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Racial and Ethnic Disparities in RA

Medically Reviewed by Sabrina Felson, MD on April 03, 2022

There is no cure for rheumatoid arthritis, and symptoms can take a serious toll over time. But earlier diagnosis along with newer medications and treatment protocols have greatly improved the outlook and quality of life for those with the disease.

Still, not all racial, ethnic, and social groups have shared equally in these improvements. As with other conditions, like lupus and diabetes, research shows that minorities and people with lower income tend to lag behind other groups in getting the best care and outcomes with RA. Scientists haven’t yet figured out why this is.

And the problem persists. Despite efforts by doctors, scientists, and patients to raise awareness and increase minority participation, there was very little improvement between 2008 and 2018.

Part of the problem is that scientists don’t have enough information. The great majority of studies on RA have sample groups made up of mostly white patients. Even though minorities make up 40% of the U.S. population, they only comprised about 16% of the participants in randomized controlled studies on RA. (Randomized controlled studies are the gold standard for scientific studies.)

There is very little comparison data or information about the RA incidence rate for specific minority groups like African Americans or Hispanic people.

Still, we do know some things about how RA plays out in different minority groups.

Who Gets Rheumatoid Arthritis?

Women are three times more likely than men to get RA. In men it’s rare before age 45 and in women it typically starts sometime between 30 and 60.

About 1% of Americans get RA. In general, white Americans are thought to get RA more than other groups. But there are exceptions. The Pima and Pagago Indians of the American Indian population get RA at a much higher rate than average -- 5.3%.

In addition, from the currently available data, African Americans seem to get RA at around the same rate as white Americans, while Asian and Hispanic people seem to get it less.

Still, there is simply not yet enough data to draw firm conclusions about the prevalence of RA in different groups. More study is needed.

Race, Socioeconomic Status in RA Outcomes

Socioeconomic status is a general measure of a person’s economic and social status in society. Less money means fewer resources for medical care, and less opportunity to take good care with exercise, a balanced, nutritious diet, and de-stressing time. This can have a profound effect on health outcomes, including for RA.

Certain racial and ethnic groups -- like African Americans, Hispanic people, and others -- are disproportionately represented in groups with lower socioeconomic status.

So it’s no surprise that the people in these groups have higher levels of pain, disease activity, and disability due to RA. (“Disease activity” in RA is a measure of how widespread and intense the symptoms of a condition are, how people with it report their experience, and results from lab tests that gauge common disease markers.)

And in fact, studies show that those with the least financial resources are more likely to have the most serious forms of RA. When there are out-of-pocket expenses for medications, people of low socioeconomic status are also less likely to adhere to their health care plan. This is especially important in RA because early treatment is key to better long-term control of symptoms.

Without that early treatment (and diagnosis), you’re more likely to have serious illness including joint damage that can lead to disability -- yet another barrier to getting proper medical care. Minorities are almost twice as likely as white Americans to be unable to work due to disability.

And low income is not the only way to measure socioeconomic status. Scientists also use job-type, education level, neighborhood, and many other factors, to measure socioeconomic status.

Low socioeconomic status in childhood, even if it passes, could still raise your chance of RA later in life. For example, if you experienced:

  • Food insecurity: Feeling unsure about whether you will have enough to eat
  • Young maternal age: Having a baby before 20 years of age
  • Low level of household education: Less than 12 years of schooling

Whatever the measure, it is clear that people with low socioeconomic status who have RA experience more serious pain, disease activity, and disability than other people with the disease.

But it’s harder to figure out how much of this is due to race alone compared with other factors of low socioeconomic status.

Racial Disparities in RA Disability

One way to look at racial disparities in RA outcomes is through the lens of disability. Disability is one measure of disease progression. Serious RA symptoms with high disease activity can make someone unable to work.

Research shows that some groups have higher levels of disabling symptoms (disability) due to RA. But it’s not entirely clear whether this is due to race or ethnicity or to the social and economic class of its members and other factors.

So far, scientists seem to be able to account for most of the differences with socioeconomic, demographic, cultural, and behavioral factors. But that doesn’t mean that systemic treatment of race and ethnicity by themselves don’t play a part, just that scientists don’t yet have enough evidence to draw that conclusion.

And of course, many experts contend that it is impossible to separate race from these socioeconomic, demographic, cultural, and behavioral factors because of a history of bias and prejudice in the medical system and the society at large.

Other racial statistics on disability and RA don’t fit neatly into any particular narrative. For example, in a study on people over 65 who receive disability benefits, there were differences in the use of cutting-edge bDMARDs (biological disease-modifying antirheumatic drugs).

African Americans in this class were prescribed the drugs slightly less than white Americans, but Hispanic people were significantly more likely than both groups to get the drugs. And those differences seemed to stick when scientists tried to account for other factors (socioeconomic, demographic, and behavioral).

On the surface, this looks confusing. If lower prescription rates are due to minority status, then why were Hispanic people prescribed bDMARDs so much more often than either whites or African Americans?

Conversely, there was almost no difference between whites and African Americans in the use of opioids to control pain from RA. About 66% received opioids for this reason. And the earlier someone filed for disability, the more likely they were to get opioids. Why do racial disparities play out in other areas, but not when it comes to the prescription and use of opioids?

Scientists need much more research and more carefully designed studies to get to the bottom of these questions. And that’s why it is so important that people of color participate in clinical research and that researchers design studies to ensure that black and brown people always get care that was proven to work for their racial or ethnic peers.

Show Sources

SOURCES:

American College of Rheumatology: “Racial/Ethnic Trends in Incidence and Prevalence of Rheumatoid Arthritis in a Large Multi-Ethnic Managed Care Population.”

Annals of The Rheumatic Diseases: “Time trends in disease activity, response and remission rates in rheumatoid arthritis during the past decade: results from the NOR-DMARD study 2000–2010,” “Childhood socioeconomic factors and perinatal characteristics influence development of rheumatoid arthritis in adulthood.”

Arthritis Care and Research: The official journal of the Arthritis Health Professions Association: “Differences by sex in correlates of work status in rheumatoid arthritis patients.”

Arthritis Foundation: “Rheumatoid Arthritis: Causes, Symptoms, Treatments and More.”

Arthritis and Rheumatism: “Out-of-pocket expenses and their burden in patients with rheumatoid arthritis.”

Current Opinion in Rheumatology: “Racial, ethnic, and healthcare disparities in rheumatoid arthritis.”

JAMA: “Receipt of disease-modifying antirheumatic drugs among patients with rheumatoid arthritis in Medicare managed care plans.”

JAMA Network Open: “Demographic Characteristics of Participants in Rheumatoid Arthritis Randomized Clinical Trials.”

Seminars in Arthritis and Rheumatism: “Racial and Ethnic Differences in Medication Use among Beneficiaries of Social Security Disability Insurance with Rheumatoid Arthritis,” “Do out-of-pocket costs affect medication adherence in adults with rheumatoid arthritis? A systematic review.” 

The Journal of Rheumatology: “Health status disparities in ethnic minority patients with rheumatoid arthritis: a cross-sectional study,” “Does socioeconomic status affect outcomes in early inflammatory arthritis? Data from a Canadian multisite suspected rheumatoid arthritis inception cohort,” “The relationship between social deprivation, disease outcome measures, and response to treatment in patients with stable, long-standing rheumatoid arthritis.”

Maricopa Community Colleges: “Socioeconomic Status (SES).”

Wiley Online Library: “Socioeconomic Status, Definition.”

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