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American Women and
Health Disparities
By: David SatcherI,
Journal of American medical women's association
December 2001
In the last century,
American women have been given 30 bonus years of life, thanks to such
sweeping public health initiatives as sanitation and immunization
programs. The America of the next century, however, presents us with new,
more complex, and exceedingly interesting public health challenges. Nearly
40 million of America's 140 million women are now members of racial and
ethnic minority groups.
These women represent many diverse populations, but encompass 4 major
groups: African Americans represent 13% of the total population of US
women; Hispanic women, 11%; Asian-American/Pacific Islander women, 4%; and
American Indian/Alaska Native women, just under 1%. The remaining 71% of
American women are white.
Although these women experience many of the same
health problems as white women, as a group, they are in poorer health, use
fewer health services, and continue to suffer disproportionately from
premature death, disease, and disabilities. Many also face tremendous
social, economic, cultural, and other barriers to optimal health.
It is a growing national
challenge. The US Census Bureau estimates that by the year 2050, barely
53% of America's women will be classified as non-Hispanic white, and 25%
will be Hispanic, 14% non-Hispanic black, 9% Asian and Pacific Islander,
and just under 1% American Indian and Alaska Native.Reclassification standards under the new 2000 census have blurred these
categories somewhat, but it remains clear that if we are to leave our
children and grandchildren a healthier nation, we must address health
disparities immediately. The challenge grows more difficult when we
consider the aging population. By the year 2050, nearly 1 in 4 adult women
will be 65 years old or older, and an astonishing 1 in 17 will be 85 years
old or older.
For public health leaders,
the mission of eliminating disparities among a diverse, aging population
is daunting. Each group of minority women is made up of subgroups, who
have diverse languages, cultures, degrees of acculturation, and histories.
African-American women have a common African heritage, but they may also
have roots in the United States, Great Britain, the Caribbean, or other
countries. Hispanic women, or Latinas, have the distinction of being a
multiracial ethnic group. Many Hispanic women in the United States are
recent immigrants; most are of Mexican, Puerto Rican, Cuban, Central
American, or South American descent. Asian-American/Pacific Islander women
may be of Chinese, Japanese, Vietnamese, Cambodian, Korean, Filipino,
Native Hawaiian, or other ancestry. Nearly 75% of this population group
are foreign born, including an increasing number of immigrants and
refugees from Southeast Asia.
American Indian/Alaska Native women are members of more than 500 federally
or state- recognized tribes or unrecognized tribal organizations. Major
subgroups of this population are American Indians, Eskimos, and Aleuts.
These seemingly impersonal
statistics have faces. A potpourri of cultures, traditions, beliefs,
challenges, and family styles has always been America's greatest strength.
Our challenge for the next century is to close the disparities gap,
without compromising the uniqueness and richness of each culture. We see
disparities among these racial and ethnic groups and subgroups in almost
every area of health. In breast cancer, for example, white women have a
higher incidence rate (114 per 100 000) than African-American women (100),
but black women have a higher mortality rate (31 v 25). This likely
reflects lower rates of early detection as well as treatment disparities,
but there could also be undiscovered physiological factors. Hispanic women
have an incidence rate of 69 and a death rate of 15, compared to 75 and 11
for Asian and Pacific Islander women, and 33 and 12 for American Indian
women.
For these statistics to be
meaningful, we need to take a closer look at each subgroup. Native
Hawaiian women, for example, have an unusually high death rate from breast
cancer (25 per 100 000), although the overall rate for Asian-American
women is lower than average.
American Indian women in New Mexico report the lowest incidence (32 per
100 000) and the lowest death rate (9), but much higher rates are reported
in many other Indian Health Service areas. There is no clear explanation
for this phenomenon.
(p74) When we look at cervical cancer, we see different trends. The
incidence rate of invasive cervical cancer is higher among Asian-American
than among white women (10.3 v 8.1 per 100 000). The incidence rate is
nearly 5 times higher in Vietnamese women than in white women, yet we
cannot explain the causes of this unusually high rate.
