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The federal government acknowledges healthcare disparities, based on race, do exist. Pitt’s Stephen B. Thomas has community initiatives in place that could serve as role models for eradicating the inequality.

Grim Diagnosis,
Brighter Prognosis

Kris B. Mamula

It seems like any other Sunday morning for members of the Central Baptist Church in Pittsburgh’s Hill District. They are patiently awaiting the start of the weekly service. When an elderly gentleman from the church's predominantly African-American neighborhood arrives a few minutes early that, too, isn't out of the ordinary.

Still, something isn’t right.

Before the man takes his seat in the church pews, some friends approach him.

“You don’t look so good,” they tell Percy Thomas, a 78-year-old grandfather. “Are you sick?”

Thomas insists he is fine.

“Look,” they plead, “there are some nurses downstairs today doing health screenings. Go down there. Get checked.”

“Okay, okay,” Thomas agrees at last and walks slowly downstairs, where he meets with student nurses from the University of Pittsburgh.

The nurses there that early April day were part of a program to eliminate disparities in healthcare based on race. The program is one of the keys to the Center for Minority Health’s initiative: African-American Health Promotion, Campaign Countdown to 2010. Through this program Stephen B. Thomas, the Center’s director, wants to initiate healthcare services in churches, supermarkets, and other places where people gather, just like what happened with Percy Thomas (no relation to Stephen).

Stephen Thomas
[Kris B. Mamula photo]

“Instead of trying to figure out why people don’t show up for clinic appointments, we go to the people,” says Thomas, the Philip Hallen Professor of Community Health and Social Justice, which is a joint appointment in Pitt’s Graduate School of Public Health and School of Social Work. “It’s really about building trust.”

In addition to saving lives, eradicating health disparities in the population can have a huge payoff. Simple blood pressure screening in a church basement, for example, may identify individuals on the verge of having a stroke. Treating stroke patients costs about $15,000 during the first 90 days, according to the National Institute of Neurological Disorders and Stroke. The cost doesn’t include permanent disability, which affects 15 to 30 percent of stroke patients.

Thomas’ program isn’t limited to church basements. Barbers, beauticians, and others will be trained as community health advisors. Working with Thomas over the next three years, these advisors will take the prevention message about diabetes, heart disease, and cancer into city neighborhoods. The project is run in conjunction with the American Diabetes Association, American Heart Association, and the American Cancer Society.

The University’s effort is part of a much larger campaign. The US Department of Health and Human Services has set 2010 as the deadline to eliminate racial disparities in healthcare. As universities and medical institutions scramble for ways to meet the deadline, Pitt’s approach is emerging as a nationwide model. In fact, the Wall Street Journal chronicled the efforts of Thomas’ program in an above-the-fold front-page story that appeared in the July 10 edition.

Healthcare disparities based on race have drawn the attention of Thomas, the national media, and the federal government for good reason. Evidence continues to mount nationwide that healthcare is failing African-Americans and other racial and ethnic minorities in a big way. When it comes to healthcare, the United States is a nation of haves and have-nots.

The reality of healthcare disparities is everywhere. The black infant mortality rate is triple the rate for white babies in Pennsylvania’s Allegheny County. In South Dakota, the Lakota Sioux on Pine Ridge Indian Reservation have the shortest life expectancy in the Western Hemisphere, outside of Haiti. And Hispanic farm workers in California and elsewhere have an average life expectancy of just 49 years.

Many things can explain why some people are healthier than others. Cigarette smoking. Education level. Joblessness. Poverty. Now, race has emerged as a reliable indicator of one’s health, even though there is no biological reason for the difference. Take a look at some numbers:

Black mothers in America die from childbirth complications at a rate nearly four times higher than the rate for white mothers, according to the most recent data compiled by the US Department of Health and Human Services. Cervical cancer rates for black women are three times the rate for white women. Blacks have the highest overall risk for kidney disease, and black men have the highest death rates for cancers of the colon, rectum, lung, and prostate.

