HEALTH CARE DISPARITIES: RESPIRATORY HEALTH IN MINORITIES

CONTENTS

Preface xiMarilyn G. Foreman and Sandra K. Willsie

Impact of Cultural Competence on Medical Care: Where are we Today? 395Ute W. Rosa

The Institute of Medicine’s 2002 Report on Unequal Treatment calls attention to disparitiesin health care and proposes corrective steps. Proposed actions included improvement incross-cultural skills among providers. This article highlights evidence for unequal treat-ment, and delineates current medical educational efforts aimed at improving cultural com-petence. Improvement is needed in the uniform adoption of cultural competence curriculaand focus needs to be placed on its impact through outcomes research.

Asthma in Hispanics in the United States 401Robyn T. Cohen and Juan C. Celedon

The Hispanic population in the United States is diverse in many respects. Although thereis marked variation in the prevalence, morbidity, and mortality of asthma among His-panic subgroups in the United States, these differences are poorly understood. Futurestudies of asthma should include large samples of Hispanic subgroups that are wellcharacterized in terms of self-reported ethnicity, country of origin, place of birth, areaof residence, and indicators of socioeconomic status. Because a significant proportionof Hispanics live in poverty, public health interventions aimed at improving access tohealth care and housing conditions would have a major impact on reducing asthma mor-bidity among Hispanics in the United States.

Health Effects of Socially Toxic Neighborhoods: The Violenceand Urban Asthma Paradigm 413Rosalind J. Wright

Asthma outcomes are clearly socially patterned with asthma ranking as a leading causeof health disparities among minority and low socioeconomic groups. Yet, the increasingprevalence and marked disparities in asthma remain largely unexplained by known riskfactors. These marginalized individuals may also live in communities that are increas-ingly socially toxic, which may be related to increased psychosocial stress that also con-tributes to asthma morbidity. This article focuses on violence exposure as a usefulparadigm to understand how chronic social stressors may influence asthma expression.

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Understanding Disparities in Asthma Outcomes Among African Americans 423Jean G. Ford and Lee McCaffrey

Racial disparities in asthma morbidity and mortality are greater than differences in asth-ma prevalence. This finding suggests that following the diagnosis of asthma, blacks re-ceive substantially different care than non-Hispanic whites, through available health caresystems and their social support networks, and racial differences in relevant environ-mental exposures contribute to differences in morbidity and mortality. An overview offactors that may contribute to disparities in asthma prevalence, morbidity, and mortality,including contextual factors, is provided.

Lung Cancer Disparities in African Americans: Health versus Health Care 431Eric L. Flenaugh and Marshaleen N. Henriques-Forsythe

African Americans with lung cancer have disproportionately worse outcomes than otherethnic groups. The incidence of lung cancer in blacks has remained well above the ratesseen for the general population and the 5-year and overall survival rates for blacks withlung cancer are among the lowest of all racial groups. Many studies have focused on so-cioeconomic status of African Americans as the sole cause of these disparities. Otherstudies, however, have identified additional factors related to risks for poor outcomesin blacks with lung cancer. This article reviews data on these risks and their relationshipsto the health and health care of African Americans with lung cancer.

Disparities in Lung Cancer: Focus on Asian Americans andPacific Islanders, American Indians and Alaska Natives, andHispanics and Latinos 441Sandra K. Willsie and Marilyn G. Foreman

Significant population changes in the United States are expected over the next few dec-ades. The changing demographics inclusive of native and newly native individuals willsignificantly impact health care because racial and ethnic groups vary widely in theirrisks for disease and approach to medical care. For lung cancer specifically, racial andethnic groups differ in smoking habits, metabolism of nicotine, presentation, stage at di-agnosis, treatment received, and outcomes. This article summarizes current informationon lung cancer for American and Pacific Islanders, American Indians and Alaska natives,and Hispanics and Latinos with an emphasis on tobacco use, epidemiologic issues sur-rounding acculturation and assimilation, genetic epidemiology, and disparities in treat-ment outcomes.

Racial and Ethnic Disparities in Sarcoidosis: From Genetics toSocioeconomics 453Gloria E. Westney and Marc A. Judson

Sarcoidosis is a multisystem granulomatous disease of unknown cause that occursworldwide. The clinical expression of sarcoidosis varies by race. These racial differencesmay be the result of genetic and socioeconomic factors. Many of these genetic associa-tions are race-specific in that they are found in either African Americans or whites butnot both. Socioeconomic differences may also explain the racial disparities between Af-rican American and white patients with sarcoidosis. Finally, the phenotypic differencesbetween races may relate to an interaction between genetics and socioeconomic factors.The influences of genetics and socioeconomic status on the development and phenotypicexpression of sarcoidosis will be better understood as the mechanisms of disease devel-opment are uncovered.

