The Death Toll of Inequality: “Why Treat People Without Changing What Makes Them Sick?”

By Sahru Keiser, BCAction Program Associate of Education and Mobilization and Caitlin Carmody, BCAction Membership Coordinator

The most recent Cancer Facts and Figures 2011 from the American Cancer Society has a special section on cancer disparities and premature deaths that tells a troubling story of the least talked about cause of premature cancer deaths: inequality.

Between 1990 and 2007, cancer mortality rates decreased in the overall U.S. population—by 22% in men and 14% in women. In other words, 14-22% fewer of the people diagnosed with cancer are dying from the disease.1

However, not all segments of the U.S. population experienced this same decrease. Death rates for people with lower socioeconomic status showed little or no decrease in mortality rates and in some instances increased. And the decreases in cancer death rates for non-white populations occurred slower and later compared to white populations.2

Need a number to wrap your head around? Here it is: in 2007 (the last year for which these stats are available), 60,000 premature cancer deaths could have been avoided if everyone had the same death rates as the most educated whites.3

When it comes to breast cancer specifically, African American women continue to have a 39% higher death rate then white women, despite a lower incidence rate.4

In addition, although the incidence of breast cancer among Hispanic women is overall 27% lower than in Caucasian women, they are 20% more likely to die from the disease when diagnosed at a similar age and stage.5

This means that “the gap in mortality rates between advantaged and disadvantaged segments of the U.S. population has continued to widen.” More simply put: differences in breast cancer incidence and outcomes are evidently the result of broader, deeper social “inequities,” and in breast cancer, these inequities manifest for women of color and poor women in increased mortality rates. However, the question the report does not ask but should be asking is, why? And, what can we do about it?

The ACS’ Deputy Chief Medical Officer, Dr. Leonard Lichtenfeld concludes from this report that when it comes to increased cancer risk, “education trumps ethnicity.” He writes that: “[education] has a lot to do with our daily habits, our daily lives, whether or not we smoke, our risk of obesity and on and on.” However, historical, social, and political forces mean that we don’t all enjoy the same options when it comes to how we live our lives.

Focusing on a person’s degree of education places the burden of responsibility firmly on the shoulders of individuals rather than on the shoulders of those responsible for creating the health hazards in the first place. Equal access to education about healthy living will not fix inequality. It will not help you protect yourself from methyl iodide if you have to work in or live next to strawberry fields that are sprayed with pesticides. It will not help you eat safer fruits and vegetables if you struggle to make ends meet. And it will not help you get more physical activity if you do not have access to safe outdoor spaces. The responsibility to eliminate health risks lies not with individual self education; we need regulatory systemic changes to eliminate the risks in the first place.

Social determinants of health

Risk factors that increase or decrease our risk of disease are largely determined by the social conditions in which we live and work. These include, but are certainly not limited to:

  • Where we live. Low income communities, primarily communities of color, more often live near high-emission industrial facilities and military bases. These residentially segregated or “fenceline” communities typically experience higher levels of pollution and the associated negative health impacts (increased risk of developing cancer, asthma, etc.).
  • Health care access. Studies show that racism and discrimination is a strong determinant of health status.6  Lower quality healthcare, language and cultural barriers, as well as provider assumptions can lead to substandard care.
  • Socioeconomic status (SES):  This indicates a person’s position in the social structure and includes income, wealth, educational attainment, occupation and social status. The mechanisms through which SES are assumed to work relate to privilege, power and control.
  • Healthy lifestyle choices: Historical, social, economic, and political forces affect our lifestyle choices and inform our behavioral decisions around, for example, tobacco use, physical inactivity and poor diet.
  • Race/Ethnicity plays a significant role in determining our experiences in the world.  When linked to the other social determinants of health, our race and ethnicity often determine where we live, work, our access to health care and access to healthy lifestyle choices.

Given the recognition that the “the gap in mortality rates between advantaged and disadvantaged segments of the U.S. population has continued to widen,” we need to urgently address the social injustices related to the social determinants of health. The World Health Organization understands the importance of looking at the role social determinants of health play in health inequities: “why treat people without changing what makes them sick?”7

The field of public health is working hard to understand the full picture of health disparities.  Researchers continue to ask themselves what, why and how do we research the problem of health inequities in order to develop robust and multifaceted solutions that address all the potential factors – eliminating health inequities so we all enjoy good health. As long as organizations such as the ACS continue to propose solutions that are incomplete and continue to focus on the individual rather than addressing prevention head on, the gap in mortality rates between advantaged and disadvantaged segments of the U.S. population (i.e. women of color and low income women) will continue to widen.

Poverty and education not the only key to health disparities

Using educational attainment as an indicator for socioeconomic status (SES), the ACS found that persons with lower SES have a higher cancer burden compared to those with higher SES, regardless of race.8

But the picture is a bit more complex than they suggest.9 We know that poverty does not fully account for racial differences in health10  and within every level of socioeconomic status African-Americans typically have worse health than whites:11  “The development of chronic diseases and conditions, [such as cancer,] is affected by lifelong circumstances that are related to both socioeconomic status and race/ethnicity.”12  A retrospective review of medical records of breast cancer patients treated at one of the largest national public safety net hospitals found that African American women had both higher mortality and lower 7-year survival rates compared to white women of the same SES and health insurance status.13

When 33% and 29% of the African American and Hispanic populations, respectively, live in poverty, vs. 11% of whites, we can’t continue to separate race and socioeconomic status and address them as independent factors.14 We must look at these interconnected factors as part of a larger problem of social, economic and cultural inequities and ask questions that lead us to answers that increase our understanding of the relationship between the high percentage of communities of color in poverty and health inequities or the connection between residential segregation and inequities in breast cancer. Only by researching the answers to these complex questions will we develop the robust policy solutions we need.

