\;X;

Tf= iSSSg^^S^^^SSi

(N ^^^^^^^^W

^^H

r-:

r«

■^

•*

iiiilii ^

^^^1

en H

«1

Asian/
Pacific

-o
c
iS

l-H

Native
American

M
^

■e

.2 (u

t^ E

z<;

E
■S
3
□

■c

c
5

O
oo

Q a

111

Smoking appears to increase the risk of CVD mortality similarly
in Blacks and Whites (13). Cigarette smoking prevalence is greater
among Black than White men, but the prevalence of heavy smoking is
greater among White than Black adults (14,15).

The impact of cigarette smoking and elevated serum cholesterol
levels on heart disease mortality is similar in Blacks and Whites,
although the effect of hypertension appears to be less in Blacks than
Whites (13). Smoking cessation and prevention, and cholesterol
reduction in Blacks should reduce the incidence of heart disease.

The prevalence of diabetes mellitus, both diagnosed and
undiagnosed, is greater among Blacks than Whites (16). However, the
effects of diabetes mellitus on CVD in Black Americans have not been
assessed adequately.

Obesity is also common in Black women and may provide a partial
explanation for their excess coronary disease risk (17).

Electrocardiographic abnormalities have been found to be
predictive of CKD in White patients (18). Such abnormalities are more
common in Blacks than Whites (13,19). The impact of these
abnormalities, especially electrocardiographic evidence of left
ventricular hypertrophy (ECG-LVH) , has not been assessed
satisfactorily in Blacks.

Substantial efforts in hypertension control should continue to
improve cardiovascular disease incidence and mortality in Blacks. The
heterogeneity of blood pressure levels and hypertension prevalence in
Black populations in Africa (20,21,22) the Caribbean (23-27), and the
Americas (28) casts doubt on the proposition that genetic factors are
primarily responsible for blood pressure excess in U.S. Blacks.

Social, Cultural, and Economic Aspects

There are persistent differences between Black and White
Americans in education, occupational level, and income (29-33). On
average, Blacks have fewer years of formal education than Whites.
Those with equivalent education have access to fewer job opportunities
than Whites (34,35). Those with equivalent employment are likely to
be paid less than Whites. There is some evidence of a low incidence
of coronary disease in Blacks of high socioeconomic status (SES) (36).
Improved risk factor distributions have been associated with higher
SES, which may account for this observation. Complicating the
picture, however, is the impression that higher SES may be associated
with lower levels of HDL-cholesterol .

There is an inverse association of education with hypertension
prevalence (37). Studies of Blacks indicate that there is an inverse
association of blood pressure and/or incidence of elevated blood
pressure with both income and social class (38,39). The mechanism by
which socioeconomic status is associated with high blood pressure in

112

Blacks is unclear. High blood pressure has been related to residence
in areas of high social stress and instability as well as to coping
styles, education, and occupational insecurity. Hypertension-
associated mortality rates also show linkages with social
instability. The relationship between social factors and high blood
pressure (and associated mortality rates) suggests that hypertension
control in Black communities can be improved by interventions that are
not strictly biomedical, but which increase levels of social support.

Behavioral risk factors, such as diet, smoking patterns, and
physical activity are often part of the particular cultural patterns
that are grounded in socioeconomic circumstances associated with
increased risk. In addition, certain cultural patterns may impede
efforts to reduce risk. In particular, cultural factors may determine
the effectiveness of efforts to prevent hypertension, to lower CHD
risk by reducing risk factors, and to treat hypertension more
effectively.

Knowledge and Awareness of Cardiovascular Diseases

Data on knowledge of CVD in Blacks are inadequate but suggest
significant deficits in Blacks' knowledge concerning the association
of CVD with diet (40). Data on Blacks' health practices important for
CVD outcomes are scanty. A few demonstration and education research
efforts are seeking to apply insights obtained from studies of CVD to
Black population groups.

The impact of education, especially of reading achievement, has
been emphasized in some studies of cardiovascular health education.
For example, one school-based, cardiovascular health education study
in Chicago (41) detected racial differences in the increases in
knowledge concerning nutrition, exercise, and smoking and their
relationship to CVD after an intervention. Black children had a
smaller increase in knowledge than others and, at follow-up nine
months later, had persistently lower knowledge scores even after
adjustment for reading achievement. Reading achievement also was
significantly related to nutrition knowledge and attitudes, but not
to behavior.

Awareness of high blood pressure has increased in Blacks in the
last decade (9), but many Blacks have significant misconceptions
concerning factors that predispose to hypertension (42).

Nonadherence to antihypertensive therapy is a major problem in
achieving blood pressure control, but is not specific to Blacks.
Determinants of nonadherence by hypertensive Black patients have been
identified in several studies (43,44,45), and the effectiveness of a
number of health-education strategies in enhancing adherence has been
illustrated in studies of Black patients.

113

Access to Care

Access to care is especially relevant for chronic cardiovascular
diseases. Black Americans make fewer office visits to physicians than
do Whites, and are less likely to be seen by CVD specialists (46) This
may contribute to the less frequent diagnosis of coronary disease in
Blacks. Blacks undergo coronary arteriography less frequently than
Whites (47). Even when Blacks and Whites have coronary disease of
comparable severity, Blacks are less likely to undergo coronary bypass
surgery (48). Black patients are less likely than White patients to
be seen in physicians' offices and are more likely to be seen in
hospital clinics or emergency rooms (49). For hypertensive Black
patients, this probably has adverse effects on the continuity of care
received.

Blacks have more difficulty in entering the medical care system
than Whites and express greater dissatisfaction with services; Blacks
perceive the medical care system to be less accessible to them (50).
These perceptions can be changed and medical care use increased in a
number of settings by targeted interventions. Such interventions must
be persistent if good results are to be obtained and preserved.

Hispanics

Coronary Heart Disease and Stroke

CVD is a major cause of death in Hispanics, although the rate is
lower than in non-Hispanic Whites (2). This lower relative rate is
unexpected given their socioeconomic profile, pronounced
rural-to-urban migration and high percentage of immigrants, and the
prevalence of obesity and diabetes, particularly in women.

National epidemiological data on cardiovascular disease mortality
in Hispanics are limited, to date. Regional CHD mortality rates for
Mexican Americans in Los Angeles County (2) and Texas (51) are lower
than in Whites for both sexes. The rate of decline in CHD mortality
in Hispanics appears to have been comparable to that in Whites during
the last decade. Compared with Whites, some preliminary regional data
suggest lower stroke mortality rates in Mexican Americans (2) , but
slightly higher rates among younger Puerto Ricans in New York (52).

Hypertension

There appears to be a strong inverse relationship between SES
level and hypertension in Hispanics, similar to that found for Blacks
and non-Hispanic Whites. Among Hispanic women this effect remains even
when adjustments are made to account for the higher rate of obesity
among those with lower SES (56) .

114

Other Cardiovascular Risk Factors

Diabetes mellitus is a major problem in Hispanics , especially in
Mexican Americans and Puerto Ricans living in the United States
(57,58). However, the relationship between this risk factor and
coronary heart disease has not been adequately studied in each of the
major Hispanic groups.

The generally higher prevalence of obesity, noninsulin-dependent
diabetes, hypertension, high LDL-cholesterol and low HDL-cholesterol
levels in Hispanics might be expected to increase their CVD risk.
Evidence reviewed on the possible biological or physiological
differences between Hispanics and Whites, however, suggests that no
specific factor or set of factors explains why Hispanics as a group
appear to be at lower risk for coronary heart disease, and at equal or
slightly higher risk for cerebrovascular disease than Whites. The
existing data indicate that, though more Hispanics smoke cigarettes,
fewer are heavy smokers (53,54). There are some indications, however,
that there is heavier smoking among Hispanic youth compared to White
and Black youth.

The evidence on prevalence of smoking, knowledge about the risks
of smoking, and the frequency of practice of leisure-time exercise
suggests potentially different risks for Mexican Americans compared
to non-Hispanic Whites. Those Mexican Americans with lowest SES and
level of acculturation have significantly worse CVD risk factor
profiles than those in higher SES groups (53,54). Mexican American
women appear to improve their risk factor profile more as a result of
increased acculturation and social mobility than do men. The limited
amount of comparable data on other Hispanic groups precludes any
generalization to these other groups. The relative paucity of data
on Puerto Ricans, Cubans, and other Hispanics precludes any
conclusions about whether health behaviors could account for any
differences in cardiovascular disease risk between these groups and
non-Hispanic Whites.

Asian/Pacific Islanders

Cardiovascular Disease

Heart disease is the leading cause of death for all Asian/Pacific
Islander American groups (59). However, Asians appear to be at lower
risk of mortality from most cardiovascular diseases than other
minorities and Whites, with the possible exception of stroke. Asian
women appear to be at lower risk than men across all groups. Koreans,
Filipinos, and Chinese appear to be at lower CVD risk than Japanese.
The overall higher SES of Asians as a group may partially account for
their more favorable cardiovascular status.

115

Stroke

National data suggest stroke mortality rates in Asians are
generally similar to those in Whites as shown in Figure 9 (60), with
stroke as the third leading cause of death. Recent age-adjusted data
for Asian subgroups indicate that Japanese men stand out from most
other ethnic/gender groups, including Whites, in having very high
stroke mortality rates (59).

Hypertension and Smoking

Though hypertension may not be as significant a public health
problem among Japanese and Chinese as among Whites, Blacks, and
Hispanics , it is a significant problem among Filipinos (61). Although
the proportion of Filipinos receiving treatment for their hypertension
is comparable to or greater than that of their White cohorts, fewer
have achieved blood pressure control. Fewer Filipino women than men
had their blood pressure under control - the reverse of the gender
trends for all of the other ethnic groups studied. Filipinos, like
their fellow Asians (at least those in California), do not show
evidence of an excess prevalence of smoking compared to Whites (62) .

Other Cardiovascular Risk Factors

Existing morbidity data suggest that the standard risk factors
for CHD are significantly less prevalent among Japanese on the
mainland, in Japan, and in Hawaii than in White men in the U.S.
Patterns of associations similar to those in Whites are found between
the major risk factors and fatal and nonfatal CHD, nonfatal MI, and
acute coronary insufficiency (63,64). For the Japanese, as for
Whites, high blood pressure, cigarette smoking, and cholesterol are
important risk factors for CVD. Overall, Japanese men typically have
lower total cholesterol levels than White men. The limited data
available on cardiovascular disease risk factors among Chinese
Americans indicate that they tend to have lower levels of the major
CHD risk factors (65). However, Chinese men over 50 years of age may
have a greater prevalence of smokers (who smoke fewer cigarettes per
day) and of elevated blood pressure than White men.

The available data suggest that cardiovascular diseases are less
prevalent among Asian groups and that perhaps part of this favorable
mortality differential can be attributed to a more generally salutary
risk factor profile. However, there is enough of a difference in CHD
mortality and/or risk status among the various Asian groups and the
data are so limited that this generally favorable picture cannot be
assumed to hold true for all groups.

116

Native Americans

Coronary Heart Disease

Heart disease is a significant contributor to all-cause mortality
in Native Americans but is proportionately less of a contributor than
in the general population. If death rates from noncardiovascular
causes such as automobile accidents and alcoholism can be reduced in
the future, it is possible that heart disease may increase in Native
Americans. Currently, under age 35 years, heart disease mortality for
Native Americans is approximately twice as high as for all other
Americans .

Cardiovascular Risk Factors

Hypertension appears to be an important health problem for Native
Americans, although apparently less so than for the White population
(3) . Serum cholesterol levels in some American Indian tribes are
lower than those in the general population, but the relationship of
these lower levels to the incidence of CVD is not clear. It appears
that both obesity and diabetes are major public health concerns in
Native Americans. The Pima Indians have the highest prevalence of
type II diabetes in the United States (66) . Although sufficient data
are not available to draw firm conclusions about trends in cigarette
and alcohol use, or their contribution to CHD, cigarette smoking
appears to be less consistently prevalent in Native Americans in
different geographic locations, though alcohol abuse is more
consistently prevalent (67). Both cigarette and alcohol use
constitute a significant health hazard for Native Americans, more so
for men than for women.

Social, Cultural) and Economic Aspects

Little reseach has been conducted on the contribution of
socioeconomic factors such as low income, high unemployment, and low
education to cardiovascular disease mortality, morbidity, and risk
status in Native Americans.

Although some socioeconomic factors may contribute to an
unfavorable risk profile, other sociocultural factors may operate to
confer some protection against coronary heart disease. Many Native
American tribes maintain low cholesterol diets, engage in strenuous
physical activity as part of their daily lives, and have less
time-pressure and have lifestyles that display limited interpersonal
competition (52) . Recent increases in urbanization, in smoking, in
the fat content of diets, and in other behavioral risk factors
associated with increased westernization in Native American youth in
several tribes suggest the possible beginning of increased coronary
heart disease risk in the population.

117

OPPORTUNITIES FOR PROGRESS

Interventions proposed by the Subcommittee follow:

Risk Reduction Interventions to Promote Cardiovascular Health

There is evidence to justify health promotion interventions
directed toward minority groups that would promote dietary patterns
that would lower or maintain low blood cholesterol, would reduce or
eliminate cigarette use, would encourage an active lifestyle, and
would moderate and maintain normal body weight and blood pressure.
Effective behavior modification strategies for the treatment of CVD
and these CVD risk factors need to be developed and validated in
minority populations. Successful techniques should be taught to both
the deliverers and the receivers of health care. For example, studies
are needed of

• The determinants of cigarette smoking and alcohol use,
cessation, and cessation maintenance in all minorities.

• The relationship of obesity, especially in Black females during
and after adolescence, to lipoproteins and other factors.

• Socioeconomic status as a risk factor for CHD, hypertension,
stroke, and hypertension-related end-stage renal disease in all
minority groups.

• The factors responsible for confering some degree of protection
with regard to CHD mortality in Asian/Pacific Islanders,
despite a relatively high-risk profile.

• The impact of diabetes and obesity in Native Americans and
Hispanics .

Effective Cardiovascular Health Education

Effective strategies for cardiovascular health education among
specific minority groups should be developed. Procedures should be
indentified to facilitate the adoption of specific interventions for
cardiovascular risk factors such as high blood cholesterol levels and
cigarette smoking in the general minority populations as well as in
high-risk subgroups. The model of the National High Blood Pressure
Education Program could be adopted and modified for other risk factors
for a variety of communities. Care must be taken to consider the
different cultural values and attitudes towards CHD and certain risk
factors for CHD, such as obesity, chest pain, and particular
health-seeking behaviors. The publication and updating of a list of
DHHS health promotion and disease prevention materials, including

118

patient education materials, especially directed toward specific
minority groups, would be of value to practicing physicians and other
health care providers .

Hypertension Prevention and Control

Continued efforts at education, prevention, treatment and control
of the hypertension-related diseases, for example, stroke and
end-stage renal disease, especially in Blacks, are needed. In
addition:

• The long-term efficacy and safety of antihypertensive
medications prescribed to minorities (particularly to Blacks)
need to be examined. Do the metabolic, hemodynamic, and side
effects of treatments and their impact on CHD differ among
minorities and Whites?

• Compliance/noncompliance to antihypertensive medication
regimens needs to be studied. Why do Filipino women have
poorer blood pressure control than Filipino men? This is in
contrast to other ethnic minority groups in the United States
in which women generally have better blood pressure control
than men.

• Investigation of the links between dietary potassium, sodium,
calcium and, possibly, other dietary elements and hypertension
in Blacks and other minorities is needed.

Delivery of Medical Care

In addition to genetic, environmental, and behavioral factors,
appropriate medical care is a major determinant of morbidity and
mortality due to cardiovascular disease. Under optimal medical care
conditions, for example, a patient with essential hypertension can
achieve blood pressure control and reduce the risk of cardiovascular
sequelae. However, with variations in physician behavior and patient
care-seeking behavior, optimal medical care circumstances are
difficult to achieve for large population groups, and are equally if
not more difficult to achieve for most minority populations.
Simultaneous attention to all the elements of interaction in the
medical care setting, including both patient and physician behavior,
is necessary. Such research is needed to understand the dynamics of
medical care available to Blacks, Hispanics, Asian/Pacific Islanders,
and Native Americans because appropriate diagnosis, treatment, and
follow-up predispose for a favorable outcome. For example, studies
are needed of beliefs, awareness status, and prehospital behavior
which might delay appropriate diagnosis and treatment for individuals
with symptoms of coronary heart disease in minority communities.
Investigation is needed on how specific patterns of risk factors in
minorities influence treatment decisions. Techniques are needed that
will encourage earlier diagnosis, full use of all diagnostic

119

procedures, and earlier treatment interventions so that minorities
enter the delivery system well before an advanced disease state has
developed.

Minority Population Studies of Cardiovascular Diseases

Population-based, prospective, observational studies of coronary
heart disease (similar to the Framingham study) are needed for the
minority populations. A key component of this research would be the
validation in minorities of the major established and/or suspected
biological and psychosocial risk factors for CVD that have been
identified for the White American population. For example, among the
many Hispanic subgroups, Puerto Ricans residing in the United States
and Cubans particularly warrant such research. Another key element of
such research would be the surveillance of the offspring of indexed
cases so as to provide crucial information on trends for risk and for
disease as well as elucidating familial contribution to CVD incidence
and process. Further studies on potential differences in sudden death
rates between Blacks and Whites, by age and gender, are needed. There
is a need to monitor CVD events that occur in the community, such as
sudden death; hospital admissions and discharges of patients diagnosed
to have CVD; and emergency room visits for chest pains and related
complaints .

Direct Federal Government Activities

DHHS should serve as a catalyst to bring together, on a
continuing basis, concerned groups to focus on specific issues, such
as: cholesterol, cigarette smoking, and worksite health. These
groups should give specific attention to minority issues. The
National High Blood Pressure Education Program could serve as a model
for this activity.

Meetings should be initiated between DHHS program units and
program representatives from other Federal departments to address
health problems of mutual interest relating to cardiovascular disease
and its prevention. Specifically, information exchange and
coordination of smoking cessation arid health promotion programs should
be strengthened. The Departments of Defense and Education, for
example, could join with the several DHHS programs in these areas in
seeking to accomplish this.

Employees of the Federal Government should be urged to explore
health care plans that offer preventive health services.

More Minority Professionals for Health Care and Research

Development of innovative mechanisms to attract minorities into
the health care field and into health research needs to be undertaken
with direct and continuing input from leaders in the minority health
professions .

120

REFERENCES

1. Gillum, R. F. (1982). Coronary heart disease in Black

populations: I. Mortality and morbidity. American Heart
Journal, 104(4), 839-851.

2. Frerichs, R. R. , Chapman, J. M. , Nourjah, P., &. Maes, M. (1984)

Cardiovascular diseases in Los Angeles County,
1978-1981 ■ Los Angeles: American Heart Association,
Greater Los Angeles Affiliate, Inc.

3. Kumanyika, S. K. , & Savage D. D. (1985). Ischemic heart

disease risk factors among American Indians and Alaska
Natives . Unpublished manuscript, Task Force on Black and
Minority Health, DHHS .

4. National Center for Health Statistics. (1984). [Data on

cardiovascular disease] . Unpublished raw data.

5. Cassel, J., Heyden, S., Bartel, A. G. , Kaplan, B. H. , Tyroler,

H. A., Cornoni, J. C, & Hames , C. G. (1971). Incidence of
coronary heart disease by ethnic group, social class, and
sex. Archives of Internal Medicine, 128(6) , 901-906.

6. Tyroler, H. A., Knowles, M. G., Wing, S. B., Logue, E. E.,

Davis, C. E., Heiss, G. , Heyden, S., & Hames, C. G. (1984).
Ischemic heart disease risk factors and 20-year mortality in
middle age Evans County Black males. American Heart
Journal, 108(3;2), 738-746.

7. National Center for Health Statistics. (1965). Coronary

heart disease in adults (US NCHS Publication No. 1000,
Series 11, No.. 10). Washington, DC: U.S. Government
Printing Office.

8. Henderson M. , & Savage, D. D. (1985). Prevalence and

incidence of ischemic heart disease in U.S. Black
and White populations. Unpublished manuscript, Task
Force on Black and Minority Health, DHHS.

9. Rowland, M. , &. Roberts, G. (1982). Blood pressure levels

and hypertension in persons ages 6-74 years: United
States, 1976-80 (DHHS Publication No. (PHS) 82-1250).
Advance Data No. 84, Vital and Health Statistics.
Hyattsville, MD: National Center for Health Statistics.

10. Kuller, L. H. (1984). Stroke Report. Unpublished manuscript,

Task Force on Black and Minority Health, DHHS.

121

11. Easterling, R. E. (1977). Racial Factors in the incidence and

causation of end-stage renal disease. Transactions of the
American Society for Artificial Internal Organs, 23, 28-33.

12. National Center for Health Statistics. (1978). Total serum

cholesterol levels of adults 18-74 years: United
States, 1971-74 (DHEW Publication No. (PHS) 78-1652).
Vital and Health Statistics, Series 11, No. 205.
Hyattsville, MD: Author.

13. Kleinbaura, D. G. , Kupper, L. L. , Cassel, J. C, & Tyroler, H. A.

(1971). Multivariate analysis of risk of coronary heart
disease in Evans County, Georgia. Archives of Internal
Medicine, 128(6), 943-948.

14. Schoenborn, C. A., & Danchik, K. M. (1980, November 4). Health

practices among adults, United States, 1977. Advance

Data No. 64, Vital and Health Statistics. Hyattsville, MD:

National Center for Health Statistics.

15. Moss, A. J. (1979, September 19). Changes in cigarette

smoking and current smoking practices among adults,
United States, 1978. Advance Data No. 52, Vital and Health
Statistics. Hyattsville, MD: National Center for Health
Statistics .

16. Gillum, R. F., & Grant, C. T. (1982). Coronary heart disease in

Black populations. II. Risk factors. American Heart
Journal, 104(4;1), 852-864.

17. Roberts, J. (1966, May). Weight by height and age of

adults, United States 1960-62. (PHS Publication No.
1000). Vital and Health Statistics, Series 11, No. 14.
Hyattsville, MD: National Center for Health Statistics.

18. Kannel, W. B., Gordon, T. , Castelli, W. P., & Margolis, J. R.

(1970). Electrocardiographic left ventricular hypertrophy
and risk of coronary heart disease: The Framingham Study.
Annals of Internal Medicine, 72(6), 813-822.

19. Riley, C.P., Oberman, A., Hurst, D. C, & Peacock, P. B. (1973).

Electrocardiographic findings in a biracial, urban population.
The Birmingham Stroke Study. Alabama Journal of Medical
Sciences, 10, 160-170.

20. Williams, A. W. (1941). Blood pressure of Africans. East

African Medical Journal, 18, 109-117.

21. Shaper, A. G. , & Saxton, G. A. (1969). Blood pressure and body

build in a rural community in Uganda. East African Medical
Journal, 46, 228-245.

122

22. Vaughan, G. P. (1979). Blood pressure and heart murmurs in a

rural population in the United Republic of Tanzania.
Bulletin of the World Health Organization, 57, 89-97.

23. Johnson, B. C, & Remington, R. D. (1961). A sampling study of

blood pressure levels in White and Negro residents of Nassau,
Bahamas. Journal of Chronic Diseases, 13, 39-51.

24. Schneckloth, R. E., Corcoran, A. C, Stuart, K. L. , &. Moore, F. i

(1962). Arterial pressure and hypertensive disease in a
West Indian Negro population. American Heart Journal,
63, 607-628.

25. Miall, W. E., Kass, E. H. , Ling, J., & Stuart, K. L. (1962).

Factors influencing arterial pressures in the general
population in Jamaica. British Medical Journal, 2,
497-508.

26. Florey, C. DuV. , Aschcroft, M. T. , & Miller, G. J. (1971).

Blood pressure levels in Guyanese adults of African and
Indian origin. American Journal of Epidemiology, 94,
419-424.

27. Khaw, K. T. , & Rose, G. (1982). Population study of blood

pressure and associated factors in St. Lucia, West Indies.
International Journal of Epidemiology, 11 , 372-377.

28. National Center for Health Statistics. (1964, June). Blood

pressure of adults by age and sex. United States
1960-62 (PHS Publication No. 1000). Vital and Health
Statistics, Series 11, No. 4. Hyattsville, MD: Author.

29. Bureau of the Census. (1974, July). The socioeconomic status

of the Black population in the United States, 1973
(Current population reports, special studies. Series p-23.
No. 48). Washington, DC: U.S. Department of Commerce.

30. Center for the Study of Social Policy. (1983, July). A dream

deferred: The economic status of Black Americans
(Working paper). Washington, DC: Author.

31. Bureau of the Census. (1979, June). The social and

economic status of the Black population in the
United States: A historical view, 1790-1978 (Current
population reports, special studies. Series p-23. No. 80).
Washington, DC: U.S. Department of Commerce.

32. Bureau of the Census. (1983, July). America's Black

population: 1970-1982, a statistical view (Special
Publication PlO/POP-83 : 1) . Washington, DC: U.S. Department
of Commerce.

123

33. National Urban League. (1985, January). The state of

Black America, 1985. Washington, DC: Author.

