Not Just Black And White

By Jeffrey G. Ghassemi
Washington Post Staff Writer
Tuesday, July 25, 2006

That health disparities exist between whites and blacks in the United States is widely recognized, with the latter group faring far worse on many major health outcomes. But some experts are calling new attention to a host of lesser-known differences within the black population that they say may help explain the nature of such disparities and offer new clues about how to address them.

A small but growing body of research shows health disparities between native-born blacks and foreign-born blacks living in the United States. Carlotta Arthur, a researcher in the Department of Afro-American Studies at Smith College, in Northampton, Mass., recently highlighted some of these differences in the Journal of Health Care for the Poor and Underserved. In a review article, she cites evidence that paints a better overall picture of health for foreign-born blacks than their U.S.-born counterparts -- at least initially.

Upon arrival, for instance, black immigrants have been shown to have lower rates of cardiovascular disease, cancer, hypertension, obesity and overall chronic medical conditions than U.S.-born blacks. Yet this robustness may drop with years of residence -- a concern for health researchers and immigrant advocacy groups alike.

"Much of the research out there doesn't bother to tease apart these differences among blacks," said Arthur. "But 'blacks' in this country are not a homogenous group," she said. "They include immigrants from Africa, Central and South America, and English-, French- and Dutch-speaking Caribbean nations, as well as people now known as African Americans."

Better understanding of such health disparities is critical to improving care and controlling health costs nationwide, says Raynard Kingston, deputy director of the National Institutes of Health (NIH).

Immigrants, mostly from the Caribbean and Africa, account for a large part of the growth in the country's black population over the past 25 years, Arthur writes in her review. In the Washington area, African immigrants account for 11 percent of the foreign-born population (the second highest concentration in the U.S.) and number close to 95,000, according to U.S. Census data. Immigrants from Ethiopia, Nigeria and Ghana comprise nearly 45 percent of that figure, found a 2003 Brookings Institution report. Adding black immigrants from outside Africa brings the estimated count of recent black immigrants to the Washington area to well over 100,000, according to some experts.

While the reasons for an initial immigrant health advantage are not entirely clear, one theory points to "selective migration" -- the idea that healthier people tend to migrate. Other theories credit higher education and socioeconomic status, lower-fat diets and tighter social networks of foreign-born blacks.

But Winston Price, immediate past president of the National Medical Association, an advocacy group for physicians and patients of African descent, fears the loss of these health advantages over time. He and other experts predict that the assimilation process and associated stresses may lead to a decline in health status, a finding consistent with data on other immigrant populations.

Another factor: obstacles to accessing health care. These may include an inability to speak English, a lack of health insurance and discrimination -- bias and stereotyping -- by health providers. "Whenever there are barriers to navigating the health care system, people will have poorer outcomes," said Price.

Vera Oye Yaa-Anna, vice president of the African Women's Cancer Awareness Association (AWCAA), a Maryland-based health advocacy group, agrees. Her experiences working with African immigrants suggest that many find the U.S. health care system daunting.

"I may not have hard numbers, but I come across these people every day who say, 'I have cancer. Where do I go? What do I do?' " Yaa-Anna said. "The U.S. health care system may be better than ours, but at home we have family to help us navigate it. Here, most of our people don't go for early screening because they are lost."

The AWCAA conducted its second annual walk-a-thon last Saturday in Wheaton to raise awareness and funds for its cancer outreach programs.

Some of the research reviewed by Arthur supports the concern over growing health risks, showing lower rates of cancer screenings for certain black immigrant groups compared with U.S.-born blacks. Black immigrants were also less likely than U.S.-born blacks to have a regular place to go to for health care. Some fear that if such patterns continue for black immigrants, along with the already dismal health of U.S.-born blacks, disparities between blacks and whites could grow even larger.

Data show that U.S. blacks generally lag far behind whites on many health measures. Death rates from heart disease, for example, are twice as high among blacks as whites, according to the National Center for Health Statistics. Similar gaps exist for obesity, cancer and infant mortality. Lower socioeconomic status among U.S. blacks as well as barriers to access (similar to the ones mentioned for black immigrants) contribute to the problem.

In response to current disparities and fears over future trends, some experts are calling for more research that looks beyond race to specific factors within it, such as ethnicity, class, sex and length of residence in the United States. They claim that understanding the differences within black communities can provide new ways of thinking about disparities and addressing populations at risk. According to Arthur, cultural differences might be addressed by printing health literature in many languages and promoting services that respect different belief systems. Other efforts could address social determinants of health care, like discrimination, psychological stress and economic issues.

"The same thing has already happened with other minority groups, including Latinos and Asians," Arthur said. "It's time to start doing it for the black population."

NIH's National Center for Minority Health and Disparities, established in 2000, has already begun to focus its research on this problem. Other institutions are conducting their own studies to address the issue.

Arthur applauds the move. "After all," she said, "we may have come here on different boats, but we're all in the same boat now." ยท

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