Losing Ground: Health care disparities alarming
In Colorado, blacks and Hispanics face markedly higher infant mortality rates than whites
February 9, 2013
Editor's Note: Losing Ground is the culmination of 18 months of investigative reporting done by a veteran team of award-winning journalists at the I-News Network, the public service journalism arm of Rocky Mountain PBS. This is the fourth and final part of the series that appeared on consecutive Sundays in the Steamboat Pilot & Today on Jan. 20 through Feb. 10.
Lucero Barrios is Latina and a new mother. These are circumstances that place her squarely in a group of people affected by a shocking reality in Colorado: A Hispanic baby born in this state is 63 percent more likely than a white baby to die in the first year of life.
And Latinos aren't alone — the disparity is even more stark for Colorado's African Americans, who experience an infant mortality rate three times that of Caucasians.
The infant mortality gap is just one measurement by which the state's largest groups of ethnic and racial minorities trail whites, and it is an anomaly unto itself. Colorado's infant mortality rate is lower than the national average for whites and significantly higher than the national average for Latinos and blacks. And an I-News examination of more than a decade of health data found those disparities are widening.
Barrios' daughter, Monserrat, is healthy — a big brown-eyed girl whose favorite book features animals that make sounds when her mother pushes a button on the page.
"It was something I never thought would happen to me at a young age," Barrios said about becoming pregnant.
When it did, she took steps that may have prevented her from becoming a statistic. She made an appointment at Clinica Family Health Services, which serves predominantly the working poor. She showed up for pre-natal examinations with Dr. Carolyn Chen. She didn't drink or use drugs. And after her baby was born, she brought Monserrat to the Clinica office in Westminster for scheduled checkups.
A deeper examination of the numbers shows that the infant mortality rate for Hispanics has climbed in recent years at the same time that it was steadily falling for whites, according to data compiled by the Colorado Department of Public Health and Environment.
Disparities not new
Health disparities between racial and ethnic minorities and white Americans are nothing new — hundreds of studies during the past 20 years consistently found that African Americans and Latinos trail Caucasians in a host of measures, from life expectancy to the odds of death from cancer or kidney ailments. In Colorado, blacks are more likely to suffer from asthma, diabetes, high blood pressure, prostate cancer and obesity than whites. And Hispanics are more likely to die from flu or pneumonia, cervical cancer, diabetes and liver disease than whites.
"These disparities are real," said Amitabh Chandra, director of health policy research at the Harvard Kennedy School of Government. "Anybody who says, 'Well, these disparities don't exist,' is living in denial."
But there may be no more telling statistic about racial and ethnic health disparities in the state than the rate of infant mortality — the death of a baby in the first year of life. It is a number often cited to separate developed nations from developing ones, and it is studied extensively because it is seen by many experts as a key measure of overall health.
In the United States, infant mortality has been on a steady decline since 1958. Even so, black babies die at a rate much higher than white babies, according to data from the Centers for Disease Control and Prevention. In 2011, the rate at which black babies died before reaching their first birthday was a little more than twice that of white babies — 11.42 deaths for every 1,000 births for African Americans compared to 5.11 deaths for every 1,000 births for Caucasians.
"I find that deeply concerning," said Dr. Amal Trivedi, a practicing physician and faculty member at Brown University in Providence, R.I., whose research has been published in the New England Journal of Medicine. "You know, the rates have improved for both groups, but they're still sharply unequal, deeply unequal, and we can do better as a society."
The numbers are starkly worse in Colorado, where African American babies experience 14.5 deaths for each 1,000 births, according to an average of data from 2007 through 2011 calculated by the state health department. That figure would place black Coloradans between the overall infant mortality rates of China and Colombia, according to a World Bank compilation of health data.
The latest state numbers are scheduled to be published next spring but were provided in advance to I-News by the health department.
Since the state's first health disparity report in 2001, the infant mortality rate for whites has fallen 18 percent while for blacks it has fallen about 9 percent. And for Hispanics the rate actually has climbed throughout the past dozen years — from 7.2 deaths per thousand births in the 2001 study to 8 deaths per thousand in the most current numbers.
The data for the upcoming state report also showed other disparities:
■ Whites, on average, now live nearly a year longer than Hispanics in Colorado — and 3.4 years longer than African Americans. In 2011, the life expectancy for a Caucasian in Colorado was 80.3 years, compared to 79.4 for a Latino and 76.9 for an African American.
■ Blacks and Latinos are significantly more likely to die from diabetes than whites. For example, in the most recent data whites experienced a diabetes death rate of 13.9 per 100,000 residents while it was 35.5 for blacks and 36.4 for Hispanics.
■ Blacks experience significantly higher death rates from heart disease and stroke than whites. The death rate from heart disease among blacks is 171 per 100,000 residents, compared to 138.3 for whites. And the death rate from stroke for blacks is 48.2 per 100,000 residents, compared to 35.2 for whites. And even though blacks have seen dramatic improvement in both numbers since the first health disparities report, they have not matched the improvements seen by whites.
Only in recent years has the U.S. Census Bureau begun to measure health indicators in its data. That limited data, available from the Census American Community Survey, measures health insurance, showing a disparity between blacks and Latinos and whites that lays the foundation for dramatic differences in overall health. In Colorado, slightly more than 11 percent of whites reported having no health insurance, while 28 percent of African Americans and more than 31 percent of Latinos were without insurance.
Access to care
The problem of health disparities is as complicated as a giant ball of rubber bands, each strand representing a different piece of the puzzle involving everyone from individuals to doctors to health care administrators and insurance companies to federal and state governments.