34. Reimers, C. W. (1984). Sources of the family income differentials

among Hispanics, Blacks, and White non-Hispanics . American
Journal of Sociology, 89(4), 889-903.

35. Jencks , C. (1980). Structural versus individual explanations

of inequality: Where do we go from here? Contemporary
Sociology, 9(6), 762-767.

36. Keil, J. E., Loadholt, C. D., Weinrich, M. C, Sandifer, S. H. ,

& Boyle, E., Jr. (1984). Incidence of coronary heart disease
in Blacks in Charleston, South Carolina. American Heart
Journal, 108(3;2), 779-786.

37. Khoury, P. R. , Morrison, J. A., Laskarzewski, P., Kelly, K. ,

Mellies, M. J., King, P., Larsen, R. , & Glueck, C. G. (1981).
Relationships of education and occupation to coronary heart
disease risk factors in school children and adults. The
Princeton School District Study. American Journal of
Epidemiology, n3(4) , 378-395.

38. Syme, L. S., Oakes , T. W. , Friedman, G. D., Feldman, R. ,

Siegelaub, A. B., &. Collins, M. (1974). Social class and
racial differences in blood pressure. American Journal of
Public Health, 64, 619-620.

39. Keil, J. E., Tyroler, H. A., Sandifer, S. H. , &. Boyle, E., Jr.

(1977). Hypertension: Effects of social class and racial

admixture: The results of a cohort study in the Black

population of Charleston, South Carolina. American
Journal of Public Health, 67(7), 634-639.

40. Heimback, J. T. (1985, January). Diet and cardiovascular

disease: The public view. Public Health Reports,
100(1), 3-5.

41. Sunseri, A. J., Alberti, J. M. , Kent, N. D., Dolocek, T. A., &

Schoenberger , J. A. (1984). Ingredients in nutrition
education: Family involvement, reading and race. Journal
of School Health, 55(5), 193-196.

42. U.S. Department of Health and Human Services. (1981, September).

The public and high blood pressure: Six year
follow-up survey of public knowledge and reported
behavior (NIH Publication No. 81-2118). Washington DC:
U.S. Government Printing Office.

124

43. Caldwell, J. R. , Cobb, S., Dowling, M. , & Dejongh, D. (1970).

The drop-out problem in antihypertensive treatment: A
pilot study of social and emotional factors influencing a
patient's ability to follow antihypertensive treatment.
Journal of Chronic Diseases, 22, 579-592.

44. Hypertension Detection and Follow-up Program Cooperative Group.

(1978). Patient participation in a hypertension control
program. Journal of the American Medical Association,
239, 1507-1514.

45. Smith, E. 0., Curb, J. D., Hardy, R. J., Hawkins, C. M. , &

Tyroler, H. A. (1982). Clinic attendance in the Hypertension
Detection and Follow-up Program. Hypertension, 4(5),
710-715.

46. Aday, L. A. , & Andersen, R. M. (1984). The national profile of

access to medical care: Where do we stand? American
Journal of Public Health, 74(12), 1331-1339.

47. National Center for Health Statistics. (1983). Detailed

diagnoses and surgical procedures for patients
discharged from short-stay hospitals. United States,
1979 (DHHS Publication No. (PHS) 83-1733). Hyattsville,
MD : Author .

48. Oberman, A., &. Cutter, G. (1984). Issues in the natural

history and treatment of coronary heart diseases in Black
populations. American Heart Journal, 108(3 ;2) , 688-694.

49. National Center for Health Statistics. (1979, July 23). Office

visits by Black patients. National Ambulatory Care
Survey: United States, 1975-1976. Advance Data No. 50,
Vital and Health Statistics. Hyattsville, MD: Author.

50. James, S. A., Wagner, E. H. , Strogatz, D. S., Beresford, S. A. A.,

Kleinbaum, D. G., Williams, C. A., Cutchin, L. M. , & Ibrahim,
M. A. (1984). The Edgecombe County (NC) High Blood Pressure
Control Program: II. Barriers to the use of medical care
among hypertensives. American Journal of Public Health,
74(5), 468-472.

51. Bradshaw, B. S., & Fonner, E., Jr. (1978). The mortality of

Spanish-surnamed persons in Texas, 1969-1971. In F. D.

Bean, &. W. P. Frisbie (Eds.), The Demography of Racial

and Ethnic Groups (pp. 261-282). New York, NY: Academic Press.

52. Kuller, L. H. (1984). Stroke Report. Unpublished manuscript.

Task Force on Black and Minority Health, DHHS.

125

53. Hazuda, H. P. (1985). Differences in socioeconomic status

and acculturation among Mexican Americans and risk
for cardiovascular disease. Unpublished manuscript,
Task Force on Black and Minority Health, DHHS.

54. Castro, F. G. , Baezconde-Garbanati, L. , &. Beltran, H. (in press).

Risk factors for coronary heart disease in Hispanic populations:
A review. Hispanic Journal of Psychology.

55. Kumanyika, S. K. , & Savage, D. D. (1985). Ischemic heart

disease risk factors in Hispanic Americans. Unpublished
manuscript, Task Force on Black and Minority Health.

56. Hazuda, H. P., Stern, M. P., Gaskill, S. P., Haffner, S. M., &

Gardner, L. 1. (1983). Ethnic differences in health
knowledge and behaviors related to the prevention and
treatment of coronary heart disease. The San Antonio Heart
Study. American Journal of Epidemiology, 117 , 717-728.

57. Stern, M. P., Rosenthal, M. , Haffner, S. M. , Hazuda, H. P., &

Franco, L. J. (in press). Sex differences in the effects of
sociocultural status on diabetes and cardiovascular risk
factors in Mexican Americans: The San Antonio Heart Study.
American Journal of Epidemiology.

58. Hanis, C. J., Ferrel, R. E., Barton, S. A., Aguilar, L. ,

Garza-lbarra, A., Tulloch, B. R. , Garcia, C. A.,
Sc Schull, W. J. (1983). Diabetes among Mexican Americans in
Starr County, Texas. American Journal of Epidemiology,
118, 659-672.

59. Yu, E. S. H., Chang, C. F. , Liu, W. T. , & Kan, S. H. (1984).

Asian-White mortality differentials: Are there excess
deaths? Unpublished manuscript, Task Force on Black and
Minority Health, DHHS.

60. Kuller, L. H. (1984). Stroke Report. Unpublished manuscript.

Task Force on Black and Minority Health, DHHS.

61. Stavig, G. R., Igra, A., & Leonard, A. R. (1984). Hypertension

among Asians and Pacific Islanders in California. American
Journal of Epidemiology, 119 , 677-691.

62. Igra, A., Stavig, G. R. , & Leonard, A. R. et al. (1982).

Hypertension and related health problems in California.
Results from the 1979 California Hypertension Survey.
Hypertension Control Program, Hypertension Clearinghouse.
Sacramento, CA: Department of Health Services.

126

63. Reed, D. , McGee, D. , & Yano, K. (1983). Trends of coronary

heart disease among men of Japanese ancestry in Hawaii.
Journal of Community Health, 8, 149-159.

64. Robertson, T. L. , Kaot, H. , Gordon, T. , Kagan, A., Rhoads , G. C.,

Land, C. E., Worth, R. M., & Belsky, J. et al . (1977).
Epidemiologic studies of coronary heart disease and stroke in
Japanese men living in Japan, Hawaii, and California: Coronary
heart disease risk factors in Japan and Hawaii. American
Journal of Cardiology, 39, 244-249.

65. Kumanyika, S. K. , & Savage, D. D. (1985). Ischemic heart

disease risk factors in Asian Americans. Unpublished
manuscript. Task Force on Black and Minority Health, DHHS.

66. Sievers, M. L. , & Fisher, J. R. (1981). Diseases of North

American Indians. In H. R. Rothschild (Ed.), Biocultural
Aspects of Disease (pp. 191-252). New York, NY:
Academic Press.

67. Sievers, M. L. (1968). Serum cholesterol levels in southwestern

American Indians. Journal of Chronic Diseases, 21, 107-115.

127

SUBCOMMITTEE ON CHEMICAL DEPENDENCY

EXECUTIVE SUMMARY

Introduction

This report reviews the role that chemical dependency plays in
contributing to the health disparity between Blacks, Hispanics,
Asian/Pacific Islanders, and Native Americans and the nonminority
population. Using excess mortality rates in minority populations due
to cirrhosis, cancer, and unintentional injuries as a basis, the
Subcommittee chose to include alcohol abuse, illicit drug abuse, and
cigarette smoking as elements of chemical dependency. The
Subcommittee did not include the abuse or misuse of licit drugs.
Although these substances may contribute to the health disparity, few
data are available on which to base an analysis.

The 19 79 Surgeon General's report. Healthy People, indicates that
alcohol misuse is a factor in more than 10 percent of all deaths and
may be higher among minorities (1). Tobacco use is a factor in more
than 16 percent of all deaths; nearly 90 percent of all lung cancers
are caused by cigarette smoking (2). No similar statistics are
available for illicit drug abuse.

Because data on the prevalence of chemical dependency for the
minority population are limited, it is difficult to know the extent of
the problem among minorities and the resultant impact on health
status. Excess deaths among minorities due to cirrhosis, heart
disease, unintentional injuries, homicide, and cancers of the mouth,
larynx, tongue, esophagus, and lung provide insight into the problems
of chemical dependency. Figure 10 illustrates the average annual
death rates by race for chronic liver disease and cirrhosis, one of
the indicators of the problem of alcohol abuse.

Alcohol

Alcoholism and alcohol-related problems are complex and involve
a wide range of medical, social, and legal problems that impact on
different populations at risk in different ways. All persons of a
particular group are not at equal risk for alcohol-related adverse
health outcomes. However, an inadequate body of research exists on
the impact of alcohol and alcohol-related problems on minority health
status. The majority of national studies, to date, were designed to
elicit baseline data on the general population. As a result, minority
samples from these surveys generally are too small to draw definitive
statements and conclusions about alcohol use and the nature and
extent of alcohol-related problems among minorities.

129

2.6

— 1

■|S

^£

l-H

■f!

ts g

ii <

-a

■c

;■:■:■:■:■:•:■:■:■:■:

•;■;■;•;■:•;■;■;■:■:

^pllMiipilf:

^^1

^"---'^— ^B

^ s

o
in

130

Blacks

Few studies exist on the subject of alcohol and Blacks; however,
there is evidence that alcohol abuse has a major impact on the health
of Blacks. Using cirrhosis deaths as an indicator of high alcohol
use, cirrhosis mortality rates have declined consistently among all
race-sex groups in the United States since 1973, but they are still
disproportionately high among Black Americans (3). Overall, the
cirrhosis mortality rate for Blacks is nearly twice that of
nonminorities (4). In addition, Blacks suffer disproportionately from
the health consequenes of alcoholism, including esophageal cancer.

A national survey conducted in the 1960s indicated that Black and
White men differed little in their drinking patterns, but that Black
women had a higher proportion of abstainers and of heavier drinkers
than Whites (51 percent versus 39 percent and 11 percent versus 7
percent, respectively) (5). The quantity and frequency of alcohol
consumption for Black and White males are comparable when social class
is controlled (6) . A 1979 national survey of American drinking
practices found that both Black males and females were more likely to
classify themselves as abstainers than Whites (30 percent versus 25
percent for males and 49 percent versus 39 percent for females,
respectively) (7). Overall, Black drinking patterns are similar to
those reported in the general population, with rates varying greatly
along geographic, sex, and religious dimensions.

Blacks appear to be at disproportionately high risk for certain
alcohol-related health problems. National Cancer Institute data
indicate that between 1979-1981, the incidence rate of esophageal
cancer for Black males, aged 35-44 years, was ten times that of Whites.
Alcohol consumption is believed to be a primary etiologic agent in the
development of this cancer. Fetal alcohol syndrome (FAS) is a
health consequence associated with heavy alcohol use in pregnant women
(8). Current data on FAS are inconclusive for Black women, and further
investigation is required to define the relationship between alcohol,
the prevalence of FAS, and related effects.

Data from national surveys show that Black youths, ages 14-17,
drink less than White youths, have consistently higher abstention
rates, and have consistently lower heavy drinking rates and similarly
lower alcohol-related social consequences than their White
counterparts (9) . Black males begin to report high rates of heavy
drinking and social problems due to drinking after the age of 30,
compared with White males where heavy and problem drinking is
concentrated in the age group of 18 to 25 years.

Hispanics

Studies of Hispanic drinking practices and consequences are less
available and not as informative as those for Blacks. Mortality
statistics for the United States do not identify Hispanics separately,

131

and, until 1976, most other common measures of alcohol-related problems
such as arrest and hospital discharge rates did not provide a
Hispanic identifier. Although some information is available from
regional surveys, these data are limited to specific subpopulations
such as Mexican Americans. Nonetheless, there is some indication that
Hispanics , particularly young males, suffer disproportionate health
consequences as a result of their use of alcohol.

Deaths from cirrhosis of the liver are a general indicator of
high alcohol use within a given population. Several studies suggest
that death rates from cirrhosis among Mexican Americans and Puerto
Ricans may be higher than among the general population. While there
is some indication that Hispanics are overrepresented in the mortality
statistics for alcohol-related causes, these data stem mainly from
studies in a few cities or counties in the Southwest. Little is known
about the health consequences of alcohol use among Hispanics in the
rest of the United States.

The 1979 National Institute on Alcohol Abuse and Alcoholism
National Survey indicates that based on self-reported data, Hispanic
American males ages 18 and older have higher levels of heavy drinking
and higher rates of alcohol-related problems than do nonminorities
(10). Hispanic females, however, reported being either abstainers or
light drinkers. The most recent study on drinking patterns suggests
that young Hispanic males, ages 18 to 29 years, tend to drink more
heavily than either Black or White youths and young adults (34
percent, 17 percent, and 29 percent, respectively) (11).

Native Americans

The Indian Health Service reports that five of the top ten causes
of death among Indians are directly related to alcohol: accidents (21
percent), cirrhosis of the liver (6 percent), alcoholism (3.2
percent), suicide (2.9 percent), and homicide (2 percent). National
mortality statistics indicate that these five causes account for 35
percent of all deaths among Native Americans (12). A recent report
based on age-adjusted mortality rates found that the mortality rate
from alcohol-related causes of death was more than three times higher
among Native Americans than that of other groups. Among Alaska
Natives, alcoholism and alcohol-related problems are a major health
problem. Alaska Natives, who comprise 17 percent of Alaska's
population, account for 60 percent of the alcoholism deaths in that
State (13).

Unintentional injuries account for an estimated 21 percent of all

deaths in the Native American population and are the leading cause of

mortality. The Indian Health Service estimates that 75 percent of all
accidental deaths among Indians are alcohol-related (12).

The fourth-ranked cause of death among Native Americans,
cirrhosis of the liver, accounts for nearly 6 percent of total deaths,
compared with 1.7 percent of the total deaths for the Nation.

132

According to one study, cirrhosis mortality rates for Native
Americans are higher than rates for Black or White adults, and the
highest rates for Native Americans occur at younger ages. Examination
of the sex-specific data reveals that Native American women have much
higher cirrhosis mortality rates than either Black or White women at
all age levels (12).

The diagnosis of alcoholism accounts for an estimated 3.2 percent
of all Native American deaths, which is approximately four times the
rate for the Nation. Researchers suggest that this diagnosis might be
ranked even higher if all deaths from alcoholism were accurately
reported.

Suicide accounts for 2.9 percent of all deaths within the Native
American population, or twice the national percentage. It is
estimated that 80 percent of all deaths by suicide within the Native
American community are alcohol-related (12).

The tenth-ranked cause of death in Native American communities is
homicide, which accounts for an estimated two percent of total deaths.
The Indian Health Service reports that 90 percent of homicides com-
mitted within Native American communities occur while either the per-
petrator, the victim, or both are under the influence of alcohol (12).

Another medical consequence of alcohol abuse for which some
Native Americans appear to be at higher risk is fetal alcohol
syndrome/ fetal alcohol effects (FAS/FAE), although the risks appear
variable depending upon the tribal group. An epidemiological study of
FAS among Native Americans of the Southwest concluded that the
incidence and patterns of recurrence of FAS among the three groups
studied (Plains Indians, Navajo, and Pueblo) showed consistent dif-
ferences, ranging from a high of 10.3 per 1,000 live births for Plains
Indians, to 1.3 per 1,000 live births in the Navajo population (14).

Alcohol use varies tremendously from one tribe to the next--some
tribes have proportionately fewer drinking adults than the U.S.
population as a whole (30 percent compared to 67 percent) whereas
other tribes have more drinkers (69 to 80 percent) --with the
prevalence of alcohol-related problems also being highly variable
(15). The ability to define subpopulations at risk is important in
terms of preventive measures. Clearly, the health consequences of
alcohol use and abuse for Native Americans are a major public health
concern that must be addressed.

Asian/Pacific Islanders

The impression that Asian/Pacific Islanders do not consume as much
alcohol as the general population is generally supported by research
studies. However, because of the wide variations in drinking among
the different Asian nationalities, it is difficult to arrive at

133

generalizations without specifying country of origin and understanding
some of the historical-cultural factors that contribute to the
differences among Asian subpopulations with regard to the use of
alcohol .

There is evidence of wide variation among Asian/Pacific Islander
groups in terms of problem behavior related to alcohol consumption,
although very little research exists in this area (16). Native
Hawaiians, however, appear to be at increased risk for excess
mortality from alcohol-related motor vehicle accidents (17).

Research on the so-called "flushing reaction" shows that
approximately 50 percent of persons of Asian background metabolize
alcohol much more quickly than do Caucasians, causing a "flushing
reflex" and a high degree of discomfort, which may provide some
protection against heavy drinking and related problems. However, the
relationship between this sensitivity and the use of alcohol needs
further exploration.

Drug Abuse

National surveys of drug and alcohol abuse have been designed to
focus on the general household population. Consequently, there are no
national data on race- or ethnic-specific rates for drug abuse or the
health consequences of drug abuse. Estimates of the prevalence must
be viewed conservatively, since certain potentially high-risk
subgroups such as persons with no fixed residence or institutionalized
populations (e.g., college students living in dormitories) are not
included in the sample. Data on admissions to treatment centers,
emergency room visits, and medical examiner cases among minorities
provide some data on the consequences among minority populations.

Another problem in obtaining data on minorities is that Blacks,
Hispanics , Native Americans, and Asian/Pacific Islanders are sampled
proportionately to their numbers in the general population. The
actual sample size for minorities is substantially smaller than that
for Whites (1,093 Blacks sampled in the 1982 National Household Survey
on Drug Abuse (NHSDA) and 4,520 Whites). Blacks and Hispanics are
being oversampled in the 1985 NHSDA in an effort to provide more
reliable estimates of drug abuse prevalence in minority populations.

Despite these data limitations, the studies that have been done
suggest that drug abuse-related morbidity and mortality in Blacks,
Hispanics, and Native Americans are greater than for the White
population. Data on the Asian population do not indicate similar
excess mortality.

Data from the 1982 NHSDA indicate that the prevalence of reported
drug use within the household population is generally higher in urban
areas than in suburban or rural areas (18). Thus, to the extent that

134

minorities are more likely to reside in inner-city areas, they may be
at greater risk of drug abuse and, ultimately, the negative social and
health consequences associated with drug abuse.

The overall prevalence of drug abuse in the general household
population, ages 12 and older, is about the same for minorities as it
is for Whites (18). Minorities were more likely than Whites to report
marijuana as their only form of illicit drug use. Among both
minorities and Whites, the highest levels of current drug use were
reported by young adult males, ages 18 to 25 years. Among young adult
White men, 21 percent reported current use of marijuana only (19).
Thirty-six percent of young adult minority men reported current use of
marijuana only.

Another important aspect of marijuana use among minorities is
that unlike the pattern for young adult Whites, a decreasing trend in
use has not been observed among minority young adults, ages 18 to 25
years. The decreasing trend of marijuana use among White youths, ages
12 to 17 years, however, does appear to be paralleled by a decreasing
trend among minority youths in that same age group (19).

The health consequences of drug abuse may be greater for
minorities than for nonminorities as a result of the route used to
administer the drugs. To the extent that minorities are more involved
in the intravenous use of drugs, they are at increased risk of
potentially fatal infections from hepatitis B virus, bacterial
endocarditis, and acquired immune-deficiency syndrome (AIDS) (20-22).

A few follow-up studies of narcotic addicts hospitalized and
treated for their drug problems suggested that they experienced
greater-than-expected rates of accidents, suicides, homicides, and
deaths due to overdose (23) . Data specific to minorities are not yet
available to determine if traffic accidents are associated with
illicit drug use (24). Additional studies of the health consequences
of drug abuse that report data with racial and ethnicity identifiers
are discussed in the minority-specific sections of this report.

Blacks

Data from the 1980 census indicate that Blacks constitute 11.5
percent of our population; however, they constitute 22.5 percent of
the population of the inner cities (25). As such, they may be at
greater risk of drug abuse and its consequences. Evidence of higher
rates of drug use in populations having no fixed residence is provided
by a 1983 study of drug use among tenants of single-room occupancy
hotels (SRO) in New York City. Results suggest that Blacks have
higher rates of drug use than Whites for marijuana, cocaine, heroin,
and illicit methadone. Further analysis of a sample of Blacks matched
for age and sex from the household population and the SRO
population indicated that SRO tenants were three times as likely to
have used drugs recently as were the New York City household
residents (26) .

135

Data obtained from the 1982 National Drug and Alcoholism
Treatment Utilization Survey (NDATUS) , a national survey of public and
private treatment units, suggest that Blacks are three times more
likely to be in treatment for a drug abuse-related problem than are
Whites (27).

Data from the Drug Abuse Warning Network (DAWN) --gathered from
treatment programs, emergency rooms, and medical examiner cases--
indicate that minorities are more likely than nonminorities to be
involved with more dangerous drugs and with more dangerous
combinations of drugs. (Generalizations to the total population
cannot be made from the DAWN data, which are based on 27 metropolitan
areas and a panel of emergency rooms outside these metropolitan
areas.) For example, 31 percent of Black treatment clients reported a
primary problem with heroin, cocaine, or PCP, a figure three times
that reported by White clients. They were also more likely to report
use of other substances, with inhalants being the drug most commonly
included (19). Heroin use is difficult to measure in the household
survey because it is a relatively rare event; it is more likely to
involve the nonsampled population, and it is more likely to be
underreported .

Recent medical examiner data reported to DAWN show increases in
positive toxicology for cocaine with or without other drugs for all
races over the past three years. Between 1982 and 1984,
cocaine-related deaths among Blacks tripled (51 to 177), while they
doubled among Whites (149 to 312) (28). Heroin trends have been
relatively stable over the same time period. The percentage of
PCP-related deaths alone or in combination with other drugs
increased in Blacks from 50 percent in 1983 to 58 percent in
1984 (personal communication. National Institute on Drug Abuse, 1985).

DAWN data for 1984, taken from emergency room episodes only,
showed that, of 96,047 cases, Blacks were somewhat more likely than
were Whites to have used more dangerous routes of cocaine
administration--by injection (used by 49 percent of Blacks versus 40
percent of Whites) and by smoking or freebasing (9 percent of Blacks
versus 3 percent of Whites) . Because these data are not based on
statistical sampling procedures, generalizations to the total
population cannot be made (19) .

Some data are available to suggest a relationship between drug
abuse and homicide. A study conducted by the New York City Police
Department in 1981 and 1982 found that 53.1 percent and 46.4 percent,
respectively, of drug-related homicides involved Black victims (29).

Hispanics

Data from the 1980 census indicate that Hispanics constitute 6.4
percent of our population; however, they constitute 10.8 percent of
the population of the inner cities (25). As such, they may be at a

136

somewhat greater risk of drug abuse and its consequences. Results
from the 1983 SRO study of drug abuse in New York City suggest that
Hispanics have higher rates of drug use than non-Hispanic Whites for
marijuana, cocaine, heroin, and illicit methadone (26).

Multiple drug use is a problem for all minorities. Data from
hospital emergency room cases and from drug abuse treatment programs
indicate that Hispanics were more likely than Whites to report a
primary problem with heroin, cocaine, or PCP. In addition, inhalants
were the most commonly reported category of other drugs used. A
dramatic increase in reports of positive toxicology for cocaine was
found among the Hispanic population. Between 1982 and 1984,
cocaine-related deaths among Hispanics tripled (16 to 49), while they
doubled among Whites--from 149 to 312 (19).

Recently, it has been suggested that prevalence of inhalant use
by Hispanic youths is high. Although this cannot be supported by
household and high-school population surveys, a 1979 study of
Mexican American children and adolescents in Los Angeles barrios found
prevalence of inhalants 14 times that of the general population (30) .

The 1982 NDATUS suggested that Hispanics are 2.7 times more
likely to be in treatment for a drug abuse-related problem than are
Whites (27).

The 1984 DAWN data indicate that of those treated for
drug-related emergency room episodes, 42 percent of Hispanics as
compared with 40 percent of Whites administer cocaine by injection; 6
percent of Hispanics as compared with 3 percent of Whites administer
cocaine by smoking or freebasing. Both are more dangerous routes of
administration than the intranasal route and lead to more frequent use
of the drug (19). Recently, intravenous use of a "designer" drug,
meperidine-analog-synthesis (MPTP) , has been associated with early
onset of chronic Parkinsons disease symptoms in drug addicts (31) .
While cases are still being identified, a large proportion of the
initial cases were Hispanic (personal communication, Paul Jarbe) .

