Latino Health Disparities: Latino Health Disparities: A Cultural Paradox?A Cultural Paradox?

Eliseo J. Pérez-Stable, M.D.Eliseo J. Pérez-Stable, M.D.Professor of MedicineProfessor of Medicine

Division of General Internal Medicine Division of General Internal Medicine Department of Medicine, UCSFDepartment of Medicine, UCSF

October 27, 2005October 27, 2005

Disparities and DifferencesDisparities and Differences

• Disparities implies a difference that Disparities implies a difference that demonstrates a disadvantage for a group demonstrates a disadvantage for a group that has been traditionally disenfranchisedthat has been traditionally disenfranchised

• Some differences may not be classified as Some differences may not be classified as disparities–White men have more CADdisparities–White men have more CAD

• Disadvantaged groups may have better Disadvantaged groups may have better outcomes for leading causes of death–outcomes for leading causes of death–Latinos and AsiansLatinos and Asians

Race or Ethnicity?Race or Ethnicity?• Racial categories fit geographic

origins of humans

• Ethnicity refers to self-identity with a national origin or cultural group

• Admixture may confound categories

• Census uses racial categories and subgroups and Hispanic ethnicity

• Self identification = gold standard

Social Class and Race/EthnicitySocial Class and Race/Ethnicity

• Race has been a substitute for Race has been a substitute for defining social class in the U.S.defining social class in the U.S.

• Gradient of health outcomes at all SES Gradient of health outcomes at all SES levels comparing Blacks and Whiteslevels comparing Blacks and Whites

• Education and income are insufficient Education and income are insufficient measuresmeasures of social classof social class

• Measures of wealthMeasures of wealth• Generation of social classGeneration of social class• Community measures for segregation, Community measures for segregation,

safety, inequality, acculturation…safety, inequality, acculturation…

TB Rate Ratio by EthnicityTB Rate Ratio by EthnicityDemographics and SESDemographics and SES

Demographic SES+ Crowding

Afr Amer 9.6 4.4 2.1/2.0

Latino 6.5 2.8 1.6/4.1

Asian 3.8 3.5 3.3/4.5

Am Indian 4.6 2.3 1.9/3.6

Catwell MF, AJRCCM 1997; 157:1016

Demographic ChangesDemographic Changes

• 35% of persons in the US did not identify as White in the 2000 census

• Immigrant tsunami of the the 20th century may be waning, but…

• Spanish is an important language• Birth rates are highest for non-

Whites––population growth• California is a minority majority state

ChaosChaos

Latino EthnicityLatino Ethnicity

• Admixture of major racial categories in Admixture of major racial categories in

Latino America for 500 years– European, Latino America for 500 years– European,

Indigenous, and AfricanIndigenous, and African

• • Ethnicity refers to self-identity with a Ethnicity refers to self-identity with a

group––diversity in USgroup––diversity in US

• • National background, cultural identityNational background, cultural identity

• • Genetic componentGenetic component

Our HistoryOur History

• Americas had 75 million Americas had 75 million inhabitants in 1500inhabitants in 1500

• By 1600, over 50% were deadBy 1600, over 50% were dead• Victims of disease, forced Victims of disease, forced

labor, war, ….labor, war, ….• The greatest genocide known The greatest genocide known

in historyin history

Race and GeneticsRace and Genetics• More genetic variance within than between More genetic variance within than between

racial groups–no genetic basis for raceracial groups–no genetic basis for race

• Race/ethnicity identifies group more likely Race/ethnicity identifies group more likely to share specific allelesto share specific alleles

• Random coupling will eliminate race––ever?Random coupling will eliminate race––ever?

• Interaction with environment–gene Interaction with environment–gene expressionexpression

• Ancestral Informative MarkersAncestral Informative Markers

3,899 SNPs in 313 genes in 4 U.S. 3,899 SNPs in 313 genes in 4 U.S.

racial groupsracial groups

Stephens, et al Science 2001

# S

NP

s

Common to:

25% of SNPs are Pan Racial25% of SNPs are Pan Racial

21% of SNPs are racially specific21% of SNPs are racially specific

Contribution

45%

52% 24%

61%

15%3.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

MexicanAmerican

Puerto Rican

Percent

Ancestral

Admixture

Native AmericanAfrican

European

Genetic Origins of LatinosGenetic Origins of Latinos

Latinos in the U.S.Latinos in the U.S.

