Disparities in Breast Cancer Deaths

A recent article in the New York Times highlighted the disparities in breast cancer survival for black women.   This is certainly not a new problem, nor is it the first time the issue has been written about, and yet the disparity persists.  Even though breast cancer is more common (has a higher incidence) in white women, it is more deadly for black women.  Almost 70% of white women diagnosed with breast cancer will reach the 5 year survival mark, whereas only 56% of black women will.  This difference can’t be explained away using biology either.  Even though the deadliest kind of breast cancer is more common in black women, it only represents 10% of diagnosed cases.

Female Breast Cancer Incidence and Death Rates (from Cancer.gov)

	Breast
Racial/Ethnic Group	Incidence	Death
All	127.8	25.5
African American/Black	118.3	33.8
Asian/Pacific Islander	89.0	12.6
Hispanic/Latino	89.3	16.1
American Indian/Alaska Native	69.8	16.1
White	132.5	25.0

Statistics are for 2000-2004, age-adjusted to the 2000 U.S. standard million population, and represent the number of new cases of invasive cancer and deaths per year per 100,000 women.*

 

In 2011, Whitman, Orsi and Hurlbert published “The racial disparity in breast cancer mortality in the 25 largest cities in the United States” in Cancer Epidemiology, which studied the breast cancer disparities in the 25 most populous US cities.  They found that eight cities had statistically significant disparities that were worse than the US as a whole which had a rate ratio of 1.4 (1.4 breast cancer deaths of black women for every 1 death for white women).  The eight cities were Memphis (2.09), Denver (1.74), Los Angeles (1.7), Houston (1.65), Chicago (1.61), Milwaukee (1.61), Boston (1.59), San Diego (1.49) and Dallas (1.48).  

Even though the issue of breast cancer disparities has been around for many years, this seems to be the first and only study looking into disparities are a local level.  These types of studies are important in reducing disparities as they generally get a response from local governments, media and communities.  After the study was published Chicago passed an ordinance to increase the distribution of cancer screening resources.  Moreover, the Senior Vice President for Strategic Planning at one of the largest hospital chains in Memphis convened a meeting with the study’s authors and other experts to brainstorm ways to reduce the disparity in the city at the top of the list.  Some other city and local newspapers covered the study while pointing out their own score (Denver, Houston).  

What Is Causing This Disparity?

The Whitman, Orsi and Hurlbert study found that median income and segregation were significantly related to a city’s rate ratio.  Which is no surprise as those tend to come up when studying all kinds of disparities.  Income is a huge social determinant of health - the World Health Organization (WHO) states that “higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health.”  Segregation generally results in a lack in access to health centers, doctors and hospitals. The farther doctors are, the longer an individual has to take off of work or the harder it is to find transportation - people of color tend to be the least able to get past these barriers.

What this all means is that black women generally get diagnosed with breast cancer at later stages than white women.  Once a cancer is at stage III or IV, the survival rate plummets (the relative 5 year survival rate for a woman diagnosed with stage 2 breast cancer is 93% whereas stage 3 and 4 are 72% and 22% respectively).  Black women also generally start their treatment later than white women.  Lack of access to care is not the only reason why black women tend to be diagnosed and received care later.  There is still a great deal of distrust of doctors and hospitals in black communities because of abuses like the Tuskegee syphilis experiment (where doctors studied the progression of syphilis in black men without telling them they had the disease or treating them for it).  A great book that looks at another example of how the medical establishment mistreated black patients is The Immortal Life of Henrietta Lacks.  

What Can We Do?

Tackling health disparities as an individual can often feel overwhelming, but there are things you can do, especially when it comes to supporting breast cancer screening and early treatment.  One of the biggest is to support health centers like Planned Parenthood which are often the best option for not only breast cancer screening, but also cervical cancer screening (another area where there is a disparity between black and white women).  Also, get involved with local politics and advocate for the equitable distribution of funds for health care and health centers.  

Long Term Unemployment and Mental Health

“Injustice anywhere is a threat to justice everywhere.” 

*Martin Luther King Jr.

In the news: Unemployment Benefits Cut

The current unemployment rate in the United States is 6.7% (December 2013), a rate that is down from the height of the Great Recession.  Unemployment benefits have been in the news because Congress failed to renew an aid program for the jobless. Roughly 1.3 million Americans lost their insurance benefits last month. States vary on the number of weeks an unemployed person receives benefits.