A 1981-82 New York City Police Department study of drug-related
homicides found that 34.2 percent involved Hispanic victims. In 1982,
the percentage of Hispanic victims increased to 41.8 (29). Reports
based on the New York City medical examiner cases from 1967 to 1970
indicate an overrepresentation of Hispanics among narcotic addiction
deaths. An investigation of 927 deaths among New York City narcotic
addicts in 1971 found that 16 percent were Puerto Rican.

Native Americans

Data obtained from the 1982 NDATUS suggest that Native
Americans are twice as likely to be in treatment for a drug
abuse-related problem than are Whites (27).

137

Treatment data were collected nationally in 1983 on a voluntary-
basis through the Client Oriented Data Acquisition Process (CODAP) ,
(based on 23 states, Washington, D.C., and territories; California
represented 46 percent of treatment admissions). The proportion of
1983 CODAP client admissions, excluding alcohol, was 0.6 percent for
American Indians/Alaska Natives. Although the representation of
Native Americans in the CODAP service area is unknown, this rate of
admissions is one and a half times the representation of Native
Americans in the U.S. population. CODAP also indicated that American
Indian clients were more likely than White clients to report a primary
problem with heroin, marijuana, or PCP. Native Americans also were
more likely to report the use of "other" drugs than White clients.
The most common type of the "other" drugs category reported was
inhalants (19).

Few studies and surveys of drug abuse have focused on minority
subgroups of the population, however, one survey of Native American
youth, (7th through 12th grade in Indian reservation schools) has been
conducted annually since 1975. Results from this survey for 1980-81,
on the lifetime prevalence of substance use for Native American high
school seniors, show that for 10 of 12 substance categories, Native
Americans have higher lifetime prevalence rates of substance use
than high-school seniors nationally. "Ever-use" of marijuana (88
percent) and inhalants (34.4 percent) by Native American seniors, in
particular, far exceeds that for national high-school seniors, which
is 59.5 percent and 12.3 percent respectively (32). Although lifetime
prevalence rates provide an indication of exposure, figures on
frequency of use for a given time period provide a better indication
of consequences and/or problem use. When frequency of substance use
for Native American youth (grades 7-12) is compared with a sample of
similarly aged non-Native American urban youth, a striking difference
is evident for marijuana. In 1980-81, 13.4 percent of Native American
youth reported daily use of marijuana in the 2 months before the
survey as compared with 2.6 percent of the non-Native American urban
youth (32).

Asian/Pacific Islanders

There is a paucity of data on prevalence of drug abuse among
Asian/Pacific Islanders. The little information that is known
suggests that the incidence of drug abuse is lower than that of the
White population; however, existing data are insufficient to draw any
definitive conclusions.

The 1983 treatment data collected through CODAP reported that
only 0.8 percent of all the clients admitted were Asian/Pacific
Islanders; thus, this group appears to be underrepresented in the
treatment population (19). The proportion of the Asian/Pacific
Islander population in the United States is 1.6 percent.

138

A 1971 New York City investigation of 927 deaths among narcotic
addicts, during a 9-nionth period, found only 2 percent of the deaths
were Asian/Pacific Islander, although, representatively, a much larger
Asian American population resides in that area.

Smoking

Cigarette smoking is the chief preventable cause of death in the
United States. Cigarette smoking is a causal factor for coronary
heart disease and arteriosclerotic peripheral vascular disease; cancer
of the lung, larynx, oral cavity and esophagus; and chronic bronchitis
and emphezema. It is also associated with cancer of the urinary
tract, bladder, pancreas, and kidney, and with ulcer disease and low
birthweight (2).

Differences exist between the smoking behavior of minorities and
nonminorities , and the incidence and gravity of cigarette-related
diseases varies. The most important of these are differences in the
smoking behavior of nonminority and minority males, especially for
Blacks and Hispanics (33) .

Blacks

The National Health Interview Surveys (NHIS), conducted by the
National Center for Health Statistics (NCHS) , are the major sources of
data on the smoking behavior of the U.S. population. Data from NHIS,
for the period between 1965 and 1980, show a steady decline in the
prevalence of smoking, a decline evident for both Whites and Blacks.
The prevalence of Black male smokers declined from 59.6 percent in
1965 to 44.9 percent in 1980. Among White males, the prevalence of
smokers declined from 51.3 percent in 1965 to 37.1 percent in
1980 (34).

Substantial differences exist between cigarette smoking patterns
of Blacks and Whites, yet the way in which these differences affect
the health outcome of Blacks versus Whites is unclear. Differences
have been observed in total smoke exposure as measured by age of
initiation, number of cigarettes smoked per day, and tar and nicotine
content of cigarettes smoked.

The prevalence of cigarette smoking among Black males has
consistently exceeded that of White males; however, only small
differences in prevalence exist between White and Black females.
Significant differences do exist, however, between Black and White
females with respect to number of cigarettes smoked per day. Black
females have a higher prevalence of "never-smokers" than do White
females at every income level above $5,000. Differences observed
between Black and White males are not explained by occupational,
educational, or income differences. However, the highest prevalence
of White males who have never smoked was in the lowest income level
(below $3,000) while the lowest prevalence of never smokers among
Black males was in the lowest income level.

139

NHIS data on numbers of cigarettes smoked indicate that Whites
are heavier smokers than Blacks. Among White males, 35.9 percent were
heavy smokers as compared with 11.9 percent among Black male smokers.
Similarly, White female smokers smoked more cigarettes per day than
did Black female smokers. For White females, 23.8 percent smoked more
than 25 cigarettes a day versus 7.5 percent for Black females (35).
In contrast, both Black males and females smoked cigarettes of higher
tar content than did either White males or White females . Although
the percentage of Blacks who ever started smoking is lower than the
percentage of Whites who ever started smoking, once started. Blacks
are less likely to attempt to quit or to quit successfully.

The effect these differences in smoking patterns have on
mortality and morbidity patterns exhibited by Blacks and Whites is
unknown; however, it is clear that nearly 90 percent of all lung
cancers are caused by cigarette smoking and that smoking-related
cancers seem to be particularly high among Blacks. Blacks have higher
incidence rates for the tobacco-related cancers of the lung,
esophagus, pancreas, and stomach. (For more discussion, refer to the
Summary Report of the Task Force Subcommittee on Cancer.) Smoking
appears to increase the risk of cardiovascular disease mortality in
both Blacks and Whites. It is not known, however, how differences in
smoking patterns between Blacks and Whites affect differences in
cardiovascular disease for these groups. (Further information is
contained in the Summary Report of the Task Force Subcommittee on
Cardiovascular and Cerebrovascular Disease.)

Hispanics

Lung and esophageal cancer morbidity and mortality rates, known
to be related to smoking, are lower for Hispanics than for
non-Hispanic Whites and Blacks. An exception to this has been
reported for New Mexico Hispanic females, among whom the incidence of
esophageal cancer is 20 percent higher than non-Hispanic Whites .
Studies suggest a link between the development of esophageal cancer
and smoking and alcohol consumption, with the latter two having a
synergistic effect (36).

It is not adequate only to consider smoking-related cancer data
as indicators of future risk for any group; current smoking behavior
patterns must also be considered. Overall prevalence rates of smoking
among Hispanics are relatively low due to the consistently lower rates
of smoking observed among Hispanic females; however, prevalence rates
among Hispanic males are quite high. Recent surveys of smoking
behavior in California, Texas, and New Mexico indicate that Hispanic
males appear to be smoking as frequently as their non-Hispanic White
counterparts, although their consumption levels appear to be lower (37)
Data from the 1980 NHIS indicate that 40.9 percent of Hispanic
males and 22.9 percent of Hispanic females were current smokers as
compared with 38.2 and 31.4 percent of Whites, respectively (33).

140

Examination of data from the "Know Your Body" program showed that
male and female Hispanic adolescents exceeded both male and female
White and Black adolescents in self-reported current cigarette use.
Findings from that survey and others suggest that, as cigarette use
increases among Hispanics, incidence rates for tobacco-related cancers
may increase in Hispanics, and that prevention efforts aimed at this
group are needed in the future.

Native Americans

Limited data are available from which to examine smoking behavior
and its health consequences in the Native American population.
Overall, Native Americans have smoking-related, lung cancer rates
lower than those of Whites; however, the relative frequency of lung
cancer differs among tribes. For example, among Oklahoma Indians,
where the lung cancer standardized mortality ratio is higher than in
other tribes, both cigarette smoking and lung cancer mortality more
closely mirror the national average. In contrast. Native Americans of
the Southwest, who seldom smoke, have low rates of smoking-related
lung cancer (2) . Environmental and cultural factors such as urban,
rural, and reservation living conditions may play a role in this
discrepancy.

Data do exist for Native American high-school seniors and the
prevalence of smoking among this population. Based on a study that
compared the lifetime prevalence of substance use between 1980-81 for
Native American high-school seniors and national high-school seniors.
Native American high-school seniors exhibited a prevalence rate for
cigarette smoking of 72.3 percent, compared with 71.0 percent for high
school seniors in the Nation (19). Although not significantly
different from the rate reported nationally, the smoking prevalence of
Native American youth needs to be more closely monitored, as one
indicator of future risk for smoking-related cancers.

Asian/Pacific Islanders

The prevalence of smoking among Asian/Pacific Islanders is
unknown due to the paucity of data. Certain subgroups within the
Asian population do exhibit excess incidence and mortality for some
smoking-related cancers. For example, Hawaiians have excess mortality
for cancer of the lung (refer to the Subcommittee Report on Cancer) .
Also, the incidence of esophageal cancer is 2.5 times higher for
Japanese males than White males; 1.8 times higher for Chinese males
than White males; and 1.6 times higher for Chinese females than for
White females (2). Major risk factors for esophageal cancer are
smoking and alcohol consumption, with the use of both having a
synergistic affect. Finally, excess risk for pancreatic cancer has
been found among cigarette smokers; pancreatic cancer incidence is
about 20 percent higher among Chinese females than among Whites, and
an upward trend in incidence exists for Chinese of both sexes.

141

Although the prevalence rates of smoking for Asian/Pacific
Islanders are unknown, it is clear that an increased incidence for
certain smoking-related cancers exist among subgroups of the Asian
population.

OPPORTUNITIES FOR PROGRESS

Interventions proposed by the Subcommittee follow:

• Promote the initiation and/or expansion of efforts to develop
coping skills in children and adolescents, ages 9 to 15 years,
to delay or prevent the use of substances such as tobacco,
drugs, and alcohol, with special emphasis on the needs of
minorities .

• Foster the development of peer-group instruction programs in
school settings designed to strengthen resistance to the use of
substances such as tobacco, drugs, or alcohol, with special
emphasis on the needs of minorities.

• Perform research into cirrhosis, including studying the basic
biological mechanisms involved in the development of cirrhosis
of the liver in Black, Native American, and Hispanic
populations .

• Develop programs to prevent alcohol-related unintentional death
and injury among Blacks, Hispanics , Native Americans, and
Native Hawaiians . Epidemiological research is needed to
define further the subpopulations of each minority group that
are at greatest risk so that prevention and education efforts
as well as early intervention and treatment programs can be
developed and targeted with greater likelihood for success.

• Investigate the biological consequences of alcohol use in
terms of its contribution to excess mortality among minority
groups. The role of alcohol use in hypertension, the role of
alcohol use in the development of some cancers in Blacks, and
the extent to which alcohol is a factor in the adverse
pregnancy outcomes among all minority groups, especially Black
and Native American women, are suggested topics.

• Determine the nature and extent of smoking among Hispanics,
Native Americans, and Asian/Pacific Islanders so that the
health consequences associated with smoking in these
populations might be understood and appropriate prevention
strategies developed.

142

• Study the prevalence, etiology, and consequences of drug
abuse among Blacks, Hispanics , Native Americans, and Asian/
Pacific Islanders through case-control cohort, or historical
cohort epidemiological studies utilizing culturally sensitive
instruments .

• Develop improved incidence and prevalence data gathering
techniques to assess alcohol and drug abuse among all
minority groups.

• Develop mechanisms in concert with appropriate state and

local entities to support specialized drug abuse prevention and
treatment programs in rural and urban Native American/Alaska
Native communities.

• Encourage Blacks to enter smoking cessation programs
and maintain cigarette abstinence.

• Review DHHS health professionals' training programs to ensure
the inclusion of education about alcohol and drug abuse in
the curricula.

• Provide assistance to appropriate organizations for health
care professionals to ensure that education on

alcohol and drug abuse is included in their training curricula.
This includes training in the diagnosis and prevention of
alcohol and drug abuse in a variety of patient populations,
including ethnic minorities; in referring patients to appropriate
treatment settings; and, in the provision of direct service and
treatment that is relevant to the specific minority patient.

• Encourage private sector organizations to train minority
research scientists and health care providers in substance
abuse research, diagnosis, and treatment.

143

REFERENCES

1. U.S. Department of Health and Human Services. (19 79). Healthy

people: The Surgeon General's report on health promotion

and disease prevention (DHEW (PHS) Publication No. 79-55071).

Washington, DC: U.S. Government Printing Office.

2. Report of the Subcommittee on Cancer. (1985). Unpublished

manuscript, Task Force on Black and Minority Health, DHHS .

3. Grant, B. F., & Aiken, S. (1984, November). Reported cirrhosis

mortality-United States. Centers for Disease Control
Morbidity and Mortality Weekly Report, 33(46), 657-659.

4. Williams, M. (1982). Blacks and alcoholism: Issues in the 1980s.

In Alcohol Health and Research World (Vol. 6, No. 4).
Bethesda, MD: National Institute on Alcohol Abuse and
Alcoholism.

5. Cahalan, D., Cisin, I., & Crossley, H. (1969). American

drinking practices (Monograph No. 6). New Brunswick,
NJ: Rutgers Center for Alcohol Studies.

6. National Institute on Alcohol Abuse and Alcoholism. (1980, August).

Facts in brief: Alcohol and Blacks. Rockville, MD:
National Clearinghouse for Alcohol Information.

7. Cahalan, D., & Room, R. (1974). Problem drinking among

American men (Monograph No. 7). New Brunswick, NJ: Rutgers
Center for Alcohol Studies.

8. Herd, D. (1985). A review of drinking patterns and alcohol

problems among U.S. Blacks. Unpublished manuscript,
Task Force on Black and Minority Health, DHHS.

9. Rachal, J. V. (1982). Alcohol abuse among adolescents. In

Alcohol Consumption and Related Problems. (Alcohol and
Health Monograph No. 1, p. 69). Rockville, MD: National
Institute on Alcohol Abuse and Alcoholism.

10. National Institute on Alcohol Abuse and Alcoholism. (1980, August).

Facts in brief: Alcohol and Hispanics ■ Rockville, MD:
National Clearinghouse for Alcohol Information.

11. Caetano, R. (1985). Patterns and problems of drinking among

U.S. Hispanics. Unpublished manuscript. Task Force on Black and
Minority Health, DHHS.

144

12. National Institute on Alcohol Abuse and Alcoholism. (1980, August).

Facts in brief: Alcohol and American Indians. Rockville, MD:
National Clearinghouse for Alcohol Information.

13. U.S. Department of Health and Human Services. (1981). Fourth

special report to the U.S. Congress on alcohol and
health (DHHS Publication No. (ADM) 81-1080).
Washington, DC: U.S. Government Printing Office.

14. May, P. A., Hymbaugh, K. J. , & Aase, J. M. (1983). Epidemiology of

fetal alcohol syndrome among American Indians of the Southwest.
Social Biology, 30(4), 374-385.

15. May, P. A. (1984). Alcohol and drug abuse prevention

programs for American Indians: Needs and opportunities.
Prepared for the National Institute on Alcohol Abuse and
Alcoholism, Division of Extramural Research.

16. National Institute on Alcohol Abuse and Alcoholism. (1982).

Special Population Issues. (DHHS Alcohol and Health
Monograph No. 4). Rockville, MD: Author.

17. Alcohol Epidemiology Data System. (1984). [Internal report on

native Hawaiians]. Unpublished raw data, prepared for the
Director, National Institute on Alcohol Abuse and Alcoholism.

18. Miller, J. D., Cisin, 1. H. , & Gardner-Keaton, H. (1983).

National Survey on Drug Abuse: Main findings 1982.
Rockville, MD: National Institute on Drug Abuse.

19. National Institute on Drug Abuse. (1985, May). Drug abuse among

minorities . Unpublished manuscript. Task Force on Black
and Minority Health, DHHS.

20. Decker, M. D., Vaughn, W. K. , Brodies , J. S., Hutcheson, R. H. ,

& Schaffner, W. (1984). Seroepidemiology of hepatitis B in
Tennessee prisoners. Journal of Infectious Diseases,
150, 450-459.

21. Centers for Disease Control. (1984). Update: Acquired

immunodeficiency syndrome (AIDS), United States. Centers
for Disease Control Morbidity and Mortality Weekly
Report , 33, 661-664.

22. Mills, J., & Drew, D. (1976). Seerratia Marcescens Endocarditis:

A regional illness associated with intravenous drug abuse.
Annals of Internal Medicine, 84, 29-35.

23. Joe, G. W., Lehman, W. , & Simpson, D. D. (1982). Addict death

rates during a four-year posttreatment follow-up. American
Journal of Public Health, 72, 703-709.

145

24. Joscelyn, K. B., Donelson, A. C, & Jones, R. K. (1980).

Drugs and Highway Safety 1980. Ann Arbor, MI:
University of Michigan Highway Safety Research Institute.

25. Bureau of the Census. (1981, October). 1980 census of

population. Standard metropolitan statistical areas
and standard consolidated statistical areas: 1980
(PC8G-S1-5). Washington, DC: U.S. Government Printing
Office.

26. Frank, B. (1983, June). Drug use among tenants of single

room occupancy (SRO) hotels in New York City. New York, NY:
New York State Division of Substance Abuse Services.

27. National Institute on Drug Abuse. (1983). Main findings

for drug abuse treatment units, September 1982.
Rockville, MD: Author.

28. Drug Abuse Warning Network. (1985, March). Medical Examiner

Drug file. Rockville, MD: Alcohol, Drug Abuse, and Mental
Health Administration.

29. New York City Police Department. (1982). Homicide analysis.

New York, NY: Crime Analysis Unit.

30. Padilla, E. R. , Padilla, A. M. , & Morales, A. (1979). Inhalant,

marijuana, and alcohol abuse among barrio children and
adolescents. International Journal of Addictions, 14,
945-964.

31. Langston, J. W. , Ballard, P., Tetrud, J. W. , & Irwin, I. (1983).

Chronic parkinsonism in humans due to a product of meperidine-
analog synthesis. Science, 219 , 979-980.

32. Getting, E. R. , Beauvais, F. , & Edward, R. (1982). Drug use

among Native American youth: Summary of findings
(1975-1981) . Fort Collins, CO: Western Behavioral Studies
Institute.

33. Department of Health and Human Services. (1985, June).

Subcommittee report on cancer in minorities.
Unpublished manuscript. Task Force on Black and Minority
Health, DHHS .

34. Office of Smoking and Health. (1984). Differences in

smoking behavior in minority populations. Unpublished
manuscript. Department of Health and Human Services.

146

35. Darby, C. A. (1985, May). Smoking prevalence among Black

and White males and females. Washington, DC: Office
of Smoking and Health.

36. Glynn, T. J. (1984). Smoking-related cancers and the

U.S. Black population. Bethesda, MD: National Cancer
Institute; Smoking, Tobacco, and Cancer Program.

37. Glynn, T. J. (1984). Prevention and cessation of smoking

and cancer risk among Hispanic Americans. Bethesda,
MD: National Cancer Institute; Smoking, Tobacco, and
Cancer Program.

38. Marcus, A. C, & Crane, L. A. (1985, February). Smoking

behavior among U.S. Latinos: An emerging challenge for
public health. American Journal of Public Health,
75 (2), 169-172.

147

SUBCOMMITTEE ON DIABETES

EXECUTIVE SUMMARY

Introduction

Diabetes mellitus was the seventh leading cause of death in the
United States in 1980 and is one of the six major contributors to the
disparity in health status between minorities and nonminorities (1). The
significance of diabetes as a health problem is increased by its
association as a risk factor for other major diseases, including
coronary heart disease and peripheral vascular disease. Complications
include kidney failure, diseases of the eye, and vascular
complications that may result in amputations.

There are two major types of diabetes, according to currently
accepted clinical definitions. Insulin-dependent diabetes mellitus
(IDDM) , formerly classified as type I diabetes, accounts for 5 to 10
percent of all the cases of diabetes in the United States. IDDM may
occur at any age but typically develops in childhood or young
adulthood. Specific genetic markers are associated with IDDM. It is
slightly more prevalent in the White population. Noninsulin-dependent
diabetes mellitus (NIDDM) , formerly classified as type II, is the more
common form of the disease, accounting for 90 to 95 percent of all
cases. Type II diabetes is most often found in middle-aged and older
adults, especially women. Data from the National Center for Health
Statistics (NCHS) reveal that diabetes is more prevalent among
minority groups than in the general population and that the excess of
morbidity and mortality among minorities occurs overwhelmingly in
type II (NIDDM). Although national statistics often do not distinguish
between the two types of diabetes, the dominance of type II is
significant because the risk factors for the two types are not
identical. This report focuses on the risk factors and treatment
issues related to the excess NIDDM in minorities.

A glucose tolerance test is most commonly used to identify
diabetes in an individual patient, but this assessment technique has
changed over time. Consequently, lack of comparability in the
criteria used to define diabetes in clinical studies is problematic
when attempting to estimate the extent of diabetes among the minority
populations. Relatively few reports and studies of minority
prevalence rates have used the widely accepted National Diabetes Data
Group (NDDG) criteria for definition of the several types of diabetes.
In this report, the term diabetes will be used when the two major
types have not been distinguished, and the term NIDDM will be used
when data specifically refer to that type as defined by the NDDG.
Failure to distinguish between the two types of diabetes does not,
however, change the overall prevalence information, since the 90 to 95
percent of diabetic people identified in clinical studies, both
minorities and nonminorities, are noninsulin-dependent diabetics.

149

Comparison of mortality data between the White population and the
minority population shows disproportionately higher mortality rates
from diabetes among Blacks, Hispanics, Native Americans, and Asian/
Pacific Islanders compared with non-Hispanic Whites.

Blacks

The prevalence of diabetes is 33 percent higher in the Black
population than in the White population (2). Data from NCHS show that
the rate of diabetes is 50 percent greater among Black females than
the rate in White females. In all populations, NIDDM is related to
obesity. The prevalence of obesity among Black females is striking
when compared with the White population as shown in Figure 11 (3). It
has been shown that the majority of Blacks who are diabetic are
overweight women. Furthermore, according to several studies,
complications of diabetes are more frequent among the Black population
of diabetics when compared with their White counterparts. The
prevalence of macrovascular disease or large-vessel disease causing
heart disease and stroke, and microvascular or small vessel disease,
which leads to kidney failure and blindness, appear to be more
frequent among Blacks with diabetes than in Whites with diabetes.

The National Diabetes Control Program, administered by the
Centers for Disease Control (CDC) , has provided some data on pregnancy
outcome for Blacks with diabetes, in selected geographic areas. One
model project in South Carolina revealed that the birth rate per 1,000
women was higher for Blacks with diabetes compared to Whites with
diabetes (2). However, the pregnancy outcome among this population
showed that the perinatal mortality rate among diabetic Blacks was
three times that of diabetic Whites and 8.5 times that of nondiabetic
Whites (4). From this and other published reports, it is clear that
diabetes during pregnancy is associated with a greater number of
infant deaths among Blacks than Whites.

Evidence shows that mortality attributed to diabetes increases
with age in both Whites and Blacks. Until recently, the rate peaked
at younger ages in Blacks, an effect attributed to the shorter
lifespan among Blacks and to the conjectured earlier onset of
disease.

Native Americans

Before the 1930s, diabetes mellitus was infrequently diagnosed
among Native Americans. However, in the past 20 years, diabetes
mellitus has been recognized as highly prevalent among American
Indians and Alaska Natives, with diabetes-related mortality rates 2.3
times higher than in the general population. Among the more than 500
federally recognized tribes of American Indians and Alaska Natives,
the prevalence rate of diabetes is highest among the Pima Indians, who
have the highest rate of diabetes in the world. This rate is 10 to 15
times higher than the overall United States rate for diabetes and is
predominantly of NIDDM. Compounding the increased prevalence of

150

a
s

(4-1

■M

Oft

■2

< a

e -^

00 C.

1 ^

u m

5 V

151

diabetes is the associated prevalence of obesity among this tribe.
Some studies have found that those of full American Indian heritage
are more susceptible to the disease than those of lesser heritage.
The implication is that genetic factors play a part in this disease,
although changes over time suggest behavior as a possible additional
predispositional factor. Some studies have suggested that the
increased prevalence of diabetes and obesity among American Indians
may be related to the ingestion of more calories, less fiber, and less
physical activity compared to their ancestors. The complications of
diabetes take a further toll on the American Indian population with a
significant prevalence of diabetic kidney disease requiring dialysis
and diabetic retinopathy resulting in blindness. Also, American
Indians incur disproportionately higher rates of amputations because
of vascular complications secondary to diabetes (5) .

