Racial and Ethnic Approaches to Community Health Reach 2010 Program

Racial and Ethnic Approaches to Community Health (REACH 2010 Program)

The health objectives for the United States for the 21st century have been described in The Federal Initiative to Eliminate Racial and Ethnic Health Disparities and Healthy People 2010. The national interest in the areas of racial and ethnic disparities has been renewed with the public health initiatives with the leadership for the discussion being taken by the Center for Disease Control and Prevention. The overall health of the nation has improved a lot, but the members of the minority groups in the ethnic and racial areas have not been benefited. This includes the African-Americans, Alaska Natives, American Indians, Asian-Americans, Hispanic-Americans and Pacific Islanders.

This segment of our population is more likely to have poor health and premature deaths than the white Americans. During 1992 to 1998, the deaths from breast cancer have come down noticeably, but there are more deaths among black women than whites. Even in the area of Pap tests, the white women have greater chances of receiving these tests. These tests detect precarious changes in the cervix, which help to prevent the invasive cervix cancer. Looking at figures for 1999, African-Americans had a 29% higher chance of death from diseases of the heart. This led to a 40% higher probability of death due to strokes. In the case of diabetes, and compared to whites, American Indians and Alaska Natives are 2.6 times more susceptible, African-Americans are 2.0 times susceptible, and Hispanics are 1.9 times more susceptible. (Racial and Ethnic Approaches to Community Health (REACH) 2010: Addressing Disparities in Health 2003)

Only 25% of the U.S. population is African-American or Hispanics, but they constitute 56% of the adult AIDS cases, 73% of the new HIV infections among adults, and 82% of the pediatric AIDS cases. The National Immunization Survey for 1998-2000 shows 11 major urban areas with racial or ethnic disproportionate populations, which is 10% when compared to the national level, and they show age-appropriate childhood immunization. The studies in 2001, for Hispanics and African-Americans more than 65 years, showed that they were less likely to be vaccinated for influenza or pneumonia. The infants from the African-American, American Indian and Puerto Rican infants had much higher infant mortality rates than whites, though the overall U.S. infant mortality in 2000 had come down to 6.9 infant deaths per 1000 live births. The ratio of deaths among blacks when compared to whites was 2.5. (Racial and Ethnic Approaches to Community Health (REACH) 2010: Addressing Disparities in Health 2003)

In the coming years, it is expected that the population in the racial and ethnic minority groups are going to be an even larger portion of the U.S. population. Without a concerted effort to eliminate the differences in the health situation of the minorities, the numbers affected among them will continue to increase. For eliminating the racial and ethnic disparities in health, community driven programs are critical, as they will be easily acceptable to the communities. These need the support from sound prevention research in order to be successful. The federal, state, local and tribal governments and communities must support this research with new and innovative partnerships. The Racial and Ethnic Approaches to Community Health (REACH 2010) had been organized by CDC for eliminating disparities in health status that are seen among the ethnic minority population in important health areas. This was started in 1999 to concentrate on six very important health problems: cardiovascular disease, immunizations, breast and cervical cancer screening and management, diabetes, HIV / AIDS, and infant mortality. African-Americans, American Indians, Alaska Natives, Asian-Americans, Hispanic-Americans, and Pacific Islanders are the minorities being targeted by REACH.

Community coalitions in designing, implementing, and evaluating community-driven strategies to eliminate health disparities will be supported by REACH through a two-phase, 5-year demonstration project. The coalition organizations used by REACH 2010 will have the community organization and three others. One of these other three will be a local or state health department, or a university or a research organization. The planning will be done over 12 months and the receivers of the REACH grants will use local data to design a complete community action plan that will concentrate on one of the six areas already decided, and specifically concentrate on one or more of the ethnic minorities. This plan will then be executed over the next four years, with the community groups carrying out the activities and also evaluating. CDC will thus be the major leader in carrying out these objectives, as mentioned. (Racial and Ethnic Approaches to Community Health (REACH) 2010: Addressing Disparities in Health 2003)

