Across the nation communities are rapidly identifying and housing their most vulnerable people experiencing homelessness. Building on these examples, Community Solutions and the Institute for Healthcare Improvement have launched the 100,000 Homes Campaign, an historic effort to eliminate chronic homelessness by July 2014.
More than 70 years have passed since the beginning of the Public Health Service syphilis study in Tuskegee, Alabama, and it has been over a decade since President Bill Clinton formally apologized for it and held a ceremony for the Tuskegee study participants. The official launching of the Tuskegee University National Center for Bioethics in Research and Health Care took place two years after President Clinton's apology. How might we fittingly discuss the Center's 10th Anniversary and the topic 'Commemorating 10 Years: Ethical Perspectives on Origin and Destiny'? Over a decade ago, a series of writers, many of them African Americans, wrote a text entitled 'African-American Perspectives on Biomedical Ethics'; their text was partly responsible for a prolonged reflection by others to produce a subsequent work, 'African American Bioethics: Culture, Race and Identity'. What is the relationship between the discipline of bioethics and African American culture? This and related questions are explored in this commentary.
The 10th Anniversary of the establishment of the Tuskegee University National Center for Bioethics in Research and Health Care represents a decade of initiatives directed at transforming the painful memory of the United States Public Health Services Study of Untreated Syphilis in the Negro Male into a new commitment to community empowerment and the formation of a new paradigm that places ethics at the center of scientific inquiry.
The manuscripts presented in this issue of the Journal of Health Care for the Poor and Underserved represent the views and findings of an array of researchers from different ethnic communities within the U.S., united by one common thread: They all represent communities plagued by health disparities that adversely impact them in comparison with national and local averages. Minority and underserved communities often lack adequate access to information regarding their health and often, when information is available, it is not presented in a manner that lends itself to community acceptance. In the fight to reduce health disparities, however, minority institutions are often the unsung heroes.
Minority-serving institutions (MSIs) are trusted members of their communities, with their faculty often serving in multiple capacities within the community at large. Such individuals work on behalf of their institutions to raise awareness about health disparities and to disseminate helpful health information. The papers in this issue speak to the vital role of minority institutions serve in the fight to reduce health disparities in their communities through innovative research approaches that address some of the most pressing health issues facing our society. Additionally, each paper includes a discussion of the relevant bioethical issues and implications of the research. These discussions provide the moral context that must be incorporated in future research efforts that have a direct impact upon human beings and their environment.
In accordance with the role of MSI in combating health dispaties, this publication is dedicated to the 10th Anniversary of the Tuskegee University National Center for Bioethics in Research and Health Care and its collaborative partnerships with The Historically Black Colleges and Universities Research Network, the Center for Medicare and Medicaid Services, and the Morehouse School of Medicine/Tuskegee University/University of Alabama at Birmingham Comprehensive Cancer Center Cancer Research Partnership.
Vivian L. Carter is the Assistant Director for Community Partnership with the Tuskegee National Center for Bioethics in Research and Health Care and Associate Professor of Sociology in the Department of Psychology and Sociology at Tuskegee University (TU), where she can be reached at (334) 727-8737; firstname.lastname@example.org.
Stephen Olufemi Sodeke is Associate Director and Professor of Allied Health Sciences at the Tuskegee University National Center for Bioethics in Research and Health Care.
Timothy Turner is the Deputy Director for Research and Training, Tuskegee University National Center for Bioethics in Research and Health Care and Associate Professor of Biology, Tuskegee University College of Agriculture.
Development of a global HIV vaccine will require enrollment of a large number of adults and adolescents in clinical trials. Involvement of homeless young adults in these trials will be particularly important because they often practice high-risk behaviors and are disproportionately infected by HIV. This qualitative study explores factors that might affect future participation of homeless 18- to 24-year-olds of diverse racial/ethnic backgrounds in HIV vaccine trials (HIVVTs). Twenty males and females attended focus groups. Participants expressed concern about seroconversion, the trustworthiness of the researchers and/or government agencies conducting trials, vaccine side effects, and possible negative behavior change as a result of being vaccinated. Understanding the personal perspectives of high-risk young adults will enable researchers to tailor protocols to their individual needs and cultural values and, in so doing, potentially enhance willingness to participate in HIVVTs.