• More similarities than differencesMore similarities than differences

• Central role of Spanish languageCentral role of Spanish language

• Cultural themes unifyCultural themes unify

• Racial admixture–500 yearsRacial admixture–500 years

• Common cultural heritage: Common cultural heritage:

–Catholics, Spain, IndigenousCatholics, Spain, Indigenous

Definition of Epidemiologic Definition of Epidemiologic ParadoxParadox

• Outcomes are better than Outcomes are better than expected based on the known or expected based on the known or standard predictive risk factorsstandard predictive risk factors

• Low SES does not always Low SES does not always translate to worse outcomestranslate to worse outcomes

% LBW Rates by Ethnicity% LBW Rates by Ethnicity

23456789

101112131415

African American Latina White

Study

Fuentes-Afflick E and Lurie P, Arch Pediatr Adolesc Med 1997

Death Rate by Ethnicity, US 2000Death Rate by Ethnicity, US 2000

WW B B L L A/PIA/PI

Heart DiseaseHeart Disease 130130 191 89 191 89 72 72

StrokeStroke 25 25 44 20 44 20 24 24

DiabetesDiabetes 12 12 29 29 19 19 9 9

• Age-adjusted per 100,000 NCHS

Causes of Death, US 2001Causes of Death, US 2001

Latinos %

Heart Disease 23.9

Cancer 19.7

InjuryInjury 8.48.4

Stroke 5.7

DiabetesDiabetes 5.05.0

HomicideHomicide 2.92.9

Liver DiseaseLiver Disease 2.92.9

Whites %

Heart Disease 29.7

Cancer 23.3

Stroke 6.8

COPD+ 5.6

Injury 3.9

Flu/pneumonia 2.6

Diabetes 2.6

NHANES Self-Reported Rates NHANES Self-Reported Rates of CV Outcomes 1999-2000of CV Outcomes 1999-2000

Cond Total

MA

Total

White

Men

MA

Men

White

Wom

MA

Wom

White

MI 2% 4% 2% 5% 1% 2%

CHF 2% 2% 2.2% 2.4% 1.7% 1.6%

CVA 2.2% 2.3% 2.4% 1.8% 1.8% 2.5%

U.S. Asthma Mortality 1990-1995U.S. Asthma Mortality 1990-1995Average Annual Rates per Million

11.315

40.75 40.9

0

10

20

30

40

50

Mexican White African

American

Puerto Rican

Homa et al. 2000Homa et al. 2000

Adverse Demographic Profile Adverse Demographic Profile for Latinosfor Latinos

• Less household income on averageLess household income on average

• About 30% live in poverty and have less About 30% live in poverty and have less wealth at every level of incomewealth at every level of income

• Fewer average years of education and Fewer average years of education and proportion of college graduatesproportion of college graduates

• Fewer than half of Latinos 25 years or Fewer than half of Latinos 25 years or older completed high school compared older completed high school compared with 77% of Whiteswith 77% of Whites

• More single-parent householdsMore single-parent households

ProportionsProportions(Premature Mortality)(Premature Mortality)

GeneticGenetic

30%30%

Health Health carecare

10%10%

Determinants of Health

BehaviorBehavior

40%40%

• GeneticGenetic

• Behavioral Behavioral

• EnvironmentalEnvironmental

• Social SettingSocial Setting

• Health careHealth care

SocialSocial15%15%

EnvironmentEnvironment5%5%

Source: McGinnis JM, Russo PG, Knickman, JR. Health Affairs, April 2002.

Adverse Social and Access FactorsAdverse Social and Access Factors

• Lower functional health literacyLower functional health literacy• Limited English proficiency–25%Limited English proficiency–25%• Lowest health insurance coverage– 40% Lowest health insurance coverage– 40%

between 18-64 y are uninsuredbetween 18-64 y are uninsured

• Mexicans have the lowest insurance Mexicans have the lowest insurance coverage of any national origin group coverage of any national origin group

• Less access to primary care MDLess access to primary care MD

• Twice as likely to report using ER as Twice as likely to report using ER as primary source of careprimary source of care

Access to Markets with Healthy Access to Markets with Healthy Foods for Diabetics in New YorkFoods for Diabetics in New York

• Food targets: Fruit, vegetables, 1% fat milk, Food targets: Fruit, vegetables, 1% fat milk, diet drinks, high fiber breaddiet drinks, high fiber bread