Hispanics

Among the 14.6 million individuals of Hispanic origin in the
United States, the prevalence rate of diabetes among Hispanic
Americans is more than three times the rate of the non-Hispanic White
population (6,7). Although current prevalence data are limited to
Mexican Americans, the nationwide Hispanic Health and Nutrition
Examination Study (HHANES) will assess the prevalence of the disease
in Mexican Americans, Puerto Ricans , and Cuban Americans and will
evaluate their access to health care services for their diabetes.
Population-based studies in the southwest United States show that
Hispanic women in low-income urban barrios are four times more likely
than Hispanic women living in the suburbs to have the disease, and
Hispanic men are twice as likely. Although barrio women show a higher
diabetes rate than barrio men, the ratio is reversed in suburban
Hispanics. These findings are correlated with higher prevalence of
obesity among Hispanic women living in the barrio. Obesity, however,
is probably not the sole contributor to the increased prevalence of
diabetes among Mexican Americans . This finding may in part be
clarified by a study of the relation of obesity to acculturation,
which found that, over time, acculturated Mexican American women
became less obese; no correlation between acculturation and obesity
was found for Mexican men (7). Inconsistencies and differences in
prevalence rates for different clinical studies of Hispanics may be
complicated by possible genetic contribution from an admixture with
Native Americans known to be at high risk for diabetes.

From available data, it is clear that NIDDM is a major health
burden contributing to excess morbidity and mortality in the Mexican
American population. The data are still inadequate, however, to say
with certainty whether this increased prevalence of diabetes is shared
by other Hispanic subgroups. More data will be forthcoming for Puerto
Rican and Cuban Americans in the Hispanic HANKS.

152

Asian/Pacific Islanders

Few studies have analyzed data on diabetes among Asian/Pacific
Islanders. One study with limited information compared Japanese
Americans living in Hawaii, Los Angeles, San Francisco, and Seattle
with diabetic Japanese living in Japan. Although not representative
of the widely different Asian subpopulations , these data are important
to indicate disparities in one group of the Asian minorities.
Japanese Americans have exhibited consistently higher rates of glucose
intolerance, diabetes, and mortality associated with diabetes than
Japanese in Japan. In most populations, females suffer from diabetes
more than men. Among the Japanese Americans, however, this situation
is reversed: Males have higher rates of diabetes than females.
Diet, which is much higher in fat in Japanese Americans than Japanese
in Japan, may explain some of the difference in the prevalence of
diabetes between these groups . Sociocultural effects with
psychological consequences may likewise contribute to the reversal of
the ratio between the sexes: older Japanese American men are likely
to have suffered displacement from their roles as family leaders
during the reassimilation of Japanese into our culture since World
War II (8) . Data reviewed on these differences are only suggestive
and point out the need for additional research on psychological and
psychosocial correlates to diabetes and its consequences.

Prevention of Diabetes and Its Complications

Almost half the cases of diabetes in Americans are likely to go
unreported, according to the estimate of the American Diabetes
Association (ADA). Some 10.6 million Americans --about 4.5 percent of
our population- -may suffer from the disease. Because of the close
association of diabetes with obesity, it also has been estimated that
control of obesity could prevent almost 300,000 cases a year. Obesity
control among minorities, therefore, might prevent a part of the
disproportionate burden of diabetes experienced by minority
populations .

With significant advances in the treatment and the management of
diabetes during the past decade, increased attention has been paid to
identifying strategies to reduce the complications of diabetes.
Exemplary programs that provide continuing outpatient diabetes care to
populations that are more than 80 percent Black have operated in
Memphis, Tennessee since 1962 and in Atlanta, Georgia since 1968.
Both programs use a team approach in educating and treating diabetic
patients. The major goal of these programs is to prevent or delay the
development and progression of complications in patients diagnosed
with diabetes. Reports of results from these programs support the
hypothesis that a preventive approach to the consequences of diabetes
is effective in terms of therapeutic effects and cost control (9).

153

Since diabetes has reached epidemic proportions among some
American Indian tribes, the Indian Health Service (IHS) has
established Model Diabetes Care programs to develop, implement, and
evaluate the effectiveness of culturally acceptable diabetes
prevention and management programs (10). During the past six years,
considerable progress has been made at specific IHS sites in
delivering high-quality and culturally acceptable diabetes care.
Although these sites serve only about 10 percent of the IHS service
population, additional projects have been established recently to
improve diabetes care and disseminate treatment strategies to other
communities .

OPPORTUNITIES FOR PROGRESS

The following areas were identified by the Subcommittee as most
significant in narrowing the disparity in the morbidity and mortality
due to diabetes and its complications between the minority and
nonminority populations.

• Availability and distribution of educational and
informational materials for diabetic patients and those at risk
of diabetes is vitally important. The scope of the National
Diabetes Information Clearinghouse should be expanded to
address the individualized needs of minority groups for
diabetes-related information. When materials are developed,
they should take into account the socioeconomic and educational
levels of their target populations and, when appropriate, their
language needs .

• Under the auspices of the National Diabetes Advisory Board,
DHHS should support the development and inclusion of culturally
specific materials in the education and certification process
of diabetes educators .

• As part of the educational process of both patients and health
care provider trainees, the synergistic effects of smoking,
hypertension, hyperlipidemia, and obesity should be stressed as
having adverse effects on the optimal management of diabetes.

• DHHS- and State-funded CDC Diabetes Control Programs,
which have fostered participation of State and Federal
efforts in diabetes control, have demonstrated positive impact.
States should be encouraged to continue these programs.

• Existing federally funded programs such as the Women, Infants,
and Children (WIC) programs and nutrition programs for the
elderly should be used as possible opportunities

to screen high-risk minority individuals for diabetes.

154

• It is believed that earlier treatment of asymptomatic
diabetes can prevent diabetic complications inasmuch as it is
the complications rather than the diabetes per se that are
responsible for much of the diabetes-related morbidity and
mortality. Because NIDDM is more likely to occur in those over
age 50, blood glucose screening or measurement of the
glycosylated hemoglobin (hemoglobin AlC) in minority
individuals may be appropriate. ^

• The DHHS should encourage State and local health departments to
address the needs of those who have diabetes in areas where high
concentrations of minority populations are located. DHHS,
through CDC and the National Diabetes Information Clearinghouse,
can provide information and technical assistance to facilitate
State and local diabetes control activities.

• Private organizations concerned with diabetes such as the
ADA and the American Association of Diabetes Educators should
be encouraged to focus some of their efforts and resources on
issues specific to minority populations.

• In federally sponsored programs, DHHS should emphasize aspects of
diabetic care related to prevention of diabetic complications
that are the sequelae to poor diabetic control.

• Encouragement should be given to developing curricula

for health care providers that are minority and culturally
sensitive and to expanding the role of certain health
professionals such as dietitians and nurse practitioners
in the care of people with diabetes .

• Additional research on the prevalence of diabetes and its
complications among the various minorities is needed.
Well-designed epidemiologic studies are needed to characterize
the distribution of diabetes among minorities and monitor
trends in both prevalence of diabetes and related
complications. Studies should elucidate the effects of
variables such as physiologic differences, influences of
various diets, acculturation, and genetic admixture on the
pattern of disease.

• Environmental factors should be examined as possible
contributors to the increased prevalence of diabetes during the
past four decades among Native Americans, Blacks, Asian/Pacific
Islanders, and Hispanics .

• The DHHS should encourage the development of national data on the
prevalence of diabetes and its complications among the minority
groups by oversampling the minority populations in national
surveys .

155

REFERENCES

1. Drury, T. , Harris, M. , & Lipsett, L. (1981). Health: United

States, 1981. Prevalence and management of diabetes.
Washington, DC: U.S. Department of Health and Human Services.

2. Rosemann, J. F. (in press). Diabetes in Black Americans. In M.

Harris (Ed.), Diabetes Data Book.

3. Bonham, G. S., & Brock, D. W. (1985). The relationship of diabetes

with race, sex, and obesity. American Journal of Clinical
Nutrition, 41, 776-783.

4. Wheeler, F. C, Collmar, C. W., & Deeb, L. C. (1982). Diabetes

and pregnancy in South Carolina. Diabetes Care, 5, 561-665.

5. Sievers, M. L. , & Fisher, J. R. (1981). Diseases of North

American Indians. In H. Rothschild (Ed.), Biocultural Aspects
of Disease. (p. 191-240). New York, NY: Academic Press.

6. Bureau of the Census. (1981). Age, sex, race, and Spanish

origin of the population (Supplementary report PC-80-51-1).
Washington, DC: U.S. Department of Commerce.

7. Stern, M. (1984). Factors relating to increased prevalence

of diabetes in Hispanic Americans . Unpublished manuscript.
Task Force on Black and Minority Health, DHHS.

8. Fujimoto, W. Y. (1984). Diabetes in Asian Americans.

Unpublished manuscript. Task Force on Black and Minority
Health, DHHS.

9. National Diabetes Advisory Board. (1983). Diabetes mellitus, the

continuing challenge. (DHHS Publication No. (NIH) 83-2624).
(p. 496-3583).

10. Davidson, J. (1985). Diabetes . Unpublished manuscript. Task

Force on Black and Minority Health, DHHS.

156

SUBCOMMITTEE ON HOMICIDE, SUICIDE,
AND UNINTENTIONAL INJURIES

EXECUTIVE SUMMARY

Introduction

Injuries, intentional and unintentional, are among the leading
causes of death in the United States. This Subcommittee investigated
the major disparities in mortality between the majority population and
Blacks, Hispanics, Native Americans, and Asian/Pacific Islanders in
the areas of homicide, suicide, and unintentional injuries. Of these,
homicide and unintentional injuries account for 35 percent of the excess
deaths in Blacks under age 45 years. They remain important contributors
for Hispanics and Native Americans as well.

Since the reordering of national health priorities that resulted
in the Surgeon General's 1979 report. Healthy People, homicide
increasingly has been recognized as a preventable public health
problem for which the health sector needs to devote greater attention
and energy. Traditionally, problems of violence and homicide have
been left to the criminal justice system. Prevention of homicide is a
new endeavor for public health, and it presents an opportunity for the
public health field to deal with a previously ignored health problem.

In 1983, homicide accounted for more than 19,000 deaths in the
United States, an overall rate of 8.2 deaths per 100,000 population, a
rate far higher than that of any other industrialized Nation (1).

Homicide is the 11th leading cause of death in the United States.
For Americans of ages 1 through 65, homicide accounts for more than
726,000 potential years of life lost annually, an index for which
homicide ranks fourth among all causes of death. (Potential years of
life lost were computed to age 65. Data were computed from NCHS
public use data tapes by the Violence Epidemiology Branch, Centers for
Disease Control.) After heart disease, homicide accounts for more
excess mortality among Black Americans than any other cause of death.

Analysis of national and local homicide data indicates that Black
males and females and Hispanic males have rates of death far in excess
of the rates of their peers in the general population (see Figures 12
and 13) . Native Americans have rates of death from unintentional
injuries far greater than the general population. Suicide and
homicide also occur at higher rates among the Native American
population. Chinese women over age 45 have suicide rates
significantly in excess of those for White women of comparable age.

157

= ^

S S^

o .a

«S V

v,2

«^ w

Deat
and

-§

'3
0:1

158

1/5

■a ^

a* .

« c

9i B
fiX) o

^ J:?

m ■':■:■

m ■:■>

■*

■

■*

^^^^H

■

■s

^£2

.2 <u

S E

Z <

Cfl

.:>d

c
3

- —

•^

c
o

^ i

•^ o

j:^

^(£

1
<

c«

.2 u

ts s

-b

z <

■s

•§ 3

» ^
», s

•±5
1

■a
§

■3

■h

[ I

Cli

159

Blacks

• In 1983, Blacks accounted for 43 percent of homicide victims,
although Blacks represent only 11.5 percent of the population (2).

• Black males have a 1 in 21 lifetime chance of becoming a homicide
victim. The chance for White males is 1 in 131 (3).

• Black females have a 1 in 104 lifetime chance of becoming a
homicide victim. The chance for White females is 1 in 369 (3).

• Higher Black homicide rates are found in all regions of the
United States but are particularly high in the largest cities
of the Nation (data compiled by the Task Force on Black and
Minority Health) .

• Black males have the highest rates of homicide: 69.2 per
100,000 for Black males compared with 10.3 per 100,000 among
White males, in 1981 (1).

• Black females have the second highest rate of homicide: 12.9 per
100,000 compared with 3.1 among White females, in 1981 (1).

• Homicide is the leading cause of death for Black males of ages
15 to 44 (1).

• The homicide rate for Black males, ages 15-24, in 1981, was 78.2
deaths per 100,000 population compared with 14.4 per 100,000
for White males 15 to 24 years of age, a difference of more
than five-fold (1).

• The homicide rate for Black males, ages 25 to 34 years, was
136.9 per 100,000 in 1981 compared with 17.6 for White males of
the same age group, 7.8 times as great (1).

Hispanics

National data are not available for homicide deaths among Hispanic
populations, but data from the five-State southwestern region,
where more than 60 percent of Hispanics reside, show that during
the period 1976 to 1980, the homicide rate was 21.6 per 100,000,
more than 2.5 times the rate of the non-Hispanic White population
(7.7 per 100,000) in the same geographical area (4).

Native Americans

The homicide rate among American Indians in 1980 was 18.1, 70
percent higher than the rate for the general population (5) .

160

• American Indians have the highest rate of death from unintentional
injuries or "accidents," both overall and at age-specific inter-
vals. In 1980, the death rate from accidents among American
Indians was 107.3 per 100,000, significantly greater than the
rate of 42.3 per 100,000 for the U.S., all races. Motor vehicle
injuries account for the majority of accidental deaths. Among
American Indians, the death rate from motor vehicle injuries

was 61.3 per 100,000 American Indians compared to 22.9 for the
United States aggregate population (5).

• The death rate from suicides among American Indians was 14.1 per
100,000 in 1980, approximately 20 percent greater than the
general population (5). Within some tribes, the rate is much
higher. American Indian suicide victims are generally younger
than those in the general population with suicide rates peaking
at ages 15 to 39, compared with the general population in which
suicides most often occur after age 40 (7).

Asian/Pacific Islanders

• The risk for suicide in Chinese females rises considerably after
age 45 and increases with advancing age (6) .

Selected Dimensions of Homicide

Homicide is seldom an isolated event. Much homicide is preceded
by nonfatal conflicts and violence that come to the attention of police
or are the occasion for visits to hospital emergency departments.

• Most homicides in the United States involve relatives and
acquaintances. Of all homicides in 1983, 19 percent were
committed by members of the victims' families, 38 percent by
acquaintances, 15 percent by strangers; offenders were unident-
ified in 28 percent.

• Most homicides are committed against persons of the same race
as the offender. In 1983, 94 percent of Black victims were
slain by Black assailants, 88 percent of White victims were
slain by White assailants (8).

• Among Black males of ages 15 to 24:

--more than 65 percent of homicide deaths in 1979 were not re-
lated to criminal events.

--54 percent of homicide victims were killed by persons known
to them, usually acquaintances (8).

• Approximately 60 percent of all homicides are committed with
firearms --handguns , rifles, or shotguns (7).

161

Factors Associated with Homicide

Considered as a public health problem, the high homicide rate can
be related to psychological factors related to mental processes and
behavior; external environment including physical, historical-cultural,
social, educational, and economic environments; lifestyle, or individual
and group ways of life, and physiological factors related to age and
gender .

• Psychological factors. Homicide differs from other health
problems in that it is the outcome of mental processes that
result in conscious efforts to inflict physical harm upon another
human being. There appears to be broad agreement that persons
who commit homicide and other violent crimes fall into one of

a number of groups. These include:

--Normal, adequately socialized people exposed to extremely
provocative or frustrating situations or circumstances. In
some instances, their violence tendencies are exacerbated by
inhibition- lowering drugs.

--Persons committed to a violent lifestyle with supporting
attitudes and values. This includes both normal individuals
who consider that violence is appropriate in certain circum-
stances and other individuals who fail to develop adequate
inhibitions against violent behavior because of disturbed
developmental patterns. Although personal characteristics are
related to participation in violence, actual violent behavior
results from interactions of individuals with their environments,
Among the external factors that facilitate or impede violent
behavior are cultural attitudes towards violence, socioeconomic
conditions, and availability of weapons.

• Environment. Although occupying one of the most healthful
physical environments in the world, the United States has long
had higher levels of internal violence than other
industrialized nations. Violence is also accepted in American
culture to a degree exceeding that of many other nations.
Television programs, movies, and printed media often present
violence as entertainment to the American public.

Within the United States, as in other western countries, rates
of homicide are highest in large cities. Numerous studies
conducted over a period of many years note that violent crime,
its offenders, and its victims are most often found in urban
areas characterized by low income, physical deterioration,
welfare dependency, disrupted families, lack of social
supports, low levels of education and vocational skills, high
unemployment, high proportion of single males, overcrowded and
substandard housing, low rates of home ownership or single
family dwellings, mixed land use, and high population density (9).

162

Blacks live in a society that has a long tradition of
discrimination against minorities. Hispanics , Asians, and
Native Americans have also been victims of discrimination.

• Lifestyle. Several types of behaviors are associated with
increased risk for homicides. The National Institute on Alcohol
Abuse and Alcoholism has estimated that about one-half of all
homicides in the United States are related to use of

alcohol (10). An estimated 10 percent of homicides nationwide
are associated with use of illegal drugs (estimated by Research
Triangle Institute, North Carolina). In some of the
Nation's largest cities, the number of drug-related homicides
is more than 20 percent (11).

• Physiological factors. Being male and being young are the most
prominent risk factors for involvement in homicide as a victim
or as a perpetrator.

OPPORTUNITIES FOR PROGRESS

Many, if not most, homicides are preceded by patterns of nonfatal
violence that can provide targets for efforts at prevention (12).
Research indicates that homicide often is the end product of
youthful training in the use of violence that began in the home and
through interactions with peers in school and communities (13).
Children who engage in persistent antisocial and violent behavior
from an early age are at significant risk for becoming deficient in a
variety of social skills, including education, communication, and
work habits that are essential to a well-adjusted adult life (14).

Development of Preventive Intervention Strategies

Enough is known about homicide risks to suggest some useful
starting points for applying public health concepts of primary,
secondary, and tertiary prevention. As interventions in these areas
are developed and tested over time, some demonstrably effective
prevention strategies may emerge.

Primary Prevention

Primary prevention in the public health sense involves averting
the initial occurrence of a disease, defect, or injury. In the case
of homicide, primary prevention efforts need to be directed at those
social, cultural, technological, and legal aspects of the environment
in the United States that facilitate perpetuation of the Nation's
extraordinarily high homicide rates. The following examples
illustrate the types of preventive strategies that need to be
developed. Implementation of these strategies will require that
health professionals join with others in an effort to eradicate
factors that impair health by facilitating homicide.

163

• Effective health strategies to prevent homicide must begin by
enlisting greater public and professional interest and concern.
The Public Health Service should take the lead in developing a
new health promotion campaign specifically focused on homicide.
The campaign should increase public and professional awareness
that homicide is a serious national problem and that it is
preventable. By comparing the American homicide rate with
that of other nations, the campaign can also convey the message
that the high rate of American homicide can no longer

be tolerated.

• Physicians and other health care providers need to develop
greater understanding of homicide as a public health problem
for which the health sector should accept greater responsibil-
ity. Information on homicide and other violence should be
incorporated into the curricula of medical schools, nursing
schools, schools of social work, and continuing professional
education.

• Community self-help. High rates of homicide and other violence
are problems for which Black, Hispanic, and Native American
communities need to accept greater ownership. By accepting
responsibility for homicides that occur within their own
communities, minority citizens empower themselves to press more
actively for adequate and comprehensive efforts at prevention.
Community approaches might include:

--developing a continuing media campaign to educate the community
and the general public that violence and high homicide rates
are unacceptable. Messages should be culturally relevant and
feature appropriate role models who are suitable for the target
population.

—establishing a consortium or community council of civic,
religious, political, youth, and other community leaders who
are committed to the proposition that violence and homicide in
the community are unacceptable and preventable. This group
would meet regularly to exchange ideas and information and,
with help from other experts if needed, would develop
constructive approaches to prevention of violence and homicide.

--developing an information bank on violence and homicides that
occur in the community.

--mobilizing community resources to maximize the potential for
violence reduction and homicide prevention.

--developing a community policy toward firearms.

164

--developing model programs for community-based homicide
prevention. Promising approaches are provided by such
projects as the House of Umoja in Philadelphia (15), which has
reduced gang-related homicides among young Black men;
Neighborhood Crime Prevention projects, and the "Big Brother"
program, which could provide Black role models for high-risk
children from single-parent families.

--reducing violence on television. Several consumer and
professional groups have begun advocating reduction of
television violence. The National Parent Teachers Association
and other organizations have issued program selection
guidelines to enable parents to choose programs that demonstrate
appropriate prosocial behavior.

Secondary Prevention

Secondary prevention in the public health sense involves halting
or slowing the progression of a disease or other health problems. In
the case of homicide, secondary prevention efforts should be directed
to individuals manifesting early signs of behavioral and social
problems that are logically and empirically related to increased risks
for subsequent homicide. Family violence, childhood aggression,
school violence, adolescent violence, alcohol abuse, and drug abuse are
important focal points for efforts at secondary prevention of
homicide. In the case of Black and Hispanic homicide, such preventive
efforts are particularly needed in low-income, inner-city communities
characterized by high rates of violence, family disorganization,
unemployment, and school drop out.

• Family violence. More programs targeted to minority populations
should be implemented to assist parents in parenting skills and
in providing effective discipline that avoids excessive
punishment .

• School-based education programs. Health education curricula
extending from elementary through high school should include
teaching children how to manage hostility and aggression by
nonviolent means and channeling children's energies into
education, work, community projects, and recreation. The Boston
Youth Program is an example of an innovative school-based program
for homicide prevention (16).

• Mental health programs. Because aggressive and antisocial
behaviors in children are often associated with later delinquency
and violence, improved mental health interventions are needed.

• Chemical dependency. Programs to reduce chemical dependency need
to be incorporated into strategies aimed at prevention of homicide,
suicide, and unintentional injuries in minority populations.

165

Tertiary Prevention

Tertiary prevention is concerned with situations in which a
health problem is already well established, but efforts can still be
made to prevent further progress toward increased disability and
death. In relation to homicide, the problems of greatest concern are
types of serious violence between intimates and acquaintances that are
associated with elevated risk for homicide. Preventive efforts
include:

• Hospital emergency departments can help to prevent homicides
through improved medical record keeping on assaults. Homicides
frequently are preceded by nonfatal assaults that bring victims
into hospital emergency rooms. Records should include complete
information on the circumstances of an assault and a method
for identifying repeat victims of assaults. Blood alcohol
levels should be measured and recorded as should evidence, if
any, of drug use.

• Improved medical protocols need to be developed for identifying
female victims of domestic violence. Many of these persons are
not identified as battering victims because they do not
volunteer this information and are not questioned about
possible battering. A model emergency room protocol for
identifying adult victims of domestic violence has been
developed for hospitals in the State of New York and can be
adapted for use elsewhere (17).

• Preventive interventions for victims of domestic violence should
be introduced and tested in health care settings. A leader in
this field has been the Harborview Medical Center in Seattle,
which has developed a comprehensive intervention model that
addresses the needs of victims of spousal violence, child
sexual abuse, rape, elder abuse, and assaults by strangers (18).

• High rates of minority youth homicide in the Nation's largest
cities are associated from time to time with violence that
develops among rival youth gangs. The House of Umoja in
Philadelphia provides an example of a successful, minority-directed
program aimed at prevention and reduction of gang homicide. An
important outcome of this effort was the formation of a community
agency, Crisis Intervention Network, that has worked to prevent

a resurgence of gang violence through communication with concerned
parties and organizational efforts to combat the environmental
and social conditions that foster gang violence (15).

Interventions Targeted Toward Native Americans

• The Indian Health Service (IHS) is focusing greater efforts at
reducing death and disability from unintentional injuries, suicide,
and homicide by improving:

166

--prevention activities in the form of health education, risk
identification, and working with other agencies responsible for
law enforcement programs .

--assistance to injury victims through improved IHS clinical
services, emergency medical services, including assisting
communities to improve ambulance services.

--rehabilitation through clinical services and alcohol programs,
mental health, and health education.

--providing medical personnel with training in emergency care
skills .

• Efforts to prevent injuries from motor vehicle accidents should
include encouraging use of seat belts and child restraints in
cars and trucks, use of helmets for motorcyclists, and restraints
for passengers riding in the backs of pickup trucks.

• Because American Indian tribes differ considerably in language,
culture, and traditions, consultation with tribal leaders is
vital when planning or implementing health interventions targeted
toward American Indians.

Efforts at preventing or reducing unnecessary deaths from
homicide, suicide, and unintentional injuries in all minority
populations require a cooperative approach from diverse disciplines
outside the traditional public health sector.

