The Department of Health and Human Services (HHS) is teaming up with the National Hispanic Medical Association (NHMA) to provide leadership training, mentoring, education and outreach programs with the hope of improving health among Hispanics. 

The initiative was announced in March during NHMA's annual conference here. "We believe in developing leadership of doctors," said Elena Rios, MD, MSPH, President and CEO of the National Hispanic Medical Association, a nonprofit group that represents Latino doctors working in the U.S., during a press conference in between conference sessions. 

According to a statement, the two-year initiative's goals entail recruiting Latinos for senior-level positions at HHS and developing a national leadership training program for Hispanic doctors and public health professionals in conjunction with NHMA's National Hispanic Health Foundation, which is affiliated with New York University's Robert F. Wagner Graduate School of Public Service. The initiative also calls for a national education campaign on diabetes and obesity to be carried out by NHMA's medical societies in New York, Texas and California. "We want to work with our doctors, schools and elected officials in these states so they can be responsive to cultural competency and language and other issues that affect Hispanic health," said Dr. Rios. 

Dr. Luis Esteves, chairman of the NHMA board, said the education program at NYU is aimed at helping Spanish-speaking families improve their nutrition and exercise, and begins with training doctors to be community health leaders. 

According to NHMA, Hispanics are 1.5 times more likely to get diabetes as non-Hispanic whites and have a 40 per cent higher death rate related to the disease. Hispanics aged 20-74 are also more overweight than non-Hispanic whites, with an 11 per cent higher overweight rate in males and a 26 per cent higher rate in females. They are also more obese, at a 7 per cent higher rate in males and a 32 per cent higher rate among females. Dr. Estevez added that a Hispanic child has a 50 per cent chance of developing diabetes, while the general population has a one-third chance of developing diabetes. 

Dr. Rios said at the press conference that NHMA has 25,000 Hispanic doctors for members, among about 36,000 total Latino doctors in the country. She said the new partnership will be with the HHS Office of Minority Health (OMH) and will focus on improving diabetes and obesity rates through education and outreach. 

Part of the initiative will encompass fellowships that train public health managers who are Hispanic to be better leaders. The education component, Dr. Rios said, will focus on partnering with Latino caucuses and school lunch programs to improve nutrition and health. 

Ernest Moy, PhD, of the Agency for Healthcare Research and Quality, also spoke at the press conference, citing two reports released by the agency in January. He said they found that in over 50 per cent of measures, Hispanics received both poorer quality of care and access to care than the rest of the population. 

According to the 2005 National Healthcare Disparities Report, Hispanics received poorer quality of care than non-Hispanic whites for 53 per cent of quality measures and had worse access to care for 88 per cent of access measures. The report also said that 59 per cent of health disparities in quality care experienced by Hispanics are becoming larger, and about 80 per cent of access disparities are becoming larger. Among the quality care measures found to be worsening for Hispanics as opposed to non-Hispanic whites include substance abuse treatment, diabetes services, hospital treatment of heart attack and pneumococcal vaccine for the elderly. 

Dr. Moy said that while health disparities are getting smaller for most minorities, they are getting larger for Hispanics. "There is a need for this issue to be addressed," he advised. "The time to turn the tide is now. If we don't do it, it will get worse." 

Bringing Out The Leader Inside 

Dr. Rios said the budget for the two-year partnership has been developed, but not finalized with OMH. She believes the partnership can have a significant impact on Hispanic health. "We have to do more," she said. "We want doctors in NHMA to learn more about what they can do in the community. We will have doctors talk to state officials to change things in schools. We will train doctors on how to do that." 

More outreach efforts are desired, Dr. Rios added, as well as more avenues to spread health information such as online portals. More healthy foods are needed in the Hispanic diet. "We do need to take care of our own community," she said. "We need to have them [Hispanic doctors] be leaders in their community." 

Dr. Estevez also said that more Latino physicians are needed in the U.S. "We're building a pipeline with colleges," he said. "We also feel there is a paucity of Latino leadership in hospitals, including federal ones, and health plans." 