In fact, minorities are affected more often, receive less aggressive treatment, and die sooner than whites from every major cause of death, according to Thomas.

The latest proof of disparities in healthcare came in March in a troubling study by the Institute of Medicine, a nonprofit organization based in Washington, DC. The institute found that minorities in the United States receive lower quality healthcare than whites, even when insurance coverage and income are the same. The report found that when compared to whites, minority patients were less likely to be given appropriate medications for heart disease, receive kidney dialysis or organ transplants, or undergo heart bypass surgery.

Even among recipients of Medicaid, the government healthcare program for poor people, the institute found that blacks were almost four times more likely than whites to have their legs amputated because of diabetes.

Still, a majority of doctors surveyed believed that disparities in how people are treated within the healthcare system “rarely” or “never” happen based on income, educational status, or racial or ethnic background, according to a Kaiser Family Foundation report, also issued in March. Those doctors may be mistaken.

“The evidence is overwhelming that disparities exist for a number of reasons,” says Rodney Hood, past president of the National Medical Association, which represents more than 25,000 African-American doctors. “There is a huge amount of denial of the problem, especially in the medical community.”

Racial disparities in healthcare are nothing new, according to Thomas. The problem was spotlighted locally during the past year in Black Papers, written for the Urban League of Pittsburgh, which received widespread local media attention. The authors are Ralph L. Bangs, an adjunct faculty member at the Graduate School of Public and International Affairs; associate professor of psychiatry Ken Thompson; and then-Pitt graduate students Haslyn Hunte and Trista N. Sims. Bangs serves as a research associate and co-director of the Urban and Regional Research Program at Pitt’s Center for Social and Urban Research; while Thompson is the Soros Foundation Physician Advocate Fellow at Pitt and director of the Institute for Public Health and Psychiatry at Western Psychiatric Institute and Clinic.

Black Papers, funded by the University, Birmingham Foundation, Jewish Healthcare Foundation, and the UPMC Department of Community Initiatives, contained some alarming findings.

For every 1,000 African-Amer- ican babies born between 1994 and 1998 in Allegheny County, 18 died before their first birthday. For the same number of births, that compares to only about five white baby deaths—one-third the black death rate. For every white man who died of heart disease during that time, nearly three black men died. And for every white man who died of diabetes, more than two black men died.

The Center for Minority Health spotlights these disparities at annual conferences that are hosted by the University. Academic and clinical healthcare leaders from around the country are among the people who attend. The most recent meeting, the National Minority Health Leadership Summit, was held in January, and was funded, in part, by the US Department of Health and Human Services’ Office for Civil Rights.

There is no simple explanation for why race and ethnicity affect medical care. But here’s an idea. Maybe everything has gotten too complicated. We drown in information. To make the world more manageable, we generalize. We judge. Doctors are no different. “Physicians are like everybody else,” says Hood. “You bring your biases to the table.”

Jeannette E. South-Paul, professor and chair of the University’s Department of Family Medicine, says the problem is seeded in doctors’ earliest training. “We prioritize what we can count and measure and see,” she says. “We revere evidence.” For that reason, cultural, psychosocial, and other factors that influence health get short shrift.

Better known is what doesn’t account for why some groups of people get sick more often and die younger than others. For example, biological and genetic differences fail to explain why whites live longer than blacks after cancer treatment, according to a study released in April by Memorial Sloan-Kettering Cancer Center in New York. Similarly, the Pitt report is based on the premise that biological and genetic differences between races are meaningless when it comes to susceptibility to disease.

A review of similar programs nationwide reveals that the University and affiliate UPMC are developing one of the most comprehensive approaches to eliminating health disparities. Atlanta and Seattle have similar programs, but none has as broad a campaign as Pittsburgh’s, according to the Wall Street Journal.