The association between low socioeconomic status (SES) in minority groups and higher incidence and mortality from cervical cancer was examined using two large U.S. databases. With cases from 1973 to 1992, all registries of the Surveillance, Epidemiology, and End Results (SEER) (except Hawaii) were used to calculate incidence rates of in situ and invasive cervical cancers by race group. SES indicators were derived from the Regional Economic Information System, Department of Commerce. Higher levels of SES indicators were related to decreased risk and lower incidence of invasive cancers in all race groups, but especially white and black populations, and to increased incidence of situ cancer in these populations. Results suggest that higher SES status is related to a decrease in invasive cervical cancer, but an increase in in situ cervical cancer in recent years. These findings may explain the racial differences in cervical cancer incidence and help target intervention programs.
This study is a secondary analysis of data from the 1987 and 1992 National Health Interview Surveys. Analyses compared adults who do not have a usual source of care and those who identified usual sources of care in 1987 and 1992. Between these years, the estimated number of adult Americans without a usual source of care rose from 29.7 to 39.4 million. Adults were 0.75 times less likely to identify a physician's office and 1.8 times more likely to identify an outpatient clinic as that source of care in 1992 than they were in 1987. These changes were observed among Americans of all demographic and socioeconomic backgrounds. Increasing numbers of adult Americans without a usual source of care and shifts in care from physicians' offices to outpatient clinics may reflect deteriorating access to care. This may affect quality and costs of medical care, demanding continued surveillance of sources and access to care.
Twenty-five years ago at the time of this writing, the first National Conference on Health Care for the Poor and Underserved was held at Meharry (in 1988). That year too, President Reagan invited me to serve on the Council of Graduate Medical Education, and two years later, I was elected Chair. During my tenure as Chair, the Council developed a landmark report on the human capital needs to adequately attend to the health of the U.S. population, pointing out the impending shortage of providers, especially in primary care and for underserved communities.
In a health care system that rewards procedures in volumes of care rather than quality and value, the poor and underserved are often the victims of poor quality of care. The recently-implemented Patient Protection and Affordable Care (ACA) incentivizes quality of care by rewarding value of outcomes rather than volume of interaction. However, poor communities have a history of difficulty attracting doctors because they have very few resources to incentivize them, and because of their challenging and unsafe living conditions. Yet at the time of that 1988 conference Meharry Medical College’s students and residents were becoming increasingly comfortable with caring for the poor and the underserved, and around three-quarters of them ended up going on to practice in underserved communities, taking up careers consistent with Meharry’s mission. Meharry had for many years been providing care to the poor and underserved populations in North Nashville, though at great financial loss to the hospital’s bottom line.* The 1988 Conference on Health Care for the Poor and Underserved was an indication of Meharry’s commitment to this work, and it was thus appropriate for Meharry to serve as host. Out of this conference came the idea of a journal dealing with the needs of the poor and the underserved and strategies for meeting those needs. Thus, the Journal of Health Care for the Poor and Underserved was born (its first issue appearing in 1990). [End Page xiii]
David Satcher, MD, PhD
In 1985, Secretary Margaret Heckler of the Department of Health and Human Services reported on excess deaths in the Black population, adding impetus to this area of research and priority policy focus. But in 1988, no African American had ever held the position of Assistant Secretary for Health or Surgeon General or Director of the Centers for Disease Control and Prevention. Furthermore, in 1988 the nation had not yet made a commitment to the elimination of disparities in health. Even later, for the first decade of the Centers for Disease Control and Prevention’s (CDC’s) Healthy People program (1991–2000), there were no goals and objectives in this area. The establishment of the Healthy People program did, however, bring much-needed focus to the challenge and needs of the underserved, among whom African Americans were over-represented.*
Tipper Gore, whose husband was a U.S. Senator from Tennessee at the time (four years later to be elected the nation’s Vice President), provided the dinner keynote at the 1988 Meharry conference on health care for the poor and underserved. She addressed the topic of the mental health needs of children. Her remarks that evening highlighted the fact that the poor and underserved were a population that cut across racial and ethnic lines who were not only greatly underserved but also disproportionately affected by mental illness. There was perhaps no better example of the effects of mental health disparities than the fact that people suffering from mental illness can experience a life [End Page xiv] expectancy of up to 25 years less than the rest of the population. While Mrs. Gore would go on to become Second Lady of the United States and a mental health advisor to the Clinton Administration, in 1988, there had never been a single Surgeon General’s Report on Mental Health (the first would come 10 years later).
