HEALTH DISPARITIES

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HEALTH DISPARITIES

• Jan Hutchinson MD MPH

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NIH DEFINITION of HEALTH DISPARITIES

• Differences of incidence, prevalence, mortality
  and burden of disease and other adverse health
  conditions that exist among specific population
  groups in the US

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THE REALITY

• Same medical condition, not same health care

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What About Healthcare Disparities?
African-Americans suffer strokes as much as 35
percent higher than whites do, but are less
likely to receive major diagnostic and
therapeutic interventions
Less likely to be on waiting lists for
transplants or to receive dialysis.
Note In 1999, African Americans accounted for
66 of all deaths from CVD in the State of
Maryland
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CARDIAC CARE

• AA half as likely to undergo angioplasty and
  coronary bypass surgery as white Americans
• More death and disability secondary to
  cardiovascular disease

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DIABETES

• Prevalence among AA 70 higher than whites
• Prevalence among Hispanics double that of whites

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CANCER

• AA have cancer death rate 35 higher than whites

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HIV/AIDS

• Leading cause of death for AA males 25-44
• Third leading cause of death of Hispanic males
  25-44
• Hispanics and AA accounted for 2/3 cases in l998
• Higher rates of infection
• Lower rates of survival

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IMMIGRANT AND CITIZEN CHILDREN

• Less health care and access to health among low
  income immigrant and citizen children
• No Medicaid or SCHIP eligibility for immigrant
  children for the first 5 years in the US

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Health Disparities for AI/ANs

• Reflected in an array of mortality and morbidity
  statistics
• In 1996-98, the causes for a number of
  age-adjusted death rates for AI/ANs far exceeded
  that for the US, all races
• 638 greater for alcoholism
• 400 greater for tuberculosis
• 291 greater for diabetes
• 215 greater for unintentional injuries, etc

Source Trend in Indian Health (2000-2001). Page
7.
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10 Leading Health Indicators? LGBT disparities

• Physical activity ?
• Overweight and obesity ?
• Tobacco use ?
• Substance abuse ?
• Responsible sexual behavior
• Mental health ?
• Injury and violence ?
• Environmental quality (social) ?
• Immunization
• Access to health care ?

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Health Behavior/Acculturation Hypothesis Is
Acculturation Bad for Your Health?

• Greater acculturation is associated with
• Increased rates of infant mortality, low birth
  weight
• Overall cancer rates
• High blood pressure
• Adolescent pregnancy
• Smoking, alcohol consumption, illicit drug use
• Decreased fiber consumption
• Depressive symptoms?

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MINORITIES

• More disabilities from unmet mental health needs

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Prevalence of Depressive Episodes (Psychiatric
Disorders in America, 1991)

• Lifetime One year
• Sex
• Men 3.6 2.2
• Women 8.7 5.0
• Ethnicity
• White 6.6 3.7
• Black 4.4 3.3
• Hispanic 5.6 3.9 significant
  difference (p

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Source NHANES III, Scott Levin, PDDA
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KATE

• 1745 (early report of slavery)
• Slave girl who killed her child
• out of her senses
• South Carolina Assembly
• No trial
• ? What happened to Kate ?

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SECY STATE JOHN CALHOUN

• THE AFRICAN IS INCAPABLE OF SELF CARE AND SINKS
  INTO LUNACY UNDER THE BURDEN OF FREEDOMMERCY TO
  GIVE HIM GUARDIANSHIP AND PROTECTION FROM MENTAL
  DEATH

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BENJAMIN RUSH MD

• 1746-1813
• Father of American Psychiatry
• Leading mental health reformer, co-founder of
  first anti-slavery society in America
• DIAGNOSIS- NEGRITUDE, mild form of leprosy
• ? The Cure ?

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RACISM AND PSYCHIATRY

• Primitive psychological organization (uniquely
  fit for slavery)
• Mental health-contentment
• Derangement-protest

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G.STANLEY HALL

• American Journal of Psychology
• American Psychological Association
• ADOLESCENCE (Africans, Indians, and Chinese are
  adolescent races in a stage of incomplete growth)

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DR. SAMUEL CARTWRIGHT

• Authority on medical care of negroes
• 1851 identified two types of mental illness
• Diagnostic symptom of absconding from service
• DIAGNOSIS- DRAPETOMANIA

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DRAPETOMANIA

• Sulky and dissatisfied behavior
• Therapeutic early intervention
• Keep negroes in submissive state
• and treat like children with care
• Treatment and Prevention--??