• 173 stores in East Harlem and 152 stores in 173 stores in East Harlem and 152 stores in Upper East SideUpper East Side

• Had all 5 categories: 9% vs. 48%Had all 5 categories: 9% vs. 48%• More likely to live on a block with no store More likely to live on a block with no store

selling foods in E Harlem–50% vs. 24%selling foods in E Harlem–50% vs. 24%• Example of disparities in environmental Example of disparities in environmental

justice issues complicating behaviorjustice issues complicating behavior

AJPH 2004; 94: 1549-54AJPH 2004; 94: 1549-54

Diabetes, Hypertension Diabetes, Hypertension and Cigarette Smokingand Cigarette Smoking

Do these risk factors or Do these risk factors or conditions explain the conditions explain the

paradox?paradox?

Diabetes Prevalence in Latinos

• NHANES III: 20% Mexican Americans vs. 11% Whites have DM

• Increase of 20% to 35% in 15 years• Undiagnosed diabetes 4%• Up to half of Latinos unaware of DM• 95% of diabetes is type 2• Prevalence in Puerto Ricans similar

Disparities in Diabetes Treatment and Outcomes

• CDC report--compared to Whites, CDC report--compared to Whites, Latinos were less likely to have:Latinos were less likely to have:– Dilated eye exam(56% vs. 60%)Dilated eye exam(56% vs. 60%)– Foot exam (47% vs. 56%)Foot exam (47% vs. 56%)– A1C test (18% vs. 27%)A1C test (18% vs. 27%)

• Latinos have more LE amputationsLatinos have more LE amputations• Mexican Am have more retinopathyMexican Am have more retinopathy• More proteinuria and ESRDMore proteinuria and ESRD

Hispanic HANES, 1982-1984:Hypertension Prevalence

Men Women

Mexican Am 23% 20%

Puerto Rican 20% 18%

Cuban American 21% 14%

=

NHANES III Hypertension Rate

Men Women Total

Mexican Am 23% 22% 23%

African Am 34% 31% 32%

White 25% 21% 23%

Burt Hypertension 1995; 25:305

NHANES Hypertension RateNHANES Hypertension Rate

MenMen Women Women Total Total

Mex AmMex Am88-9488-94 23%23% 22%22% 23%23%99-0099-00 27%27% 30%30% 29%29%

WhiteWhite88-9488-94 25%25% 21%21% 23%23%99-0099-00 28%28% 29%29% 29%29%

Hypertension Control in Latinos - Have We Made Any Progress?

• HHANES 1982-8420% controlled at <140/90

• HHANES 1988-199224% controlled

• San Antonio and LaredoFewer aware, treated and controlled

• South Bronx 23% Puerto Ricans controlled

• Less knowledge about CAD prevention

Hypertension Awareness Hypertension Awareness and Control, 1999-2000and Control, 1999-2000

• Awareness: 58% Mex Am vs. 68% Whites• Only 50% of Mex Am men were aware• Similar awareness among women• Treatment rates lower: 39% vs. 59%• Control among those treated: 40% vs. 54%• Only 33% of Mex Am men at goal• +60 y more aware, treated, less control• Slow improvements in 1990s

Behavioral FactorsBehavioral Factors

• Less cigarette smokingLess cigarette smoking

• More alcohol consumed - menMore alcohol consumed - men

• Nutritional habits less healthyNutritional habits less healthy

• Less physical activity - womenLess physical activity - women

• More violence - DV plus More violence - DV plus

• Less adherence to medicationsLess adherence to medications

Cigarette Smoking in the U.S. – 2002Cigarette Smoking in the U.S. – 2002National Health Interview SurveyNational Health Interview Survey

% Men % Women

WhiteAfrican AmLatinoAsianAm Indian

25.527.122.719.040.5

21.818.710.8 6.540.9

8 years or less9-11 yrs schoolhigh school diplCollege degree

25.438.129.813.6

13.530.922.110.5

Below poverty 36.9 30.1

MMWR 2004;53:427-431

Biochemical Smokers in Biochemical Smokers in Mexican American LatinosMexican American Latinos

• Underreporting occurred in up to Underreporting occurred in up to 25% of Mexican American smokers25% of Mexican American smokers

• Former smokers misclassified - 11%Former smokers misclassified - 11%

• Never smokers misclassified in 4%Never smokers misclassified in 4%

• 12.1% of smokers had non-smoker 12.1% of smokers had non-smoker cotinine levelscotinine levels

