Several deadly diseases strike black Americans harder and more often than they do white Americans.
Fighting back means genetic research. It means changing the system for testing new drugs. It means improving health education. It means overcoming disparities in health care. It means investments targeted to the health of black Americans. And the evidence so far indicates that these investments will pay health dividends not just for racial minorities, but for everyone.
Yet we're closer to the beginning of the fight than to the end. Some numbers:
- Diabetes is 60% more common in black Americans than in white Americans. Blacks are up to 2.5 times more likely to suffer a limb amputation and up to 5.6 times more likely to suffer kidney disease than other people with diabetes.
- African-Americans are three times more likely to die of asthma than white Americans.
- Deaths from lung scarring -- sarcoidosis -- are 16 times more common among blacks than among whites. The disease recently killed former NFL star Reggie White at age 43.
- Despite lower tobacco exposure, black men are 50% more likely than white men to get lung cancer.
- Strokes kill 4 times more 35- to 54-year-old black Americans than white Americans. Blacks have nearly twice the first-time stroke risk of whites.
- Blacks develop high blood pressure earlier in life -- and with much higher blood pressure levels -- than whites. Nearly 42% of black men and more than 45% of black women aged 20 and older have high blood pressure.
- Cancer treatment is equally successful for all races. Yet black men have a 40% higher cancer death rate than white men. African-American women have a 20% higher cancer death rate than white women.
Genes definitely play a role. So does the environment in which people live, socioeconomic status -- and, yes, racism, says Clyde W. Yancy, MD, associate dean of clinical affairs and medical director for heart failure/transplantation at the University of Texas Southwestern Medical Center.
Yancy says that all humans have the same physiology, are vulnerable to the same illnesses, and respond to the same medicines. Naturally, diseases and responses to treatment do vary from person to person. But, he says, there are unique issues that affect black Americans.
"We must recognize there are some arbitrary issues that are present in the way we practice medicine and dole out health care," Yancy tells WebMD. "It forces us to think very carefully about the very volatile issue of race and what race means. At the end of the day, all of us acknowledge that race is a very poor physiological construct. Race is a placeholder for something else. That something is less likely to be genetic. It is more likely to have to do with socioeconomics and political issues of bias as well as physiologic and genetic issues that go into that same bucket. Some racial differences are more nuances. But there are issues of disparity and there are issues relative to racism that operate in a very broad context."
Like Yancy, LeRoy M. Graham Jr., MD, says the time is ripe for Americans to come to grips with these issues. Graham, a pediatric lung expert, serves on the American Lung Association's board of directors, is associate clinical professor of pediatrics at Morehouse School of Medicine in Atlanta, and serves as staff physician for Children's Healthcare of Atlanta.
"I just think we as physicians need to get more impassioned," Graham tells WebMD. "There are health disparities. There are things that may have more sinister origins in institutionalized racism. But we as doctors need to spend more time recognizing these disparities and addressing them -- together with our patients -- on a very individual level."
Black Americans and Lung Disease
A 2005 report from the American Lung Association shows that black Americans suffer far more lung disease than white Americans do.
Some of the findings:
- Black Americans have more asthma than any racial or ethnic group in America. And blacks are 3 times more likely to die of asthma than whites.
- Black Americans are 3 times more likely to suffer sarcoidosis than white Americans. The lung-scarring disease is 16 times more deadly for blacks than for whites.
- Black American children are 3 times as likely as white American children to have sleep apnea.
- Black American babies die of sudden infant death syndrome (SIDS) 2.5 times as often as white American babies.
- Black American men are 50% more likely to get lung cancer than white American men.
- Black Americans are half as likely to get flu and pneumonia vaccinations as white Americans.
"There are a couple of reasons," Graham says. "One is that 71% of African-Americans versus 58% of white Americans live in communities that violate federal air pollution standards. When we look at African-Americans in terms of demographic distribution, they are more likely to be located near, if not next to, transportation corridors, and to places where the air is drawn."
Another reason is that a higher percentage of black Americans than white Americans live close to toxic waste dumps -- and to the factories that produce this waste.
Genetic differences may also play a role. For example, it is clear that cigarette smoking causes lung disease. Cigarette smoking is declining faster among blacks than among whites -- but blacks still die of lung diseases more frequently than white Americans. This could be due to health care disparities -- blacks may get diagnosed later, when diseases are harder to treat -- but it could also be due to genetic susceptibility.
"The environment is involved, and there is potential genetic susceptibility -- but we also have to talk about the fact that African-Americans' social and economic status lags behind that of Caucasians," Graham says. "And low socioeconomic status is linked to more disease."
