It took Ala Stanford Frey 18 years of training to become a paediatric surgeon. It took a month of violence to get her involved in examining why ethnic minorities have more diseases and injuries than the majority population. Frey, one of only two female African American paediatric surgeons in the United States, was raised by a single mother in impoverished and crime-ridden North Philadelphia, Pennsylvania. She returned to Philadelphia in 2006, wanting to give something back to the community. She thought her contributions would come through surgery. Then the shootings escalated.
"So many people were being shot — two to three a day in September 2006," she says. Some would return for follow-ups after surgery; many wouldn't, because they lacked health insurance or feared questioning by police. Those fears jeopardized the patients' long-term health, Frey says. She expressed her concerns to the dean of the medical school at Temple University, where she worked, and was told that such occurrences were part of a bigger picture. "He said this was a health-disparity issue," Frey recalls.
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Temple University: working on health issues for minority groups.
Dramatic example
A disproportionate rate of gunshot injuries in a minority community is a dramatic example of public-health disparity, and it isn't the only one. Latinos and African Americans together make up just over a quarter of the US population of 300 million, but diabetes and some forms of cancer and heart disease strike these groups almost twice as much as the general population.
Focusing on minorities: Ala Stanford Frey (top) and Maria Rosario Araneta.
Many minority researchers want to investigate health problems facing their own communities. Funding from the National Center on Minority Health and Health Disparities in Bethesda, Maryland, is helping them establish centres of excellence and research collaborations. Scientists who follow these paths are finding rich multidisciplinary opportunities, including researching genetic and molecular differences among races, conducting clinical trials that capture under-represented groups, and studying aspects of behaviour and environment affecting minority health.
Bernard Miller, a researcher at Washington University in St Louis, Missouri, and a participant in the National Institutes of Health (NIH) minority network, is looking at the roles of both behaviour and biology in diabetes. When Miller went to Washington University as a fellow, he worked with Sam Klein, who was studying triglycerides and fatty acids. Miller noticed "black and white differences" — literally — in metabolism. African Americans in the study had more difficulty in clearing fatty acids and triglycerides. Those differences could lead to obesity and diabetes.
Miller says that, overall, there is ample funding for diabetes research in the United States. But he adds that the NIH often directs money towards molecular mechanisms, when it should focus on ways to combat obesity and investigate metabolism — issues that seem specific to minority populations. Miller is comparing majority and minority groups with diabetes and seeing how both react to medical and lifestyle interventions.
Maria Rosario Araneta, a diabetes researcher at the University of San Diego, California, is also investigating the differences in diabetes, but among people of her own Filipino ethnicity. Their rate of type-2 diabetes is even higher than among African Americans — even in populations not considered obese. "Biologically, we're very different," she says. Comparing a study on Filipinos with the results of an earlier, broader longitudinal study on diet and health, she noticed that type-2 diabetes occurred four times more often in normal-weight Filipinos compared with Caucasians. At a conference, Araneta heard about a group of relatively thin diabetic Filipino men at a US veteran hospital. "It baffled me, because most of the other diabetes patients were obese," says Araneta. It is stranger still, she says, given that they have access to care — a peculiarity that deserves further investigation. Many health researchers cite lack of access to health care as a major factor in disease disparities.
Although Araneta receives funding from the NIH, she's had difficulty obtaining grants to investigate the Filipino population. One grant response called the Filipino cohort "a low-impact population" and added that the same health information could be obtained from studying the Japanese population. Araneta says the two groups have enough cultural and genetic differences to warrant separate study.
Apart from differences in disease prevalence, minority groups sometimes disproportionately experience complications. Leonor Nunez, a researcher at Duke University Medical Center in Durham, North Carolina, says that some researchers, minority and otherwise, are finding genetic markers that provide clues to differences in disease pathology. She has noticed that Hispanic people with diabetes have a higher incidence of retinopathy and wonders whether there is a biological or genetic basis for this.
Filling the ranks
TEMPLE UNIV.
Raul Dela Cadena supports work on health disparities.
Enrolling minority patients in clinical trials can be difficult because some groups distrust the US medical community. Some Latinos worry that their immigration status will be questioned; many African Americans remember the 40-year Tuskegee experiment, in which doctors withheld treatment from African American men with syphilis to study how the disease progressed.
Having minority scientists involved in clinical trials can help. But there are not enough to go around. Filipinos are roughly as likely as the average population to be doctors; Latinos and African Americans much less so. Historically black colleges and universities, founded before desegregation laws that came into effect in 1964, are attempting to address that. Sandra Harris-Hooker, director of the minority biomedical research support programme at Morehouse School of Medicine in Atlanta, Georgia, says that Morehouse focuses on training physicians in health-disparities issues and so far doesn't have enough of its own researchers to build a strong research programme. To combat that, Morehouse is establishing ties to other universities.
"Because we're small, we do better if we collaborate both internally and externally," Harris-Hooker says. Collaborations have included neuroscience and cardiovascular research with Emory University and Georgia Institute of Technology both in Atlanta, Georgia, and work on cancer with the University of Alabama in Birmingham. Still, with less than 1% of the NIH's budget devoted to health disparities (see 'Slow progress on research funding'), these aren't enough to close the gap between minority groups and the general population, she says.
Jada Bussey-Jones, an assistant professor of medicine at Emory University, believes the patient–doctor relationship is part of the problem. She is researching minority perceptions of physicians and is writing curricula to help train doctors working with minorities. Perception needs to shift on both sides, she says. "No one wants to be called a racist, but experience might colour the lens in which we see the world or a patient."
George Littleton, associate dean of the graduate school at Howard University in Washington DC, says that minority researchers are making a difference by asking questions about health disparities that others might not ask. But differences in rates of high blood pressure, obesity, diabetes and prostate cancer are too prevalent to be addressed by minority scientists alone — even though historically black colleges and universities, such as Howard, are trying to train more.
"I would like to say that these young black kids are going to go into the community and make a difference," Littleton says. "But we need everybody."
Slow progress on research funding
US organizations wishing to hire minority biomedical researchers face a battle after years of flat government research funding.
Tiffany Gary, an epidemiologist at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, had ample publicly funded opportunities as an undergraduate. But many of the programmes for which she served as a mentor haven't contacted her for follow-up information or new assignments.
Foundations such as the Howard Hughes Medical Institute (HHMI) still offer minority mentorships. And although Elizabeth Ofili, associate dean of clinical research at the Morehouse School of Medicine in Atlanta, Georgia, notes that funding is tight, institutions specializing in minority education find ways to do more research. Morehouse has gained two or three researchers a year via National Institutes of Health (NIH) career-development awards. And the university works with non-minority doctors, as long as 30% of their patients are from minority groups.
Temple University in Philadelphia is using the NIH's R25 programme, which gives short-term training and emphasizes minorities in health research. Last summer, 14 Temple students took part. "We need to educate the principal investigators to use their research to focus on areas that may be related to health disparity," says Raul Dela Cadena, an assistant dean at Temple's medical school.
Elizabeth Ofili: infrastructure needed.
R25 is a feeder into another NIH programme for postdocs, the T32 grants. Universities like them because they bring in research funding. Leonor Corsino, a fellow at Duke University Medical Center in Durham, North Carolina, used a T32 to secure her current post and her school received a supplement for hiring someone from a minority group. Duke's minority recruitment and retention committee are what attracted Corsino: "People here at Duke were really interested in getting a minority in the department." But other Latino researchers are few and there are no African American fellows. That doesn't look likely to change, unless funding for minority training and recruitment increase.
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