In his 1992 presidential campaign, Governor Bill Clinton of Arkansas took on health reform as a major component of his platform, and read the report of the Council of Graduate Medical Education that brought attention to the need for providers in poor and underserved communities. As...
To examine the likelihood of enrollees in the Nebraska Every Woman Matters program being screened for breast and cervical cancer.
We explored the relationship between sociodemographic characteristics and receiving cancer screening services.
Older and Native American women were more likely than younger and White women to have mammograms ordered [adjusted odds ratio (OR)=1.41, 95% confidence interval (CI) 1.08, 1.85]. African American [OR=0.54, 95% CI 0.46, 0.64] and Native American women [OR=0.47, 95% CI 0.39, 0.55] were less likely than White women to have clinical breast exams performed. Native American [OR=0.19, 95% CI 0.16, 0.23] and African American women [OR=0.56, 95% CI 0.46, 0.68] were less likely than White women to have a Pap test performed.
Receiving cancer screening services was related to race; thus, understanding barriers for screening for minority women is warranted.
Migrant farm workers (MFWs) are considered a high-risk group for tuberculosis. MFW tuberculosis cases reported to the Centers for Disease Control and Prevention represented 1 percent of all reported tuberculosis cases from 1993 to 1997. Most of these cases (70 percent) were reported from Florida, Texas, and California. MFW tuberculosis cases were more likely to be male, foreign-born, or Hispanic and to have a history of alcohol abuse and homelessness than were non-MFWs. Most (79 percent) foreign-born MFWs were from Mexico. HIV status was poorly reported, with results available for only 28 percent of MFW and 33 percent of non-MFW cases. Of the MFWs tested, 28 percent were HIV infected, whereas 34 percent of non-MFWs were HIV infected. Twenty percent of MFWs move or are lost to follow-up before completing therapy; these cases pose a management challenge for the nation's tuberculosis control efforts.
(1) To determine the infant mortality rate (IMR) in American Indians/Alaska Natives (AI/AN) and whites between 1995-1999 and 2000-2004. (2) To compare the leading causes of infant mortality in AI/AN and whites. (3) To examine differences in neonatal vs. postneonatal causes of death in whites and AI/AN.
Using the 1995-99 and 2000-04 Centers for Disease Control and Prevention's National Center for Health Statistics national linked birth/infant death data, we examined neonatal and post-neonatal IMR among AI/AN and whites.
AI/AN experienced significantly greater overall IMR in 1995-1999 and 2000-2004 than whites. While the reduction in the IMR between these time periods was statistically significant for whites, the reduction among AI/AN was not. We found that AI/AN had an IMR 1.5 times as high as that of whites.
While the overall IMR has decreased in AI/AN, disparities in postneonatal IMR persist between AI/AN and Whites.
Disparities in survival among people with AIDS continue in the treatment era, with a higher rate of death among African Americans than among Whites, Latinos, and Asians/Pacific Islanders (API). Few studies have been able to identify underlying reasons for this disparity. The authors' objectives were to determine the extent of disparities in AIDS-related death by race/ethnicity, and examine factors that may contribute to or explain these differences. Using San Francisco surveillance data, racial/ethnic differences in survival among residents diagnosed with AIDS between 1996 and 2002 were analyzed using Kaplan-Meier survival and Cox proportional hazards regression techniques. The data confirm that a disparity in survival after AIDS persists between African Americans and Whites, Latinos, and APIs in San Francisco. Underlying causes of this disparity are multiple, but many of them are amenable to intervention and should be addressed.
To identify how health insurance coverage trends changed for Hispanic children between 1996 and 2005.
Data from the Current Population Survey Annual Social and Economic Supplement were analyzed to determine health insurance coverage rates for Hispanic children and logistic regression was used to determine the role of race/ethnicity on health insurance status, adjusting for citizenship status, child characteristics, migration status, and geography.
The proportion of uninsured Hispanic children decreased significantly. However, the increased likelihood of a Hispanic child being uninsured relative to non-Hispanic White children did not change during this period.
Expansions in public health insurance programs between 1996 and 2005 increased health insurance coverage for Hispanic children but disparities between Hispanic and non-Hispanic White children persist.
Primarily, this is a Sankofan socio-ethical analysis of the moral foundation of the Tuskegee University National Bioethics Center's decade of operation. The first section of the study will do the following: a) a Sankofan socio-ethical analysis of the Center's raison d'être; and b) definitions of ethical terms and the social world of the infamous syphilis study. The second section, as a result of the analysis, will address the Center's following challenges: c) the Center's challenge of theory and practice; d) the Center's challenge of moral heritage; and e) the Center's challenge of the future.