167

REFERENCES

1. National Center for Health Statistics. (1984, December).

Health, United States 1984. (DHHS Publication No. (PHS)
85-1232). Washington, DC: U.S. Government Printing Office.

2. Federal Bureau of Investigation. (1984). Uniform crime reports

of the United States, 1983. Washington, DC: U.S.
Department of Justice.

3. U.S. Department of Justice. (1985, May). The risk of

violent crime. Washington, DC: Author.

4. Smith, J. C, Mercy, J. A., & Rosenberg, M. L. (1984).

Comparison of homicides among Anglos and Hispanics

in five southwestern states. Atlanta, GA: Centers for

Disease Control.

5. Indian Health Service. (1984, June). Indian Health Service

chart book series (No. 421-166:4393). Washington, DC:
U.S. Government Printing Office.

6. Liu, W., & Yu, E. (1985). Ethnicity and mental health. In

J. Moore, & L. Maldonaldo (Eds.), Urban Ethnics . Beverly
Hills, CA: Sage Publications.

7. Baker, S. P., O'Neill, B., & Karpf, R. S. (1984). The injury

fact book. Lexington, KY: Lexington Books, D.C. Heath and
Company.

8. Rosenberg, M. L., Gelles, R. J., Holinger, P. C, Zahn, M. A.,

Conn, J. A., Fajman, N. N. , &. Karlson, T. A. (1984).
Violence, homicide, assault, and suicide. Closing the gap
health policy project. Unpublished manuscript.

9 . President's Commission on Law Enforcement and Administration of

Justice: The Challenge of Crime in a Free Society. (1967).
Washington, DC: U.S. Government Printing Office.

10. John, H. W. (1978). Alcoholism and criminal homicide: A

review. Alcohol Health and Research World, 2, 8-13.

11. New York City Police Department. (1982). Homicide analysis.

New York, NY: Crime Analysis Unit.

12. Hawkins, D. F. (1984, December). Longitudinal -situational

approaches to understanding Black-on-Black homicide.
Unpublished manuscript, Task Force on Black and Minority
Health, DHHS.

168

13. Petersilia, J. (1980). Criminal career research. A review of

recent evidence. In N. Morris, & M. Tonry (Eds.), Crime and
Justice (Vol. 2). Chicago, IL: University of Chicago Press.

14. Loeber, R. (1982). The stability of antisocial and delinquent

child behavior: A review. Child Development, 53, 1431-1446.

15. Falakah, F. (1984). Call and catalytic response: The House

of Umoja. In R. Mathias, P. DeMuro, & R. Allinson (Eds.),
Violent juvenile offenders. An Anthology (pp. 231-237).
San Francisco, CA: San Francisco National Council on Crime
and Delinquency.

16. Prothrow-Stith, D. (1985, January). Interdisciplinary

interventions applicable to prevention of interpersonal
violence and homicide in Black youth. Unpublished
manuscript. Task Force on Black and Minority Health, DHHS .

17. State of New York Department of Health. (1984, August 19).

Hospital emergency department protocol: Identifying

and treating adult victims of domestic violence

(Health Facilities Series H-48) . New York, NY: Author.

18. Klingbeil, K. (1985, January). Comprehensive model to detect,

assess, and treat assaultive violence in hospital settings.
Unpublished manuscript. Task Force on Black and Minority Health,
DHHS.

169

SUBCOMMITTEE ON INFANT MORTALITY AND LOW BIRTHWEIGHT

EXECUTIVE SUMMARY

Introduction

The death of an infant is a personal tragedy and an event that
causes us to look at the functioning of medical and social systems.
Infant mortality, the rate at which babies die before their first
birthday, has been viewed historically as a sensitive indicator of the
well-being of these systems. Under age 60, the rates of death from
infant mortality are higher than for any other cause of death. In
1983, there were 39,400 infant deaths, a provisional rate of 10.9 per
1,000 births (1). While this represents a striking decline during the
20th century (from about 100 deaths per 1,000 live births in 1900) the
United States does not compare favorably with other industrialized
nations. Infant mortality rates are lower in the Scandanavian
countries, Japan, most of Western Europe, Canada, and Australia (2).
Although Blacks have shared in the decline in infant mortality, a
significant disparity remains with Black rates being essentially twice
those of Whites, 20.0 versus 10.5 in 1983, depicted in Figure 14.

Infant mortality rates have two main components: neonatal
mortality rate or deaths of infants within the first 28 days of life,
and postneonatal mortality or deaths from 28 days to one year. At the
turn of the century, postneonatal deaths accounted for most infant
deaths, but presently, neonatal deaths are predominant (Figure 15).
Neonatal deaths are thought to reflect preexisting health conditions
of the mother and the medical care she and her baby receive during
pregnancy, at the time of delivery and shortly thereafter. There have
been major improvements in the neonatal death rate in the past two
decades. Postneonatal mortality is more reflective of living
conditions, quality of care for children and medical care for
treatable conditions such as infections. Of course, these two sources
of risk for babies are not separate since the factors that influence a
woman to obtain early prenatal care may be the same things that
influence the quality of parenting and availability and use of
services after the birth (3) .

The sources of data for infant mortality are death certificates
filed by States, which are then reported to the National Center for
Health Statistics. States vary in their reporting of other
characteristics of mothers and infants, which limits analysis of
infant mortality by ethnicity. Other data sets such as birth
certificates and surveys provide more data on ethnicity and include
information on birthweight, which is a major risk factor for infant
mortality. Insight into the variability of poor pregnancy outcome can
be obtained by looking at low birthweight (LBW) , specifically, the
proportion of births that are below 2,500 grams, about 5-1/2 pounds.

171

o
in

7t ^

U. NX

►S-'

172

no
S

175 "J

OO 'O

O"*

\o VO

1 \

/ /

/ J

/ 1

/ /

I -

/ /

' /

^ /

/^ i

c f

8 /
z /

c
o

n /

en i

£ (

^ 1

/ \

.■s

^ 1

5 '

/
1

—

\
\
)

(

)

00
0\

2 ^

CTs

IT)

173

The distinction between normal and low birthweight is a powerful one
in regard to infant mortality, but LBW actually includes two
subgroups: preterm deliveries and small for gestational age babies,
which may or may not be preterm. In the research projects and data
that are described here, it is not always possible to distinguish
these two subgroups, although they are discussed in some detail in the
full report.

Although less than seven percent of babies are born with low
birthweight, they contribute two-thirds of the deaths in the first
month of life and approximately 60 percent of all infant deaths (4) .
Among White babies, 5.6 percent are LBW as opposed to 12.4 percent for
Black babies. Puerto Ricans occupy an intermediate position (9.1
percent). Other Hispanic groups show better outcomes, approximately
5.7 percent for Mexicans and 5.8 percent for Cubans. Data for
Hispanics are based on reports from 22 States which encompass an
estimated 90 percent of Hispanic births. Asians generally show good
perinatal outcomes. The best outcomes are among Chinese (5.3
percent), while 6.9 percent of Filipino births are below 2,500 grams.
Data for American Indians show favorable birth outcomes and low
birthweight rate of 6.2 percent (Figure 16) (5). A number of factors
have been identified as relating to the risk of low birthweight and
infant mortality. The broad range and complexity of these problems
should lead to caution in presuming quick or simple solutions to the
problem of infant mortality in the United States or the disparity
between groups. This report addresses what we know about etiologic
factors, recommendations for immediate action, and areas where
reasearch is needed.

Etiologic Factors

The many risk factors associated with poor perinatal outcome
among minorities that appear to be related to low socioeconomic status
include: (1) low income and inadequate insurance coverage that often
reduce access to appropriate medical care, (2) preexisting disease
conditions, (3) poor nutrition, (4) inadequate housing and crowded
living conditions, (5) limited maternal education, (6) stressful work
environments, (7) disrupted families and lack of social supports, and
(8) problems of transportation and child care that impede use of
services. All are more prevalent among poor and minority women.
Furthermore, childbearing patterns are related both to pregnancy
outcome and ethnicity. Populations with worse pregnancy outcomes tend
to include more teenage mothers, more unmarried mothers and more
unintended births (Table 15). This report addresses how the factors
leading to pregnancy and the care received during pregnancy relate to
the well-being of the baby. When many of the social risk factors
(education, marital status, trimester of first care, parity, age) are
controlled, Black women still have twice the risk of bearing LBW
babies as do comparable Whites. Nevertheless, the group of Black
women controlled for social risk factors has half the LBW incidence of
the Black population as a whole. This finding cautions us that this

174

1/1 u
o

^ (J

CQ S
u 2

O in

XxXx^XxiiXxiiix'^x::::-:;:;:;:-:-:

i;;

< c 1-

o <=a ^

o
c
'5.

I 3

c
o
Z

175

Table 15

Childbearing Patterns Among Racial and Ethnic Groups, 1982

American Indian,

White

Black

Hispanic*

Asian

Alaska Native

Age of Mother

Under 15

4,153

5,395

1,288

126

15-19

357,948

140,534

60,369

6,278

8,749

20-24

958,509

207,640

115,275

23,872

15,364

25-29

961,053

143,748

90,393

36,303

10,236

30-34

503,847

69,781

47,999

26,394

4,886

35-39

136,664

21,341

18,056

8,146

1,627

40-44

19,027

3,966

3,809

1,351

287

45-49

853

236

201

131

Percent of Births to Mothers Under Age 20

12.3 24.6

18.3

6.2

21.5

Percent of Births to Mothers Over Age 35

5.3 4.3

6.5

9.4

4.7

Marital Status: Out-of-Wedlock Births

Number 355,180 335,927 86,488 8,642 14,998

Percent 12.1 56.7 25.6 8.4 36.3

Parity

Percent First Births

43.3

39.2

37.0

41.8

36.9

Percent High Parity (4-I-)

8.6

14.2

16.4

10.7

17.0

SOURCE: National Center for Health Statistics.

*Refers to births to residents of 23 States reporting Hispanic origins of the mother on birth certificates. These States accounted
for an estimated 95 percent of all births of Hispanic origin in the United States in 1982.

176

is a difficult, complex issue that offers no simple solutions.
Although much is known about the risks for LBW and infant mortality,
much remains to be learned.

Based on the review of literature and NCHS data, four major areas
can be highlighted:

• The importance of family planning/pregnancy prevention
among teenagers , given the disproportionate number of teen
parents who are minorities.

• The importance of assuring early and continuous prenatal

care and appropriate levels of maternity, newborn, and infant care
to minority women.

• The importance of aggressive outreach, case management, and
expanded patient education services for minority women.

• The importance of adequately financing the providers and
hospitals that care for minority women, who are often uninsured
or rely on Medicaid.

Blacks

The neonatal mortality rate (NMR) for Blacks in 1981 was 13.4 per
1,000 live births, almost twice the rate for Whites (7.1). The
postneonatal mortality rate (PNMR) for Blacks was 6.6, twice the
3.4 rate for Whites (6). In 1983, 11,060 Black babies died before one
year of age (1) .

There are three components of excess risk for infant mortality
for Blacks: increased risk of bearing a low birthweight baby;
increased risk of neonatal death among normal weight babies; and
increased risk of postneonatal death, regardless of birthweight,
relative to Whites. These risks are related to (but not fully
explained by) childbearing patterns. Black women are much more likely
to have a teenage birth, an out-of-wedlock birth, or a high parity
birth, all of which are more likely to be unintended and associated
with adverse perinatal outcome.

A focal point for lowering infant mortality is to improve
services designed to help women, especially teenagers, avoid unwanted
pregnancies. Pregnant Black women are less likely to receive prenatal
care early in pregnancy. In 1982, 61 percent of Black mothers
received care in the first trimester compared with 79 percent of White
mothers. Black mothers were twice as likely as White mothers (10
percent versus 5 percent) to receive either no care or care beginning
in the third trimester of pregnancy (5). It is also possible that
there is a biologic role influencing birthweight that gives a
different meaning to low birthweight for Blacks than for Whites. This
issue deserves research attention. It is clear, unfortunately, that
normal weight Black babies have far higher rates of neonatal mortality

177

than White babies. This may reflect the prenatal care received, other
health behaviors of the mothers, quality of care in hospitals
providing routine obstetrical care, or other factors. To the extent
that deaths occur after the baby has left the hospital, excess deaths
may reflect living conditions or health knowledge and health behavior
on the part of the mother and family.

Postneonatal mortality rates are higher for Blacks for all major
causes of death except congenital anomalies. Sudden infant death
syndrome (SIDS) is the leading cause of postneonatal death, and
research is continuing on its causes and prevention. Accidents are
another major cause of death and may be related to dimensions of
living conditions, knowledge of health behaviors, or quality of care
provided to children (7). Among all groups, the mother's education is
strongly associated with infant mortality, presumably because it taps
these dimensions, as well as reflecting access to well and sick baby
health care services. There are a number of specific risks regarding
adverse pregnancy outcome such as the role of stress or infection that
are suspected of influencing the disparity between Black and White
rates. Specific health conditions related to perinatal outcome among
Blacks are discussed in the report. In many cases, research currently
under way should add to the presumptive evidence for the effect of
these factors or their relationship with race. The relationship of
economic conditions to health, especially infant mortality, is another
area that deserves further research. The Subcommittee urges that
further research address these factors.

Hispanics

As the second largest minority group, Hispanics present a complex
picture in terms of low birthweight and infant mortality. There is
considerable variation within the Hispanic population, and while
postneonatal mortality rates are elevated, the birthweight
distributions are generally favorable. Subgroups must be discussed
separately, however.

Mexican Americans

As the largest component of the Hispanic population in the United
States, and given their geographic concentration, there are more data
on Mexican Americans than for other groups. Babies of Mexican
American mothers have a relatively good birthweight distribution,
which is somewhat surprising given their social and economic
characteristics. Demographically, Mexican American women have fairly
high rates of teen childbearing and more high-parity births. Their
rates of out-of-wedlock childbearing are lower than those for Black
women (but higher than those for Whites), and there is a greater
tendency to be in a two-parent household than among Black mothers.

Only 58 percent of Mexican American mothers begin prenatal care
in the first trimester, less than for Blacks or non-Hispanic Whites (5)
The neonatal mortality rate appears good in some analyses, but

178

other studies suggest that rates are artificially low due to
underreporting (8). Recent studies suggest that, compared with
non-Hispanic Whites, Mexican Americans have higher neonatal mortality
at any particular birthweight (9).

This debate draws attention to the data and research needed to
address the interrelationships among intrinsic birthweight
distribution, health behaviors and prenatal care, and the access to
and use of health care services. For Mexican Americans, the question
of how individual health endowments and behaviors affect perinatal
outcome are complicated further by the role of migration. The
selectivity of migration may mean that Mexican women who migrate to
the United States represent a selected, or healthier, subgroup.
Because many Mexican American women are of low socioeconomic status,
issues regarding access to subsidized care are extremely important to
them and to the outcome of their pregnancies .

Puerto Ricans

The birthweight and hence infant mortality rates for United
States -born Puerto Ricans are less favorable than those for Mexican
Americans. The low birthweight rate is 9.1 percent overall and 9.6
percent for United States -born Puerto Ricans. This is the highest for
any Hispanic group. The proportion of low birthweight is between the
rates for Whites and for Blacks. This is not too surprising because
their childbearing rates are in many ways more like patterns seen in
the Black population than those seen among other Hispanics. For
example, among Puerto Ricans, 48 percent of births were out of
wedlock, but among Mexican Americans, it was only 14 percent. The
economic circumstances of many Puerto Rican women are such that
considerations regarding socioeconomic status, access to health care,
and health education and behaviors that apply to Blacks, apply to
Puerto Ricans as well. Fuller understanding of the differences among
the several Hispanic populations requires better data systems that
collect information on ethnicity and requires creative ways of dealing
with data for small subpopulations .

Cubans and Other Hispanics

Data on birthweight show a favorable distribution for Cubans.
The low birthweight rate for Cubans is 5.8 percent; it is somewhat
higher among United States -born Cuban mothers. This is not
surprising, given their apparently better socioeconomic status than
that of Mexican American or Puerto Rican women. For example, Cuban
women have a relatively low proportion of births occurring
out-of-wedlock (14 percent) and high rates of use of prenatal care (80
percent beginning in the first trimester) . It is not presently
possible to construct mortality rates for Cuban births; moreover, much
of the research does not provide sufficient information on ethnicity
or a large enough number of cases to draw conclusions about Cuban or
other Hispanic outcomes .

179

Native Americans

National data for American Indians and Alaska Natives indicate
that birthweight distribution and neonatal mortality for Native
Americans are quite good and have shown improvement over time.
Unfortunately, postneonatal mortality is quite high. The reduction in
postneonatal mortality should be a high priority. Special
considerations for American Indian and Alaska Natives are the high
rates of death from unintentional injuries and the possible influence
of diabetes or alcohol use of the mother on perinatal outcome or
postneonatal deaths (10). As with all populations, health education,
living conditions and access to health care are especially important.
Use of well baby care and the quality of sick baby care must be
considered.

Neonatal mortality rates and the birthweight distribution are
favorable and have improved along with improvements in prenatal care
for American Indians and Alaska Natives. These good outcomes are
observed despite the relatively poor patterns of prenatal care among
American Indians and Alaska Natives with far more women receiving late
prenatal care or no prenatal care at all than among Whites.
Birthweight has the predictable relationship with prenatal care--i.e.,
the earlier the care, the better the birthweight--but the level of
care is depressed and birthweight is not. Clearly there is room for
improvement in the receipt of prenatal care, but a number of questions
are raised.

Data problems, evident for other subgroups, are even greater for
Native Americans. Diversity within the Native American population and
likely changes over time in the proportion of American Indians who so
declare themselves in official documents create special problems. The
Indian Health Service data systems are an excellent beginning for
understanding infant mortality, but additional data are highly
desirable.

Asian/Pacific Islanders

The Asian/Pacific Islander population within the United States is
quite diverse, and available data are often not adequate. In general,
perinatal outcomes are good among Asian/Pacific Islander women with
relatively low rates of low birthweight (6.5 percent). Chinese had
the lowest rate (5.3 percent) and Filipinos the highest rate (6.9
percent) of low birthweight. Asian/Pacific Islander mothers are less
likely than White mothers to be teenagers (6 percent versus 12 percent
among Whites) or unmarried (8.4 percent vs. 12.1 percent for Whites).
Maternal education and socioeconomic status are relatively high among
many Asians, and prenatal care patterns are good, with 75 percent
beginning care in the first trimester. Southeast Asian refugees

180

present a somewhat different picture, with considerable variability
and numbers too small to permit national estimates of rates. Some
groups, for example the Hmong, have cultural patterns of very early
childbearing that may place them at greater perinatal risk.

OPPORTUNITIES FOR PROGRESS

The following are highlights of the Subcommittee's deliberations
regarding needs in the area of infant mortality:

• Personal reproductive responsibility should be enhanced through a
variety of channels, including enlarged content of health
education for providers and lay audiences, improved family
planning services, research on prevention of unplanned
pregnancies, and the development of improved approaches to
fertility regulation. Further research is needed on behaviors
associated with unplanned pregnancies, including perceived risks
and benefits of methods of fertility regulation. This is
especially true for teenage women who constitute an important
segment of the minority childbearing population.

• Since many risks exist before pregnancy or are actualized early
in pregnancy, steps should be taken to improve our ability to
increase minority women's knowledge of risks during pregnancy and
of the value of early and ongoing prenatal care. Research should
elaborate the mechanisms by which the planning of pregnancies
influences prenatal care and pregnancy outcome. Behavioral
approaches to accurate dating of pregnancies should be explored.

• Use of prenatal care is influenced by the availability and
accessibility of services. Many minority women, especially
teenagers, receive their care through Federal or State-subsidized
services or must pay for their own care. It is important to
lower barriers created by coverage patterns for high-risk women
low physican participation in Medicaid; problems with processing
claims/eligibility quickly; caring for women who move during
pregnancy; and others.

• Provision of technical assistance to State Title V agencies and
other providers of care for mothers and infants interested in
trying innovative approaches to funding care programs. Continue
to monitor changes in expanded eligibility resulting from the
Child Health Assistance Program (CHAP) in terms of
characteristics of new eligibles, use of care and outcomes.

• High-risk women often need a larger array of services than
others, and minority women are often high risk. The Subcommittee
recommends ways to address these needs through expanded nutrition
supplements, health education services, provider and patient
education regarding risk assessment, and recognition of preterm
labor and removal of arbitrary limits to services.

181

• Special attention should be given to aspects of prenatal care
designed to identify women at risk of preterm labor. Presently
there are innovative programs designed to identify and treat
women at risk of preterm labor. These programs should be
evaluated and considered for replication. Similarly,
regionalization of care for women at high risk has been valuable
and should be maintained.

• Although it is clear that early prenatal care is valuable, it is
also clear that more should be known about how the specific
components of care influence women's likelihood of coming for
care and the effect of that care. Research is needed on the
other health-related behaviors women may engage in during
pregnancy that are related to pregnancy outcome but not
necessarily a part of typical prenatal care. Special attention
should be given to improving techniques to help pregnant women
stop smoking.

• A number of conditions can be screened during pregnancy and
knowledge of identified risks can then influence treatment or
type of care. For example. Black women are at increased risk of
bearing twins, and multiple pregnancies are high risk for early
labor and adverse outcome; recent immigrants, especially Asians
and those from parts of the developing world, are at risk of
hepatitis B which affects the neonate and creates a carrier pool.
Screening for such conditions is important to secure optimal
care.

• A number of areas require improved research and attention by
health providers, such as the role of stress, type of employment,
transportation problems, and nutrition on pregnancy, the use of
prenatal care and pregnancy outcome. Comprehensive health
education for providers and information campaigns for the public
could address avoidable health risks during pregnancy.

• A model state brochure should be developed for low-income
pregnant women describing simply how and where to obtain Medicaid
eligibility, the need for early care, avoidable risks to the
fetus (e.g., smoking), and a list of providers accepting Medicaid.
Assure that the message is delivered to high-risk groups in
culturally appropriate forms.

• The Federal Government should continue to review and sponsor
mechanisms to aid in local and state investigations of infant
deaths in areas of high or changing infant mortality rates.

• The Department should coordinate with the American College of
Obstetricians and Gynecologists and other professional organiz-
ations to review the influence of malpractice insurance on Medicaid
participation and to seek an appropriate vehicle for assessing

the role of uncompensated care in influencing pregnancy outcome.

182

Assess evaluations and consider replication of innovative models
of active follow-up programs to support families of infants at
high risk of postneonatal disease. Support groups in other
disease areas have had documented successes. Their value in
regard to assisting parents of high-risk infants should be
evaluated.

Many postneonatal deaths are due to injury. The recent
improvements in seat belt protection for children and childproof
containers should serve as a model for preventing other sources
of accidental death for infants. The 1990 Objectives for the
Nation which have focused attention to the role of seat belts in
child safety, and other areas (such as death from burns) could be
considered at the mid-decade review.

To understand better the interplay of social, biological and
environmental factors associated with low birthweight and the
relationship of low birthweight to infant mortality among
minority groups, research should address birthweight-specif ic
mortality rates for minority groups, investigate the role of
nutrition or generational effects as an influence on the
relatively high low birthweight rates for apparently low-risk
Black women, and attempt to verify and explain the apparently
favorable birthweight distributions found among Mexican American
and Native American women.

Research on the perinatal period has paid far less attention to
the factors associated with postneonatal mortality. It is
recommended that research be increased and directed at the
preventable causes of postneonatal mortality, including the
interrelationship of individual and familial behaviors, health
care delivery factors, use of well and sick-baby care;
immunizations for babies, and sources of accidental death such as
risks associated with substandard housing.

Research is needed on the link between economic conditions and
infant mortality to specify better the interplay between the
individual, financing differences, and structural factors.
Expanded research on economic aspects of infant mortality in
conjunction with sociocultural factors may help explain the
relatively good outcomes experienced by Asian/Pacific Islanders
and Native Americans.

Most of the large programs, like Maternal and Infant Care (MIC),
Improve Pregnancy Outcome (IPO), and the Special Supplemental
Food Program for Women, Infants, and Children (WIC) have only
partially been evaluated. More complete evaluations of these
programs should be undertaken. Evaluation techniques have not
kept pace with the programs; specific recommendations for
strengthening evaluations are made in the Subcommittee report.

183

Evidence is accumulating to document the value of nutrition
programs (such as WIC). Continued research and implementation
should be considered.

• States should be encouraged to modify their birth and death
certificates to include better identification of ethnic groups,
especially Hispanics (already available on the certificates from
22 states). Furthermore, the addition of certain new items of
information on the birth certificate (such as smoking,
prepregnancy weight and height, and insurance coverage, and so
forth) could be extremely beneficial in monitoring and studying
the factors that influence pregnancy outcome.

• The National Infant Mortality Surveillance project done by CDC in
collaboration with NICHD, HRSA, NCHS and the State vital
registrars is developing a national data base of linked birth and
death records for 1980 that will provide valuable data for
analyzing infant mortality. The extension of this project to a
linked birth and death record for all births and infant deaths is
planned by NCHS. It is strongly recommended that this project
begin with the 1982 birth cohort and be continued.

