Eliseo Perez StablesM.D. is director of the National Institute on Minority Health and Health Disparities (NIMHD) at the National Institutes of Health (NIH). He sat down with WebMD to discuss the field of health disparities and how his research aims to improve interventions not only in clinical settings but throughout the community.
Editor's note: This interview has been edited for length and clarity.
WebMD: Health disparities are a relatively new field. What is its focus and purpose?
Perez Stables: In terms of health outcomes, poor people fare worse than people with more resources. Forty years ago, it was observed that African Americans and other groups, especially American Indians and Alaska Natives, had far worse outcomes when compared to the general population and the white American population. . In other words, preventable conditions exist, and it's not because someone has bad genes or behaves badly. It comes from identity factors, i.e. socio-demographic factors.
WebMD: What drew you to health disparities?
Perez Stables: About 40 years ago, when I was a medical resident, I noticed that my Latino/Hispanic patients responded differently to me. I felt this connection and bond. I asked, „What does it mean that I'm Latino?“ Is it because I'm fluent in Spanish? ” No, there were other things involved that led me to research this field.
It started with this patient-clinician communication model, language was a big part of it, and it evolved from there. It gradually expanded to all races and ethnicities and realized that in some cases the results were actually better than the typical results.
WebMD: Your institute funded research showing that ethnic and racial disparities are harming the United States Up to $451 billion annually. Break it down.
Perez Stables: Most of the costs to society come from premature deaths, or premature deaths, and we lose productivity in their jobs, families, and communities. The average woman in the United States lives into her early 80s, whereas a man's girlfriend is 2-3 years younger, so we know where we should be.
When people get sick and can't work or their work is restricted, that's a cost. Perhaps with proper intervention they could have worked another 5 or 10 years. People with high blood pressure can't control their blood pressure and have a stroke at age 60. They are still in their prime. Maybe you're thinking about retirement, but you're still working. You don't become a retiree in the same way after having a massive stroke.
Another area is excessive medical costs. When you get sick, you need further diagnosis and treatment. Prevention costs resources, but it could have cost less. For example, let's say your kidneys are failing and you need a transplant or dialysis. If you convert it regularly, it's tens of thousands of yen. Well, if he had taken certain medications, he might have been able to prevent kidney failure or delay it by 10 to 15 years.
WebMD: Are biological factors also at play?
Perez Stables: This includes biology because we are all living systems with biology and behavior. One important concept is race or ethnicity. There is no biological formula. There are several elements to it, and this is where people get confused.
For example, for 500 years Latin America was a region of mixed populations of people of African origin, indigenous peoples of the Americas, and European colonizers. Twenty generations later, there are now many different mixtures.
I believe that biological pathways, such as metabolic pathways that lead to diabetes, that may differ by socio-economic stressors and identity are still being understood. Why don't all really heavy people develop diabetes? Less than 50%. Some people don't know what their sensitivities are.
There are also genes that increase the risk of certain cancers. The breast cancer gene is probably the most famous. But there is actually a gene that protects against breast cancer, and it has only been found in women with indigenous backgrounds in Latin America.
WebMD: Your research shows that environment and living conditions influence gene expression. Could you please explain how it works?
Perez Stables: This is the field of social epigenomics. It's evolving. The epigenome concept includes changes that occur in genes due to external factors. The areas where this is most studied are cardiovascular health, asthma, maternal health, and a little bit of cancer.
For example, if you are under the age of 5 and you are very stressed because your family is dysfunctional, perhaps there is food insecurity, and in certain situations there is violence, these adverse events will affect your epigenome. will change, and this is probably where you will be in 30 years. I'm going to get sick. That's a hypothesis.
We see poor housing, lack of quality food, and lack of bonding with parents. These may have short-term effects, which are easier to investigate. But what will it mean in 30, 40 years? We don't keep that kind of data about people all the time, so it's really hard to study.
WebMD: how Community Engagement Alliance (CEAL) We recognized them for being at the forefront of addressing the diverse consequences of COVID-19 in underserved communities.
Perez Stables: In the summer of 2020, a study was conducted to test the Moderna vaccine. After his first month or so, 90% of his study volunteers were white. Dr. Francis Collins, former NIH director, said this is unacceptable.