Nativity status seems to have a protective effect on asthma. However, there is little information in the literature on the effect of nativity status on asthma for non-Hispanic Black and White children and adolescents. This study investigates the association between nativity status and self-reported asthma in U.S. children and adolescents under 21 years of age after controlling for selected characteristics including education and income. Logistic regression was conducted using SUDAAN to estimate odds ratios from data of the National Health and Nutrition Examination Survey 1999-2004. The prevalence of asthma for U.S. children and adolescents is 14.5%, with U.S.-born exhibiting a higher prevalence (15.1%) than foreign-born (7.3%, p<.0001). In the fully-adjusted analysis, foreign-born children and adolescents were almost twice less likely than U.S.-born counterparts to report asthma. This association differs by race/ethnicity, with the lowest odds being observed in Whites (OR: 0.29, 95% CI: 0.10-0.86), followed by Mexican Americans (OR: 0.38; 95% CI: 0.25-0.56) and Blacks (OR: 0.52; 95% CI: 0.29-0.94). Moreover, this association varies by education: Foreign-born children of survey respondents who had at least a high school education were more than twice less likely than their U.S.-born counterparts to have asthma. The findings of this study underscore the importance of inquiring about nativity status when studying asthma among U.S. children and adolescents.
We used vital statistics and census data to determine whether mortality rates in Philadelphia were associated with neighborhood poverty, and to what extent excess mortality among African Americans was associated with neighborhood poverty. Gender-specific, age-adjusted mortality rates for 1999-2001 were strongly associated with neighborhood poverty among both women and men overall, and among both African Americans and non-Hispanic whites. The actual number of deaths among African Americans was 5,305 higher than it would have been if African Americans had had the same gender- and age-specific mortality rates as the average for non-Hispanic whites in Philadelphia, and 1,944 higher than if African Americans had had the same gender- and age-specific rates as non-Hispanic whites in the same neighborhood poverty categories. The excess mortality associated with neighborhood poverty and the socioeconomic factors that force large numbers of African Americans into poverty and high-poverty neighborhoods appear to be major factors in excess mortality among African Americans.
Using the National Health Interview Survey, we examined associations among race/ ethnicity, insurance coverage, and cancer screening, and assessed changes in the magnitude of disparities over the past decade. Outcomes included recent cervical, breast, and colorectal cancer screening. Rates of colorectal screening increased for all racial/ethnic groups and some insurance groups from 2000 to 2008. However, rates of Pap tests and mammograms remained stagnant, and even decreased for certain groups. Some Hispanic-White and Asian-White disparities in cancer screening were reduced or eliminated over this time period. However, in 2008 Asians continued to have lower odds of Pap tests and Hispanics lower odds of colorectal cancer screening, even after accounting for potential confounders. There were no significant changes in Black-White disparities. The uninsured continued to be at a disadvantage for all three types of cancer screening, relative to the privately insured, as were publicly insured individuals with respect to colorectal cancer screening.
This study investigated relationships between health insurance status and health-related quality of life (HRQOL) using the 2000 Medical Expenditure Panel Survey data. Health-related quality of life was measured using the SF-12 Physical Component Summary (PCS) and SF-12 Mental Component Summary (MCS). The analysis controlled for sociodemographic and attitudinal variables and medical conditions. The analysis also investigated and controlled for possible reverse causality between HRQOL and health insurance in the models. After adjusting for covariates, individuals without health insurance had significantly lower mean PCS scores (beta=-5.8; SE=0.4) than those with health insurance. The adjusted association between no health insurance and MCS scores (beta=-1.1; SE=0.4) also was significant. The adjusted difference in HRQOL among people with health insurance and those without it exceeds or is comparable to adjusted differences in HRQOL between people with each of various medical conditions and people without them.
Mexican immigrant status has been associated with decreased obesity, but this pattern may be changing. We draw from 2001-2006 NHANES data on Mexican Americans to examine whether body mass index (BMI) and waist circumference vary by country of birth and among the U.S.-born by language.
Among women, U.S.-born Spanish speakers had the highest mean BMI, followed by immigrant women, while U.S.-born English speakers had the lowest mean BMI. Immigrant men had a lower mean BMI than U.S.-born men. These patterns were similar for waist circumference and persisted after adjusting for socioeconomic status (SES) and other covariates.