• Cotinine measure may be betterCotinine measure may be better

Ethnic Differences in Serum Cotinine Levels: NHANES 3

>15 ng/mlpercent

≤15 ng/mlpercent

African Amssmokernon-smoker

962

498

Whitessmokernon-smoker

942

698

Mexican Amssmokernon-smoker

721

2899

JAMA 1998;280:135-139

Nicotine Metabolism in Blacks, Nicotine Metabolism in Blacks, Whites, Chinese and LatinosWhites, Chinese and Latinos

• Metabolic clearance of nicotine & cotinine Metabolic clearance of nicotine & cotinine in Latinos was similar to Whites, higher in Latinos was similar to Whites, higher among Blacks and lower among Chineseamong Blacks and lower among Chinese

• Intake of nicotine(mg) per cigarette:Intake of nicotine(mg) per cigarette:– Chinese: Chinese: 0.73 0.73 – Latinos: Latinos: 1.051.05– Whites Whites 1.101.10– Blacks Blacks 1.41 1.41

• Nicotine intake = tobacco smokeNicotine intake = tobacco smoke

Latino Paradox in CV Disease?

• Prevalence of smoking is lowerPrevalence of smoking is lower• Hypertension and lipids similarHypertension and lipids similar• Obesity more commonObesity more common• Physical inactivity more commonPhysical inactivity more common• Less BP & DM awareness and controlLess BP & DM awareness and control• Diabetes rate is 2-4 timesDiabetes rate is 2-4 times• Lower SES by income, educationLower SES by income, education• Fewer heart attacksFewer heart attacks• Fewer procedures to treat CADFewer procedures to treat CAD

CHD Prediction Scores By EthnicityColor in Framingham?

• Applied sex specific CHD functions to 6 ethnically diverse cohorts

• White and Black men and women prediction of CHD events works well

• Japanese & Latino men and American Indian men & women–risk is overestimated

• Adjust for different rates of risk factors and underlying rate of CHD

JAMA 2001; 286:180-7

Is culture a protective factor?Is culture a protective factor?• Lower heart disease mortality rates

despite higher or similar prevalence of cardiovascular risk

• Unidentified factors that are protective against chronic diseases

• More social support through community or social networks?

• Genetic factors?

Proposed Explanations of Proposed Explanations of ParadoxParadox

• Healthy immigrant effectHealthy immigrant effect• Salmon hypothesis–return to die Salmon hypothesis–return to die

at home and deaths not recordedat home and deaths not recorded• Misclassification of ethnicity in Misclassification of ethnicity in

diagnosis and deaths––Latinos diagnosis and deaths––Latinos misclassified as Whitesmisclassified as Whites

• Census undercounts (increase)Census undercounts (increase)

What About What About Acculturation?Acculturation?

Role of Acculturation?

• NHANES III: Mexican Americans born in the US and speaking Spanish have higher adjusted SBP than English speaking counter parts - 123.9 vs. 121.5 mm Hg

• US born Spanish speaking was significant in logistic regression models for men and women for SBP, BMI and current smoking

• Bicultural Latinos at highest risk?

Sundquist, AJPH 1999; 89:723

Are Latina Women at Higher Risk?Are Latina Women at Higher Risk?

• Women 25 to 64 years showed adjusted SBP higher for Mexican Americans in HANES III

• SBP was intermediate between Whites and African Americans

• Not observed for women 18 to 24 years of any ethnic group

Sacramento Area Latino Study on Aging: Sacramento Area Latino Study on Aging: Cohort StudyCohort Study

Study PopulationStudy Population– 1,789 Latinos aged 60+, Mexican ancestry (85%) 1,789 Latinos aged 60+, Mexican ancestry (85%) – Mean age at baseline: 71 (60-101); 58% womenMean age at baseline: 71 (60-101); 58% women– 51% born in Mexico or another Latin American 51% born in Mexico or another Latin American

country and were Spanish speakingcountry and were Spanish speaking– Baseline: 1998-99 & 4 –year follow upBaseline: 1998-99 & 4 –year follow up

In home clinical evaluations and interviewIn home clinical evaluations and interview– Cultural orientation assessed by the Cuellar Cultural orientation assessed by the Cuellar

scalescale • language, contact with own ethnic group vs. language, contact with own ethnic group vs.