• Much of the evaluative research on infant mortality interventions
was undertaken before some major changes in the U. S.
demographics, poverty populations, financing shifts and changes

in treatment systems . It is recommended that more contemporary
data collection and prospective studies be undertaken. Data
should be disaggregated by race and ethnicity, providing detail
within major ethnic groups such as Hispanics, and adequate cases
for comparison of adolescent with nonadolescent mothers.

• Data on insurance coverage of women and infants should be
improved, especially in regard to those eligible and receiving
Medicaid. These data could aid in our understanding of the role
of financing and service delivery issues regarding infant
mortality.

• Several national data bases (e.g., the National Natality Survey,
the National Survey of Family Growth, and the National
Longitudinal Survey- -Youth Cohort) include rich data regarding
pregnancy outcome. Improvements are recommended to enhance their
value in regard to increasing knowledge of infant mortality/low
birthweight for minorities and for research on teenage
childbearing.

• Research on some ethnic groups (e.g. , Indochinese refugees) will
be better served by data collection and research efforts directly
addressing their health concerns, rather than oversampling in
multipurpose surveys. In other cases, valuable data sets exist
regarding specific minority groups and could receive further
analysis, e.g., the Puerto Rican Fertility Survey or Indian
Health Service data.

184

The opportunities summarized above point to issues in education,
information, research, and services where advances could be made.
Infant mortality is a complex problem with many medical and
nonmedical aspects. There are no simple solutions, but there are
many things that we know about fertility, pregnancy and infant care
that can help address the problem of infant mortality, a problem that
takes a disproportionate toll on minorities.

185

REFERENCES

1. National Center for Health Statistics. (1984, September 21).

Annual summary of births , deaths , marriages , and
divorces: United States, 1983. Monthly Vital
Statistics Report 32(13). Hyattsville, MD: Author.

2. National Center for Health Statistics. (1984, December).

Health, United States, 1984 (DHHS Publication No. (PHS)
85-1232). Hyattsville, MD: Author.

3. Wallace, H. M. , Goldstein, H. , & Erickson, A. (1982). Comparison

of infant mortality in the United States and Sweden. Clinical
Pediatrics, 2j., 156-162.

4. McCormick, M. C. (1985). The contribution of low birth weight to

infant mortality and childhood morbidity. New England
Journal of Medicine, 312, 82-90.

5. National Center for Health Statistics. (1984, September 28).

Advance report of final natality statistics: United States,
1982. Monthly Vital Statistics Report, 33(6), Supplement.

6. National Center for Health Statistics. (1984, December 20).

Advance report of final mortality statistics: United States
1982. Monthly Vital Statistics Report, 22(8), Supplement.

7. National Center for Health Statistics. (1984). Vital Statistics

of the United States, 1979, Volume lI--Mortality ,

Part A (DHHS Publication No. (PHS) 84-1101). Hyattsville,

MD : Author .

8. Markides, K. S., & Hazuda, H. P. (1980). Ethnicity and infant

mortality in Texas counties. Social Biology, 27, 261-271.

9. Williams, R. L. , Binkin, N. J. , & Clingman, E. (in press).

Pregnancy outcomes among Hispanic women in California.
American Journal of Public Health.

10. Indian Health Service. (1984, June). Indian Health Service

chart book series (No. 421-166:4393). Washington, DC:
U.S. Government Printing Office.

186

HEALTH SERVICES AND RESOURCES FOR MINORITIES

Introduction

The health status differences observed among U.S. population
groups are in part related to the health care resources and services
available to individuals. Some of the factors that cut across
disease-related areas and affect health status patterns are: health
services' utilization; health care financing; availability of health
care facilities and personnel; health knowledge and behavior; and the
influence of health education on health knowledge and behavior. The
Task Force examined these factors and analyzed, where possible, their
impact upon the health of minorities.

Access, Utilization, and Financing

National surveys measuring current health care utilization
indicate that minority populations receive health care services at
levels similar to those of nonminorities ; differences, however, in the
patterns of utilization remain. The large differences in gross
indicators of health care access and utilization, such as number of
visits to a physician, that existed between nonminority and minority
populations have diminished since the creation of Medicaid and
Medicare. Both of these important health-financing programs have
enabled large segments of disadvantaged and older minorities to gain
access to needed health care. However, the poor health status
observed in many minority groups and differences remaining between
minorities and nonminorities in types of care and financing, suggest
that minorities still have poorer access to and use of comprehensive
and high-quality health care.

Detailed national-level data describing the health service
patterns of U.S. minority populations are not available. The minority
groups for whom the most health information is available are Blacks
and, to a lesser extent, Hispanics . Data describing Hispanic
subgroups are limited and generally obtainable only through combining
several years of national survey data or through small studies.
Comprehensive data on the health service patterns for many Native
Americans are not available. Although the Indian Health Service (IHS)
data describe the extent and nature of the services provided,
it serves only those residing on or near reservations, approximately
60 percent of the American Indian and Alaska Native population (") . The

Calculations are based on the following formula:

1980 Census = 1.5 million American Indians and Alaska Natives
IHS service population = 888,000 (i.e., 59 percent of total)
Two-thirds live off the reservation.

187

Asian/Pacific Islander population includes many subgroups that differ
in cultural characteristics, health needs, and health care patterns.
Because few sources identify subgroups and because Asian/Pacific
Islanders account for less than 2 percent of the U.S. population,
very little information about health services to this minority
and its subgroups exists. Most data on Asian/Pacific Islanders
reflect dominant subgroups such as the Chinese, Japanese, and
Filipinos. The following discussion, therefore, concentrates on
information relating to Blacks and, when available, other minorities.

Use of Health Professionals

From 1978 to 1980, the National Health Interview Survey, reported
4.7 as the average annual number of physician visits per person in
this country. The number of visits was similar for Black, Hispanic,
and White populations, although Mexican Americans, at 3.7 had a
noticeably fewer visits. When these data are examined by age,
however, more pronounced differences in utilization patterns emerge.
The average annual number of physician visits for minority children is
fewer than for White children. On the average. White children under
age 17 visit a physician 4.5 times each year compared to 3.5 for
Hispanic children and 3.2 for Black children (1). Vaccination rates
among children, an important indicator of the use of preventive health
measures, also show differences. Sixty-seven percent of White
children, one to four years old, were vaccinated against measles in
1983 compared with only 57 percent of minority children (2).

A clear pattern of lower use of preventive health services is
seen among minority adult populations. Nearly eight out of ten White
women seek prenatal care during the first trimester of pregnancy
though only six out of every ten Black women seek this care. Except
for Cuban women, rates of prenatal care in the first trimester among
Hispanics women from the 22 States that report Hispanic origin are
lower than those of Black women; rates for Native American women are
among the lowest of any racial or ethnic group in the United States.
Asian/Pacific Island women, as a group, have levels of first trimester
prenatal care similar to those of White women (2); however, rates vary
significantly between the different subgroups. Unfortunately,
detailed national information about screening and diagnostic services
received by different population groups is not available. Limited
studies indicate that nonminorities receive more cancer-screening
tests, breast examinations, prostate palpations, and proctoscopies
than do minorities (3) .

Dental services are used less frequently by minority populations
than by nonminorities. From 1978 to 1980, 56 percent of Whites
reported visiting a dentist in the previous year compared with 37
percent of Blacks. Hispanics also visited dentists less frequently
than Whites. Among Hispanic subgroups, Mexican Americans, at 35
percent, had the lowest percentage of dental visits in the previous
year (1). Forty-eight percent of Asian/Pacific Islanders and 40
percent of Native Americans (4) reported visiting a dentist during the

188

previous year. The lower use of dental services by minority
populations begins in childhood; 68 percent of White children, ages 4
to 16 years, were reported to have seen a dentist in the previous
year. The rate was 44 percent for Black children, ages 6 to 14 years,
and 39 percent for Mexican American children (1).

Sources of Care

Having a usual source of medical care has been found to be a good
predictor of use of health services and suggests a greater continuity
of care, associated with improved health outcomes. A 1977 study of
national medical care behavior reported that 13 percent of Whites have
no usual source of medical care; 20 percent of Blacks and 19 percent
of Hispanics reported this (5).

Continuity of health care is related to the location of medical
service. There is greater continuity of care when patients are able
to revisit the same provider. Seventy percent of the White population
reported using a physician's office as their usual source of care
compared with 54 percent of Hispanics and 46 percent of Blacks. Twice
as many Blacks and Hispanics as Whites reported hospitals and health
clinics as their usual source of medical care (5). The widespread use
of hospitals and public health clinics for medical care by Blacks also
was documented in the 1980 NHIS. In that year, 25 percent of all
visits to physicians made by Blacks occurred in hospital clinics or
emergency rooms compared with 11 percent by Whites (6).

The same survey also revealed differences in the patterns of
hospital utilization by minority groups. From 1978 to 1980, Blacks
reported hospital stays that averaged two days longer than those of
Whites (11 days versus 9 days). The average hospital duration for
Hispanics was slightly shorter than that for Whites (1).

Ability to Pay for Services

A prerequisite for access to medical care is the ability to pay
for services, which in turn largely depends on income and health
insurance. The median income for all Black and Hispanic families is
substantially lower than for White families resulting in less
disposable income available for the direct and indirect purchase of
health care. Family income for Asian/Pacific Islanders, however, is
not low, due in part to living patterns in which several wage-earning
adults live in the same household, although their individual wages may
be low. Viewing the Asian/Pacific Islander household income only on a
national average level masks subpopulation differences and the wide
diversity of income levels.

Health Insurance

Payment for health services is generally made through some form
of health insurance. Although a survey conducted in 1982 by the
Robert Wood Johnson Foundation found that only about nine percent of

189

the American population had no health insurance coverage of any kind.
Black and Hispanic groups had noninsurance rates that were two to
three times higher than Whites (7) . Recent systematic information
about the insurance status of Asian/Pacific Islanders and American
Indians and Alaska Natives living outside IHS service areas is not
available. The predominant source of funding for health care for
those under 65 years old in the United States is employment -based
third-party health insurance. However, because most minorities
experience higher unemployment rates, fewer minorities can obtain this
kind of health insurance (8).

Medicaid has become an important source of health insurance for
many minorities. The 1982 Robert Wood Johnson survey found that 20
percent of Blacks and 13 percent of Hispanics use Medicaid as their
only source of health insurance (7).

Although Medicaid has enabled many minority families to have
access to medical care, reimbursement schedules limit the range of
available health services, and frequent changes in program eligibility
tend to disrupt the continuity of health care.

In addition to Medicaid, funding for medical services for
refugees is available through Title XIX State medical programs. This
program particularly affects several of the Asian/Pacific Islander
populations. During their first 18 months in this country, most
Southeast Asian refugees are covered by Medicaid or receive medical
help through Refugee Medical Assistance.

Having some form of health insurance is related to using health
services and to whether people report having a usual source of medical
care (9). Twenty-five percent of the medically uninsured report
having no usual source of care compared to only 13 percent of those
covered by private insurance, 11 percent of those covered by Medicare,
and 15 percent of those enrolled in Medicaid (5) .

The continuity of health insurance, generally defined as the
proportion of the year a person is covered by health insurance, is
related to employment status and to changes in Medicaid eligibility,
and has an impact upon health care utilization. Greater proportions
of minority groups are without insurance for some portion of the year
than are the nonminority population. Those with less continuity of
health insurance use health services less frequently than those who
are insured all year round (9).

Though all Americans 65 years of age or older are covered by
Medicare, it does not provide full reimbursement for all health care
needs. The White population supplements Medicare with private
insurance twice as often as does the Black population (69 percent
versus 31 percent) (10). Although data are sparse, an analysis of
Medicare utilization information in 1978 revealed that more Whites
than non-Whites were reimbursed for physician and other medical
services (597 per 1,000 of enrolled Whites versus 521 per 1,000

190

enrolled non-Whites). Reimbursement amounts per person served that
year also appear to be more for Whites ($373) than for non-Whites
($348) (11).

Knowledge of the health care utilization and access patterns of
minority populations is fragmented, because little or no information
is available for minority population subgroups. More data on these
populations is needed for a fuller understanding of the health care
services they are actually receiving and need.

Health Professionals

One of the key elements of quality health care is the
availability of well-trained health care providers. The degree to
which the availability of these professionals differs between minority
and nonminority groups may play a crucial role in reducing disparities
in overall health status. The Task Force compiled and analyzed data
on the distribution of health personnel in counties where at least 20
percent of the population consists of a single minority (12). Although
analyses indicate that some counties with a high density of Blacks,
Hispanics, and Asian/Pacific Islanders had numbers of health care
professionals at least equal to the number located in areas with a
lower proportion of minorities, this "index of availability" of care
may be misleading. County-wide distribution of physicians and other
health care professionals does not reveal practice patterns,
accessibility, or actual availability of those professionals to
individual minority communities. Furthermore, since many of the
counties analyzed are urban, this information may simply reflect the
tendency for health care professionals to cluster in cities.
County-level analyses of physician distribution, for example, do not
indicate the number of professionals who accept Medicaid/Medicare
payments or whose practices might be located in minority areas. Many
areas with larger numbers of professionals also tend to be those with
medical schools or other institutions whose teaching staff are
not available as practitioners. Thus, the truly available resources
for minority health care may be considerably less than implied by
statistics .

Existing studies suggest that health professionals who are from
the same cultural background as their patients may be able to
communicate better with their patients and thereby have a positive
influence on many of the factors that affect health outcome.
However, with some notable exceptions among selected subgroups of
Hispanics and Asian/Pacific Islanders, minorities are substantially
underrepresented among students and practitioners of virtually all
major health and allied health professional disciplines (13).
Most minorities receive health care from providers who do not share
their own ethnic/cultural background.

191

Minorities are also underrepresented in research and teaching
positions in health sciences. An insufficient number of role models
and teachers who are sensitive to the training needs of minorities has
a negative effect upon the training of future minority health
professionals .

Although data are limited on the number, distribution, and practice
patterns of specific minority health professionals, current information
suggests the following:

• The proportion of Blacks among health professionals is
relatively low and not likely to change appreciably in the near
future. In virtually none of the States surveyed for this report
do the number of Black graduates of medical, dental, or pharmacy
schools even approach the proportions of Blacks in the
population. If the number of Black graduates continues to

rise, as it has during the past two decades, it is still
unlikely that the proportion of Black professionals will
significantly increase in the near future.

• Studying the distribution of health professionals within the
Hispanic population is particularly difficult because of the
various subpopulations in this group. Nonetheless, Mexican
Americans and Puerto Rican living in the U.S. appear to be
significantly underrepresented in the health professions.
Generally, Hispanic health care providers are unevenly distributed
among Hispanic communities.

• Asian/Pacific Islanders, as a group, appear to be dispropor-
tionately overrepresented among health professionals in training
and in private practice. However, data for identifying the
distribution of health professionals within Asian/Pacific
Islander subgroups are not readily available nor are data
identifying that proportion of Asian/Pacific Islander health
care providers which cares for Asian/Pacific Islander patients.

• Many American Indians and Alaska Natives receive health care
through the Indian Health Service, a health delivery
system created for the purpose of meeting their health needs.
The IHS is attempting to make greater use of indigenous health
workers and to tailor services more closely to individual
tribal needs. However, for American Indians and Alaska Natives
not living on or near reservations--nearly two-thirds of the total
population- -the scarcity of American Indian and Alaska Native
health providers becomes problematic when cultural differences
affect access to care.

192

Health Education and Information

The higher rates of the incidence and prevalence of certain
health conditions for minority populations is a compelling reason to
identify ways in which the health status of minorities can be improved
through health education interventions. Data have clearly illustrated
that each of the six priority areas that contribute significantly to the
disparity in health status has components or controllable risk factors
that are amenable to health education efforts. Such factors include
the use of tobacco, the maintenance of healthful dietary practices,
and the management of stress (14).

Behavioral, social, cultural, and ethnic variables that exist
within minority populations may affect the delivery of health
information to a significant degree and should be considered when
designing a health education intervention. Although some similarities
do exist within a minority group or between minority groups,
differences in such aspects as educational level, socioeconomic
status, and religion should be examined for their potential impact on
the design and implementation of a health education program. A common
characteristic found in each of the four minority groups addressed by
the Task Force is the important role played by the family in
disseminating health information and in providing support to assist
the individual in complying with a prescribed health action (15). It
remains difficult, however, to identify those specific behavioral
and/or cultural variables that affect health behavior within each
minority population because of the limited amount of research
concerning minority health beliefs, attitudes, and practices.
Clearly, additional data are needed in this area to tailor health
education programs more carefully to the needs of minorities.

Health education interventions for the four minority groups
identified should be directed at improving the awareness of
individuals and communities about controllable risk factors associated
with the causes of excess death and disability (16). Such measures
can occur in a number of settings--schools , worksites, medical care
facilities, and communities. Health education activities should
foster the development of lifestyles that maintain and enhance the
state of health and well-being as well as increase public and
professional awareness of risk factors that affect minority health
status .

Variables that affect the development and implementation of a
health education intervention include the nature of the target
population, the types of interventions available, and the kinds of
outcomes to be expected--health or otherwise (17). Above all, the
educator must understand the critical problems, the likely delivery
mechanisms, and the strategies for implementation.

193

Specific priority health behaviors, among the most important in
minority populations and most likely to be affected by health
education interventions include: smoking, diet and nutrition, social
support behaviors, exercise, alcohol and drug misuse, maternal and
child health issues, safety issues, stress management, sexually
transmitted diseases, and teenage pregnancy.

Because so many factors can enhance or impede the effectiveness
of a health education strategy, it is important to consider the
factors that contribute to making a hef.lth message and its
dissemination special for a given population. Such factors might
include the influence of community leaders and groups, the community's
attributes, an individual's perception of barriers to care and to
engaging in a specific health action, the environment, demographic
parameters, the nature of the innovation, and the channels available
for communication.

Differences in health status underscore the importance of
providing health education to minority populations; however, consensus
has not been reached on how best to develop health education programs
and strategies, how to effect change, and how to disseminate these
strategies. Therefore, efforts need to be expanded or initiated to
elucidate those factors that contribute to the design, implementation,
and diffusion of successful health education interventions in all
minority populations and subgroups in the United States.

Conclusion

Differing patterns of health services' utilization, health
insurance coverage, access to health providers, and the availability
of appropriate health education materials and programs contribute to
the disparity in health status between minority and nonminority
groups. Further study and identification of specific ways to improve
minority access to each of these health resources is essential to
improving the health status of minority groups in the United States .

194

REFERENCES

1. Trevino, F. M. , & Moss, A. J. (1984, December). Health

indicators for Hispanic, Black, and White Americans
(DHHS Publication No. (PHS) 84-1576). Vital and Health
Statistics, Series 10, No. 148. Hyattsville, MD: National
Center for Health Statistics.

2. National Center for Health Statistics. (1984, December).

Health, United States, 1984 (DHHS Publication No. (PHS)
85-1232). Washington, DC: U.S. Government Printing Office.

3. Warnecke, R. B. (1981). Intervention in Black populations. In

C. Mettlin, & G. Murphy (Eds.), Cancer among Black
Populations . New York, NY: Alan R. Liss, Inc.

4. National Center for Health Statistics' Health Interview Survey,

data cited in Gerzowski and Adler, Health Status of Native
Americans . Unpublished manuscript.

5. Kasper, J. A., & Barrish, G. (1982). National health care

expenditures' study. Data preview 12: Usual sources
of medical care and their characteristics (DHHS
Publication No. (PHS) 82-3324). Washington, DC: National
Center for Health Services Research.

6. Collins, J. G. (1983, June). Physician visits, volume, and

interval since last visit. United States, 1980 (DHHS
Publication No. (PHS) 83-1572). National Center for
Health Statistics. Washington, DC: U.S. Government Printing
Office.

7. Butler, J. (1983). Updated report on access to health

care for the American people. (Special report, V. Weisfeld,
Ed.) Princeton, NJ: The Robert Wood Johnson Foundation.

8. Trevino, F. , & Moss, A. (1983). Health insurance coverage and

physician visits among Hispanic and non-Hispanic people. In
Health, United States, 1983. (DHHS Publication No. (PHS)
84-1232). Washington, DC: U.S. Government Printing Office.

9. Wilinsky, G. R. , & Walden, D. C. (1981, November). Minorities,

poverty, and the uninsured. Paper presented at the 109th
annual meeting of the American Public Health Association,
Los Angeles, CA.

10. Cafferata, G. L. (1984). National health care expenditures'

study. Data Preview 18: Private health insurance
coverage of the Medicare population (DHHS Publication
No. (PHS) 84-3362). Washington, DC: National Center for
Health Services Research.

195

11. Muse, D., & Sawyer D. (1982, April). The Medicare and

Medicaid data book, 1981. Department of Health and
Human Services, Health Care Financing Administration, Office
of Research and Demonstrations. Washington, DC: U.S.
Government Printing Office.

12. Report of the Working Group on Health Professionals. (1985).

Unpublished manuscript. Task Force on Black and Minority Health, DHHS.

13. Bureau of Health Professions. (1984). Minorities and women

in the health field, 1984 (DHHS Publication No (HSRA)

HRS-DV 84-5). Washington, DC: U.S. Department of Health and

Human Services.

14. U.S. Department of Health and Human Services. (1979). Healthy

people: The Surgeon General's report on health promotion

and disease prevention (DHEW (PHS) Publication No. 79-55071).

Washington, DC: U.S. Government Printing Office.

15. National Heart, Lung, and Blood Institute. (1984). Development

of diffusion strategies among culturally diverse populations
(NIH Publication No. 84-2697). Washington, DC: U.S. Department
of Health and Human Services.

16. Office of Disease Prevention and Health Promotion. (1981).

Strategies for promoting health for specific populations
(DHHS Publication No. (PHS) 81-50169). Washington, DC:
U.S. Department of Health and Human Services.

17. Kolbe, L. , &. Iverson, D. (1984). Comprehensive school health

education programs. In J. D. Matarazzo, S. M. Weiss, J. A. Herd,
N. E. Miller, & S. M. Weiss (Eds.), Behavioral health: A handbook
of health enhancement disease prevention. New York, NY:
John Wiley and Sons.

196

Inventory of DHHS
Program Efforts

Survey of Nonfederal
Organizations

INVENTORY OF DHHS PROGRAM EFFORTS IN MINORITY HEALTH

An inventory of Department of Health and Human Services' program
efforts in minority health was compiled to provide the Secretary and
the Task Force with a comprehensive description of all programs,
current or planned, that relate specifically to minority populations.
This information was used by the Task Force in the recommendation
development process to ensure that the suggested activities would
provide new directions to existing departmental initiatives. The
inventory also will be useful to organizations and individuals
actively involved with minority health issues.

The inventory obtained information from the following agencies:

Alcohol, Drug Abuse, and Mental Health Administration

Centers for Disease Control^

Food and Drug Administration

Health Care Financing Administration ^ .

Health Resources and Services Administration .

National Institutes of Health,

Office of the Assistant Secretary for Health

Office for Civil Rights

Office of the Secretary v

Office of Human Development Services

Social Security Administration.

The program descriptions were based on those data maintained in
each agency's data management system; they varied greatly in the
amount of detail provided. Although the inventory originally was
intended to identify programs that focused on minority populations
specifically, it was found that many programs benefitted all
populations, including minorities. In some instances, it was possible
to identify the extent of activities targeted to minorities; for
others it was difficult to separate minority-specific components from
the overall program. It is important to note that this compilation of
DHHS programs and projects represents the first such grouping of
departmental activities in the area of minority health.

Ouestionnaire Development

A four-page questionnaire was developed requesting
program- level officers to indicate whether their programs addressed the
following areas: cancer; cardiovascular and cerebrovascular disease;
diabetes; arthritis and other musculoskeletal disorders; nutrition;
disease and disorders of the eye; infectious diseases; digestive
disorders; genetic disorders; infant mortality and maternal health;
homicide, suicide and unintentional injuries; chemical dependency and
related diseases; mental health and illness; occupational health;
respiratory diseases; dental health; kidney disorders; or some other
disorder .

197

Another series of questions requested descriptions of programs
and how each program addressed minority health issues. The major
classes of activity were: health service delivery, research and data
collection, health professions' development, and health
educat ion/ inf ormat ion diss eminat ion .

Overall, the questionnaire attempted to gauge the extent of
existing programs that addressed the minority health concerns.

Data Collection

Inventory questionnaires were distributed to the major components
of DHHS : the Assistant Secretary for Health, the Assistant Secretary
for Human Development Services, the Administrator for the Health Care
Financing Administration, and the Commissioner of the Social Security
Administration who, in turn, distributed them to their respective
operating divisions. Instructions were provided that explained the
purpose of the survey and the required information. Meetings were
held with each agency contact to explain the nature of the Task Force
and answer questions. More than 195 questionnaires were submitted by
the agencies. Each questionnaire was reviewed for clarity and
completeness by Task Force staff.

Data Analysis and Reporting

The program descriptions reflect the broad diversity of the
programs administered by DHHS. Although some submissions focus on
broad research issues that, by their very nature, included minority
health issues, others focused on model demonstration programs that
target specific minority groups. To preserve the richness of the
descriptions, no attempt was made to combine the material into broader
classifications .

