Endocrinology: Leptin Serves Body as Energy Signal Immunology: A Mechanism Discovered for Antibody Deployment Pathology: Tumor Suppressor Shows Another Way to Get Job Done Health Disparities: Symposium Explores Reasons and Remedies for Health Care Disparities Discovery Rewrites Text on Tendon Development P53 Relative May Confer Sensitivity to Cancer Drugs Targets Found in Worm Insulin Signaling Study Suggests Hypnosis May Benefit Wound Healing   Cambridge Health Alliance Names New CEO Howard Koh Urges Political Action in Public Health Alumni Week Preview New HMS Registrar Announced News Brief In Memoriam: Albert DeFriez   Students, Faculty Aid Refugee Families   Crossing Cultural Barriers a Patient at a Time   Front Page

HEALTH DISPARITIES Symposium Explores Reasons and Remedies for Health Care Disparities Americans may be exquisitely aware of the denial of basic human rights to the Kurds and other minority groups abroad, which has been depicted so vividly in the media. But they seem less conscious of the extent to which racial and ethnic minorities are denied access to basic necessities like health care in this country. "Everyone here has stressed the importance of the rigor of research," said Janice Cooper (right), shown with (from left) Joseph Betancourt, Dolores Acevedo-Garcia, S.V. Subramanian, and Nancy Krieger. (Photo by Suzanne Camarata) "Racial inequality shows up in every facet of American life--in schools, courts, housing, employment. And it certainly shows up in health," said Pedro Noguera, the Judith K. Dimon professor of communication at the Harvard Graduate School of Education. Recent studies show that these disparities go unnoticed not just by the vast majority of whites, but even by those who are most discriminated against. "Only 36 percent of African Americans believe disparities exist between health care for whites and for African Americans," said Kalahn Taylor Clark, the W.K. Kellogg fellow in health policy research at the John F. Kennedy School of Government. Noguera and Clark were among more than a dozen speakers at a symposium on health disparities research in the U.S. held on April 11 at HSPH. "Despite a longstanding awareness, the scientific study of racism and health is clearly still in its infancy." --Nancy Krieger Though participants were drawn from the Harvard faculty, the conference was the brainchild of a trio of students. Spurred by increasing evidence that racial disparities in health exist and the need to know why, the students had begun to meet informally with other students, but felt disconnected from the broader community. "We were definitely isolated," said Debra Perez, a PhD candidate in the interfaculty program in health policy at Harvard University. "We were doing research not knowing there were other students of color in other colleges doing this research, too." Perez--along with Carlotta Arthur, research fellow in the Department of Health and Social Behavior at HSPH, and Janice Cooper, a doctoral student in health policy at Harvard University--approached Rushika Fernandopulle, executive director of the interfaculty program for health systems improvement. Inspired by the publication of a recent Institute of Medicine report outlining health care inequities, Fernandopulle was looking for ways to address the problem. "Disparities research was on our agenda," he said. The idea for the symposium was born. One of the themes to emerge from the day-long event is that though strides have been made, the field of health disparities research faces many challenges. "Despite a longstanding awareness, the scientific study of racism and health is clearly still in its infancy," said Nancy Krieger, HSPH associate professor of public health in the Department of Health and Social Behavior. Researchers have been busy identifying racial disparities in health care by comparing the number of mammographies, immunizations, and bypass surgeries in African-American and white populations--findings that make up the body of the recent IOM report. But to get a better sense of why disparities exist, and what can be done about them, scientists need to take a harder look at one of their most basic variables--race. Measuring Race "The term race is commonly used but rarely studied," said Thomas LaVeist, of the Bloomberg School of Public Health at Johns Hopkins. "Race is some combination of biological and social factors, but what is the evidence for each? We need to figure that out and how to measure it." Many speakers agreed that one of the big challenges will be to sort the effects of race from those of class. Several years ago Ichiro Kawachi, working with HSPH colleague Bruce Kennedy, showed that states with the greatest economic disparities had the highest morbidity and mortality. Those same states--Louisiana, Mississippi, Alabama, Texas, and New York--are also areas where African Americans cluster. "What is accounting for the pattern--race or income inequality?" asked Kawachi, HSPH professor of health and social behavior. "It is both." The Seeds of Disparity Though clear-cut answers to the race-class dilemma are lacking, presenters offered tantalizing hints about what may go into the creation of health disparities. S. V. Subramanian, HSPH assistant professor of health and social behavior, surveyed more than 50,000 non-Hispanic blacks and whites living in various neighborhoods and found that blacks living in segregated metropolitan areas were most likely to report poor health--and they were more likely to do so than whites living in the same area. Dolores Acevedo-Garcia found that first-generation immigrants were less likely to start smoking than were their children, though intriguingly, children with two foreign-born parents were less likely to start than those with only one foreign-born parent. "We need to go beyond acculturation and language to explain the effect," said Acevedo-Garcia, HSPH assistant professor of health and social behavior. "We need to think more about mediating and modulating factors." One place researchers should go is into the clinical setting, said John Ayanian, HMS associate professor of medicine and health care policy. "How do systems of care create disparities?" he asked. In addition to being fragmented, hospitals and clinics are often characterized by a lack of coordination of care, poor information systems, and a lack of feedback to physicians. Perhaps most damaging of all, "there is a legacy of discrimination that is not often recognized by most health care providers, especially white health care providers," he said. "Disparities arise even when providers are well-intentioned." He described how physicians tend to regard white patients as more compliant and pleasant. Unfortunately, such expectations can become self-fulfilling. "Patients who are more satisfied with their treatment tend to adhere to their regimens," said Joseph Betancourt, HMS assistant professor of medicine at Massachusetts General Hospital. Courses in cultural competency might help to counter physician bias, though so far, there is no evidence that such courses change clinical outcomes. Another, and possibly more effective approach, is to add more minorities to the physician population. "We need to be more critically conscious about the pipeline," said Joan Reede, HMS dean for diversity and community partnership and associate professor of medicine. "What are the factors that hinder our minority students from choosing and pursuing medical careers? We need to see the factors that hinder medical students from staying and being promoted." --Misia Landau