REACH 2010: Eliminating Racial and Ethnic Health Disparities

Introduction to Racial and Ethnic Health Disparities in the U.S.

The health objectives for the United States in the 21st century have been described in The Federal Initiative to Eliminate Racial and Ethnic Health Disparities and Healthy People 2010. National interest in racial and ethnic health disparities has been renewed through public health initiatives, with the Centers for Disease Control and Prevention (CDC) taking the lead in guiding this discussion. Although the overall health of the nation has improved considerably, members of racial and ethnic minority groups have not benefited equally. These groups include African-Americans, Alaska Natives, American Indians, Asian-Americans, Hispanic-Americans, and Pacific Islanders.

This segment of the population is more likely to experience poor health and premature death than white Americans. Between 1992 and 1998, deaths from breast cancer declined noticeably overall, yet Black women continued to die at higher rates than white women. Even in the area of Pap tests — which detect precancerous changes in the cervix and help prevent invasive cervical cancer — white women were more likely to receive them. According to 1999 figures, African-Americans had a 29% higher chance of dying from heart disease and a 40% higher probability of death due to stroke. In the case of diabetes, compared to whites, American Indians and Alaska Natives were 2.6 times more susceptible, African-Americans were 2.0 times more susceptible, and Hispanics were 1.9 times more susceptible (Racial and Ethnic Approaches to Community Health [REACH] 2010: Addressing Disparities in Health, 2003).

National Health Disparity Data by Minority Group

Although African-Americans and Hispanics make up only 25% of the U.S. population, they account for 56% of adult AIDS cases, 73% of new HIV infections among adults, and 82% of pediatric AIDS cases. The National Immunization Survey for 1998–2000 identified 11 major urban areas with disproportionately large racial or ethnic minority populations; childhood immunization rates in these areas were approximately 10% lower than the national level. Studies conducted in 2001 found that Hispanic and African-American adults over the age of 65 were less likely to be vaccinated for influenza or pneumonia.

Infant mortality rates among African-American, American Indian, and Puerto Rican infants were substantially higher than those for white infants, even as the overall U.S. infant mortality rate fell to 6.9 deaths per 1,000 live births in 2000. The ratio of infant deaths among Black infants compared to white infants was 2.5 (REACH 2010: Addressing Disparities in Health, 2003).

In the coming years, racial and ethnic minority groups are projected to comprise an even larger share of the U.S. population. Without a concerted effort to eliminate health disparities, the number of minority individuals affected by preventable illness and death will continue to grow. Community-driven programs are essential to this effort, as they are more readily accepted by the communities they serve. These programs require the support of sound prevention research, and federal, state, local, and tribal governments must foster new and innovative partnerships to advance that research.

The REACH 2010 Program: Structure and Goals

The Racial and Ethnic Approaches to Community Health (REACH 2010) program was organized by the CDC to eliminate health disparities among ethnic minority populations in six priority health areas: cardiovascular disease, immunizations, breast and cervical cancer screening and management, diabetes, HIV/AIDS, and infant mortality. Launched in 1999, the program targets African-Americans, American Indians, Alaska Natives, Asian-Americans, Hispanic-Americans, and Pacific Islanders.

REACH supports community coalitions in designing, implementing, and evaluating community-driven strategies through a two-phase, five-year demonstration project. Each REACH 2010 coalition must include a community organization and at least three partner organizations, one of which must be a local or state health department, a university, or a research organization. During the first 12-month planning phase, grant recipients use local data to develop a comprehensive community action plan focused on one of the six priority health areas and one or more targeted ethnic minority populations. Over the following four years, community groups carry out and evaluate the plan's activities, with the CDC serving as the lead organization overseeing these objectives (REACH 2010: Addressing Disparities in Health, 2003).

Health Disparities in Alabama: Disease Burden and Demographics

To examine health disparities at the state level, Alabama provides an instructive case. The total population of Alabama is approximately 4,369,862, of whom 52% are women (2,272,543). The racial and ethnic breakdown of women in Alabama is as follows: white, 71.2%; Black, 26.95%; Asian and Pacific Islander combined, 0.66%; American Indian and Alaska Native combined, 0.33%; and Hispanic, 0.81% (Overview of Region IV).

Heart disease, cancer, stroke, and chronic obstructive pulmonary disease (COPD) are the leading causes of death in the state. Alabama's death rates from heart disease and stroke exceed the national average. Heart disease alone accounted for 30% of all deaths in Alabama in 2000, totaling 13,406. Stroke caused 3,183 deaths in the same year — approximately 7% of total state deaths — making it the third leading cause of death. According to the Behavioral Risk Factor Surveillance System (BRFSS) survey conducted in Alabama in 2001, 31.6% of adults had high blood pressure, 32.7% had elevated blood cholesterol, 9.6% had diabetes, 23.8% were current smokers, and 62.6% were overweight or obese. At least one of these five major risk factors for heart disease was present in 82% of the adult population (State Program: Alabama Capacity Building).