If we look at death rates
for diseases of the heart, African-American women are clearly at risk,
with a staggering 147 deaths per 100 000, compared to 88 for white women,
70 for American Indian/ Alaska Native women, and 63 each for Hispanic
women and Asian-American/ Pacific Islanders. This reflects rates of
obesity and the lack of access to preventive health care services,
including blood pressure screening and management.
We cannot make assumptions
about the health status of any particular racial group. Asian Americans
are often viewed as a "model" minority because of their low
unemployment and disease rates. Asian-American/Pacific Islander women age
65 and older, however, have the highest death rate from suicide (8 per 100
000) of all women in their age group, 4 times higher than the rate among
elderly black women and twice the rate of white women.
Disparities are perhaps
most striking when we look at the human immunodeficiency virus (HIV) and
acquired immune deficiency syndrome (AIDS) rates among women. Twenty
percent of Americans currently living with HIV are women, and 77% of those
are African American or Hispanic. Many people are shocked to learn that
AIDS is the second leading cause of death among African-American women age
25 to 44, their peak childbearing years, which leaves untold numbers of
children motherless
and affects entire communities. Not surprisingly, we also see disparities
in key risk factors for disease. The Surgeon General's Report on Women and
Smoking, released March 2001, reported that Alaska Native women have the
highest rate of smoking at a discouraging 35%, compared to 24% for white
women, 22% for African-American women, 14% for Hispanic women, and 11% for
Asian and Pacific Islander women.
In obesity, another major
risk factor, we see significant disparities that clearly affect rates of
disease. Non-Hispanic black women have the highest rate of obesity, 38%,
compared to 35% for Mexican-American women, and 22% for non-Hispanic
whites.
We know that cultural and lifestyle factors play a role in these
disparities.
We have begun to address
these differences through Healthy People 2010, the nation's health agenda
for the next decade. Healthy People 2010 has 2 overarching goals: to
increase the quality and years of life and to eliminate health
disparities. Healthy People 2010 has 220 objectives relevant to women's
health, including cancer, heart disease, stroke, diabetes, and access to
quality health services. Goals for most ethnic groups are equal, even
though some are starting from different baselines. For example, we want to
reduce the death rate from breast cancer to 22.3 per 100 000, regardless
of baseline disparities.
At the heart of Healthy
People 2010 is improved access to such clinical preventive services as
mammography and Papanicolaou tests. We also need improved access to
high-quality health education and mental health and support services at
the community level, so specific ethnic and cultural needs can be
addressed. Health providers must use the clinical setting to better
educate underserved women about risk factors they can modify, such as
smoking and obesity, using culturally and linguistically appropriate
approaches.
This cannot be done
without change in the structure of the US health care system, including
the increasing influence of market forces, changes in payment and delivery
systems, and welfare reform. Reinventing health care delivery is nearly
useless without evaluating how these systemic changes will affect the most
vulnerable and at-risk populations. Federal, state, and local public
health agencies must redouble their efforts to address language and other
access barriers and reduce disparities for these underserved Americans.
Throughout the federal
health agencies, strategies are being developed to address health
disparities. One model to watch is the Breast and Cervical Cancer Early
Detection Program sponsored by the Centers for Disease Control and
Prevention. It has grown from 8 states in 1991 to 50 states, 6 US
territories, the District of Columbia, and 12 American Indian/ Alaska
Native organizations in 2000. More than 2.7 million breast and cervical
cancer screening tests have been provided to more than 1.7 million
underserved women from inception through March 2000. Federal and state
programs now are addressing how to provide appropriate treatment for the
women who are screened.