We all discussed strategies. From these early conversations, he said, CEAL was born. We wanted to create infrastructure to revitalize the community. At first, we didn't know what the results would be, so we said, „Please participate in this clinical trial.“ When the vaccine was released in December (2020), we had to convince everyone to get vaccinated.
We have seen how bad conditions are for Black communities, Latinos, American Indians, and Native Hawaiians and Pacific Islanders. The number of deaths was two to three times the average, but by fall 2022, mortality rates had decreased overall and the gap had narrowed or disappeared. It was a success.
Although we are in the midst of a transition, CEAL continues as an infrastructure for community engagement and partnerships between community organizations and academic researchers to make a difference in community health. Masu. Currently, there are 21 teams across the country.
WebMD: I mentioned that some of the results were better. One of your areas of research shows that African Americans who engage in unhealthy behaviors are less likely to be depressed than whites and most Latinos. What factors may be at play?
Perez Stables: It has long been known that African Americans are less likely to be diagnosed with depression and are actually less likely to commit suicide. Latinos are somewhere in between. It's not as high as whites, but it's not as low as blacks either.
The idea is that instead of feeling depressed, you eat, drink, and smoke. When I first heard about this (the pioneering social research being done by James Jackson at the University of Michigan), I couldn't agree with it, and because there was no data for Latinos, I decided to test it. Common unhealthy behaviors may include a sedentary lifestyle, smoking, and drinking alcohol. Probably malnutrition is his fourth, but this is more difficult to measure.
Among Puerto Ricans, chronic stress does not lead to more depressive symptoms, but does tend to lead to more unhealthy behaviors, using the (Hispanic Community Health Study/Latino Survey). I did. However, Mexican Americans did not fit this model at all. (Two-thirds of Latinos in the United States have a Mexican background.) Stress made them more depressed and they engaged in even more unhealthy behaviors to cope.
It was not separated by gender because the sample size was not large enough to say anything about Cubans or Central Americans.
WebMD: Another focus for you is how Latino heritage and adaptation to American culture influence smoking behavior. Could you please expand it?
Perez Stables: I am Cuban myself. Cigarette smoking was much more prevalent in Cuba. In the United States, Latinos have lower rates of smoking. Again, US data is driven by Mexicans. The pattern for Cuban Americans and Puerto Ricans is more heavy smoking and higher rates of smoking. I think it's pretty consistent.
Well, Mexicans and Central Americans, and interestingly Dominicans, have much lower rates of smoking.
Generally, it is also influenced by social mobility. In general, women are more likely to smoke and men are less likely to smoke as they become more acculturated. Traditional gender roles for women in Latin American cultures may serve as a protective factor against tobacco and alcohol. That's one hypothesis.
For men in the United States, there are social environments where smoking is not necessarily as cool as it is in Latin America. The same thing can be seen among Chinese men who immigrate to the United States. Smoking rates were high when they were in China. They came to the United States and smoking rates dropped dramatically.
WebMD: What can patients and physicians do to ensure that all factors that drive health outcomes are considered and that the best care is received and provided?
Perez Stables: Sometimes clinicians don't do the best job, and that's not their fault. It's about understanding who the patient is in a social context, not something the system facilitates.
We know their age and gender. We usually know their racial and ethnic background. Sometimes people ask me where I'm from. The patient's place of origin is important, maybe not for many, but for some. Therefore, it is necessary to know that the patient has migrated to one part of the country, but his family is from another part. For immigrants, that matters.
And socio-economic status is often completely ignored in clinical care. If you at least know the patient's educational background, communication will be smoother and you will be able to understand where you need to be more specific or sophisticated depending on your educational background, and ask, „How far have you studied?“ It gives you the feeling that you are not threatening the patient. Do you go with school? ”
WebMD: We will be talking about the initiative “Understanding and Addressing the Impact of Structural Racism and Discrimination on Minority Health and Health Disparities.”
Perez-Stable: We funded 38 research grants. Most are observational, examining associations between constructs that lead to harmful outcomes. For example, we know that heart attack and transplant care is particularly bad in areas with fewer social resources.
Developing intervention studies takes time, and the NIH has committed resources to doing this using a community-based approach. Most will address issues such as access to affordable and healthy food, and how it can impact housing, green spaces, community violence and health care. The quality of education is also an issue, which is even more difficult.
Communities don't exist in isolation, so they need good health care, and the health system needs to know about the community, so it works both ways.