| There has been an endless struggle to
improve health; however, solutions have
been found for a majority of health
problems. Since the ninth century, for
example, life expectancy has remarkably
improved from 47 to 78 years; however,
not equally for all races and ethnic groups.
Despite remarkable technological breakthroughs
in the health care industry and
advancement in knowledge of social and
behavioral aspects of health care, health
status of populations remained far from
optimal, especially the underserved
socioeconomically disadvantaged and
racially and ethnically diverse populations. Diversity can be defined as “differences
among groups of people and individuals
based on ethnicity, race, socioeconomic
status, gender, exceptionalities, language,
religion, sexual orientation, and
geographical area.” Other frequently
mentioned parameters of diversity also
include “age, education level, and physical
disabilities.” The United States is a country
of diverse populations. About one-third of
the total population constitutes minorities.
Diversity in health is generally
concentrated on cultural and racial
variations. Although race and ethnicity are
the prime bases to describe health
disparity, health care providers must realize
that addressing cultural diversity goes
beyond superficially knowing the values,
beliefs, practices, and customs of African-
Americans, Asians, Hispanics/Latinos,
Native Americans /Alaskan natives and
Pacific Islanders. Apart from racial
classification and national origin, there are
many faces of cultural diversity as
described in its definition.  Health disparities are reflections of
overall health care quality, limitations,
and challenges. When it comes to good
health and good health care, far too many
Americans have been left out and left
behind. According to recent data,
Americans receive about half of the
recommended medical care for most
major illnesses. Minorities receive
significantly less and quality care and
disproportionately suffer from the burden
of disease. They live with health problems
and die sooner from wide variety of acute
and chronic diseases. For example,
African-Americans are more likely than
any other racial and ethnic group to
develop and die from certain cancers
than their white counterpart.
Hispanics in the United States are
50% more likely to develop diabetes.
Similarly, Native Americans have more
than twice the incidence of developing
diabetes than whites. Asian Americans
represent only 4% of the U.S. population,
but suffer more than half of the nation’s
chronic hepatitis-B. There are eight times
as many blacks as whites with AIDS.
Blacks are nearly twice as likely as whites
to die from diabetes. There is a higher
mortality rate due to breast and
endometrial cancer among African-
American females than white females. The most common and immediate
reasons for diversity in health factors
include genetic predisposition or other
biological factors. However, there are
very few genetic and biological
conditions responsible for health
diversity which can differentiate among
the people of different racial and ethnicThe most common and immediate
reasons for diversity in health factors
include genetic predisposition or other
biological factors. However, there are
very few genetic and biological
conditions responsible for health
diversity which can differentiate among
the people of different racial and ethnic groups. There are various other factors
clearly associated with health disparity,
including access to health care,
socioeconomic condition, health
insurance status, and cultural and
spiritual beliefs. More than 45 million
Americans do not have health insurance;
18% of Asians and Pacific Islanders, 20%
of African Americans, and 32% of
Hispanics are without health insurance
coverage. The uninsured are less likely to
have a source of medical care. Their
opportunities for routine screening,
recommended immunization, and
exposure to prevention programs such as
smoking cessation, physical activity,
lifestyle modification, and diet
management are reduced. Once health
insurance is interrupted, it could take a
while to reestablish services with another
provider. Even with health insurance,
minorities are less likely than whites to
receive adequate health care. They are
much less likely to receive diagnostic and
therapeutic intervention for the majority of
dreadful diseases. the United States is generally lower
compared to whites. According to a
recent report, the primary care physicians
of minorities are also less likely to be
board certified with limited resources and
specialty care facilities. Even the
difference of socioeconomic status
between the patient and provider has a
negative impact on the quality of care.
Biases and stereotyping among
physicians are evidenced in many studies.
According to some studies, physicians
were 40% less likely to recommend
cardiac catheterization for African-
Americans compared to whites; in fact,
heart-related health problems are more
prevalent among African-Americans. According to our recent survey among
the Hispanic population in Miami,
immigration status, language barrier, time,
and transportation factors were indicators
of poor health care access as well as poor
health outcomes. According to the U.S.
Census Report, 21 million people living in
the U.S. have no or limited English skills.
Around 12 million individuals live in a
linguistically isolated household in which
no person over the age of 14 speaks
English well. According to the study of
providers caring for non-English speaking
patients, over half of the providers
strongly believed that their patients did
not adhere to medical treatments because
of cultural and linguistic barriers. 
There is a need for fundamental change
in the health care system to solve this
problem. A number of studies indicate
that health insurance coverage would
dramatically reduce racial and ethnic
disparities in health care. The most
effective way to benefit minorities is
through the expansion of Medicaid and
the State Children’s Health Insurance
Program with improvement in eligibility
criteria. Efforts to eliminate disparities
must also be part of a broader effort to
improve the quality of care delivered to
the individual patient. The most
immediate need to improve treatment
outcomes for minorities is cultural
competence among health professionals,
especially by providing culturally
responsive and spiritually sensitive health
care practices and increasing the diversity
of the health workforce. To meet the
needs of culturally diverse groups, health
care providers must engage in the
process of becoming culturally
competent, defined as “a set of congruent
behaviors, attitudes, and policies that
come together in a system, agency, or
among professionals and enables that
system, agency, or those professionals to
work effectively in cross-cultural
situations.” Language access for
patients is one of the components of
cultural competence.
With increasing racial and ethnic
diversity in the United States, the
diversity of the health workforce has not
changed. African-Americans, Hispanics,
and Native Americans account for only
six to seven percent of health
professionals despite constituting almost
FALL 2005 21
one-third of the United States
population. This is because of poor
educational and economic opportunities
among minority populations. Various
studies show that minority health
professionals are more likely to care for
minority patients, including those that are
low-income and uninsured. Improving minority health and
eliminating racial and ethnic health
disparities also depend on the availability
of accurate health data by race and
ethnicity. It is also important to know how
vigorously the health promotion and
disease prevention programs are among
these communities. The federal
government should increase the budget
for these activities. Despite these facts,
for every health care dollar spent, less
than five cents goes to public health
programs. A weak public health
infrastructure, insufficient resources, and
a lack of coordination among agencies
and between the public and private
sectors are other issues that should be
addressed.
Diversity in the health care workforce
would improve the health status of
minorities and other economically and
socially disadvantaged populations. The
educational system preparing health care
professionals needs to take effective steps
to invest in cultural competence, workforce
diversity, minority data collection and
reporting, and overall public health. These
efforts should be aimed at improving
access and the quality of health care
facilities and establishing a patientcentered
health care system. Private health
care providers need not only to diversify
their health care structures and staffs but
also to motivate their staff to increase their
awareness, skill, knowledge, and desire to
treat patients from different cultural
backgrounds and to assess the needs and
quality of care given to diverse patients. It’s
no longer a dream but an expectation that
all Americans, regardless of skin color or
social status, have equal opportunity to
prevent and overcome disease and live
longer, happier, and healthier lives.
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Nasar U. Ahmed, Ph.D., is chair of the
Departement of Epidemiology and
Biostatistics in the Stempel School of
Public Health at Florida International
University. |