Now let us analyze the health disparities in a particular state. We have taken the study of the state of Alabama for this purpose. The total population of Alabama is 4,369,862, consisting of 52% women - 2,272,543 in number. The distribution of these women in racial and ethnic terms gives whites 71.2%, blacks as 26.95%, Asians and Pacific Islanders together as 0.66%, the American Indian and Alaska Natives together as 0.33%, and Hispanics as 0.81%. (Overview of Region lV) Heart diseases, cancer, stroke and COPD (Chronic Obstructive Pulmonary Disease) are the major causes of death. The National level of death due to heart diseases and stroke is exceeded by the rate for Alabama women. This is the leading cause for death in Alabama, and in 2000 has caused 30% of the deaths in the state, or a total of 13,406. Individually, stroke has caused 3,183 deaths in the same year, which is about 7% of the states deaths, and comes out as the third most important cause. According to the BRFSS (Behavioral Risk Factor Surveillance System), which is another survey conducted in Alabama in 2001, the adults in Alabama had high blood pressure among 31.6% of the adults, blood cholesterol in 32.7%, diabetes in 9.6%, current smoking habits in 23.8%, overweight or obesity in 62.6%. These are all high risk factors for heart diseases. Of the five factors mentioned, at least one was present in 82% of the population. (State Program: Alabama Capacity Building)

Heart disease, cancer, unintentional injuries, homicide/suicide and HIV infection are judged to be the leading cause for years of potential life lost (YPLL) before the age of 75 for the entire population. Alabama had the tenth-highest rate of death due to lung cancer among all the states. Of all the deaths in Alabama, in 1999, Cancer accounted for 21%. The deaths among men from this disease were 69% higher among men than women. In 2002, the American Cancer Society has estimated that a total of 22,600 new cases will be diagnosed, of whom, 3,200 will be for lung, 2,200 of colorectal, and 3,100 among women for breast. (Chronic Diseases, Risk Factors, and Preventive Services, Alabama) The death has been estimated by the Society to be 9,800 among Alabama residents. Death rates for cancer and COPD for Alabama women are in line with the national rates. Looking into the figures for counties, there were some in which the breast cancer deaths among African-American women were higher at 30 per 100,000 as compared to 20 per 100,000 for the white women. Diabetes had been diagnosed among 241,000 adults in Alabama in 2000. In 1999, there were 1,341 deaths due to diabetes in Alabama, and this was the eighth highest rate in the country. Asthma is not tracked in Alabama even though the attacks from the disease cause the highest amount of school absenteeism, and the disease attacks have increased by 75% from 1980, by 1994. Except HIV, Alabama has a higher rate of infection than all other diseases. (Overview of Region lV)

With regard to the disparities in health in Alabama, the Hispanics had the lowest rate of deaths due to strokes, while the blacks had the highest rates. Again with regard to the incidences of stomach, gall bladder, liver and cervical cancers, Hispanics were found to have a higher rate. Another case on insulin sensitivity showed that black children were 405 more sensitive than white children, and the insulin response was twice as high. African-American, Mexican-American and Pima Indian youth have been shown in studies to have higher insulin levels, which suggest a genetic predisposition to insulin resistance. This suggests compensated insulin resistance, and when this is coupled with the insulin resistance that occurs during puberty and due to obesity, the result could be Type 2 diabetes. (Health Disparities and Non-insulin Type 2 Diabetes) There is also a health disparity for the people in the have-not and have sections of the population, which could be a reflection of the baby boom echo or the aging of baby boomers. This is especially seen in the racial and ethnic minorities. The absence of teeth among people above 65 is 1 out of 4 on a national level, but in Alabama, it is one out of 3. Teeth loss has been coming down from the 50s. Dental caries, untreated is found among 1 in 5 children nationally, but in Alabama, it is one in three.

Whole communities and population groups are affected by the health disparities. Thus it is a very important public health function to remove these differences. For this purpose, providers and services must be stationed in underserved minority community areas to expand and maintain the efforts. Partnerships must be built up at all levels, and these include public and private providers: public health department, hospitals, MCH programs, Ryan White programs, health centers, free clinics, universities, and school-based health care programs. All of them must work together so that other communities are inspired to take up the challenge. This will build up partnerships between national organizations representing racial and ethnic minorities, physicians, State and local health departments and State governments. Straightforward measures like blood pressure checks cannot eliminate such health disparities - the difficulties are far more complex and broad ranging. The fight against infant mortality also involves a fight against smoking, poor nutrition, and substance abuse. The fight against cancer involves the issues of tobacco, poor nutrition and substance abuse. The absence of hope for a meaningful future will also be attacked in this fight against disparities in health.

