HEALTH CARE DISPARITIES

The son of an African-American Air Force service member, M. Roy Wilson, moved during his youth from place to place around the globe, spending much of his time in Japan. Wilson added his first initial “M,” which stands for “Maseo,” a Japanese name meaning “true man,” in honor of his Japanese mother. “I officially changed my name out of respect for her,” he recalls. Those days of youth molded Wilson into a bicultural and bilingual individual – distinctions that are perhaps the reason he understands his mission as clearly today as the new president of the Texas Tech University Health Sciences Center.

Wilson, who holds M.D. and M.S. degrees, is the first individual at Texas Tech elected to the lifetime appointment of the Institute of Medicine of the National Academies, considered one of the highest honors in the fields of medicine, health care and public health. An ophthalmologist and a national leader in glaucoma research, he also serves on the advisory council and as chairperson of the Strategic Plan Subcommittee for the National Center on Minority Health and Health Disparities of the National Institutes of Health (NIH). Wilson is focusing his vision on making the Health Sciences Center a leader in addressing health care disparities, which often are the result of socioeconomic, cultural and geographic barriers.

“Health disparities are not just limited to minority populations, but also exist between many other types of populations, such as rural versus urban populations or uninsured versus insured populations. So, given the different kinds of populations that Texas Tech serves in terms of socioeconomic status, ethnicity, border and rural communities, this is an excellent opportunity to focus on these areas,” Wilson says.

The National Institutes of Health defines health disparities as differences in the incidence, prevalence, mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States. The American Medical Association (AMA) reports that health disparities are the result of the complex interaction of biologic, genetic, social, cultural and environmental factors, as well as specific health behaviors. Further, the AMA reports that health disparity also is the outcome of racial and ethnic differences in rates of access, utilization and prescription of health care services. The NIH notes that the magnitude of the relationship between racial biases and health must be examined further in the context of socioeconomic, environmental and behavioral factors.

Disparities exist in the United States in overall health, in access to health care and in the quality of care. “A disparity is the difference between one group and another; researchers have documented these differences among groups, and the differences are considered to be either inequitable or unjust,” explains James Rohrer, Ph.D., professor in the Division of Health Services Research. “An example of a health disparity is that the life expectancy for African-Americans is shorter than that for Caucasian-Americans. An example of health care access disparity is that a person who lives in rural West Texas has to consider how far away a doctor is, compared to an urban resident. In quality of care, disparities are exemplified by disadvantaged groups in the United States receiving less than the highest quality of care,” Rohrer notes.

Multi-dimensional in scope and discussed for decades in health services research, access has both geographic and financial dimensions, Rohrer notes. “We have an issue of socioeconomic differences in our society resulting in disparities in health care. However, we always should keep in mind the fact that medical care is not the most important determinant of health.” A combination of factors are involved in disparity issues, including one’s basic biological situation and hereditary disposition to disease, as well as the environmental hazards one is exposed to, such as the physical environment, pollution, social problems within the family, or stresses of living in a dangerous neighborhood. One’s own behavior, lifestyle, amount of alcohol or drug intake, unsafe sexual behavior, eating habits, all have to do with how healthy a person is. “We are trying to do other things to change people’s behavior and their environment. Then, perhaps we could make larger strides toward reducing disparities in health,” he comments.

Roberto Escobar, Maria Dominguez, and Raquel Escobar.
"We don't have insurance, but we're on a sliding scale discount at our clinic. Our family's major medical concern is having a stroke from complications of diabetes. I would like to see the clinic expand and bring in more services, like dental specialists and others."

In a nationwide study, published in 2000 in the Journal of the American Medical Association, nearly two-fifths of adults who lacked health insurance for a year or more reported not being able to see a physician when needed in the past year due to cost, and nearly 70 percent of those in fair or poor health reported such barriers. These barriers were greatest for women, blacks, the unemployed and those with low incomes. Long-term uninsured adults also were much less likely to receive mammography, Pap smears, colon cancer screening, hypertension and cholesterol screening.

Rohrer notes that researchers must carefully present their findings regarding disparities, so as not to make illogical cause-and-effect assumptions. “For example, in Texas, we are very interested in Hispanic versus non-Hispanic whites in regard to their health status. The demographics of the state show that many of the individuals in the state who are Hispanic in origin do not have health insurance, and because they don’t have health insurance, they may end up using lower levels of health care services, having a possible bearing ultimately on their health. Researchers should point out that the reason why Hispanics do not have insurance is that a large proportion of the population is in lower income brackets, due mainly to the fact that a significant proportion of Hispanics do not finish high school or seek higher education. Disparities are often results, not causes,” Rohrer emphasizes.

Ethnicity also is a major disparity issue in Texas. The statistics associated with major diseases, such as diabetes, cancer and heart disease show differences in prevalence of disease and health care utilization for minority populations. In the United States, the prevalence of diabetes in African-Americans is approximately 70 percent higher than for whites, and the prevalence in Hispanics is nearly double that of whites. African-Americans and Hispanics have higher hospital rates for diabetic complications. For men and women combined, African-Americans have a cancer death rate that is 35 percent higher than that for whites. African-Americans are half as likely to undergo angioplasty and coronary surgery as white Americans. Obesity, a risk factor for both diabetes and heart disease, generally is higher among minority populations — even at young ages. Among Texas fourth grade boys, 17.7 percent of whites, 21.6 percent of African-Americans, and 30.1 percent of Hispanics are overweight.