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Source: http://www.washingtonpost.com/blogs/wonkblog/wp/2013/12/20/unemployment-benefits-for-1-3-million-workers-expire-next-week-heres-what-you-should-know/

Long Term Unemployment

Most economists define chronic unemployment to be a period of unemployment lasting longer than six months. It is important to note when calculating most unemployment statistics, those that are underemployed or not actively searching for a job are not counted. In November 2013, the chronically unemployed made up 37% of total unemployed people. While the overall unemployment rate is lowering over time, the rate of the chronically unemployed remains stagnant.

For those that experience long periods of unemployment, it is more challenging to get a job. The reasons for this could be an outdated skill set or a possible employer’s bias to hire someone currently unemployed. The long-time unemployed tend to be people who worked in manufacturing or construction and are older. Many companies do not look at the resumes of the long-term unemployed.

Source: http://www.motherjones.com/politics/2013/12/longterm-unemployment-recession-charts

Long-term Unemployment and Mental Health

People that are unemployed understand the stress associated with joblessness. The process of looking for a job, in many cases, is much harder than the jobs itself. No income, high levels of uncertainty, and limited health insurance is terrifying. WBEZ (Chicago Public Media) had a segment about the emotional expense of unemployment. This conversation went beyond the financial toll of unemployment to the impact of mental health. Chronic unemployment is associated with higher rates of depression and suicide.

In 2011 the CDC found that suicide rates rise when the economy is bad. The federal government statistics on suicide released in May 2013 showed a 28% increase in suicides for 35-64 year olds between 1999 and 2000. The unemployment rate peaked in 2009. Researchers find that those who are looking for work are about twice as likely to end their lives as those who have jobs.  As economic stress increases, the incidence of anxiety disorders increase. To add to the pain of losing a job, most people quickly lose health insurance. Without health insurance, it is expensive to see a doctor or mental health provider. The Affordable Care Act might help people obtain health insurance in the future. It is important to point out that unemployment and suicide are not causal but rather correlated factors.

Back to that funding cut

Long term unemployment is a serious problem and not just for the economy. Long-term joblessness is a serious risk factor for suicide and depression. Much of the national discussion about unemployment benefits are centered on time limits - the number of weeks of unemployment benefits available for the newly unemployed. However, placing time limits on unemployment benefits is hurting the group of people who have the hardest time finding employment - the long-term unemployed. In many cases, unemployment benefits are not handouts, they are lifelines. The link between unemployment and mental health must be discussed and not stigmatized. I urge Congress to renew spending for unemployment programs. In honor of Martin Luther King Jr., if you see injustice somewhere do something. Contact your Representatives and Senators and let them know how you feel.

Water = Life

Early on Thursday, residents of Charleston, West Virginia began to notice a licorice smell in the air because of a chemical spill in the Elk River. Since then, nearly 300,000 people have been unable to use their tap water for fear of being exposed 4-methylcyclohexane methanol, a chemical used to process coal that can cause skin and eye irritation, nausea and vomiting.  Though experts say that the chemical isn’t lethal, they admit to not knowing much about the chemical and it’s effects on people’s health.  

Thankfully, the National Guard and other emergency aid agencies have been able to distribute bottled water to residents of the affected counties.  However, there has been some worry about price gouging to the point that the State Attorney General encouraged citizens to report anything they noticed.  Many West Virginia residents are frustrated with the situation as well as the company that spilled the chemical and rightly so. Citizens in West Virginia are undoubtedly suffering because of this chemical spill.  Not only those who have been exposed to the toxin and gotten sick because of it, but also the wage workers in the counties that have been shut down.  Many people in the service industry (like waiters) are out of work until restaurants, hotels, and stores open again.  These tend to be the people who can least afford to go without wages.

The Benefits of Clean Water

We in the United States often take water for granted.  Most of us have never experienced a drought, a disaster that cuts off water, or a chemical spill like the one in the Elk River.  Getting the water we need has always been a simple matter of turning on a faucet, so we don’t always appreciate how important water is for life.  We need water …

1.) to live - water plays an essential part in the work our cells do to keep us alive which is why people can generally only survive 3 days without water.

2.) for sanitation purposes - without an adequate water supply, sanitation suffers and disease spreads.

3.) for personal hygiene - think about it - showers, hand washing and brushing your teeth all require water.

When people don’t drink enough water, the health consequences are myriad - from headaches, constipation, and kidney stones to dehydration (which means you don’t have enough fluid to get blood to your organs).  If you have to drink unclear water you could suffer non-fatal issues like those in West Virginia or you could contract a water borne illness like dysentery and hepatitis A.