others, celebration of traditions (0-30 pts) others, celebration of traditions (0-30 pts) higher score higher Anglo orientationhigher score higher Anglo orientation

– Cognition (3MS)Cognition (3MS)

Haan, M, SCAIA (2005)

Anglo cultural orientation Anglo cultural orientation Protective of Cognitive DeclineProtective of Cognitive Decline

Incidence of Alzheimer’s Disease was 15.4% Incidence of Alzheimer’s Disease was 15.4% in Mexican born and 12.4% in US bornin Mexican born and 12.4% in US born

• Hazard of cognitive decline per point on Hazard of cognitive decline per point on cultural scale HR=0.98 95% CI (0.96-0.99) cultural scale HR=0.98 95% CI (0.96-0.99)

• 1 point increase means higher Anglo 1 point increase means higher Anglo cultural orientationcultural orientation

• Adjusted for age and gender, baseline Adjusted for age and gender, baseline diabetes and strokediabetes and stroke

Risk of dementia associated with combined Risk of dementia associated with combined income and education in study participantsincome and education in study participants

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Income <$1,000,Education <=8 years

Income <$1,000,Education >8 years

Income =>$1,000,Education <=8 years

Income =>$1,000,Education >8 years

Socioeconomic Status

HR

fo

r d

em

en

tia

/CIN

D

Adjusted for age, type 2 diabetes, stroke, gender, cultural orientationAdjusted for age, type 2 diabetes, stroke, gender, cultural orientation

Cancer

Cancer Incidence by Site and Ethnicity in Men, U.S. 2000

(per 100,000 age-adjusted)

Af Am API White Latino

Prostate 234 83 145 103

Lung 117 52 76 42

Colon 61 45 56 38

Stomach 11 15 6 10

Cancer Mortality Rates - Men

African AmericanAfrican American 53 53 27 27 96 96 8 8 1212

WhiteWhite 22 22 21 21 68 68 5 55 5

Asian/P.I.Asian/P.I. 10 10 13 13 34 34 14 1114 11

Latino Latino 16 13 16 13 3131 8 8 8 8

Am. Ind/Alaska Nat 14 12 Am. Ind/Alaska Nat 14 12 42 42 6 6 66

Prostate Colon Lung Liver StomachProstate Colon Lung Liver Stomach

Per 100,000

Cancer Incidence by Site and Cancer Incidence by Site and Ethnicity in Women, U.S. 2000Ethnicity in Women, U.S. 2000

(per 100,000 age-adjusted)(per 100,000 age-adjusted)

Af Am API White Latino

Breast 102 78 116 69

Lung 46 23 44 19

Colon 45 31 36 23

Uterus 14 12 22 14

Cervix 11 10 8 14

NCI, SEER,

Cancer Mortality Rates Women

African AmericanAfrican American 31.0 5.7 31.0 5.7 19.6 33.6 19.6 33.6

WhiteWhite 24.324.3 2.4 2.4 13.9 34.6 13.9 34.6

Asian/P.I.Asian/P.I. 11.011.0 2.7 2.7 8.9 15.1 8.9 15.1

Latina Latina 14.8 3.3 14.8 3.3 8.0 10.9 8.0 10.9

Am. Indian/Alaska NativeAm. Indian/Alaska Native 12.4 2.9 12.4 2.9 8.9 20.9 8.9 20.9

Breast Cervical Colon LungBreast Cervical Colon Lung

Per 100,000

Preventive Services BRFSS, Preventive Services BRFSS, United States 2001-2002United States 2001-2002

Screening Test

Latinos Whites

Mammo

Women 40+

84.7% ever

73.5% 2 yrs

90.3% ever

77.1% 2 yrs

Pap Smear

Pap Smear 3y

94.0% ever

85.8%

96.9% ever

88.8%

FOBT 2 yrs

Scope ever

20.1%

37.9%

32.0%

49.2%

Latino Paradox in CancerLatino Paradox in Cancer

• Lack of diagnosis not likelyLack of diagnosis not likely

• Less smoking, less PA, more obesityLess smoking, less PA, more obesity

• Less screening but not explain gapLess screening but not explain gap

• Difference in rates explained by other Difference in rates explained by other

mechanisms mechanisms

• Gene-Environment interactions?Gene-Environment interactions?

