The great divide

University scientists take aim at the vast disparities that segregate us into a nation of medical haves and have-nots
By Barbara Knox

Taking a few minutes between haircuts, Brian Davis relaxes on one of the black metal stacking chairs lined against the wall in the waiting area of his shop, Brian D’s Old School Barbers, in North Minneapolis.

“African American men,” he says, gesturing at himself, “we don’t talk about retirement. For us, we work and then we die.”

We’re talking about health disparities, about why African Americans suffer at much higher rates of disease than do their Caucasian American counterparts, and why African Americans may not seek medical screening to help catch serious illness before it becomes fatal illness.

“There’s a fear of hospitals that goes back a long, long way,” says Davis. “A lot of African Americans think, ‘Hospitals, that’s a place you go to die, not to get help.’”

Davis has thought a lot about health disparities that plague his friends and neighbors in North Minneapolis, and he’s stepped into a leadership role by volunteering to host Clipper Clinics in his barbershop. The brainchild of Kola Okuyemi, M.D., M.P.H., director of the U of M Medical School’s Program in Health Disparities Research, Clipper Clinics are mobile operations that set up shop for the afternoon in a neighborhood barbershop or beauty salon and invite residents to come in for free blood pressure, cholesterol, glucose, and HIV screening.

“I remember one guy,” says Davis, “who happened to be passing by and came in for screening. His blood pressure and blood sugar turned out to be through the roof, and they rushed him off to Hennepin County Medical Center. Later, he came by and told us, ‘Man, you all saved my life.’”

The haves and have-nots

The problem of health disparities has been well documented. Famously, Martin Luther King Jr. brought it up in his remarks to the Medical Committee for Human Rights in 1966, when he reportedly said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

Among the disenfranchised when it comes to health care are people in poverty, African immigrants, African Americans, Native Americans, Latinos, the LGBTQ community, and homeless people.

Under the enormous umbrella of “health disparities,” certain statistics (from the Centers for Disease Control and Prevention) stand out starkly:

  • African Americans are seven times more likely to die from HIV/AIDS than Caucasian Americans.
  • Twice as many babies born to African Americans, Native Americans, and Native Alaskans die before 1 year of age, as compared with Caucasian Americans.
  • In 2009, homicide rates were 665 percent higher for African Americans than for Caucasian Americans.
  • The African American preterm birthrate is 60 percent higher than Caucasian Americans’.

The list seems endless. Rates for high blood pressure, prostate and breast cancers, obesity … all higher among minority and lower socioeconomic status groups as compared with middle-class whites. 

In our own backyard, too

Minnesota consistently rates as one of the country’s healthiest states — and is recognized as having one of the top health care systems — with a glaring exception: “Minnesota has the largest health disparities in the country,” says Okuyemi, “even larger than states where there is a deeper level of poverty. Yes, we have one of the best health care systems, but it doesn’t reach out to everyone.”

“It might not surprise you to learn that life expectancy for a black male living in urban D.C. is 59, while for a white male living 15 miles away in Potomac, Maryland, it’s 82,” says Jasjit Ahluwalia, M.D., M.P.H., executive director of the U’s Center for Health Equity. “But would it surprise you to learn that the life expectancy of people living in certain parts of northeast Minneapolis is 20 years fewer than for people who live 15 miles away in Wayzata?”

Critical mass

The number of scientists researching health disparities, designing programs to mitigate the problem, and influencing public policy to affect long-term change has reached a critical mass that has given the University of Minnesota gravitas in this area.

In the Medical School and beyond — in nursing, public health, pharmacy, and dentistry as well — dozens of projects are focused on eliminating the gap between the healthy and the unhealthy, and numerous community clinic partnerships are seeking to improve health care in underserved parts of Minnesota.

“The U is a great place for disparities research because of the growing infrastructure here,” says Katy Kozhimannil, Ph.D., an assistant professor in the School of Public Health, who studies health policy that affects reproductive-age women and their families. “It’s one thing to care about disparities, but another thing to effectively build organizations that can innovate around this problem.”