Who Doesn’t Have Access to Clean Water

It is estimated that currently 1 billion people worldwide do not have access to clean water and that each year 3.4 million people die because of it (Water Facts - Water.org).  Most of the people without access to clean water live in Africa and the Middle East which not only compromises their health, but also keeps them from rising out of poverty.  This is especially true in Africa, where many people (mostly women) have to walk 3 hours both ways to collect unclean water for their families.  “The United Nations estimates that Sub-Saharan Africa alone loses 40 billion hours per year collecting water; that's the same as a whole year's worth of labor by France's entire workforce!” (Poverty In Africa Begins With A Lack of Clean Water)

What Can We Take From the West Virginia Water Crisis

As with most things, we can use this disaster to do something positive.  Below are some ideas on how to do so.

1.) Finally get your 3 day  to 2 week supply of water that FEMA recommends in case of emergencies

2.) Start conserving water by turning off the faucet while brushing your teeth, not throwing away water, shortening your showers, etc

3.) Donate to organizations that help people around the world without access to clean water.  The Water Project is a good one.

Happy New Year! (And an ObamaCare update!)

Happy New Year! Welcome to 2014, a year that is sure to bring many new twists and turns to the Affordable Care Act. Most people agree that the rollout of ObamaCare (starting October 1, 2013) was flawed. But it is a new year so let’s reflect on ObamaCare in 2013 and anticipate ObamaCare in 2014.

Here is a quick summary

The Affordable Care Act (ACA) was signed into law on March 23, 2010 and it still remains the law (although some people think it is has been repealed). 

During the writing of the law and the constitutionality hearings regarding the law, some things got messy. For example, some states opted out of expanding Medicaid and states had the option to run their own “Health Insurance Exchanges” or let the federal government take control of the insurance enrollment process. Sometime in 2010, Republicans started calling the ACA ObamaCare with a negative connotation.

Flash forward to 2012, Obama embraced the the term and the ACA is now called ObamaCare. I just wanted to clear that up. Affordable Care Act = ACA = ObamaCare.

October 1, the “Health Insurance Exchanges” opened and the previously uninsured started shopping for an insurance policy. Or that was the plan. In reality, major technology glitches for the federally run insurance exchanges and most state run insurance exchanges prevented people from signing up for insurance.

New things that started January 1, 2014

Parts of ObamaCare that went into effect on January 1:

1. The start of coverage for people who signed up for ObamaCare. For those individuals (nearly 2 million)  who signed up for insurance and paid their first premium between October 1 and December 24, coverage started on January 1, 2014. For those individuals who live in states that expanded Medicaid, coverage also started January 1.
2. Coverage for people with pre-existing conditions. Starting in 2014, insurance companies cannot deny coverage for individuals with preexisting conditions.
3. The individual mandate. The individual mandate is the part of the law that requires individuals get health insurance or pay a fine. In 2014 the fine for not being insured is $95 or 1% of income, whichever amount is higher. The fine will raise each year. The White House has issued several hardship exemptions for those who insurance is deemed too expensive or who experience unique situations. A huge group of people who will fall into this category are those in the states that did not expand Medicaid. In those states, people ‘make too much money’ to qualify for Medicaid but not enough money to qualify for tax credits to purchase insurance on the insurance exchange marketplace, can file a hardship exemption.
4. Minimum insurance benefits. From now on, insurance policies have to cover preventative services and other health services defined in the law. Which is why some insurance policies were cancelled.

What to wait for in 2014

1. A functioning website. Marketplace.gov as well as the insurance exchanges the state-run exchanges seem to be working. But, hey, anything could happen. A golden rule in my life is if the success of something is 110% dependent on functioning technology, be cautious. This isn’t pessimism, people, it is reality.
   
2. Enrolling enough people. The White House wants to enroll 7 million people by the end of March 2014. About 2 million have enrolled. Based on the interest people have in obtaining health insurance, I think this is a reachable goal. But it will take a lot of website functionality and work.
3. Payment of premiums. To get coverage with ObamaCare insurance options, the individual has to pay their premium. Many people that are signing up for ObamaCare insurance have never had insurance and a premium might be a new (and scary) concept. Not many people are discussing this point, so maybe I am worried over nothing. In full disclosure, I work at a Federally Qualified Health Center and am in this thing everyday with patients.
4. Formal proof of insurance from insurance companies. The process of signing up for insurance has a lot of moving parts - the human needs to correctly determine income and correctly fill out the online application for the insurance marketplace, the insurance marketplace has to do some sort of fancy identity check, the marketplace has to talk to the insurance company, and the insurance company has to contact the human. In 2014, we will hear both success stories and horror stories.
5. Will insurance = Health? We will have to wait much longer than 2014 to answer this but it is the huge question. Will Insurance improve health? Insurance alone certainly does not save money nationally or improve individual health. Obtaining an insurance policy is only a small part of overall well-being.

As you can see, 2013 was a big year for ObamaCare but 2014 will be even bigger.