In another study, published in 2003 in the journal Ethnicity and Disease, the authors used data from the Third National Health and Nutrition Examination Survey to assess the prevalence of uncontrolled hypertension and hypertension-related organ damage among African-Americans and United States immigrants of African descent. Region of residence and immigrant status were significantly associated with control and complications of hypertension. African-American women from the South, for example, had significantly higher age-adjusted hypertension prevalence (54 percent) compared to African-American women from other regions of the United States (49.8 percent) or African women immigrants (38.4 percent).

Research at the El Paso campus focuses on two broad areas, the disease processes and the Mexican-American population. “Diabetes, and all the complications associated with it, is terrific and enormous. Tuberculosis is a problem on the border, particularly with the individuals becoming resistant to drugs for treating the disease. Obesity is a major problem, as are childhood immunizations. However, the essential crisis exists within access to health care,” states Darryl Williams, M.D., executive director of the Office of Border Health and principal investigator of the Hispanic Center of Excellence at the Texas Tech Health Sciences Center El Paso campus.

In his work, Williams has followed children who live in the colonias, or small border communities that generally have no electricity, running water, or sewage facilities, to determine how many were obese and when they began to become obese. “I saw that when children of the colonias are tiny kids, neither boys nor girls were obese. When they go to grade school, in the case of both boys and girls, sometime between the ages of 7 and 10, the group begins to get overweight. By the time they reach the ninth grade, nearly 70 percent of the boys are at risk for being overweight. These children clearly are overweight, and we have seen an increasing number of obese children with type 2 diabetes.” Part of the next study will determine the reasons for the statistics, an important question.

Bill Kennedy, Edwin Rigsby and Jessie Kennedy.
Bill Kennedy's wife has Alzheimer's disease; he is waiting to see if she qualifies for Medicaid. Edwin Rigsby, a retired X-ray and lab technician, says one of the hardest hit areas of rural health care is emergency response. Jessie Kennedy believes that health care costs are enormous, though he says his coverage is adequate.

However, in some areas of health status and access, African-Americans and Hispanics fare better than non-Hispanic whites do. For example, African-Americans are more likely than whites to have Pap smears and blood pressure monitoring; and Hispanics have similar infant mortality rates as non-Hispanic whites and lower rates of death because of cancer or suicide. In many ways, the Hispanic population is healthier than the non-Hispanic white population, Rohrer comments, noting that health care researchers call the phenomenon, “the Hispanic paradox.” As another example, Randolph Schiffer, M.D., chairperson of the Department of Neuropsychiatry, has found in a research study that Hispanics have a low incidence rate of multiple sclerosis when compared to the general population, although researchers do not know why.

Researchers at the Texas Tech Health Sciences Center in Amarillo have examined the overall measure of community health. Based on a survey done through the Amarillo Bi-City-County Health District and on a model of the Centers for Disease Control and Prevention, researchers looked at behavioral risk factors as they related to the self-rated health of individuals. “The best measure of how healthy people are in a community is how healthy individuals are,” says Rohrer, lead author of the study. “Self-rated health involves individuals testing how unhealthy they are. I looked at what predicts poor health among those who say they are unhealthy. For example, persons who judged themselves to be ‘obese’ rated themselves as less healthy than those who were at a normal weight. Persons who smoked excessively rated themselves as less healthy than those who reported being obese. Those individuals who live in neighborhoods where they feel unsafe reported that their health was worse because of the stress of living in fear. If people identified themselves as having no friends, then they rated themselves as less healthy, as did those who belonged to no groups, churches or clubs. Social isolation, with the stress of living in unsafe neighborhoods, is having a big impact on the health of people. These are the environmental and psychosocial factors that we tend not to look at when we consider health.”

Economics and culture are not the only factors that create disparities: Where a person lives and the vast West Texas geography affect access to care. “In West Texas, we’ve got just a handful of metropolitan areas, and they’re surrounded, depending on where you are, by a very sparse population. In some cases, it’s 20 miles to the gate and the first paved road for some rural residents. Some federal and state leaders do not understand that it’s 80 miles from Lajitas in the Big Bend to the nearest physician or hospital,” says Don McBeath, managing director of Telemedicine and Rural Health for the Texas Tech University Health Sciences Center.

Of the 21 rural counties in Texas without a doctor, 17 of those counties are in the service area of the Texas Tech Health Sciences Center. In two-thirds of those counties, people older than age 64 make up 15 to 30 percent of the total population; these counties also have the highest proportion of the elderly (individuals older than 85). The health disparity faced by many rural residents is mainly an issue of inadequate health care infrastructure, strained by poverty and uninsurance as well as the effects of serving a proportionately larger elderly population with their increased health care needs, McBeath notes.

Under Wilson’s experience and leadership in the arena of studying and addressing health disparities, the Texas Tech University Health Sciences Center is focusing on four key priorities: increasing funded, peer-reviewed research; providing leadership in improving the health of the community; decreasing health disparities in minority and rural populations; and increasing participation of minority and rural students at the Texas Tech University Health Sciences Center, consistent with the Texas Higher Education Coordinating Board’s “Closing the Gaps” Initiative.