Q&A: 'Time to get to work' on disparities in health care after decades of similar research

Americans belonging to racial, ethnic, or socioeconomic minority groups experienced a higher burden of stroke, according to results from the All of Us Research Program presented at the American Academy of Neurology Annual Meeting.

Julián N. Acosta, MD, a postdoctoral research fellow in the department of neurology at Yale School of Medicine, and the study’s other authors compiled data on stroke prevalence and incidence from the NIH’s All of Us Research Program, a large database for biomedical and demographic research from American participants. Acosta and colleagues focused on trends related to socioeconomic minority groups and also analyzed racial and ethnic demographics.

“Racial and ethnic differences in the risk for ischemic stroke and intracerebral hemorrhages are well established. Black, Hispanic, and Asian people have a greater risk for intracerebral hemorrhage risk than white people,” José Biller, MD, FACP, FAAN, FANA, FAHA, professor and chairperson of the department of neurology at Loyola University Chicago, said in response to the study.

“Compared to whites, Black individuals have an approximately two-fold increased risk for first-ever stroke,” Biller told Healio Neurology. “Rates of cerebral infarction are higher in African Americans and Hispanic Americans, specifically Latinos, than in whites, attributed in part to a higher prevalence of arterial hypertension and diabetes mellitus in these groups.”

Historically, Indigenous Americans and Pacific Islanders also have increased stroke incidence, but they were not included in the study, Biller noted. While presenting the study results, Acosta explained that the All of Us database does not yet provide such information.

Healio Neurology spoke with Biller to learn more about his perspective on the study results from Acosta and colleagues, with a focus on the racial and ethnic data.

Healio Neurology: What stood out to you in reading the results from Acosta and colleagues?

Biller: It seems to me that we are rediscovering what has been appreciated for a long time — that critical issues pertaining to health outcomes are proven to be rooted in differences of social status, income, ethnicity, gender, disability, sexual orientation, and more. There is research from the United Kingdom on this from 14 years ago and from the WHO from ten years ago. Another paper from ten years ago, which I contributed to, from the American Heart Association looked at racial and ethnic disparities in stroke care, specifically the American experience. It’s clear that these are important issues, but I think that the issue of poverty needs to be emphasized as well, and that is something that is notable all over the world. It's not just a phenomenon isolated to the United States. A position paper on poverty and health published by the American Academy of Family Physicians is very on target.

Healio Neurology: How important is it to determine the impact of biological factors vs. socioeconomic factors?

Biller: This is a very fundamental question, isn't it? If you look at the abstract from Acosta and colleagues, it is very important to note that the All of Us Research Program that was launched by the NIH in 2018 is expected to last at least ten years and include a million people or more who are living the United States who are willing to share their electronic health records. Besides their demographic database information, there will be a number of biomedical biological materials that will help us understand the importance of other issues that may account for these disparities, disparities that are clear and well known.

On the other hand, we know that there are differences in the distribution of the burden of risk factors. When it comes to stroke, we know that there are differences in stroke incidence and prevalence. We know that there are differences in mortality among different racial and ethnic groups. Furthermore, there are disparities in stroke care between these minority groups compared with whites. In the United States, this means Indigenous Americans, Alaskan Natives, Black individuals who are not of Hispanic origin, Hispanic individuals, including persons from Mexican, Puerto Rican, Cuban, Central, or South American origin, and Pacific Islanders or other ethnic groups that are underrepresented.

We are also talking about prevalence that is significantly higher among individuals who are older, disabled, and low income. We know that there is disparity in care for African Americans. We know also that the incidence of stroke increases with advancing age, but what we don’t have in the abstract is what all that means. For low-income individuals who are living in areas with food deserts where they are not able to easily access healthy food, as was mentioned in the media in a very eloquent way, that can account for the consumption of an unhealthy diet, which can lead to obesity, hypertension, diabetes, and other factors that can increase the risk for stroke and other conditions.

Acosta and colleagues found the stroke prevalence to be higher among Blacks, as well as older, disabled, and low-income individuals. When they looked at those who reported an incidence of stroke, which was from a smaller pool of participants, they found a rate of 2.6%. They also found that this was higher among Black and Hispanic individuals.

Healio Neurology: What is the take-home message and how does this affect clinical practice?

Biller: To me, the take-home message is that we have known about these issues over a long period of time, so the issue is not one of identification. We need to apply the proper solutions, which include education and equal access to health care. What appears to be very obvious is that regardless of limitations on definitions, racial and ethnic disparities in stroke still exist. As we wrote ten years ago, they include differences in biological determinants of disease and disparities throughout the continuum of care, including access to quality health care.

The other issue that is very important is that access to participation in research has been traditionally limited among minority groups. There are a number of explanations for that phenomenon; in the United States, for example, there were instances of people belonging to minority groups being deprived of available medications or proven treatments, or subjected to unethical practices. Clearly, this has been a major issue, and you can understand the hesitancy of these communities to participate in research. We need to acknowledge these disparities and we need to understand the factors that contribute to them. We need to do more research. To me, we need to be pragmatic and implement solutions to improve universal access to healthcare. I don't think that we can ignore what is known throughout the world about the impact of poverty in health.

What will be the predicted lifespan of a child born in Malawi compared to a child born in Japan? We know that information. Particularly during the COVID-19 pandemic, we are in one of the worst public health crises. We need to work together more than ever. You can see that the same issues of disparity with the availability of vaccines in rich countries versus poor countries. It seems that we are not learning the lessons that, to me, are the root and the cause of these issues. There is so much information that has been available to us for decades. This is a time to get to work to broaden healthcare access.

References:

Acosta J. Stroke disparities across racial and other minorities: Results from the “All of Us” research program. Presented at: American Academy of Neurology Annual Meeting; April 17-22, 2021 (virtual meeting).

Cruz-Flores S et al. Stroke. 2011;doi:10.1161/STR.0b013e3182213e24.

Czapp P, et al. Poverty and health - The family medicine perspective (position paper). Available at: https://www.aafp.org/about/policies/all/poverty-health.html#poverty. Accessed April 20, 2021.

UK Parliament POST. Ethnicity and health, January 2007. Available at: https://post.parliament.uk/research-briefings/post-pn-276/. Accessed April 20, 2021.

WHO. Rio political declaration on social determinants of health. Available at: https://www.who.int/sdhconference/declaration/en/. Accessed April 20, 2021.

60 Minutes. Racism's corrosive impact on the health of Black Americans. Available at: https://www.cbsnews.com/news/60-minutes-disease-black-americans-covid-19-2021-04-18/. Accessed April 27, 2021.