by Brenda Salgado
Here’s an alarming statistic: African American women are much more likely to die from breast cancer than white women, and the mortality gap has actually widened over the past 20 years. In 1980, breast cancer mortality rates were similar for both African American and white women. By 1990, African American women had a 16 percent higher mortality rate than white women, and by 2004 this difference had grown to 36 percent.
African American women are also more likely to be diagnosed with breast cancer at a younger age and at a later stage, and have more aggressive forms of the disease. These disturbing trends have led to a much-needed focus on why these differences exist and what can be done to alleviate them. Research has focused on screening rates, access to health care, treatment differences, and increasingly, genetic differences. While much of this research is important, it ignores other factors—social and economic injustices like poverty and racism—that also affect health outcomes. Are we missing the boat because our focus is not broad enough to capture all the things that matter?
Differences in health outcomes are often referred to as “disparities.” “Disparity” simply means “difference.” In the social justice and public health fields, discussions about eliminating these differences have already begun to focus on addressing the root causes in our social and physical environments. In the breast cancer world, however, research on disparities has focused primarily on genetics and personal behavior. BCA challenges this conventional approach to addressing breast cancer inequities. Eliminating differences in breast cancer incidence and outcomes requires us to look deeply and honestly at how issues of race, economic status, and political power—things outside an individual’s control—affect who enjoys good health and who does not, and whether or not communities are engaged in the decision-making processes that will ultimately affect their resources and overall health.
At the 2007 California Breast Cancer Research Program Symposium, David Williams of the Harvard School of Public Health talked about why we are missing the mark when it comes to improving health outcomes for African American women.1 So far, medical research has made insufficient progress in reducing health inequities, and in many cases they have increased despite all efforts. Williams made a strong case for charting a new course if we are to succeed. Different ways of thinking and innovative solutions are needed, or we will continue to see these inequities grow.
In his plenary speech at the symposium, Williams spoke of lessons learned from looking at racial health differences across a number of diseases, and how taking a broader approach is critical to our understanding of breast cancer inequities. Part of the problem of the current focus on genetics and personal behavior is that we are ignoring other factors such as social and economic conditions that potentially have a much bigger impact on health inequities.
Williams also shared the following information:
- In 2001, African Americans had higher death rates than whites for all 15 leading causes of death in the United States, including cancer.
- African Americans have elevated death rates compared to other racial groups at all ages of the life span.
- In 1998, occurrences of “excess death,” the number of people who die in the United States every year due to health disparities, exceeded 96,000 for African Americans. This equates to 265 people per day. His analogy: imagine a fully loaded jumbo jetliner crashing, where everyone aboard died, every day of the year.
- Public policies have both created and maintained racial segregation in the United States, and racial segregation plays a critical role in determining economic status, educational and employment opportunities, pathogenic living conditions, access to medical care, and the ability to eat well and engage in healthy behaviors.
- African Americans receive fewer medical procedures and lower quality medical care, even after controlling for health insurance, economic status, co-morbidities, severity of disease, and the type of medical facility.
- Infant mortality is highest for African Americans, regardless of the mother’s level of education or income. In fact, the overall infant mortality for African American women with the highest education and income levels is still worse than that of the most economically disadvantaged and least educated white mothers, pointing to serious implications of quality of life, stress, and racism.
Why does all this matter for breast cancer? Because, clearly, the inequities we see in breast cancer are not unique. They are part of a larger pattern that needs to be understood and addressed if progress is to be made.
As a health advocacy organization, BCA is committed to educating the breast cancer world about these inequities and to making sure they are addressed by policy makers and researchers. But we know it will take tremendous public pressure to push policy leaders to deeply examine the role that current public policy plays in creating and maintaining health inequities. We must look beyond the usual suspects of health care access and genetics to include the root causes of breast cancer.
This approach is not new in the field of public health, but clearly it is a conversation that is now entering the mainstream. This year, the documentary series “Unnatural Causes: Is Inequality Making Us Sick?” aired on public television stations around the country, along with resources, educational materials, and discussion guides.2 Community screenings and discussions based on the film are helping to reframe the debate about health in the United States.
Earlier in 2008 the Center for American Progress issued a related report, Geneticizing Disease: Implications for Racial Health Disparities.3 The authors tell the cautionary tale of BiDil, the first race-specific medication targeted at African Americans with heart failure, and the ethical, research, and funding controversies surrounding its approval. The report also makes the case that placing all our emphasis on treating disease once it has arisen will come at the cost of preventing disease from occurring in the first place.
The World Health Organization also released a report, Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health.4 The report states that the “toxic combination of bad policies, economics, and politics is, in large measure, responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible” and that “social injustice is killing people on a grand scale.”
If our world health leaders understand this, surely the leaders in breast cancer can too. Breast cancer advocates must demand that a portion of the resources currently dedicated to breast cancer “disparities” are used to address the social injustices that impact our health and to improve the social conditions of everyone in society. To be sure, many who profit from developing new treatments, biotechnologies, and genetic testing will not want to see this happen, which is why we must create the public pressure to make it happen.
Studying the genetics of African American women’s breast cancer is part of the puzzle, but it is simply not enough and may ultimately have the least impact in decreasing health inequities over time. It’s true that some new genetic research and biotechnologies have led to important medical advances, and we should not discourage these. But we must make sure that these new treatments and technologies also serve public health and do not undermine our efforts to create a more just and fair society.
If not, we will never eliminate that 36 percent difference in mortality for African American women with breast cancer. And it’s high time we did.
1 The Social Context of Breast Cancer: Evidence, Challenges, and Implications Symposium program:www.cbcrp.org/symposium/program/index.php. Scroll to the plenary session on Racial and Ethnic Disparities in Breast Cancer, to find links to David Williams’s slides and an audio file of his presentation.
2 For more information about “Unnatural Causes: Is Inequality Making Us Sick?” go towww.unnaturalcauses.org.
3 Jamie D. Brooks, et al., Geneticizing Disease: Implications for Racial Health Disparities, Center for American Progress, January 2008. Online atwww.americanprogress.org/issues/2008/01/geneticizing_disease.html.
4 Commission on Social Determinants of Health, Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health, World Health Organization, August 28, 2008. Online atwww.who.int/social_determinants/en/.
Take Action: Get informed about how inequities are linked to disease. Visitunnaturalcauses.org to watch clips from the PBS series exploring racial and socioeconomic inequalities in health. To learn more about how you can get involved in BCA’s work in this area, contact Brenda Salgado, program manager at 415.243.9301 ext. 15.