Dr. Estevez said they need to affect activities on a direct patient care level, societal level and policy level through education and advocacy. 

An audience member added that diabetes is an immense problem of the working uninsured poor, and becomes an even greater health problem when they get older. Dr. Estevez added that a majority of uninsured Latinos work. 

Following the press conference, when asked what specific roles OMH and NHMA will play in the partnership, Dr. Estevez said the latter will take on the active role in the communities. "NHMA will be on the front lines," he said. "HHS will be taking more of the 10,000 feet [distance] view, giving guidelines, but not dictating specifics." 

NHMA is also sponsoring 10 scholarships/grants for Hispanic public health students. "We have mentorship with medical students, and they're acting as mentors [to] high school and college kids," Dr. Estevez said. 

Dr. Estevez said the effort also goes beyond medical and nursing students. He said that it is great if the students want to enter the medical profession, but those who want to be lawyers or other professions can help, too. "The main focus will be the hope that NHMA, through its providers, can educate the general public and by extension the Latino community," he said. "We know there are not enough Latino physicians in the short-run, so we'd like to educate everybody." 

Developing critical public service leadership skills to effect change in health disparities among Hispanics, and increasing awareness about health policy and advocacy principles at the federal level to create policies that improve the health status of Hispanics, were some of the educational objectives the NHMA leadership fellowship outlined at the conference. 

Federal government incentives that are available to physicians who treat the Hispanic population were also discussed at the conference. Dr. Estevez explained that there are certain incentive payments available for providing linguistically appropriate services to patients. "There is a bonus payment for that," he said. 

Initially the two-year program will focus on recruitment and then on cultural sensitivity and training. 

Growing Health Concern 

Hispanic health disparities are growing, even while there are no cultural competency and language resources to address them, said Dr. Rios. The Institute of Medicine (IoM) commissioned a two-year study that came out recently on the disparity of Hispanics requiring new health insurance coverage, safety nets and providers. She said decreasing employer insurance increases the number of uninsured, while decreased federal support for Medicare/Medicaid increases the need and burden on states. 

According to the chapter entitled "The Health Status and Health Behaviors of Hispanics," by Jose L. Escarce, MD, PhD, Leo S. Morales, MD, PhD, and Ruben G. Rumbaut, PhD, within the IoM report, "Hispanics and the Future of America (2006)," the rapid growth in the Hispanic population, and especially in the number of Hispanic youth, represents one of the most dramatic and important demographic trends affecting the United States. Relatively new groups, including Dominicans, Salvadorans, Guatemalans, and Columbians, have grown rapidly, adding their numbers to well-established populations of Mexican, Puerto Rican and Cuban origin. 

"On numerous dimensions, foreign-born Hispanics, i.e. immigrants to the United States, have better health indicators than their U.S.-born counterparts," the report said. "Among the foreign-born, moreover, health status and health behaviors may differ by degree of acculturation to American culture. Mortality advantage of Hispanics in comparison with whites is present throughout most of the age range, although the advantage grows at older ages. However, Hispanic infants and men ages 15-24 have slightly higher death rates than their white counterparts." 

But the report says that compared with non-Hispanic whites, Hispanics have higher rates of Type 2 diabetes and other manifestations of abnormal glucose metabolism. They also have higher rates of obesity. 

The report's chapter on "Access to and Quality of Health Care" by Dr. Escarce and Kanika Kapur, PhD, says that low average income and education are obstacles to receiving timely and appropriate health care. Low-income people are less likely to afford the out-of-pocket costs of care, even if they have health insurance coverage. Low income may impair people's ability to navigate the complex health care delivery system, communicate with health care providers, and understand providers' instructions. 

The report further says that Hispanics' low incomes and occupational characteristics are associated with low rates of health insurance coverage. Lacking health insurance makes the costs of health care services prohibitive for many people and is the most important barrier to adequate health care access. 