It's not a simple question of access to health care itself, but access to specialists. Even within HMOs, Graham says, blacks get specialist referrals less often than whites.
"I wonder if minority populations put as much pressure on their doctors to get specialty referrals," says Graham, who works to empower black community groups to know what they should expect from their health care. "And there may be more insidious, darker reasons why doctors are less likely to refer African-American patients. But as a specialist myself, I know that patients who get to see me have gone to their doctors and said, 'This isn't working.'"
African-Americans and Heart Disease, Stroke
Heart disease and stroke disproportionately affect African-Americans. Why?
"What sets the stage for the more aggressive and higher incidence of heart disease in African-Americans is a very high incidence of high blood pressure," Yancy says. "This predisposes African-Americans to more heart disease, kidney disease, and stroke. And heart failure -- an African-American is much more likely to get there with an absence of previous heart disease. That is most important. This makes us focus on high blood pressure as it forces heart failure."
Clinical trials show blacks and whites respond differently to treatments for high blood pressure. Indeed, treatment guidelines suggest that doctors should consider different drugs based on a patient's race.
But Yancey says that a closer look at the data shows that race tends to be a marker for more complicated high blood pressure treatment.
"Data suggests that all therapies do equally well -- but patients at higher risk need more intensive therapy," he says.
A similar situation exists for heart failure. A promising treatment for heart failure didn't seem to be working -- until researchers noticed that it worked much better for black patients than for white patients. A study of black patients confirmed this finding -- and provided tantalizing evidence that the drug will help patients of all races with certain disease characteristics.
"The way this discussion of race differences has been helpful for the whole field of cardiology, is it is exposing new treatment options for all people with heart failure, African-American and Caucasian," Yancy says.
Black Americans and Diabetes
Black Americans -- and Mexican-Americans -- have twice the risk of diabetes as white Americans. In addition, blacks with diabetes have more serious complications -- such as loss of vision, loss of limbs, and kidney failure -- than whites, notes Maudene Nelson, RD, certified diabetes educator at Naomi Barry Diabetes Center at Columbia University.
"The theory is that maybe it is access to health care, or maybe a cultural fatalism -- thinking, 'It is God's will,' or, 'My family had it so I have it' -- not a sense of something I can have an impact on so it won't hurt me," Nelson tells WebMD. "But more and more there is thinking it is something that makes blacks genetically more susceptible. It is hard to tell how much of it is what."
The Forgotten Killer
There is, indeed, evidence that African-Americans may have a genetic susceptibility to diabetes. Even so, Nelson says, the real problem is empowering patients to keep their diabetes under control.
"Patients often have the sense that they are not as much in charge of managing their diabetes as their doctor," Nelson says. "Where I work, in various settings, there is an emphasis on patients. We say this is what your blood sugar is; this is what influences your blood sugar; you have to remember to take your meds. So as a diabetes educator I know there has to be an emphasis on patients putting out more effort to manage their own health."
It's easy to say people with diabetes should learn how to control their disease. But the tools for this kind of self-empowerment often aren't available in black neighborhoods, says Elizabeth D. Carlson, DSN, RN, MPH. Carlson, a postdoctoral fellow in the division of cancer prevention and education at the University of Texas M. D. Anderson Cancer Center in Houston, studies the social determinants of health.
"I go to this black neighborhood 20 minutes from my house in a white neighborhood, and the health education they get in school is much worse than the health education my kids get," Carlson tells WebMD. "It is not just formal education, but everyday things. It's being afraid to go out and exercise because you live in a high-crime neighborhood. It's not having transportation to your health care provider. It's not having decent fresh fruits and vegetables in the local grocery."
Black Americans and Sickle Cell Anemia
It's no surprise that sickle cell anemia affects African-Americans far more than it does white Americans.
This, clearly, is a genetic disease that has little to do with the environment. Yet even here -- with a killer disease -- social and political issues come into play.
Graham notes that the cause of sickle cell anemia has been known since the 1950s. But for many generations, he says, sickle cell anemia has not had the funding and research attention it deserves.
"If you look at the time and attention devoted to sickle cell anemia, it pales when compared to cystic fibrosis and other genetic diseases," Graham says. "There are actually more Americans with sickle cell disease than with cystic fibrosis -- 65,000 to 80,000 versus 35,000 to 40,000 -- but the amount of money spent on cystic fibrosis research outstrips sickle cell anemia by many fold. This is a shame on the medical research arm of our nation."
To its credit, Graham says, the National Institutes of Health is changing this situation. One reason for this change -- as research into lung disease, heart disease, and diabetes shows -- is the growing realization that the health of black Americans isn't a racial issue but a human issue.