To be sure, access to health care is one issue — and numerous experts interviewed by I-News believe the Affordable Care Act will mean that access to health insurance, a doctor and preventive care dramatically will improve for many. But there's another critical component — a catchall that experts refer to as the "social determinants" of health.
Some of those determinants are obvious — poverty and lack of education can play important and negative roles in a person's health. But the list is much deeper. Where you live. Whether you buckle your seat belt. What you eat and drink. How much you exercise. Even which school you attend.
"Now my own view is … that healthcare and health insurance are important," said Chandra, the Harvard health policy researcher. "But when you're talking about life expectancy, and you're talking about people's health, the social determinants of health are far more important than the health care determinants of health."
Waving a magic health insurance wand, he said, would solve only part of the problem.
"Giving people health insurance — how does that affect their walking and working out and eating better foods?" Chandra asked. "I don't know — it doesn't, it really doesn't."
Factors affect health
Dr. Mark Schuster, chief of the division of general pediatrics and vice chair for health policy in the department of medicine at Boston Children's Hospital, was the lead author of a study that looked at health disparities through the eyes of 5,119 randomly selected fifth-graders attending public schools in and around Birmingham, Ala., Houston and Los Angeles. The study found significant racial and ethnic disparities — many of them tied to poverty — in factors that determine a person's health.
For example, black and Latino children were much less likely than white children to wear seat belts or bike helmets and reported significantly lower levels of physical activity.
"When I think of health, I don't just think of health care. I think of any factors that affect health," Schuster said.
As a physician, Schuster regularly talks about the importance of seat belts and bike helmets with his patients. But he can't make them comply.
"If everyone had access to health care and to well visits and to preventive care, I would hope that there would be some improvement to these kinds of indicators," Schuster said. "But I don't want to suggest the pediatrician is the major player in whether kids wear seat belts, whether they wear bike helmets."
And even talking about some of the factors that play into a community's relative health can be controversial.
Christelyn D. Karazin founded a group called "No Wedding No Womb!" after becoming concerned about the explosion in births of black babies to unmarried women — a number that now stands at 73 percent nationally. She attributes that statistic, which she fell into when she had her first child out of wedlock, to a confluence of social changes and the unintended consequences of government programs — the sexual revolution, for example, and welfare programs that she believes encouraged women to have babies and penalized them by cutting their benefits if they married.
And she thinks that births to single mothers is another of those strands in the rubber band ball — that having a baby, staying healthy, and getting good pre-natal care is difficult enough in ideal circumstances and doubly hard for young, single women of color who are in or just above poverty.
She thinks that changing the dynamic in the African American community — achieving a change where more children are born into two-parent households, thereby having a better shot at growing up away from poverty — is a critical component of closing the gaps in a number of areas, including health, that is being ignored.
"It's like, when is it going to be taken seriously?" she asked. "When we're at a 90 percent out-of-wedlock rate? At a 100 percent out-of-wedlock rate?"
In Denver, Grant Jones has dedicated the past 14 years of his life to trying to improve health in his community. He is the founder and executive director of the Center for African American Health, an organization that sponsors classes on things like diabetes management and screenings for things like prostate cancer.
Jones said he finds himself frustrated by men who won't get screened, or who send their wives in their place to a diabetes class. But in the same breath, he also recognizes how much of health is tied to decisions made by individuals — and how daunting it can be to get people to take small steps that can help them live healthier lives.
He knows this because he is Exhibit A.
Jones belongs to a fitness club, and as a 65-year-old with high blood pressure, he knows he should work out several times per week. But often he goes only once or twice, because there's always work to do or a meeting to attend. When he thinks about that, he imagines someone else using the I-have-a-meeting excuse, and how he'd probably respond, "Is that meeting more important than your health?"
"I tell people that, but I don't do it," he said.
For Lucero Barrios, being 21 and a mom means college is on hold. She is single, though Monserrat's father is involved in the little girl's life and attends many of her doctor's appointments. Still, Barrios lives at home and relies on her mother, step-father and older sister to care for Monserrat while she works part-time as a bank teller.
Sitting in a conference room at Clinica, she talked about her hope of returning to college one day, maybe to study finance or another subject that would help her establish a career in banking. And she marveled at the little girl in the pink warm-up suit, laughing as she shared the message on Monserrat's shirt: "I woke up on the wrong side of the crib today."
She talked about her daughter's ability to wave "hello" and "goodbye," about how quiet she becomes with a book she likes, about her love for frogs.
"Maybe she'll be a vet, or a marine biologist or something," Dr. Chen said.
"I hope," Lucero answered.
Amid the troubling numbers, there are some indications that things are changing, although the signals are mixed.
In 1999, for example, the average black Coloradan could expect to live 73.7 years — which was more than five years less than the average white Coloradan, who could expect to live 78.8 years. By 2011, the gap had closed considerably. Hispanics, meanwhile, were stuck — experiencing a life expectancy that actually slipped in comparison to whites over the past decade. And the life expectancy for blacks in 2011 was down nearly a year from the 77.8 years calculated in 2006.
Daunting challenges remain — for individuals, for communities, for society, for the health care system.
"There have been a lot of studies," said Dr. Ashish Jha, a health policy professor at the Harvard University School of Public Health who has done extensive research on the quality and costs of health care and how it affects minorities and the poor. "We don't need another study that says we have a problem. Now we need more information that says here's how we begin to do something about it."
For more information, visit http://www.inewsnetwork.org. Contact Kevin Vaughan at firstname.lastname@example.org or at 303-464-4936. This report was made possible, in part, by grants from The Colorado Health Foundation and the French-American Foundation.