The “Pittsburgh experience” is waging the battle in the streets. “We have to go where people live,” Thomas says. Larry E. Davis, dean and Donald M. Henderson Professor of the School of Social Work, concur: “He [Thomas] has hit a nerve. It’s an idea whose time has come.”

Pitt’s Center for Minority Health, which is within the University’s Graduate School of Public Health (GSPH), is spearheading Pitt’s efforts to improve the health in the black community. Here are some other examples.

When Thomas found out last year that thousands of city school students, many African-American, were facing suspension because they didn’t have required immunizations, he asked the University to step in. Chancellor Mark Nordenberg co-chaired the Greater Pittsburgh Measles Immunization Task Force with Pittsburgh Public Schools Superintendent John W. Thompson, and Thomas chaired the executive committee, which provided nearly 11,000 school-age children with booster shots for measles, mumps, and rubella. Administering the shots were nurses who traveled in vans to grocery stores, churches, and the YMCA. “There was this sense that we’re all in this together,” Nordenberg told the Wall Street Journal. “We’re talking about our neighbors.”

And earlier this year, the Center for Minority Health established satellite offices at UPMC’s Magee-Womens Hospital and Lemington Home for the Aged, a skilled nursing facility. Office staff is helping to assure that patients follow doctors’ orders, and understand the care they are receiving, says Thomas.

The Center continues to attract backing from private foundations and state agencies. What’s more, the Center was chosen by the state to coordinate all anti-smoking programs.

“We hope the Pittsburgh experience can be repeated nationally,” says Bernard D. Goldstein, dean of GSPH and professor of environmental and occupa-tional health.

Pitt’s approach to ending racial disparities in healthcare goes beyond doctors and patients. Nearly two dozen departments within the University are helping improve economic development, education, housing, job training, and other opportunities in five city neighborhoods under the federal Community Outreach Partnership Centers
program (COPC).

COPC participants include the schools of social work, law, education, medicine, and public and international affairs. The US Department of Housing and Urban Development is funding COPC through August 2003 with a $400,000 grant. Improvements in education and employment are expected to translate into improved health because there seems to be a correlation between quality of life issues and health.

South-Paul says the University’s medical education curriculum is being changed to improve student sensitivity to issues of race and culture in healthcare, and University researchers are increasingly asking questions that involve minority healthcare. “Does that fix it? No. But we’re moving in that direction,” she says.

The Center for Minority Health has also formed a community advisory board that will help increase black participation in clinical trials while providing community feedback on University research projects. Here again, the University is ahead of the curve.

Minority involvement in clinical trials has been lacking nationwide. For example, blacks and Hispanics make up a growing percentage of Americans infected with the virus that causes AIDS. But minorities are roughly half as likely as whites to participate in HIV treatment trials, according to a study in May that appeared in the New England Journal of Medicine. Starting next year, the National Institutes of Health will no longer review grant proposals for studies that don’t include minorities in clinical trials.

Pitt has raised more than $1 million to support Thomas’ programs through the Pittsburgh Foundation, the Heinz Endowments, the Maurice Falk Medical Fund, and the Pennsylvania Department of Health. Thomas plans to raise an additional $4 million during the next few years. If the success of this spring’s health promotion campaign in one elderly man’s life is any indicator, the money will be well spent.

Back in the basement of Central Baptist Church that April morning, a University of Pittsburgh student nurse takes Percy Thomas’ blood pressure. The reading is dangerously high. A friend offers to take him to the hospital. He is reluctant, but agrees finally.

After treatment in the emergency room, Thomas is admitted to the hospital for three days. Changes in his diet and medications cut his sky-high blood pressure.

Now he’s back to his normal routine at home, having narrowly averted what may have been a catastrophic stroke. He divides his time between church work, and volunteering at a nursing home where he fills water pitchers and does other chores for patients.

Since that morning in church, Percy Thomas has also become a believer in Pitt’s approach to preventive healthcare. “It’s a godsend,” he says.

Kris Mamula is senior editor of this magazine.

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