Badrinath Konety, M.D., M.B.A., is one of the innovators. Director of the U’s Institute for Prostate and Urologic Cancers, he leads the Center for Healthy African American Men through Partnerships (CHAAMPS), a pioneering new center that looks beyond physiological causes of disease to simultaneously explore environmental, behavioral, and psychosocial factors that contribute to much higher rates of disease and violent death for African American males.

“The fact that African American men suffer from disproportionately high rates of disease has been well documented,” says Konety, “but the conditions that lead to those diseases have gotten much less attention. Establishing strong community partners and developing ideas that float up from all of those partners will be key to our mission.”

Working with these partners — which so far include 100 Black Men Inc., the National USA Foundation, and the Minnesota Vikings with the National Football League — CHAAMPS’ investigators will design and implement programs to intervene with at-risk African American males of all ages, from elementary school on up, with the aim of improving living conditions, diets, family relationships, education related to critical health topics, and more.

“Impacting certain rates of cancer among African American males may be a longer haul,” says Konety, “but lowering the incidences of heart disease, violence, and prostate cancer? I think all of those are more immediately viable. We’re very optimistic that our collaborative approach will make a difference.” 

Confronting entrenched bias

By designing Clipper Clinics to go out into the community and confront the problem, Okuyemi’s team has acknowledged the deep-seated lack of trust that some people have for the medical establishment. But that’s just one of many challenges.

“There are serious issues of trust in the Native American and African American communities,” says Okuyemi, “but there are also issues of discrimination and bias, sometimes unintended, when some people access the health care system.”

Those are the much more troubling problems that elude easy fixes.

“Studies have shown that health care providers have implicit bias,” explains Okuyemi. “When it comes to pain, for instance, blacks and Latinos get different treatment than do whites. There seems to be a preconception that blacks have a higher tolerance for pain, and they’re prescribed pain meds at a lower rate.”

These types of implicit biases apparently take root as early as age 7, when, according to recent studies, children rating the severity of pain suffered for the same reason — say, getting a hand slammed in the door — assigned lower levels of pain to black children.

It’s a complicated issue, Ahluwalia says. “The problems are huge and entrenched. I’ve heard more than one doctor say, ‘My job is to be a doctor, not a social worker.’ It doesn’t mean they aren’t good doctors, but the truth is, we all need to work together as a team to break through these problems.”

A changing landscape

Building a more diverse medical work-force is just one part of the solution, he says — and the U is working on that as well (see sidebar).

Okuyemi, who recently got a grant to train doctoral candidates and postdocs in building successful diversified workforces, says, “The leaders here are doing something about that, but when we say, ‘We need more black and Latino doctors,’ it doesn’t start with the medical school application committee. Applicants need good grades in college, but they needed good grades in high school to get into college, and they needed the right direction and support in grade school to make them successful in high school. … You see how massive the problem really is.”

The problem may be daunting, agrees Ahluwalia, but he’s optimistic that he, and his many like-minded colleagues at the U, can help turn the tide. “This is my career passion, and I’ve been gratified to see the landscape here at the U change over the past eight years or so when it comes to focusing on disparities. But the issue of health equity has to become part of a national dialogue because, as a nation, what we value is equity, and what shames us is inequality.”

Published on February 25, 2015

Closing the gap

The Medical School offers several programs aimed at reducing health inequities by building a more diverse workforce, including:

  • an internship designed for minority students who are interested in medical careers;
  • Urban Community Ambulatory Medicine and MetroPAP clerkships, which bring students face-to-face with the underserved communities that suffer most from health disparities and encourages them to consider careers in urban primary care medicine;
  • the Center of American Indian and Minority Health on the Duluth campus, which helps Native American students pursue health care careers; and
  • the Minnesota’s Future Doctors program, which helps college-age students from communities under-represented in medicine prepare for admission to medical school.

Intervening on behalf of women

“A lot of health disparities can’t necessarily be remedied by traditional medicine,” says Katy Kozhimannil, Ph.D., an assistant professor in the School of Public Health who is passionate about her disparities work. She focuses most of her research on health policies that affect reproductive-age women and their families. This year, her research findings helped convince the Minnesota Legislature to pass a significant new public health policy allowing Medicaid dollars to pay for doula services for pregnant women. “We’ve learned that reducing disparities means intervening much further upstream, beginning with a healthy pregnancy and birth,” Kozhimannil says.