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Race vs. Place

Christopher Myers

Race vs. Place 

LaVeist knew that to move the health disparities discourse beyond a biological conceptualization of race, to consider instead the role of place, he had to create a methodologically sound survey that might yield such data. The Exploring Health Disparities in Integrated Communities (EHDIC) study is an effort to take race and standard socioeconomic differences such as income out of the health disparities picture and to investigate the following hypothesis: If people live in the equivalent of an urban war zone, is everyone a casualty?

The analogy isn’t so far-fetched. Roland J. Thorpe Jr., PhD, an assistant scientist who worked on the study with LaVeist and fellow Center colleagues Darrell Gaskin, PhD, and Tiffany Gary-Webb, PhD, often uses military examples to illustrate the indiscriminate effects of environment. “You have whites and blacks over in Iraq fighting a war. When they come back home, the rates of whites with PTSD and blacks with PTSD are the same. Because they’ve been in the same environment together,” says Thorpe.

“You can’t make someone who is black into someone white.  But you can modify environments,” says health policy expert Sara Bleich.

LaVeist saw EHDIC as a prototype and a gamble: To propose research that might contradict long-held notions that environment, not biology, was the root cause of health disparities could have career-damaging consequences if the numbers didn’t pan out. “It’s risky to think outside the box. It truly is. Suppose I do the study and it shows disparities are no different than in the previously done national studies? How do I even get that published?” asks LaVeist. He chose to attack the problem with a meticulous, conservative methodology. His goal was to mimic NHIS’ data collection rigor to safeguard his results.

“It’s always been my practice to use very traditional research methods to study nontraditional, unconventional questions,” he says. “If I use the same techniques you are using, then you might not like my results, but to say my study is invalid, you’d have to say your own study is invalid.”

Originally, LaVeist thought he’d have to leave Baltimore to find a census tract that would meet his methodological requirements, but then the area sandwiched between Washington Village and the Union Square area popped up on the radar. With nearly equal levels of blacks and whites (51 percent and 44 percent), and nearly identical median incomes ($24,002) and high school graduation rates (just over 20 percent), the area was fertile territory for data mining.

In the summer of 2003, with funding from the National Center for Minority Health and Health Disparities and the Pfizer Corporation, surveyors canvassed the area. Each of the 1,489 respondents was asked identical health behavior and status questions as on the 2003 NHIS questionnaire, along with other psychosocial queries designed to measure potential stressors including perceived race and gender discrimination, access to social support, and feelings about medical care. Environment, including general conditions of homes and nearby vacant properties, was noted, as were physical factors such as blood pressure, body mass index, cigarette smoking and alcohol consumption.

For three years, LaVeist and his team crunched the numbers. In 2007 they published their first findings in the Journal of Urban Health. The results turned some of NHIS’ data inside out. When it came to rates of obesity, inactivity and drinking, blacks and whites in the survey area were the same. These findings contradicted the national data that adjusted for socioeconomic status; they showed blacks to have significantly higher odds of being obese and significantly lower odds of drinking.

Since then, additional studies have expanded on EHDIC’s original findings. In 2008, Roland Thorpe found that the difference in hypertension rates between blacks and whites examined in EHDIC was nearly a third lower than that measured by the National Health and Nutrition Examination Survey that adjusted for socioeconomic status. In a 2009 Journal of General Internal Medicine article, LaVeist, Thorpe and others used EHDIC to show that rates of diabetes in blacks and whites were comparable, whereas NHIS showed that African Americans were far more likely than whites to contract the disease. Obesity rates comparing African-American and Caucasian women in the EHDIC study are also being culled by Sara Bleich, PhD, an assistant professor in Health Policy and Management, to see if the trend toward shrinking racial disparities holds true.

LaVeist sees these studies as moving toward a critical mass that could tilt possible policy solutions away from medical investigations of inherent biological differences between races, a concept LaVeist vehemently rejects. He agrees with colleague Darrell Gaskin, who uses sickle cell anemia as an example of a disease that many view as an illness solely affecting African Americans. In fact, it’s a regional disease found in parts of the world where the sickle cell trait developed to ward off malaria. This includes Greece, South America and other areas outside of Africa. “There are whites with sickle cell disease,” notes LaVeist.

The medicalization of health disparities grew out of national studies completed prior to EHDIC, he says. When those studies had been adjusted for socioeconomic differences and found large racial disparities in health status, LaVeist says the medical conclusion was, “It must be genetic.”

“But what is that gene that produces these outcomes?” he asks. “The solution isn’t isolating some gene that’s somehow producing diabetes and heart disease and obesity and stroke and homicide … all of which to me seems unlikely. Maybe the solution is that we need to understand the social and perhaps the behavioral factors that are accounting for these differences.”

Josef Coresh, MD, PhD ’92, MHS ’92, a cardiovascular epidemiologist who has focused on genetic and non-genetic biomarkers of disease, sees LaVeist’s work as complementing biomarker studies. As an example, he cites extensive efforts to parse the causes of the up to four-fold higher rates of kidney failure among African Americans, a line of research begun more than 20 years ago by Paul Whelton, MD, and Dean Michael J. Klag, MD, MPH ’87. Linda Kao, PhD ’99, MHS ’97, an associate professor in Epidemiology, and others discovered that a mutation in the MYH9 gene made people twice as likely to develop non-diabetic kidney failure. African Americans were far more likely to have the mutation than whites (60 percent vs. 4 percent). Overall, this difference is estimated to account for 70 percent of the excess risk of non-diabetic kidney failure in African Americans. 

  

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