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DYSAETHESIA AETHIPICA

• Hebetude of the mind and obtuse sensibility of
  the bodyRascality
• Differs from other mental diseases, physical
  signs and lesions
• Whipping is curative
• Natural offspring of Negro libertyto be idle, to
  wallow in filth, to indulge in improper food and
  drinks

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UPDATED DRAPETOMANIA

• Late 1960s, urban violence was due to brain
  dysfunction
• Psychosurgery was recommended treatment to
  prevent violence

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DR. T.O.POWELL

• 1895
• Supt. Of Georgia Lunatic Society
• Insanity and consumption
• Slavery is protective because of better hygiene

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THE COLORED HOSPITAL

• 1840 census shows increased rates of insanity
  among free Blacks
• Mental health experts-mental health of whites
  undermined if with AA
• The Eastern Asylum for the Colored Insane1880
• Alabama Insane Hospital-primary treatment for AA
  males was physical labor

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CROWNSVILLE, MD

• 1911, for colored insane
• AA patients were housed in segregated facilities
  and in local jails
• Some AA males lived in tents

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PUBLIC FACILITIES

• Black mentally ill went to public facilities eg
  poorhouse, jail, or insane asylum
• March 1875
• North Carolina legislature allowed 10,000 to
  build a colored asylum

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MR. WHITE

• Deaf and mute but accused of rape as a 17 year
  old
• Convicted, castrated, and institutionalized
• Thought to be MR and mentally ill
• Hearing impairment
• 72 years in prison

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MISDIAGNOSIS OF DEPRESSION IN AA

• Mistrust of mental health professionals
• Cultural barriers of language and values in
  MD-pt.
• Reliance on support of family and religious
  community when stressed
• Masking of depressive symptoms by other medical
  complaints, substance abuse, and other
  psychiatric illnesses

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ATTITUDES OF AA

• AA fear mental health tx. 2.5 times that of
  whites
• AA parents of kids with ADHD less likely to use
  medical labels and expect a shorter course
• Older AA less knowledgeable about depression

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AA ATTITUDES TOWARDS DEPRESSION

• 63 of AA believe depression is a personal
  weakness
• Only 31 of AA believe it is a health problem
• Close to 39 would handle it themselves

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MORE

• Only 1 in 4 see change in eating habits and sleep
  patterns as sign of depression, only 16 see
  irritability as a sign
• Only 1/3 would take meds for depression, compared
  to 69 of general pop
• 2/3 believe prayer and faith alone will
  successfully treat depression all or some of the
  time

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Racial and Ethnic Minority Groups and Mental
Health

• High endurance of psychiatric distress
• Use of traditional healing practices
• Language barriers
• Present for treatment in crisis
• Fewer treatment sessions
• High rates of inpatient care, especially
  involuntary
• Greater likelihood of misdiagnosis

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Quality of Care for Depression and Anxiety

• 83 saw a health care provider
• 30 received appropriate treatment
• Appropriate treatment was less likely for
• Men
• African Americans
• Less educated
• Younger than 30, older than 59
• Young et al, 2001

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UTILIZATION OF MH

• Percentage of AA receiving services only about
  half of whites
• AA feel AA docs more participatory
• Urban vs. rural
• More likely to terminate prematurely

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INPATIENT CARE

• Specialized psychiatric hospitals and beds
• High rate of repeat admits
• Delays in seeking treatment

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ACCESSIBILITY

• ¼ of AA uninsured (1.5x whites)
• Employer based coverage less (53 vs. 73)
• Better insurance benefits does not increase
  treatment seeking as much among AA as among
  whites

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Bridging the Gap Goals

• Improve communication and coordination between
  primary care, medical specialists and mental
  health providers
• Heighten awareness of the impact of depression
  and co-occurring chronic disease outcomes
• Improve recognition and treatment of depression
  in primary care settings
• Increase culturally appropriate care
• Increase community knowledge of the impact of
  depression on physical health

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Bridging the Gap Educational Intervention

• Curriculum on management of co-morbid chronic
  diseases (diabetes, CV disease, etc.) and
  depression with a focus on culture ethnicity
• Curricula tailored to target audiences (primary
  care and other health providers, legislators,
  patients, and the general public)
• Speaker training for physicians and other health
  professionals