"Specific features of the Hispanic population that affect their access to health care include degree of acculturation, language and immigration status," the report says. "More than two-fifths of Hispanics in the United States are foreign-born, and many are recent immigrants who retain their cultural beliefs and behaviors regarding health and health care. Most foreign-born Hispanics primarily speak Spanish, and fewer than one-fourth report speaking English very well. In [the year] 2000, only 28 per cent of foreign-born Hispanics were naturalized citizens, a rate lower than the rates of naturalization for other immigrant groups. Among Hispanics who are not citizens, a sizable number are undocumented immigrants. These features of the Hispanic population have both direct effects on reducing access to health care and indirect effects through their association with lower rates of health insurance coverage. The jobs available to recent and undocumented immigrants who lack proficiency in English are unlikely to provide health insurance as a benefit of employment. Furthermore, under recent legislation, recent immigrants and noncitizens may receive fewer benefits than earlier immigrants and citizens from public health insurance programs." 

Dr. Rios said NHMA's partnership with OMH will entail recruiting leaders from among the association's fellowship programs, while helping the department with obesity and diabetes. "We need to be leaders, [and] educate our doctors," she said. "Our Hispanic doctors chose three sites to train doctors to be advocates and go to schools." 

NHMA is further developing a national advisory panel with English and Spanish TV, radio and magazines to combat obesity and diabetes. "Everybody talks about health disparities, an issue we are addressing by developing a targeted framework to turn around staggering obesity and diabetes rates among Hispanics," Dr. Rios stated. 

At the conference, NHMA also announced a new partnership with Meharry Medical College in Nashville, Tenn., the largest private, comprehensive historically black institution for educating health professionals and scientists in the U.S. Meharry's president John Maupin Jr., DDS, spoke at the conference on the importance of training Hispanic medical students. "I felt today is a different day," he said when describing how he approached Meharry's board to see about allowing Hispanic students to apply. "I felt we needed to bring our training beyond African Americans to individuals of color and poor communities, and disadvantaged backgrounds beyond race." 

During the conference, Dr. Maupin and Dr. Rios signed a Memorandum of Understanding (MoU) to increase the number of Hispanic students, and pursue a mentoring program. "We ought to be able to increase the opportunities for students," he said. "Partnering can draw more funding, [too]." 

Dr. Rios said the MoU is important and historic. "We don't have a board of trustees like historically black colleges and to take the lead and help us is big, to improve the health of Latinos and black Americans," she said. "We need to fight for them and they need to fight for us." 

Dr. Maupin added that a distinct school for Hispanic students was established at Meharry this year. 

Dr. Rios said NHMA also has other goals, such as establishing five regional Hispanic Centers of Excellence that would be funded at $2 million per year; consortias with school districts and businesses to help realign Title 7 health professional recruitment and training to Hispanic communities; as well as filling a need for Medicare/Medicaid bilingual forms and medications. NHMA has further established a new online portal called HispanicHealth.info to share key health information with providers and the public. 

View From The White House 

Adm. Christina Beato, MD, USPHS, Acting Assistant Secretary for Health at HHS, said the disparities found are alarming. "If you look at the disparities report, improvements have been made, but not in the Latino community [to the same degree as others]," she said. "We're falling behind other racial minorities. The [issues are] obesity, diabetes, cardiovascular disease, strokes, amputations. More alarming is what's happening to our children." 

Declining nutrition and fitness, disintegration of families, and boys not graduating from high school are some of the related issues, she added. "We need to be motivators and leaders of communities and families," she said. "The largest growing segment is falling behind. We need to do partnerships at all levels-federal, state, businesses, churches, families-because one sector is not going to solve this problem." 

Citing the recent AHRQ report, she said in the Hispanic population diabetes is a serious issue and high disparity, as are mental health treatment for serious mental illness, patient-provider communication barriers, and Hispanic young women have higher rates of new AIDS cases. "It translates into declining socioeconomic status for the whole [not just Hispanic] population," Dr. Beato said. 

Dr. Beato said about 2 million Hispanic elderly people are entitled to federal subsidies and the new Medicare prescription drug benefit. "We need to ensure senior citizens receive this new benefit and it will help those who never had insurance get medications now," she said. 