Index of DHHS Programs

The index that follows lists either agencies or institutional
components that have ongoing or planned minority-related initiatives.
Complete descriptions of every program appear in another volume of
this report. The office address and telephone number of each program
are included in the later volume so that future users may readily
obtain additional information.

198

ALCOHOL, DRUG ABUSE, AND MENTAL HEALTH ADMINISTRATION
(ADAMHA)

National Institute of Alcohol Abuse and Alcoholism:
Division of Biometry and Epidemiology
Black and Hispanic Alcohol Problems: A National Study

National Institute on Drug Abuse:
National Drug Abuse Media Campaign
Ethnic Community Initiative
NIDA Starter Award

Minority Access to Research Centers

Prevention of Drug Abuse Among Minority Populations
Treatment of Drug Abuse Among Minority Populations
Ethnic Minority Family Mobilization Project
Estimating Mental Health Need

National Institute of Mental Health:
Prevention Program

Center for Studies of Mental Health of the Aging
Center for Studies of Minority Group Mental Health
Center for Studies of Antisocial and Violent Behavior
Center for Prevention Research

Center for Mental Health Studies of Emergencies
Center for Epidemiologic Studies
Mental Health Clinical Research Centers
Research Scientist Development
NIMH Minority Biomedical Research Support
Clinical Research Branch
Small Grant Program
Psychosocial Treatments Research

Child and Adolescent Service System Program (CAASP)
Community Support Program
National Research Service Award
Mental Health Clinical Training
National Reporting Program

CENTERS FOR DISEASE CONTROL (CDC)

Investigations and Technical Assistance

Injury Prevention

Occupational Safety and Health - Training Grants

Occupational Safety and Health - Research Grants

Childhood Immunization Grants

Health Programs for Refugees

Venereal Disease Control Grants

Venereal Disease Research, Demonstration, and Public Information

and Education Grants
Project Grants and Cooperative Agreements for Tuberculosis Control

Programs
Cooperative Agreements for State-Based Diabetes Control Programs

199

FOOD AND DRUG ADMINISTRATION (FDA)

Food Safety

Nutrition

Task Force to Increase Interaction with Minority Health Professional

Schools
Office of Consumer Affairs Communications
Consumer Affairs Education Program (Field Offices)

HEALTH CARE FINANCING ADMINISTRATION (HCFA)

Medicare

End-Stage Renal Disease Program

Medicaid

Research and Demonstration

HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA)

Indian Health Service

Community Health Center Program

Black Lung Clinics

Migrant Health Program

National Health Service Corps

Home Health Services Program

National Health Service Corps Scholarship Program

Hansen's Disease Program

Health Careers Opportunity Program

Advanced Financial Distress

Nursing Special Project Grants

Professional Nurse Traineeship Grant Program

Area Health Education Centers

Health Professionals Analytical Studies and Reports

Nurses Midwifery Office

Contract Health Service

NATIONAL INSTITUTES OF HEALTH (NIH)

Division of Research Resources:
Animal Resources Program
Biomedical Research Support Program
General Clinical Research Centers Program
Biomedical Research Technology Program
Minority Access to Research Careers Program (MARC)
Minority Biomedical Research Support Program (MBRS)

National Cancer Institute:

Epidemiology Research Program

Chemical and Physical Carcinogenesis Research Program

Biological Carcinogenesis Research Program

Nutrition Research Program

Tumor Biology Research Program

200

Immunology Research Program
Diagnostic Research Program
Preclinical Treatment Research Program
Clinical Treatment Research Program
Rehabilitation Research Program
Comprehensive Minority Biomedical Program
Resource Development Activities
Cancer Control Program

National Eye Institute:

Retinal and Choroidal Diseases Branch
Strabismus, Amblyopia, and Visual Processing
Intramural Research Program
Anterior Segment Diseases Branch

National Heart, Lung, and Blood Institute:
Heart and Vascular Diseases Program
Lung Diseases Program
Blood Diseases and Resources Program
Companion Issues

National Institute on Aging:
Behavioral Sciences Research
Systolic Hypertension in the Elderly
Public Information Office

Epidemiology, Demography, and Biometry Program
Gerontology Research Program

National Institute of Allergy and Infectious Diseases:
Microbiology and Infectious Diseases Program
Immunology, Allergic and Immunologic Diseases Program

National Institute of Arthritis, Diabetes, and Digestive and Kidney Diseases
Arthritis, Musculoskeletal, and Skin Diseases
Diabetes

Digestive Diseases and Nutrition
Kidney, Urologic, and Hematologic Diseases
Pima Indian Studies

National Institute of Child Health and Human Development:
Center for Research for Mothers and Children
Healthy Mothers, Healthy Babies Program
Center for Population Research
Intramural Program

National Institute of Dental Research:
Office of the Director
Extramural Programs

201

National Institute of General Medical Sciences:
Pharmacological Sciences Program

National Institute on Neurological and Communicative Disorders and Stroke:
Travel Fellowships for Minority Neuroscientists

Survey of Major Neurological Disorders in Copiah County, Mississippi
Chronic CNS Disease Studies: Slow, Latent, and Temperate Virus Infection
Summer Research Fellowship Program

OFFICE OF THE ASSISTANT SECRETARY FOR HEALTH (OASH)

National Center for Health Statistics:
National Hospital Discharge Survey
National Health and Nutrition Examination Survey
NHANES I Epidemiologic Follow-up Survey
Hispanic Health and Nutrition Examination Survey
National Medical Care Utilization and Expenditure Survey
National Ambulatory Medical Care Survey
National Nursing Home Survey
National Master Facility Inventory
Vital Statistics Follow-back Survey Program
National Vital Statistics Program
National Survey of Family Growth
National Health Interview Survey

Office of Public Affairs:

Healthy Mothers, Healthy Babies Coalition

Information and Education on Acquired Immune Deficiency Syndrome

Office of Disease Prevention and Health Promotion:
National Health Promotion Program
National Health Information Clearinghouse
1990 Objectives for the Nation Initiative
U.S. Task Force on Preventive Services

Office of Refugee Health:
Refugee Preventive Health
Cuban/Haitian Entrant Program
Health Program for Refugees

Office of Population Affairs:
Adolescent Family Life
Office of Family Planning

202

OFFICE OF THE ASSISTANT SECRETARY FOR HUMAN
DEVELOPMENT SERVICES (HDS)

Administration for Native Americans

Administration for Developmental Disabilities

Administration for Children, Youth, and Families (Head Start)

Coordinated Discretionary Funds Program

Administration on Aging

Title 111 of the Older Americans Act (Part B - Nutrition Services)
Title VI, Older Americans Act, Grants to Indian Tribes for Supportive
and Nutrition Services

OFFICE OF THE ASSISTANT SECRETARY FOR PLANNING
AND EVALUATION (ASPE)

OFFICE FOR CIVIL RIGHTS, OFFICE OF THE SECRETARY (OCR)

SOCIAL SECURITY ADMINISTRATION (SSA)

Health-Related Programs

203

SURVEY OF NON-FEDERAL ORGANIZATIONS
Introduction

The Task Force conducted a nationwide survey of approximately 300
individuals and organizations that represent health-specific
professional, scientific, and service groups. The survey was intended
to elicit information on ways the Department might improve the health
status of minority Americans .

The survey asked four questions:

(1) From the perspective of your organization and the people you
represent, what are the three most critical health disparities
between minority and nonminority Americans?

(2) For the disparities you identified, what appear to be the most
significant contributing factors?

(3) Highlighting specific examples known to your organization,
what kinds of health programs in the minority community have
been most successful? What has been the key element of that
success?

(4) Within the confines of the current Department of Health and
Human Services' (DHHS) programs and policies, how might DHHS
better address the disparity in the health status of minority
populations?

The following represents a summary of the 125 survey responses
received by April, 1985.

Summary of Responses

The plight of many minority people in need of health care is
captured in this excerpted comment:

"Preventive care is often a luxury that time rarely affords
minority people. One is inclined to ignore a cough, a lump in the
breast, or even an advancing pregnancy when the demands of daily
existence are overtaxing. These ceaseless demands for employment,
housing, food, clothing, legal help, public assistance, etc., are
sufficient to ensure that many illnesses or conditions reach a
critical point before health care is sought."

Socioeconomic issues influencing health status were frequently
cited as contributors to the disparity. These included: the
prevalence of poverty among minority groups, low income, unemployment,
lack of health insurance, and inability to pay deductibles or

205

copayment costs of insurance. Another aspect mentioned frequently by
respondents was the reduction in Government funding for health care
services and programs for minorities.

Many respondents believe that the major health disparities could be
reduced through improved access to health care services and programs.
These need to be designed and operated to be culturally sensitive to
the specific minority population being served. The types of services
most often advocated by respondents were health education and
disease prevention programs.

Suggestions for improving health care services and programs for
minorities were:

• Continued support for existing successful health programs.

• Minority-specific research and data collection.

• Prevention and health education programs that incorporate
bicultural/bilingual services.

• Minority participation in policy development.

• Education and training programs.

• Improved access to health care through modification of third-

party payer systems .

Specific Issues

From the perspective of your organization and the people you
represent, what are the three most critical health
disparities between minority and nonminority Americans?

For the disparities you identified, what appear to be the
most significant contributing factors?

The responses to the first two questions are reported together
because of the linked nature of the majority of responses received.
The most critical disparities identified by the respondents were in
the areas of:

• Access to health care.

• Chronic diseases.

• Pregnancy and birth disorders .

• Availability of data.

206

Access to Health Care

Problems concerning minority access to health care cut across all
responses. Some respondents cited access to health services as a
primary disparity, while others identified access as a secondary issue
or a contributing facto:p to the primary disparities. For example,
chronic disease conditions were often mentioned as a disparity;
however, access to proper health care was listed as a strong
contributor to the prevalence of this disparity.

were:

Two major areas of concern in health care access for minorities

• The lack of certain types and numbers of services and programs.

• Barriers to existing services.

In addition, the need for generally improved access, quality, and
utilization of services such as primary care, screening, detection,
treatment, follow-up, and public (health) education programs were
frequently cited. Current health services' research and promotion were
pinpointed as inappropriate or inadequate for identifying,
communicating with, convening, and involving minorities through
community-based groups, such as: schools, churches. Health
Maintenance Organizations (HMOs), worksites, and voluntary health
groups. In addition, the paucity of screening and health education
programs was identified as a leading cause of delayed diagnosis and
the poor prognosis for medical problems.

Specific problems of access to health care included:

• Lack of health care for mothers and children.

• Lack of access to services for early detection of diseases such
as cancer, hypertension, and diabetes and other specialty health
care.

• Inability of non-English speaking people to use freely the health
care system because of language and cultural barriers.

• Less access to, and inappropriate use of, health services.

• Poor quality of health care.

• Underutilization of existing health resources because of a lack
of knowledge and motivation.

• Lack of physicians in rural areas.

207

• Problems with health care facilities, including af fordability,
location, hours of operation, and transportation to and from
the facilities.

The major theme of these responses pointed to a need for more
health education programs tailored to the minority group being served,
on the following issues: prenatal and infant care, proper nutrition
and weight reduction, management of chronic illnesses, family planning
and sex education, and alcohol and drug abuse counseling. Respondents
often stressed the need for programs that emphasize preventing disease
and promoting good health and good health practices.

Chronic Diseases

Hypertension (high blood pressure), cardiovascular disease,
cerebrovascular disease, cancer, and diabetes were most often cited as
specific diseases that contribute to the health disparity. Most
respondents believed that, if adequate screening programs were available and
utilized, more chronic diseases experienced by minorities could
be detected early. Respondents also believed that effective patient
education and follow-up programs would help to reduce illness and death.

Pregnancy and Birth Disorders

Pregnancy-related concerns such as infant mortality, low
birthweight infants, and prenatal, perinatal, and postnatal care were
cited by many respondents as major issues.

Access to proper health care was again cited. In the view of
most respondents, early and adequate prenatal care and counseling is
unavailable or underutilized among minority populations. Also, access
to high technology techniques was seen as inadequate, creating a
higher incidence of complications of pregnancy and birth.

Many factors that contribute to pregnancy and birth disorders were
believed to be manageable with proper access to appropriate, adequate,
and early care. Such care includes regular prenatal checkups,
nutrition counseling, management of any chronic health problems, and
postnatal care for infants and mothers. Access to family planning
services was often mentioned as potentially helpful in reducing low
birthweight and infant mortality.

Availability of Data

Inadequacy of data on minorities was cited as a major barrier to
developing effective health care strategies and programs. The lack of
data for Hispanics and Asian/Pacific Islanders was cited most often.

208

other Disparities

Respondents noted a number of other areas of disparity:

• Homicide, suicide, and unintentional injuries; alcohol and drug
abuse; and problems related to stress.

• Inadequate education.

• Poor nutrition.

• Underrepresentation of minorities in the health professions.

• Problems related to environment, such as housing and unsanitary
living conditions.

• Discrimination, deterioration of the family structure, lack of
support services and recreational facilities, and low self-esteem.

The quality of education that many minorities receive and their
lower educational attainment have a substantial impact on their
socioeconomic status, in the opinion of respondents. Educational
deficits were believed to be caused by such factors as insufficient
parental guidance, lack of encouragement to achieve, and lack of
emphasis on education in general. Low educational attainment is seen
as both a result and a cause of low socioeconomic status .

Poor nutrition was cited by respondents as affecting nearly every
aspect of health, particularly in diseases such as diabetes and
hypertension and in relation to pregnancy and birth.

Too few minorities in health care professions was mentioned as
contributing to the cultural insensitivity that is said to exist in
many health care facilities. Factors cited for underrepresentation
include a lack of educational opportunity and financial and political
resources for training of minorities in health care professions.

Environmental concerns expressed by respondents included inadequate
housing, unsanitary and unsafe working and living conditions, exposure to
hazardous chemicals and materials in the worksite and in homes, and the
danger of lead poisoning in children.

Elements of Successful Programs

Highlighting specific examples known to your organization,
what kinds of health programs in the minority community have
been most successful? What has been the key element of that
success?

Certain common elements seemed to contribute to the success of many
health programs described by the respondents. These key elements include:

209

• Community involvement and outreach.

• Program focus on comprehensive services, including disease
prevention and health promotion.

• Program ability to improve minority access to health services.

• Cultural sensitivity to the group being served.

Examples of health programs that have been successful in minority
communities included: community outreach; hypertension control;
maternal and child health care; family planning; health education,
promotion, and prevention; bicultural and bilingual health care; and
Medicare and Medicaid. In general, improved access to medical care
was cited as a key element of a program's success; however, success
was by no means limited to this element alone.

All groups representing Blacks, Hispanics, Native Americans, and
Asian/Pacific Islanders addressed community-based health programs.
They cited comprehensive health services, such as dental care, social
services, public health education, outreach, and prevention programs,
as essential components to community health programs. The key element
of success for these programs was that they were accessible and
affordable. Other elements of success for community health programs
included cultural sensitivity, networking with other agencies in the
community, and control of health programs by community boards.

Hypertension Detection and Follow-up Programs and maternal and
child health care programs were regarded as successfully demonstrating
these qualities.

All groups emphasized health education, promotion, and prevention
programs as successes in minority communities, based on experience
with planning and delivery of services.

All groups cited Medicare and Medicaid as successful programs.
Respondents attributed success to improved accessibility and
availability of quality health care to the socioeconomically deprived.
Financial assistance and Government funding were also perceived as
increasing opportunities for minority employment in the health care
field; otherwise, such employment may not have been possible.

Suggestions for Action

Within the confines of the current Department of Health and
Human Services programs and policies, how might DHHS better
address the disparity in health status of minority
populations?

210

Respondents proposed a variety of specific ways that DHHS might
better address disparities in health status of minority populations,
including the following:

• Continue to support or fund existing health programs that have
been successful.

• Improve data collection and interpretation of data regarding
specific minority groups.

• Direct resources to prevention activities for high-risk minority
populations .

• Increase funding for health education programs and research on
health disparities.

• Incorporate bicultural/bilingual services into health programs.

• Network with private medical and social communities.

• Develop public education programs and other programs encompassed
by the 1990 Objectives for the Nation.

• Increase minority participation in policy development, education,
and training programs, thereby increasing equal opportunity for
minorities .

• Increase accessibility to quality health care.

• Encourage third-party payers to include coverage for health
promotion/disease prevention.

All groups recommended that DHHS target programs to populations
and geographic areas with the highest rates of mortality and
morbidity. They placed particular emphasis on the need to provide
adequate funding for health education, prevention, and research for
poor and minority populations and to support minority health programs
within the community.

In addition, minority groups indicated that DHHS might address
the health disparities of minority populations more effectively by
making appropriate use of viable and successful community programs and
institutions, including families, churches, schools, small businesses,
and others .

All minorities who responded to the survey endorsed minority
participation in policy development.

211

APPENDIX

DEPARTMENT OF HEALTH AND HUMAN SERVICES
SECRETARY'S TASK FORCE ON BLACK AND MINORITY HEALTH

MEMBERS

Thomas E. Malone, Ph.D., Chairperson

Deputy Director

National Institutes of Health

Wendy Baldwin, Ph.D.

Chief, Demographic and Behavioral Sciences Branch

National Institute of Child Health and Human Development

Betty Lou Dotson, J.D.

Director

Office for Civil Rights

Office of the Secretary

Manning Feinleib, M.D., Dr.P.H.

Director

National Center for Health Statistics

William T. Friedewald, M.D.

Director, Division of Epidemiology and Clinical Applications

National Heart, Lung, and Blood Institute

Robert Graham, M.D.

Assistant Surgeon General

Administrator

Health Resources and Services Administration

M. Gene Handelsman

Deputy Assistant Secretary

Office of Human Development Services

Jane E. Henney, M.D.

Deputy Director

National Cancer Institute

Donald R. Hopkins, M.D.

Deputy Director

Centers for Disease Control

Stephanie Lee-Miller

Assistant Secretary for Public Affairs

Office of the Secretary

215

Jaime Manzano (Served until August, 1984)
Formerly, Deputy Assistant Secretary
Office of Human Development Services

J. Michael McGinnis, M.D.

Assistant Surgeon General

Deputy Assistant Secretary for Health

Director, Office of Disease Prevention and Health Promotion

Office of the Assistant Secretary for Health

Mark Novitch, M.D. (Served until February, 1985)
Formerly, Deputy Commissioner
Food and Drug Administration

Clarice D. Reid, M.D.

National Coordinator, Sickle Cell Disease Program

Chief, Sickle Cell Disease Branch

National Heart, Lung, and Blood Institute

Everett R. Rhoades , M.D.

Director, Indian Health Service

Health Resources and Services Administration

William A. Robinson, M.D. , M.P.H.

Deputy Director, Bureau of Health Professions

Health Resources and Services Administration

James L. Scott (Served until June, 1985)
Formerly, Acting Deputy Administrator
Health Care Financing Administration

Robert L. Trachtenberg

Deputy Administrator

Alcohol, Drug Abuse, and Mental Health Administration

T. Franklin Williams, M.D.

Director

National Institute on Aging

216

ALTERNATES

Shirley P. Bagley, M.S.

Assistant Director for Special Programs

National Institute on Aging

Claudia Baquet, M.D., M.P.H.
Program Director, Minority Field Program
Division of Cancer Prevention and Control
National Cancer Institute

Howard M. Bennett

Associate Deputy Director, Office of Management and Policy

Office for Civil Rights

Office of the Secretary

Cheryl Damberg, M.P.H.

Research Fellow

Office of Disease Prevention and Health Promotion

Office of the Assistant Secretary for Health

Mary Ann Danello, Ph.D.

Special Assistant to the Commissioner for Science

Food and Drug Administration

Jacob J. Feldman, Ph.D.

Associate Director for Analysis and

Epidemiology
National Center for Health Statistics

Marilyn Gaston, M.D.

Deputy Chief

Sickle Cell Disease Branch

National Heart, Lung, and Blood Institute

George Hardy, M.D.

Assistant Director/Washington

Centers for Disease Control

John H. Kelso

Acting Administrator

Health Resources and Services Administration

James A. Kissko

Special Assistant

Office of Human Development Services

217

Robert C. Kreuzburg, M.D.

Acting Associate Director, Office of Program Operations

Indian Health Service

Health Resources and Services Administration

Barbara J. Lake

Special Assistant to the Director

Office for Civil Rights

Office of the Secretary

Patricia L. Mackey, J.D.
Executive Assistant to the Director
Office for Civil Rights
Office of the Secretary

Delores Parron, Ph.D.

Associate Director for Special Populations

Alcohol, Drug Abuse, and Mental Health Administration

Gerald H. Payne, M.D.

Chief, Prevention and Demonstration

Research Branch
Division of Epidemiology and Clinical Applications
National Heart, Lung, and Blood Institute

Caroline I . Renter
Office of Public Affairs
Office of the Secretary

Clay Simpson, Jr. , Ph.D.

Director, Division of Disadvantaged Assistance

Bureau of Health Professions

Health Resources and Services Administration

Ronald J. Wylie

Special Assistant to the Administrator

Health Care Financing Administration

218

SUBCOMMITTEES OF THE SECRETARY'S TASK FORCE
ON BLACK AND MINORITY HEALTH

COORDINATING COMMITTEE

Thomas E. Malone, Ph.D., Chairperson

Deputy Director

National Institutes of Health

Eileen M. Collins
Office of the Secretary

Jane Delgado, Ph.D.

Special Assistant on Minority Affairs

Office of the Secretary

Robert Graham, M.D.

Assistant Surgeon General, Administrator

Health Resources and Services Administration

Donald R. Hopkins, M.D.

Deputy Director

Centers for Disease Control

Stephanie Lee-Miller

Assistant Secretary for Public Affairs

Office of the Secretary

Clarice D. Reid, M.D.

National Coordinator, Sickle Cell Disease Program

Chief, Sickle Cell Disease Branch, National Heart, Lung, and Blood Institute

Caroline I. Reuter
Office of Public Affairs
Office of the Secretary

James Scott

Formerly, Acting Deputy Administrator

Health Care Financing Administration

Patti Birge Tyson

Executive Assistant to the Secretary

Office of the Secretary

Ronald J. Wylie

Special Assistant to the Administrator

Health Care Financing Administration

Staff Liaison:

Katrina W. Johnson, Ph.D.

Study Director, Secretary's Task Force on Black and Minority Health

219

SUBCOMMITTEE ON CANCER

Jane Henney, M.D. , Chairperson

Deputy Director

National Cancer Institute

Claudia Baquet, M.D., M.P.H.
Program Director, Minority Field Program
Division of Cancer Prevention and Control
National Cancer Institute

Cheryl Damberg, M.P.H.

Research Fellow

Office of Disease Prevention and Health Promotion

Office of the Assistant Secretary for Health

Peter Greenwald, M.D.

Director, Division of Cancer Prevention and Control

National Cancer Institute

J. Michael McGinnis , M.D.

Assistant Surgeon General

Deputy Assistant Secretary for Health

Director, Office of Disease Prevention and Health Promotion

Office of the Assistant Secretary for Health

Earl Pollack, Sc.D.
Formerly, Chief, Biometry Branch
Division of Cancer Prevention and Control
National Cancer Institute

William Robinson, M.D., M.P.H.

Deputy Director, Bureau of Health Professions

Health Resources and Services Administration

T. Franklin Williams, M.D.

Director

National Institute on Aging

Staff Liaison:
Lemuel Clark, M.D.

220

SUBCOMMITTEE ON CARDIOVASCULAR AND CEREBROVASCULAR DISEASES

William T. Friedewald, M.D. , Chairperson

Director, Division of Epidemiology and Clinical Applications

National Heart, Lung, and Blood Institute

Shirley P. Bagley, M.S.

Assistant Director for Special Programs

National Institute on Aging

Howard M. Bennett

Associate Deputy Director, Office of Management and Policy

Office for Civil Rights

Allan L. Forbes, M.D.

Director, Office of Nutrition and Food Sciences

Food and Drug Administration

Lynn A. Lars en, Ph.D.

Associate Director for Program Development

Division of Nutrition, Center for Food Safety and Applied Nutrition

Food and Drug Administration

Mark Novitch, M.D.

Formerly, Deputy Commissioner

Food and Drug Administration

Paul A. Nutting, M.D.

Director, Office of Primary Care Studies

Health Resources and Services Administration

Gerald H. Payne, M.D.

Chief, Prevention and Demonstration Research Branch

National Heart, Lung, and Blood Institute

Daniel D. Savage, M.D. , Ph.D.

Medical Officer

National Center for Health Statistics

Ronald J. Wylie

Special Assistant to the Administrator

Health Care Financing Administration

T. Franklin Williams, M.D.

Director

National Institute on Aging

Staff Liaison:
Donald Buckner, Ed.D.
Valerie Williams, M.P.A.

221

SUBCOMMITTEE ON CHEMICAL DEPENDENCY

Mark Novitch, M.D., Chairperson
Formerly, Deputy Commissioner
Food and Drug Administration

Mary Ann Danello, Ph.D., Acting Chairperson
Special Assistant to the Commissioner for Science
Food and Drug Administration

Stuart L. Nightingale, M.D.
Associate Commissioner
Office of Health Affairs
Food and Drug Administration

Robert G. Niven, M.D.