Heart disease, cancer, unintentional injuries, homicide/suicide, and HIV infection are the leading causes of years of potential life lost (YPLL) before age 75 in Alabama. The state ranked tenth highest nationally for lung cancer death rates. Cancer accounted for 21% of all deaths in Alabama in 1999, with death rates 69% higher among men than women. In 2002, the American Cancer Society estimated that 22,600 new cancer cases would be diagnosed in Alabama, including approximately 3,200 cases of lung cancer, 2,200 of colorectal cancer, and 3,100 cases of breast cancer among women. Total cancer deaths for Alabama residents were estimated at 9,800. Death rates for cancer and COPD among Alabama women were broadly consistent with national rates, though at the county level, breast cancer deaths among African-American women were notably higher — approximately 30 per 100,000 — compared to 20 per 100,000 for white women (Chronic Diseases, Risk Factors, and Preventive Services, Alabama).

Diabetes was diagnosed in approximately 241,000 Alabama adults in 2000. In 1999, there were 1,341 diabetes-related deaths in the state, representing the eighth-highest rate in the country. Asthma, though not formally tracked in Alabama, accounts for the highest level of school absenteeism in the state; disease prevalence increased by 75% between 1980 and 1994. With the exception of HIV, Alabama's infection rate for other diseases exceeds the national average (Overview of Region IV).

Regarding health disparities within Alabama, Black residents had the highest rates of stroke-related death, while Hispanic residents had the lowest. Hispanics were found to have higher rates of stomach, gallbladder, liver, and cervical cancers. Research on insulin sensitivity revealed that Black children were approximately 40% more sensitive to insulin than white children, and their insulin response was twice as high. Studies have shown that African-American, Mexican-American, and Pima Indian youth have elevated insulin levels, suggesting a genetic predisposition to insulin resistance. This compensated insulin resistance, when combined with the resistance that develops during puberty and through obesity, may lead to Type 2 diabetes (Health Disparities and Non-Insulin Type 2 Diabetes).

Socioeconomic disparities also manifest in oral health outcomes. While one in four Americans over the age of 65 has lost all of their teeth, in Alabama the figure is one in three. Nationally, untreated dental caries affect one in five children; in Alabama, the figure is one in three.

Conclusion: A Shared Vision for Eliminating Health Disparities

There is a growing conviction that all Americans must have access to the best type of health care, whether through universal health coverage or other means. This is an issue that affects all Americans, and policymakers, communities, health care providers, funding authorities, and the media must recognize it as such. It is not solely an issue for those who cannot afford health insurance. By partnering with diverse communities in research and intervention programs, the CDC is working to end racial and ethnic health disparities — an ambitious goal that has been pledged to the nation with a target of 2010.

The magnitude, difficulty, and complexity of eliminating disparities with such deep-rooted causes can lead to hesitation and skepticism, and that reality must be acknowledged. However, these hesitations and skepticism must ultimately give way to improving outcomes. All the efforts described — fighting infant mortality, cancer, diabetes, cardiovascular disease, and more — are difficult and essential parts of the same broader struggle.

There must be a national effort for the elimination of health disparities, with contributions from both the public and private sectors, individuals, and communities. Government and communities must work together to sustain and advance these developments and continue building the necessary capacities. This shared vision and developed partnership is the key to increasing awareness about health disparities — in Alabama and across the entire nation — and to advancing meaningful, lasting solutions.

References

Author Unknown. (n.d.). Chronic Diseases, Risk Factors, and Preventive Services, Alabama. Retrieved from http://www.4woman.gov/owh/reg/4/overview.htm. Accessed October 15, 2003.

Author Unknown. (n.d.). Health Disparities and Non-Insulin Type 2 Diabetes. Retrieved from http://www.medicalnewsservice.com. Accessed October 15, 2003.

Author Unknown. (n.d.). HHS Awards More Than 65 Million to Eliminate Health Disparities. Retrieved from http://apps.nccd.cdc.gov/BurdenBook/DeathCause.asp?state=al. Accessed October 15, 2003.

Author Unknown. (n.d.). Overview of Region IV. Retrieved from http://www.cdc.gov/nccdphp/exemplary/racial.htm. Accessed October 15, 2003.

Author Unknown. (n.d.). Racial and Ethnic Approaches to Community Health (REACH) 2010: Addressing Disparities in Health 2003. Retrieved from http://www.cdc.gov/nccdphp/aag/pdf/aag_reach2003.pdf. Accessed October 15, 2003.

Author Unknown. (n.d.). Racial and Ethnic Approaches to Community Health. Retrieved from http://www.epi.umn.edu/let/type_two.html. Accessed October 15, 2003.

Author Unknown. (n.d.). State-Based Diabetes Prevention & Control Programs: Alabama. Retrieved from http://www.cdc.gov/diabetes/states/al.htm. Accessed October 15, 2003.

Author Unknown. (n.d.). State Program: Alabama Capacity Building. Retrieved from http://www.cdc.gov/cvh/state_program/al.htm. Accessed October 15, 2003.