Immigrant women do not appear to be protected against a large body size, compared with immigrant men. Among the U.S.-born, women who retain Spanish are at higher risk for larger body size than exclusive English speakers. Initiatives targeting obesity should address differentials in body size patterns among immigrant and U.S.-born Mexican American men and women.
Emergency departments (EDs) are an important source of medical care in the United States. Information is limited concerning epidemiologic patterns of ED visits for infectious diseases. Data for 2001 from the National Hospital Ambulatory Medical Care Survey (NHAMCS) were analyzed for infectious disease visits. The NHAMCS is a national probability sample survey of visits to hospital EDs and outpatient departments of non-federal, short-stay, and general hospitals in the United States. Data are collected annually and are weighted to generate national estimates. In 2001, an estimated 19.8 million visits were made to hospital EDs for infectious diseases (rate=71 visits/1,000 persons). Children under 15 years old made 36% of these visits and had the highest rate of visits (rate=119 visits/1,000 persons). The rate of visits for females was 37% higher than for males (82 versus 60/1,000 persons). Although the white population had the highest volume of visits, the rate of visits for blacks was more than twice that of whites (130 versus 64 visits/1,000 persons). Laboratory tests were ordered in 84% of visits. An estimated 18% of visits to the EDs concern infectious diseases. The issue of health care access and ED use is complex and the reasons for the higher rate of visits for blacks than for whites are not fully understood.
In this study we seek to assess recent trends in complementary and alternative medicine (CAM) use based on a comparative analysis of data from the 2002 and 2007 National Health Interview Survey (NHIS). The findings suggest that CAM use, in particular the use of provider-based CAM therapies such as chiropractic care, massage, and acupuncture, have grown significantly in the U.S. This growth was more pronounced among non-Hispanic Whites than among racial and ethnic minorities, increasing an already existing White-minority gap in CAM use. Findings from this study also reveal that CAM use becomes more likely when access to conventional care has been restricted. In both 2002 and 2007, having unmet needs in medical care or having delayed care due to cost were associated with a higher chance of CAM use.
Access to timely treatment may be one contributing factor to survival differences by race/ethnicity among breast cancer patients. In this study, we examined the relationship between race and treatment delay among breast cancer patients diagnosed between 2003 and 2006 with Stage I-III breast cancer from the National Cancer Database (n=250,007). We evaluated factors associated with receipt of initial treatment more than 30, 60, and 90 days after biopsy using multivariable log binomial models to estimate risk ratios (RR) and 95% confidence intervals (CI). The average time to treatment was 34.30 days (±31.77). Independent of health insurance, stage at diagnosis, and age, Black and Hispanic patients had higher risks of 30, 60, and 90-day treatment delay compared with White patients. Further studies are needed to define the role of structural, health system, physician, clinical and patient factors in treatment delay among Black and Hispanic women and appropriate interventions.
New York State data were used to document demographic characteristics and identify the top five most prevalent disease conditions among migrant and seasonal farmworkers and their families working in the state from 2003 to 2005.
Prevalence estimates were derived using enumeration and diagnosis data provided by New York State Department of Health contractors. The sample totals ranged from 6,500 to 8,000 migrant and seasonal farmworkers and their families.
The majority of migrant and seasonal farmworkers were Hispanic with New York or Mexico the most frequently reported migrant home. Infections, muscular skeletal problems, respiratory disease, hypertension, and diabetes were the five most prevalent diseases identified.
Migrant and seasonal farmworkers in New York State experienced health conditions common among agricultural workers. Additional research and surveillance are necessary for understanding and serving their health needs.
Minimum wage policies have been advanced as mechanisms to improve the economic conditions of the working poor. Both positive and negative effects of such policies on health care access have been hypothesized, but associations have yet to be thoroughly tested. To examine whether the presence of minimum wage policies in excess of the federal standard of $5.15 per hour was associated with health care access indicators among low-skilled adults of working age, a cross-sectional analysis of 2004 Behavioral Risk Factor Surveillance System data was conducted. Self-reported health insurance status and experience with cost-related barriers to needed medical care were adjusted in multi-level logistic regression models to control for potential confounding at the state, county, and individual levels. State-level wage policy was not found to be associated with insurance status or unmet medical need in the models, providing early evidence that increased minimum wage rates may neither strengthen nor weaken access to care as previously predicted.