We have also increased our
educational efforts. In 1998 the Health and Human Services Office on
Women's Health (OWH) launched the National Women's Health Information
Center Website and toll-free telephone service (www. 4woman.gov or
1-800-994WOMAN, TDD: 1-888-220-5446). Women who cannot use the Internet
can call information specialists, including Spanish-speaking experts, to
get referrals to public and private organizations that can offer
culturally appropriate information about specific health problems. The OWH
has also launched an educational campaign that specifically targets women
of each racial and ethnic group. Pick Your Path to Health offers
simple-to-understand, culturally appropriate, weekly action steps to
improve health status.
The OWH-sponsored National
Centers of Excellence in Women's Health
and Community Centers of Excellence in Women's Health
have taken a leadership role in developing model minority outreach
programs and services.
Another good model is the
work being done at the National Cancer Institute (NCI). Last spring the
NCI launched a special populations network to address the unequal burden
of cancer; 18 grants at 17 institutions will create or implement cancer
control programs in minority and underserved populations.
The NCI, as well as many other institutes at the National Institutes of
Health, have created centers and offices designed specifically to reduce
health disparities.
Another innovative program
is the Reducing Health Care Disparities National Project at the Centers
for Medicare and Medicaid Services (formerly known as the Health Care
Financing Administration), which works at the state level to reduce health
care disparities.15 Descriptions and details of many other health
disparities programs can be found on the websites of individual health
agencies. I also recommend the Women of Color Health Data Book5; it is
rich with information on the health, lives, and backgrounds of many ethnic
groups of women.
Of course, when we discuss
the elimination of health disparities, it must be emphasized that
disparities take many forms: racial, ethnic, gender, geographic, income,
educational, cultural, and others. Many of these disparities are
interlinked. For example, some of the worst health outcomes are
experienced by poor, undereducated, African-American women in the rural
southern United States. Looking at data from specific racial and ethnic
groups, however, is an important place to start as we develop strategies
to encourage state and local health care experts to focus on our Healthy
People 2010 objectives. Clearly, the one-size-fits-all approach to public
health that was so effective for expanding the lifespan of women in the
last century will not meet the challenges of the new century.
References
US Census Bureau,
Population Division, Population Estimates Program. Resident Population
Estimates of the United States by Age and Sex: April 1, 1990 to October 1,
1999. Available at: www.census.gov/population/estimates/nation/intfile2-1.txt.
Internet release date: November 26, 1999.
US Census Bureau,
Population Division, Population Estimates Program. Projections of the
Population by Age, Sex, Race and Hispanic Origin for the United States:
1990-1999. Available at: www.census.gov/population/www/estimates/nation3.html.
US Census Bureau,
Population Division, Population Estimates Program. Projections of the
Population by Age, Sex, Race and Hispanic Origin for the United States:
1999-2100 (middle series). Available at: www.census.gov/population/projections/nation/detail/d2041_50.pdf.
US Census Bureau,
Population Division, Population Estimates Program. Resident Population
Estimates of the United States by Age and Sex: 2035-2050. Available at: www.census.gov/population/projections/nation/detail/d2041_50.pdf.
Women of Color Health Data
Book. Available at: www4.od.nih.gov/orwh/WOCEnglish.pdf.
Cancer Facts & Figures
2001. Atlanta, Ga: American Cancer Society; 2001:28.
Health, US 2000. Available
at: www.cdc.gov/nchs/products/pubs/pubd/hus/hus.htm
Healthy People 2010.
Available at: www.health.gov/healthypeople.
Women and Smoking: A
Report of the US Surgeon General. Available at:www.cdc.gov/tobacco.
Pick Your Path to Health
Educational Campaign. Available at: www.4woman.gov/PYPTH/index.htm.
National Centers of
Excellence available at: www.4woman.gov/COE/index.htm
Community Centers of
Excellence available at: www.4woman.gov/owh/CCOE/index.htm.
Minority Health Initiative
available at: www.familiesusa.org/issues/minority-health/.
http://www.jamwa.org/vol56/toc56_4.htm
(JAMWA. 2001;
56:199-205)
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