What we are doing at Breast Cancer Action

At Breast Cancer Action we are committed to ending the breast cancer epidemic. The factors that contribute to inequities in breast cancer incidence and outcomes are complex but we believe they are a direct result of interrelated racial, economic, and social inequalities that are embedded within our society and impact a person’s “cancer experience” from cancer risk to cancer death. To truly address this problem of inequities in breast cancer, we need multifaceted, complex solutions.

We need a more complete understanding of the inequities in breast cancer incidence and outcomes which is why we are developing a task force comprised of thought leaders in the field of breast cancer with a focus on inequities. This task force will help us “map” what is known about inequities in breast cancer and help inform where there are gaps, overlaps and critical issues.  It will also help us understand the current approaches to addressing inequities in breast cancer and explore how BCAction can develop policy recommendations and other potential solution-based actions to help make an impact for systemic change.

We plan to work at the community level forming collaborations with organizations serving communities of color nationwide. These relationships will help BCAction understand the needs of underserved communities, inform us of the most pressing policy and advocacy issues, and enable us to provide culturally competent and relevant information to underserved communities who bear the burden of unjust outcomes when it comes to breast cancer.

Recently in a live Twitter chat someone asked former Executive Director Barbara Brenner if Breast Cancer Action was still “radical.” Her response was “radical means getting to the root of things, and therefore BCAction will always be radical.” Eliminating breast cancer inequities will require radical work, and BCAction is committed to doing that work.

Please consider giving a year-end donation today. Your gift will ensure that BCAction remains an independent voice and vital resource for everyone affected by breast cancer.

4 Cancer Facts & Figures for African Americans, 2011-2012. American Cancer Society.
5 Cancer Facts & Figures for Hispanics/Latinos, 2009-2011. American Cancer Society.
6 Williams, D.R. & Collins, C.  US Socioeconomic and Racial Differences in Health: Patterns and Explanations. Annual Review of Sociology, Vol. 21. (1995), pp. 349-386.
7 WHO website, http://www.who.int/social_determinants/tools/multimedia/posters/en/index.html, accessed 11/22/11.
9 Anderson, N.B., Bulatao, R.A. and Cohen, B. Critical Perspectives on Racial and Ethnic Differences in Health in Late Life (2004).
10 Rushing, B. et al. Race Differences in the effects of multiple roles on health: longitudinal evidence from a national sample of older men. Journal of Health and Social Behavior 33: 126-139
11 Williams, D.R. & Collins, C.  US Socioeconomic and Racial Differences in Health: Patterns and Explanations. Annual Review of Sociology, Vol. 21. (1995), pp. 349-386.
12 Anderson, N.B., Bulatao, R.A. and Cohen, B. Critical Perspectives on Racial and Ethnic Differences in Health in Late Life (2004).
13 Komenaka, et al, (2005). Race and Ethnicity and Breast Cancer Outcomes in an Underinsured Population. Journal of the National Cancer Institute. 2010; 102:1-10
14 Taylor & Repetti, Health Psychology: What is an unhealthy environment and how does it get under the skin. Annu. Rev.Psychol. 1997. 48:411-47.
The Source—Fall/Winter 2011 | 12.14.11© 2011, Breast Cancer Action ISSN #1993-2408, published quarterly by BCAction. Articles on detection and treatment do not constitute endorsements or medical advice but are intended solely to inform. Requested annual donation is $50, but no one is refused for lack of funds. “Breast Cancer Action”, “Think Before You Pink” and the BCAction logo are the registered trademarks of Breast Cancer Action. All rights reserved. Not to be used without express written permission.
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3 Responses to The Death Toll of Inequality: “Why Treat People Without Changing What Makes Them Sick?”

  1. glenn howard says:

    Reference 13 also states
    “…..effect of sociodemographic variables on breast cancer mortality. In that study, when sociodemographic factors were included in the multivariable model with stage, the hazard ratio of breast cancer–specific death for African Americans vs European Americans became null. In our study, employment status was the only sociodemographic factor that remained statistically significantly associated with breast cancer–
    specific survival in the multivariable model. When age and employment status were included in the model with stage and ER/PR status, the effect of ethnicity/race was further attenuated and no longer statistically significant.”

    It would appear that a major factor is treatment and detection of any disease is economic.

    In addition, it would be nice to see statistics from the same groups in Canada or Europe to determine if this si country related or universal.

    One wonders why the non-white asian groups in the same socioeconomic status are not in any studies, nor the hispanic.

  2. Catherine says:

    Actually, I believe that mortality from cancer has *not* declined in the past 20 years. Now we have mammography, which can diagnose DCIS (ductal carcinoma in situ). A large percentage of “breast cancer” found via mammography is DCIS, which is actually stage 0 (not even technically cancer) and has a 100% 10 year survival rate. This and other harmless cancers are being found now that we have the technology to do so, and counting theses as “cancer” completely skews the statistics on cancer mortality. If DCIS were not counted, I think we’d find breast cancer mortality is just as high, if not higher, than it was 15 or 20 years ago.

  3. Pingback: The Elixir – It Takes A Village To Heal – Uptown Collective

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