Director, National Institute on Alcohol and Alcohol Abuse

Alcohol, Drug Abuse, and Mental Health Administration

William Pollin, M.D.

Director, National Institute on Drug Abuse

Alcohol, Drug Abuse, and Mental Health Administration

Everett Rhoades , M.D.

Director, Indian Health Service

Health Resources and Services Administration

Robert Trachtenberg

Deputy Administrator

Alcohol, Drug Abuse, and Mental Health Administration

Ronald J. Wylie

Special Assistant to the Administator

Health Care Financing Administration

Staff Liaison:

Frank Hamilton, M.D. , M.P.H.

222

SUBCOMMITTEE ON DATA DEVELOPMENT

Robert Graham, M.D., Chairperson

Assistant Surgeon General

Administrator

Health Resources and Services Administration

Jane Delgado, Ph.D.

Special Assistant on Minority Affairs

Office of the Secretary

Manning Feinleib, M.D., Dr.P.H.

Director

National Center for Health Statistics

Donald Hopkins, M.D.

Deputy Director

Centers for Disease Control

Stephanie Lee-Miller

Assistant Secretary for Public Health

Office of the Secretary

J. Michael McGinnis , M.D.

Assistant Surgeon General

Deputy Assistant Secretary for Health

Director, Office of Disease Prevention and Health Promotion

Office of the Secretary

William Robinson, M.D. , M.P.H.

Deputy Director

Bureau of Health Professions

Health Resources and Services Administration

Staff Liaison:
Clifford Patrick, Ph.D.

223

SUBCOMMITTEE ON DIABETES

T. Franklin Williams, M.D., Chairperson

Director

National Institute on Aging

Shirley P. Bagley, M.S.

Assistant Director for Special Programs

National Institute on Aging

Maureen Harris, Ph.D., M.P.H.

Director, National Diabetes Data Group Program
National Institute of Arthritis, Diabetes, and
Digestive and Kidney Diseases

Robert Kreuzburg, M.D.

Acting Associate Director, Office of Program Operations

Indian Health Service

Health Resources and Services Administration

Lois Lipsett, Ph.D.
Chief, Special Programs Branch
National Institute of Arthritis, Diabetes,
Digestive and Kidney Diseases

Everett Rhoades , M.D.

Director, Indian Health Service

Health Resources and Services Administration

Alex Sabatini

Senior Operations Research Analyst

Office of Human Development Services

Robert Silverman, M.D., Ph.D.
Chief, Diabetes Programs Branch
National Institute of Arthritis, Diabetes, and
Digestive and Kidney Diseases

Staff Liaison:

Frank Hamilton, M.D., M.P.H.

224

SUBCOMMITTEE ON HOMICIDE, SUICIDE, AND UNINTENTIONAL INJURIES

Robert Trachtenberg, Chairperson

Deputy Administrator

Alcohol, Drug Abuse, and Mental Health Administration

Thomas L. Lai ley

Deputy Chief, Center for Studies of Antisocial

and Violent Behavior
National Institute of Mental Health

Stephanie Lee-Miller

Assistant Secretary for Public Affairs

Office of the Secretary

Delores Parron, Ph.D.

Associate Director for Special Populations

Alcohol, Drug Abuse, and Mental Health Administration

Clarice D. Reid, M.D.

National Coordinator, Sickle Cell Disease Program

Chief, Sickle Cell Disease Branch

National Heart, Lung, and Blood Institute

Mark L. Rosenberg, M.D., M.P.P.
Chief, Violence Epidemiology Branch
Centers for Disease Control

Staff Liaison:

Marta Sotomayor, Ph.D.

Lionel Fernandez, Ph.D.

225

SUBCOMMITTEE ON INFANT MORTALITY AND LOW BIRTHWEIGHT

Wendy Baldwin, Ph.D., Chairperson

Chief, Demographic and Behavioral Sciences Branch

National Institute of Child Health and Human Development

Marilyn Gaston, M.D.

Deputy Chief, Sickle Cell Disease Branch

National Heart, Lung, and Blood Institute

Carol Hogue, Ph.D., M.P.H.

Chief, Pregnancy, and Epidemiology Branch

Centers for Disease Control

Vince Hutchins, M.D.

Director, Division of Maternal and Child Health

Health Resources and Services Administration

Joel Kleinman, Ph.D.

Director, Division of Analysis

National Center for Health Statistics

Staff Liaison:
Herbert Nickens, M.D.

226

STAFF: SECRETARY'S TASK FORCE ON BLACK AND MINORITY HEALTH

Katrina W. Johnson, Ph.D., Study Director
Secretary s Task Force on Black and Minority Health
National Heart, Lung, and Blood Institute

Donald R. Buckner, Ed.D.
National Library of Medicine

Gail Jacoby

National Institute of Arthritis, Diabetes, and Digestive
and Kidney Diseases

Clifford H. Patrick, Ph.D.
Social Security Administration

Marta Sotomayor, Ph.D.

National Institute of Mental Health

Support Staff

Ruth Guerrero

Health Resources and Services Administration

Sandra N. Howard

National Institutes of Health

Ann B . Jones

National Heart, Lung, and Blood Institute

Tracey Palm

National Institute on Aging

Pro Tempore Staff

Allan Cayous

Indian Health Service - Portland Area

J. David Chananie, Ph.D.

U.S. Merit Systems Protection Board

Lemuel B. Clark, M.D.

National Institute of Mental Health

Theodore 0. Cron

Office of the Assistant Secretary for Health

227

Lionel Fernandez, Ph.D.

Bureau of Health Professions

Health Resources and Services Administration

Frank A. Hamilton, M.D., M.P.H.
Commissioned Personnel Operations Division
Office of the Assistant Secretary for Health

Jessie Hackes

Office of the Assistant Secretary for Personnel Administration

Office of the Secretary

Robert F. Heil

Health Resources and Services Administration

Sonia Milligan

National Library of Medicine

Herbert Nickens , M.D.

Center for Studies of the Mental Health of the Aging

National Institute of Mental Health

Amy B. Slonim, R.D., Ph.D.

Office of the Assistant Secretary for Planning and Evaluation

Cleve W. Taylor

Division of Management Policy

National Institutes of Health

Fu Sing Temple

National Institute of General Medical Services

Valerie N. Williams, M.P.A.

Office of Health Planning and Evaluation

Office of the Assistant Secretary for Health

Louise H. Yates

Health Resources and Services Administration

Pro Tempore Support Staff

Joselyn Monroe

Division of Administrative Services

National Institutes of Health

Zoraida Villadiego

National Institutes of Health

228

PAPERS COMMISSIONED BY THE TASK FORCE ON BLACK AND MINORITY
HEALTH

Relationship of Social Class to Coronary Disease Risk Factors in
Blacks: Implications of Social Mobility for Risk Factor Change

Lucile L. Adams, Ph.D., Epidemiologist, University of Pittsburgh,
Pittsburgh, Pennsylvania

Lewis H. Kuller, M.D. , Professor and Chairman, Department of
Epidemiology, Graduate School of Public Health, University of
Pittsburgh, Pittsburgh, Pennsylvania

Ronald E. LaPorte, Ph.D., Associate Professor of Epidemiology,
Department of Epidemiology, Graduate School of Public Health,
University of Pittsburgh, Pittsburgh, Pittsburgh, Pennsylvania

Laurence 0. Watkins , M.D. , M.P.H., Assistant Professor of Medicine,
Section of Cardiology, Department of Medicine, Medical College of
Georgia, Augusta, Georgia.

Tapping the Black Communities' Endemic Alcohol/Drug Abuse Prevention
Resources

Mary Benjamin, Ph.D. , Director, Interdisciplinary Alcohol/Drug
Studies Center, Jackson State University, Jackson, Mississippi

Betty W. Fletcher, M.S.W., Associate Director, Research Training,
Interdisciplinary Alcohol/Drug Studies Center, Jackson State
University, Jackson, Mississippi

Excess and Deficit Mortality Due to Selected Causes of Death and
Their Contribution to Differences in Life Expectancy of Spanish-
Surnamed and other White Males--1970 and 1980

Benjamin S. Bradshaw, Ph.D., Associate Professor of Demography,
University of Texas Health Science Center at Houston, School of
Public Health, Houston, Texas

W. Parker Frisbie, University of Texas at Austin, Population
Research Center, Austin, Texas

Clayton W. Eifler, University of Texas at Austin, Population
Research Center, Austin, Texas

229

Patterns and Problems of Drinking Among U.S. Hispanics

Raul Caetano, Ph.D., Scientist, Alcohol Research Group,

Medical Research Institute of San Francisco, Berkeley, California

The Effective Approach and Managment of Diabetes in Black and other
Minority Groups

John Davidson, M.D., Ph.D., Director, Diabetic Clinic, Grady
Memorial Hospital, Atlanta, Georgia

Increased Prevalence of Diabetes Among Japanese Americans and the
Role of Environmental Factors in Its Genesis

Wilfred Fujimoto, M.D. , Professor, School of Medicine, Metabolism,
Endocrinology, and Nutrition, Universiity of Washington, Seattle,
Washington

Socioeconomic Position and Minority Health: A Summary of the Evidence

Mary Haan, M.P.H., Research Scientist, Berkeley, California

George Kaplan, Ph.D., Director of Human Population Laboratory,
California Department of Health Services, Berkeley, California

Family Violence and Homicide in the Black Community--Are They Linked?

Robert L. Hampton, Ph.D., Associate Professor of Sociology,
Connecticut College, New London, Connecticut

Longitudinal-Situational Approaches to Understanding Black-on-Black
Homicide

Darnell Hawkins, Ph.D., J.D., Associate Professor of Sociology,
University of North Carolina, Chapel Hill, North Carolina

Associations of Health Problems with Ethnic Groups as Reflected in
Ambulatory Care Visits

M. Alfred Haynes , M.D. , President/Dean, Charles R. Drew
Postgraduate Medical School, Los Angeles, California

230

Differences in Socioeconomic Status and Acculturation Among Mexican
Americans and Risk of Cardiovascular Disease

Helen P. Hazuda, Ph.D., Assistant Professor, University of Texas
Health Science Center, San Antonio, Texas

Prevalence and Incidence of Ischemic Heart Disease in United States'
Black and White Populations

Melford James Henderson, M.A. , M.P.H., Association of Black
Cardiologists, Cardiovascular Research Fellow, Bethesda, Maryland

Research Needs: Prevention and Intervention Strategies

Leo Hendricks, Ph.D., Associate Professor and Director of Research,
Institute of Urban Affairs and Research, Howard University,
Washington, D.C.

Expression of Diabetes Mellitus in Black Americans: Genetic,
Epidemiological, and Therapeutic Aspects

W. Lester Henry, Jr., M.D., Professor of Medicine, Howard
University, Washington D.C.

Juanita A. ArcI'L^r, M.D. , Associate Professor of Medicine, Howard
University, Was' ■ip.-,ton, D.C.

A Review of Drinking Patterns and Alcohol Problems Among U.S. Blacks

Denise Herd, M.A. , Scientist, Alcohol Research Group, Epidemiology
and Behavioral Medicine, Medical Research Institute of San
Francisco, Berkeley, California

Comprehensive Model to Detect, Assess, and Treat Effects of Assaultive
Violence in Hospital Populations

Karil Klingbeil, M.S.W., Director, Social Work Department,
Assistant Professor of Social Work, University of Washington,
Harborview Medical Center, Seattle, Washington

Stroke Report

Lewis H. Kuller, M.D., Professor and Chairman, Department of
Epidemiology, Graduate School of Public Health, University of
Pittsburgh, Pennsylvania

231

•

Nutritional Status and Dietary Patterns of Racial Minorities in the
United States

Shiriki K. Kumanyika, Ph.D., M.P.H., Assistant Professor, Department
of Epidemiology, Johns Hopkins University, School of Hygiene and
Public Health, Baltimore, Maryland

Deborah L. Helitzer, Doctoral Candidate, Department of
International Health, Johns Hopkins University, Baltimore, Maryland

Ischemic Heart Disease Risk Factors in Black Americans

Ischemic Heart Disease Risk Factors in Hispanic Americans

Ischemic Heart Disease Risk Factors in American Indians and Alaska
Natives

Ischemic Heart Disease Risk Factors in Asian/Pacific Islanders

Shiriki K. Kumanyika, Ph.D., M.P.H., Assistant Professor, Department
of Epidemiology, Johns Hopkins University, School of Hygiene and
Public Health, Baltimore, Maryland

Changes in the Criminal Homicide Rate of American Indians for the
City of Los Angeles: 1970-79

The Relative Risks of Types of Homicide Among Anglo, Hispanic, Black,
and Asian Victims in Los Angeles: 1970-79

Fred Loya, Ph.D., University of California, Los Angeles, The
Neuropsychiatric Institute, Los Angeles, California

The Black Female Criminal Homicide Offender in the United States

Cora Mann, Ph.D., Associate Professor, School of Criminology,
Florida State Univeristy, Tallahassee, Florida

Analyses Commissioned by The Task Force on Black and Minority Health:
Excess Deaths 1979-81, Excess Deaths 1969-71, Health Interview Survey,
Excess Deaths in Hispanic Populations, 1979-81, Person-Years of
Life Lost, Life Expectancy by Cause of Death

Kenneth G. Manton, Ph.D., Research Professor of Demographic
Studies, Duke University, Durham, North Carolina

232

Violence, an Epidemic; A Possible Approach: Neighborhood-Based,
Interdisciplinary, Comprehensive Health Care

Robert McGovern, M.D., Professor of Pediatrics, Director, Division
of Ambulatory Pediatrics, Southwestern Medical School, The
University of Texas Health Science Center at Dallas, Dallas, Texas

Evaluation of Interventions to Reduce Racial Disparities in Infant
Mortality

Health Insurance Coverage of Perinatal Care for Minority Women

Review of Interventions to Reduce Racial Disparities in Infant
Mortality

Case Studies of Selected Interventions: Limitations and Recommendations
for Improving Infant Mortality Intervention Data for Minorities

Margaret McManus , M.P.H., Director, McManus Health Policy, Inc.
Washington, D.C.

Coronary Heart Disease in Black Populations: Current Research,
Treatment, and Prevention Needs

Hector F. Myers, Ph.D., Associate Professor of Psychology,
University of Los Angeles, Scholar-In-Residence, Charles Drew
Postgraduate Medical School, Los Angeles, California

Interdisciplinary Interventions Applicable to Prevention of Interpersonal
Violence and Homicide in Black Youth

Deborah Prothrow-Stith, M.D. , Assistant Professor of Medicine, Boston
Univeristy, Boston City Hospital, Boston, Massachusetts

The Escalating Incidence of Homicide in the Nation's Black
Communities--Can We Intervene?

Harold Rose, Ph.D., Department of Urban Affairs, University of
Wisconsin, Milwaukee, Wisconsin

233

Analysis of Research Data on Trends and Differentials in Infant
Mortality and Low Birthweight for Black, White, Hispanic, Asian, and
American Indian Populations

Barbara Samuels, M.D. , Research Fellow, Department of Maternal and
Child Health, University of North Carolina, Chapel Hill, North
Carolina

Survival of High-Risk Minority Infants in Los Angeles County

Robert Schlegel, M.D. , M.P.H., Professor and Chair, Department
of Pediatrics, King-Drew Medical Center, Palos Verdes Peninsula,
California

Racial Variations in Self-Assessed Health and Socioeconomic Status
in the 1976 Survey of Income and Education (SIE)

William Serow, Ph.D., Professor of Economics, Florida State
University, Tallahassee, Florida

David Sly, Ph.D., Professor of Sociology, Florida State University,
Tallahassee, Florida

Minority Dental Health Manpower and Trends

Jeanne Sinkford, D.D.S., Ph.D., Dean and Professor, College of
Dentistry, Howard University, Washington, D.C.

Factors Relating to the Increased Prevalence of Diabetes in Hispanic
Americans

Michael Stern, M.D. , Professor of Medicine, University of Texas
Health Science Center, San Antonio, Texas

Interviewing Persons Hospitalized with interpersonal Violence-Related
Injuries: A Pilot Study

Burnet Sumner, Ph.D. , Assistant Clinical Professor, Department of
Surgery, University of California at San Francisco, San Francisco,
California

234

Health Care Service Delivery in Asian American Communities

Reiko True, Ph.D., Deputy Director, City and Council of San
Francisco Community Mental Health Services, San Francisco,
California

Gang Homicide in Los Angeles

Luis A. Vargas, Ph.D., Clinical Psychologist, Children's Psychiatric
Hospital, University of New Mexico, Albuquerque, New Mexico

Bibliography of Prematurity, Low Birthweight, and Infant Mortality

Analyses of Scientific Articles of Prematurity, Low Birthweight,
and Infant Mortality

Adrianna Wesley, Consultant, Centers for Disease Control, Atlanta,
Georgia

Behavioral Weight Control for Obese Patients with Type II Diabetes

Rena Wing, Ph.D., Associate Professor of Psychiatry, Western
Psychiatry Clinical Institute, Pittsburgh, Pennsylvania

Asian-White Mortality Differences: Are there Excess Deaths?

Elena S. H. Yu, Ph.D., Associate Professor of Sociology

in Psychiatry, Pacific/Asian American Mental Health Research

Center, University of Illinois at Chicago, Chicago, Illinois

Ching-Fu Chang, M.S., Graduate Research Assistant, Department of
Sociology, Pacific/Asian American Mental Health Research Center,
University of Illinois at Chicago, Chicago, Illinois

William T. Liu, Ph.D., Professor of Sociology and Director, Pacific/
Asian American Mental Health Research Center, University of Illinois
at Chicago, Chicago, Illinois

Stephen H. Kan, Ph.D., Research Associate, Pacific/Asian American
Mental Health Research Center, University of Illinois at Chicago,
Chicago, Illinois

235

Physical and Mental Health Status Indicators for Asian/Pacific Americans

Elena S. H. Yu, Ph.D., Associate Professor of Sociology in
Psychiatry, Pacific/Asian American Mental Health Research
Center, University of Illinois at Chicago, Chicago, Illinois

William T. Liu, Ph.D., Professor of Sociology and Director, Pacific/
Asian American Mental Health Research Center, University of Illinois
at Chicago, Chicago, Illinois

Paul Kurzeja, M.A. , Graduate Research Assistant, Pacific/Asian American
Mental Health Research Center, University of Illinois at Chicago,
Chicago, Illinois

236

ACKNOWLEDGMENTS

Numerous individuals assisted the Task Force on Black and
Minority Health and greatly enriched its efforts. They delivered
presentations, contributed information, assisted the Subcommittees,
and provided data bearing on the complex social and scientific issues
that were being explored by the Task Force. They were generous with
their time and thoughtful in sharing their perspectives on the diverse
problems that were under consideration. The Task Force wishes to
express its grateful thanks to the following persons:

Edgar Adams

Sylvia T. Aguirre

Loran Archer

Remy Aronoff

Michael Backenheimer , Ph.D.

Marianne Balin

Linda E. Bass

Sam Bell, M.D.

Marge Betts

Ann Blank en

William Blot, Ph.D.

Ben Bradshaw, Ph.D.

Donna Breslyn

James Buechler, M.D.

James Carlos

Ronald H. Carlson

Vivian Chang, M.D.

Vivian Chen

James Chin, M.D.

Edward Chow, M.D.

Effie Chow, Ph.D., R.N. , C.A.

C.S. Chung, Ph.D.

Roger B. Cole

Beverly Coleman-Miller, M.D.

Clark Collins

John Cooper II, Ph.D.

Blake C. Crawford

Gregory Curt, M.D.

Charles Darby

William A. Darity, Ph.D.

Fred Deer

Tinamarie Dixon

Vernon Dixon, M.D.

Pamela Dobson

Leonard A. Drabek

Thomas Drury, Ph.D.

Susan Eddins

Frances C. Edmonds, Ph.D.

Winston Edwards

Frank E. Ellis, M.D.

Marcia R. Feinleib

Lorraine Ferguson

Ed Fernandez

Phyllis Flatery

John Florez

William Foege, M.D.

Jane Lin-Fu, M.D.

Vivian Garrison, Ph.D.

George Gay

Aida Giachello

Richard F. Gillum, M.D.

Joseph Gfroerer

Dorothy Gohdes , M.D.

Patricia M. Golden

Marta Gonzalez

Frederick K. Goodwin, M.D.

Aaron Handler

M. Alfred Haynes , M.D.

Suzanne Haynes, Ph.D.

Brenda Hewitt

Robert Hoover, M.D.

Bettie Hudson

Deborah A. Hunter

Suzanne Hurd, Ph.D.

Aeolian Jackson, D.S.W.

Jerome Jaffee, M.D.

Earl Johnson

Elaine M. Johnson

Wilbert Jordan, M.D.

JoAnn Kauffman, M.P.H.

Samuel W. Kessel, M.D.

Brian Kimes, Ph.D.

Patricia Knapp

Marilyn Kunzweiler, M.P.H.

237

Timothy Larkin

William Lassek, M.D.

Harry Lee, M.D.

Joseph Levitt

Helen Lin

Francine Little

William T. Liu, Ph.D.

Janice Louie

Diana Makuc, Ph.D.

Ann C. Maney, Ph.D.

Dorothy H. Mann

James Marks, M.D.

Russell Mason

Nampeo McKenney

Michael McMullan

Arnold Mills

J. Henry Montes

Edward J. Montminy, M.D.

John H. Moore, Ph.D.

Hal ley Morgan, M.D.

Marcella Murphy

Robert Murphy

Melvin Myers

Audrea Nora, M.D.

John Nut ley

Vincent Oliverio, Ph.D.

Virginia Ono

Joan Weibel-Orlando, Ph.D.

Charlene Ortiz, M.D.

Kathy Owens

Yuko Palesch

Albert Pawlowski, Ph.D.

Nancy Pearce

David Pearl, Ph.D.

Robert C. Peterson

Mitchell B. Pierre, Jr.

Elisabeth Pitt, M.A.

Kate Prager, Ph.D.

Amelie G. Ramirez

George A. Reich, M.D.

Diane Resnikov

Y.B. Rhee, M.D.

Knut Ringen, Dr.P.H.

Norma R. Rivera

Roger Rochat, M.D.

Harry Rosenberg, Ph.D.

Ruben G . Rumbaut

David Satcher, M.D.

Lynne Schneider

Clarissa Scott, Ph.D.

Don Shopland

A. Logan Slagle

Betsy Slay

Richard J. Smith III

Matthew Snipp, Ph.D.

Ernell Spratley

Howard V. Stambler

Deborah B. Prothrow-Stith, M.D.

Louis Sullivan, M.D.

Leonora Surosky

Carol Sussman

Leonard Syme, Ph.D.

Caroline Taplin

Stephen P. Teret , J.D.

James Thompson, M.D., M.P.H.

Mary Thorngreen

Diana Torres

Fernando Trevino, Ph.D.

Robert Trotter, Ph.D.

Henrietta Villaescusa

Sylvia Villarreal, M.D.

Mary Virts

Tom Voskuhl

Monica Walters

Ed Watkins

Laurence 0. Watkins, M.D., M.P.H.

Hazel Weidman, Ph.D.

Sheridan Weinstein, M.D.

Nola Whitfield

Stacey L. Williams

Jerome Wilson

Ronald W. Wilson

Kathryn Wimsatt

Diane Wysowski, Ph.D.

John Young, Ph.D.

238

KEY TO ABBREVIATIONS

ADAMHA Alcohol, Drug Abuse and Mental Health Administration

CDC Centers for Disease Control

COSSMHO National Coalition of Hispanic Mental Health and Human

Services Organizations

DHHS Department of Health and Human Services

FDA Food and Drug Administration

HANES Health and Nutrition Examination Survey

HCFA Health Care Financing Administration

HRSA Health Resources and Services Administration

IHS Indian Health Service

LULAC League of United Latin American Citizens

NAACP National Association for the Advancement of Colored People

NCHS National Center for Health Statistics

NCHSR National Center for Health Services Research

NIH National Institutes of Health

NIAAA National Institute on Alcohol Abuse and Alcoholism

NIDA National Institute on Drug Abuse

NIMH National Institute of Mental Health

CASH Office of the Assistant Secretary for Health

ODPHP Office of Disease Prevention and Health Promotion

OHDS Office of Human Development Services

0MB Executive Office of the President/Office of Management

and Budget

OS Office of the Secretary

PHS Public Health Service

SSA Social Security Administration

239

li U-S. GOVERNMENT PRINTINQ OFFICE:

1989 - 211-280 - 814/05306

DEPARTMENT OF
HEALTH AND HUMAN SERVICES

WASHINGTON, D.C. 20201

OFFICIAL BUSINESS
PENALTY FOR PRIVATE USE, $300

POSTAGE AND FEES PAID

U.S. DEPARTMENT OF H.H.S.

391

Internet Archive Audio

Featured

Top

Images

Featured

Top

Software

Featured

Top

Books

Featured

Top

Video

Featured

Top

Mobile Apps

Browser Extensions

Archive-It Subscription

Save Page Now

Full text of "Report of the Secretary's Task Force on Black and Minority Health: Volume I: Executive Summary"

See other formats