Dr. Beato said Hispanics, and particularly Hispanic women, have done very well in terms of opening small business and home ownership, but health insurance is often a foreign thought. "With social services job, they can't afford it. But there are programs they can contribute to in small amounts-health savings accounts. Health literacy and financial literacy are the biggest issues for Hispanics," she said. 

Dr. Beato said the way medicine will be practiced, the use of biomarkers, nanotechnology, increased use of telemedicine, the issue of how information technology can be taught and relayed to prevention and education is crucial. Health research that translates to clinical practice is also key, she added. She said that in the past there was a 17-year information delay from NIH research results into New Mexico clinical practice, where she worked as a physician. "We need to use information technology to close that lag time and facilitate quality and transparency and accountability of transaction and translation to bedside care," Dr. Beato advised. "We're living longer and better, but chronic disease is moving along with that. About 70 per cent of the budget will become mandatory spending [Medicare, Medicaid, Social Security]. How do we bring the Hispanic population along and Hispanic kids? They will be affected." 

An important component of Hispanic life is family, and taking care of the elderly. Dr. Beato said much of Medicaid spending is going to nursing home care. "It's a great challenge for families who work two or three jobs," she said. "Literacy, cultural competency will be helped by our kids being brighter, go to school, mentor and come back to communities to help family and folks [there]." 

Drugs 

David Murray, PhD, special assistant to the director of the White House Office of National Drug Control Policy, said his office focuses on three areas: preventing drug abuse; getting people off of drugs and into treatment; and stopping the supply of drugs. "We need the assistance of medical providers to help with the disease of addiction," he said. "We face cynicism, which is wrong. We can make a difference with commitment." 

Dr. Murray said illegal drug use reached its highest level in 1979 in the U.S. Over the ensuing 12 years or so, there was progress made in reducing smoking, illegal drug and alcohol use, he said. However the emergence of the rave scene and club drugs between 1991 and 1997 doubled drug use in the U.S. 

Dr. Murray said the administration set goals of reducing illegal drug use among young people by 10 per cent in two years and by 25 per cent in five years. "We got [it down by] 11 per cent in the second year, we got 19 per cent in the fourth year," he said. "One drug is climbing, though...narcotic analgesics and the non-medical use of prescription drugs. We need better awareness, [and] better medical education about the dimensions of substance abuse and why it matters. We find [that with] domestic violence, [and the] incapacity to enter in the health care system [that] substance abuse and alcohol abuse is the underlying pathology. The degree we can enter early in [their] lives and get them help, [the better]." 

Observing behaviors in the emergency room and intervening then helps, too. 

Dr. Murray said he made a recent visit to Mexico and said the Mexican authorities are troubled by high school-age drug abuse near the border. The drug pipeline from South America leaves some drugs behind in Mexico. Also U.S. behavior patterns are adopted by some second-generation immigrants living in the U.S. and they go back to Mexico and spread those behaviors there, he said. 

Kids are subject to a window of vulnerability from age 12-18, when some experiment with smoking marijuana. Dr. Murray said they are looking at possible early intervention strategies, such as random drug screening in U.S. high schools. 

However an audience member said it is very difficult to get substance abuse programs for youth, and expressed concern about drug screening in high schools because those who test positive would have no access to treatment. Furthermore in the process some kids, who may have only just experimented once or twice, could get kicked off the football team or another school activity that may be their only positive outlet. 

Dr. Murray acknowledged that there are a lot of mismatched federal programs. "About half of the youth with substance abuse have comorbid mental illness," he said. "We need research capacity for/from NIDA [the National Institute on Drug Abuse], and treatment capacity." 

As far as the proposed testing, Dr. Murray said there would be a randomness to it, and they would use it to get early referral to programs, and a voucher system in Access to Recovery grants. "[Plus] keeping [people] off drugs improves their employment retainability," he said. 

Guadalupe Pacheco, MSW, special assistant to the director of OMH, said workforce development helps, and patient/provider cultural concordance helps, too.