All the fights are difficult and essential elements of the same fight. The magnitude, difficulty, and complexity of eliminating disparity with such deep-rooted causes can lead to hesitation and skepticism, and that has to be realized. But these hesitations and skepticism ultimately leads to improving results, and that has to be ensured. Leadership through conducting research, expanding and improving programs to purchase or deliver quality health services, developing programs to reduce poverty, provide children with safe and healthy environments, and expanding prevention efforts has to be essentially provided.

With poor health status among minorities is closely associated their poverty, and the lack of equality in economic opportunity - and these are important considerations. Health status is also affected by the discrimination, which must be treated as a separate variable. To accurately reflect the needs of the community and demonstrate the necessity of addressing these disparities an essential requirement is high quality and uniform data. It is not enough that the data is accurate, but it must be thorough. This is seen in charts and tables, which present categories such as white, African-American, Hispanic, Asian/Pacific Islander, and 'other'. What is meant by the "other" category has to be clearly defined, and the subgroups shown within those categories. This extra effort will improve the usability of the data at federal, state and local levels.

With efforts targeted at the general public, public officials, community decision makers and leaders, and members of ethnic and minority groups to eliminate the health disparities, education will also play a major role. The children must be educated in schools about the basic principles of equality and equity. The community must supply the expertise needed for the efforts to be effective. The community must be involved from the beginning. There must be a social contract and a shared vision between the people serving and the people being served. Skills in working with different groups within the community are an important requirement. Community workers, who are present every day in the community, like postal employees, must be invited to participate in these efforts to remove disparities in health.

These secondary efforts end up being another level of connection through individuals who are within the community and know and understand the people. The family relationships must be understood better. It is seen that in some cultures, the families retain their cohesiveness even in very trying circumstances, whereas, in others remaining cohesive at any time is a challenge. There is a functional relationship between family and health, and between family and self-sacrifice in service, and this relationship has to be understood. Critical masses of competencies must be created, and further built up on the individual strengths. Identification of people who are highly competent at navigating around problems, dilemmas and obstacles is an important task, for which no ready-made solutions are available. But, these people must be found, and they must come along with their skills, so that they can teach us about their communities and families.

There are a few dollars that float down the community channels and these sometimes spark off a competition between some members of the internal ethnic groups. These competitions are best avoided for the evident mean spirit in these fights may lead to the loss of connections within the community. To improve the health conditions of the community will require a better understanding of the community, the relationships between the health status and the racial and community backgrounds. These will help in the development of culturally sensitive strategies. The thought must be on building infrastructure and collaborations to help communities to find out and meet their own needs. To reduce disparities within communities, it may be advisable to provide enough funds to national, regional, and community organizations. These funds should be redirected as necessary to build up capacity. With the funds that are now available, an effort should be made to think about their effective reallocation, and the complete funding plan for that reallocation. To assess the needs for funds itself, the communities need funds. The leaders of the communities have to have the tools and training to help them lobby for both dollars and resources. There is also planning and strategic assessments that are required. Trust and linkages among all groups have to be built up by the political leadership of the community. The problem must be viewed in a comprehensive manner, so that all can move forward together, strategically and with awareness. This needs vision and taking advantage of the opportunity, and action must be taken.

A variety of community-based, religious, grassroots and health care organizations that serve the target population are presently involved by the University of Alabama at Birmingham Breast and Cervical Cancer Coalition with support from CDC. The action plan of this community is to reduce the differences in breast and cervical cancer screening and outcomes between African-American and white women through the use of community advisors. To support, encourage and help women obtain the cancer screening services, as also navigate the health care system; work is being done by core groups of community health advisors, nurses and church representatives. The framework for this approach is called the Multilevel Approach toward Community Health (MATCH) framework. MATCH seeks to eliminate barriers faced by women trying to access health services are to be removed through health advisors. These health advisors are community based, and here they are the agents for change of behavior, and they lend credibility to the interventions, which are to reduce the risk for breast and cervical cancer. This also increases the reach within the community.

Lifesaving prevention programs and screening services across cultural divides, that would not otherwise be reached, are extended by this method. (Racial and Ethnic Approaches to Community Health) National Center on Minority Health and Health disparities (NCMHD) of the National Institute of Health has been awarded $65.1 million for support for the year 2003. This is to be used for research on health disparities, and elimination of health disparities among racial and ethnic communities who belong to the minority groups and medically underserved. Congress has designated NCMHD to lead, coordinate, support and assess the efforts being made by NIH to reduce the health disparities among racial and ethnic communities, and medically underserved individuals, with a view to eliminating them ultimately. (HHS Awards more than 65 Million to eliminate health disparities)