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COPD: Racial Disparities in Susceptibility, Treatment, and Outcomes 463Mark T. Dransfield and William C. Bailey

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death inthe United States and mortality continues to increase particularly among African Amer-icans. Although this increase may be caused by changing smoking habits, some studiessuggest that African Americans may be more susceptible to tobacco smoke than whites.Unlike other respiratory diseases for which there are significant published data on racialand ethnic disparities in disease outcomes, such information is notably lacking in theCOPD literature. This article examines the available data concerning racial disparitiesin COPD susceptibility and care.

Health Care Disparities in Critical Illness 473Marilyn G. Foreman and Sandra K. Willsie

Disparities in critical illness are evident in a variety of racial and ethnic groups. Most da-ta available in the literature reflect variations in the incidence, presentation, diagnosis,treatment, and outcomes between African Americans and whites. Most research in crit-ical care concerning disparities relates to cardiovascular illnesses. Significantly less infor-mation is available regarding disparities in common ICU diagnoses. Data aresignificantly lacking delineating the reasons for disparities in the critically ill. Further re-search is required to elucidate the root causes for racial or ethnic differences, provide ad-equate education for health care providers, and develop and implement evidence-basedinterventions targeted for specific patient groups.

Sickle Acute Lung Injury: Role of Prevention and Early AggressiveIntervention Strategies on Outcome 487Casey W. Melton and Johnson Haynes, Jr

Acute chest syndrome in sickle cell disease is a form of acute lung injury that may prog-ress to acute respiratory distress syndrome and death. Despite recent advances in diag-nosis and treatment that have resulted in improved survival in sickle cell disease, acutechest syndrome remains the most common cause of death in this population. The currentstandards of treatment for acute chest syndrome have been reviewed. Biomedical re-search forms the basis for sound clinical decision making and implementation of inter-ventions that target prevention, diagnosis, and effective treatment options. Althoughcurrent clinical trials are ongoing to address several new potential therapeutic options,more research using preventative and interventional strategies in sickle acute lung injuryis warranted.

The Path Not Taken: Social and Cultural Barriers to ThoracicTransplantation 503Glenda M. Patterson

Religious beliefs, misperceptions, and distrust of the health care system have been citedas barriers to organ donation or transplantation in minorities. Improved training of hos-pital staff on donation protocols has been demonstrated to increase consent rates for or-gan donation. Increased interaction of minorities with ethnically appropriate transplantcandidates, recipients, and donation or procurement personnel has a positive effect ondonor rates. Programs using such practices must be expanded to overcome significantbarriers to the transplantation of solid organs. Research into additional ways to improveacceptance of organ transplantation by minorities is needed to increase participationrates.

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HIV-AIDS in Minorities 511Aymarah M. Robles and H. Gene Stringer, Jr

HIV-AIDS has disproportionately affected minority populations in the United States.Significant disparities in case rates and mortality have been noted. This article reviewsthe magnitude of the problem and the many factors involved in the development andperpetuation of these disparities. Possible measures to help correct the problem are alsoreviewed.

Obesity, Ethnicity, and Sleep-Disordered Breathing: Medical and HealthPolicy Implications 521Carolina Q. See, Edward Mensah, and Christopher O. Olopade

The obesity epidemic in the United States is a major health problem, which poses imme-diate and long-term health risks with potential for significant reduction in life expectan-cy if not curtailed. Despite affecting all segments of the population, minorities carrya relatively larger burden of the obesity threat. Obesity is a major risk factor for devel-oping obstructive sleep apnea and the metabolic syndrome, which are associated withincreased cardiovascular and cerebrovascular morbidity and mortality. This article dis-cusses the implications of the obesity trend on the prevalence of obstructive sleep apneaand health, highlights ethnic differences, reviews the resultant economic implications,and suggests public health and health policy initiatives that may be beneficial in stem-ming the obesity scourge.

A Three-Dimensional Approach to the Elimination of Racial-EthnicDisparities in Lung Health 535David Satcher and George Rust

Significant racial, ethnic, and socioeconomic health disparities have been documented inasthma, lung cancer, sarcoidosis, vaccine-preventable pneumonias, tuberculosis, andHIV-related pulmonary infections. Given the complex causation of health disparities,and their resistance to simple interventions, the authors propose a three-dimensional ap-proach for eliminating racial and ethnic health disparities in America. The three dimen-sions include surveillance and monitoring, research into causes and potential cures, andrapid-cycle testing of interventions to reduce or eliminate disparities.

Index 543

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