Language and Language and Cultural FactorsCultural Factors

What happens under the microscope

Language Concordance Matters

• Monolingual Spanish speaking patients with Spanish speaking physicians should do better

• Feel better with less pain, better health outlook, less symptoms

• Understand more of the physician instructions

• Better medication adherence?• Ask more questions–patient centered

How Much Fluency is Enough?How Much Fluency is Enough?

• Language fluency is a gradient

• Consider dialects

• Patients may avoid topics knowing limitations

• Evaluating cognition, mental health

• Literacy, understanding, jargon

Use of InterpretersUse of Interpreters

• Patients using interpreters ask less, say less, answer less

• Triangular interaction–space• Who translates matters: –

professional interpreter, trusted friend or family member

• Accuracy may be an issue

Translation of SurveysTranslation of Surveys• Standard technique: Forward/Backward• Forward from English to target language• Take new translation and back translate to

English• Different translators for each phase• Reconcile differences on review by fluent

speakers including both translators and investigators

• Colloquial use OK but has to be “correct”• Time consuming and Expensive

Health Related Quality of Life by Health Related Quality of Life by Ethnicity - Los Angeles 1999Ethnicity - Los Angeles 1999

Poor and Unhealthy Activity N Fair Health Days Limitation D

White 3376 13.1% 7.1 2.7

Latino 3267 35.6% 6.3 2.4

AA 835 21.2% 8.3 3.5

API 716 15.3% 4.7 1.7MMWR 2001; 50:556-9

How is your Health?How is your Health?

• Excellent

• Very Good

• Good

• Fair

• Poor

• Excelente

• Muy buena

• Buena

• Regular o Justa o Mas o Menos

• Mala (Pobre)

Ethnicity and Attitudes toward Ethnicity and Attitudes toward Patient Autonomy by EthnicityPatient Autonomy by Ethnicity

Tell Dx%

Tellprognosis

%

Life support%

European Am 87 69 65

Mexican Am 65 48 41

African Am 89 63 60

Korean Am 47 35 28

JAMA 1995; 274:820

Factors to Consider in Factors to Consider in Treatment of LatinosTreatment of Latinos

• FamilismoFamilismo - Helps Adherence? - Helps Adherence?• SimpatíaSimpatía Cultural Script Cultural Script for positive for positive

interpersonal interactionsinterpersonal interactions

• Personalismo–Personalismo–informal friendlinessinformal friendliness

• • ConfianzaConfianza – trust – trust• RespetoRespeto For Authority of MD For Authority of MD

Cultural ThemesCultural Themes

• Fatalismo or spiritualityFatalismo or spirituality

• Machismo Machismo

• Traditional gender rolesTraditional gender roles

• Present orientation not futurePresent orientation not future

• Pain thresholdPain threshold

discrimination discrimination color color ancestryancestry

income income nationalitynationality

beliefsbeliefs educationeducationbirth placebirth place

gene poolgene pool RACERACE EthnicityEthnicity biology biology

status status historyhistorygenetics genetics wealthwealth

cultureculture

other other health seeking behavior health seeking behavior

income income nationalitynationality

beliefsbeliefs educationeducationbirth placebirth place

gene poolgene pool RACERACE EthnicityEthnicity biology biology

status status historyhistorygenetics genetics wealthwealth

cultureculture

other other health seeking behavior health seeking behavior

What Is to Be Done?What Is to Be Done?

Ignore it, Incremental Change, Ignore it, Incremental Change, Let the Market Take Care of it?Let the Market Take Care of it?

Chaos and OpportunityChaos and Opportunity

Minority Physicians in CaliforniaMinority Physicians in California

• Practice in areas with fewer doctors and with higher percent minorities

• Provide care for more uninsured and MediCal patients

• 2000: Medical school graduates = 10% but 35% of population is now non-white

• Cultural and linguistic competency• Residents on duty August 2004 in

US–5% Black, 6% Latino, 0.3% Am Ind

Going Beyond Describing Disparities by Race/Ethnicity

• We all want interventions that workWe all want interventions that work• Need to define mechanisms or pathways Need to define mechanisms or pathways

so we can target effortsso we can target efforts• Basic research in development of Basic research in development of

intervention contentintervention content• Optimal point of interventions not clear –Optimal point of interventions not clear –

community, patients, system, clinicianscommunity, patients, system, clinicians• Continue to describe and monitor Continue to describe and monitor

disparities as natural historydisparities as natural history