buenos dias. good morning mi gente,how are you? welcome to the makinglatino health count forum. my name is mariana mcdonaldand i'm here representing with my co-chairdr. ken dominguez. wave your hand please,thank you [laughter]. the cdc atsdr latino/hispanichealth work group. we start today's workby sharing a little bit of our extraordinarily richand diverse latino culture.
so why do we do this? understanding culturalexpressions of latino traditions,values, and beliefs is an area of great importance forhealth professionals seeking to improve latino/hispanichealth. with the growth anddiversification of us latino populations, thishas become an urgent task. public health andmedical professionals, in order to be culturallycompetent in interactions
with hispanic populations,need to understand and appreciate how latinocultural expressions are not entertainment to be consumed, but instead representcore aspects of identity and behaviors. for these reasons we opentoday's event with an expression of the vibrant and resilientcultures that are the voice of latino/hispanicpeople's aspirations, hopes, and realities.
you may not know that aprilis national poetry month; happy national poetrymonth [laughter]. we had hoped to have thecountry's first latino poet laureate juan felipe herrerawith us today, but his requirements being in that position duringnational poetry month made that not possible. so today i'm goingto read to you from en espaã±ol decimos declamar,
a poem by cuban poetnicolã¡s guillã©n. known as the national poet ofcuba, guillã©n was born july 10, 1902 and died july 16 1989. he was a poet, journalist,political activist, and writer. an afro decedent, guillã©n workexpresses a personal account of the cultures, thestruggles, hopes, and cultural vitalityof afro-cubans. his poem, tengo, which we'llhear from first in spanish and then english, is theexuberant declaration
of the many joys andaccomplishments a humble person, a black man encounters in his transformedhomeland, his beloved cuba. tengo. cuando me veo y tocoyo, juan sin nada no mã¡s ayer, y hoy juan con todo,y hoy con todo, vuelvo los ojos, miro,me veo y toco y me pregunto cã³mo ha podidoser. tengo, vamos a ver,
tengo el gusto de andar por mipaãs, dueã±o de cuanto hay en ã©l, 'mirando bien de cerca lo queantes no tuve ni podãa tener. zafra puedo decir,monte puedo decir, ciudad puedo decir,ejercito decir, ya mãos para siempre y tuyos,nuestros, y un ancho resplandor de rayo,estrella, flor. tengo, vamos a ver,tengo el gusto de ir yo, campesino, obrero, gentesimple,
tengo el gusto de ir(es un ejemplo) a un banco y hablar con eladministrador, no en inglã©s, no en seã±or, sino decirle compaã±ero come sedice en espaã±ol. tengo, vamos a ver,que siendo un negro nadie me puede deterner a la puerta de un dancing o deun bar. o bien en la carpeta de un hotelgritarme que no hay pieza, una mãnima pieza y no una piezacolossal,
una pequeã±a pieza donde yo puedadescansar. tengo que como tengo la tierratengo el mar, no country, no jailã¡if,no tennis y no yacht, sino de playa en playa y ola enola, gigante azul abiertodemocrã¡tico: en fin, el mar. tengo, vamos a ver,que ya aprendã a leer, a contar,tengo que ya aprendã a escribir y a pensary a reir. tengo que ya tengodonde trabajar
y ganarlo que me tengo que comer. tengo, vamos a ver,tengo lo que tenãa que tener. [ applause ] i have, when i look at and touchmyself, i, juan, only yesterday with nothing and juanwith everything today. i glanced around. i look and see and touch myself and wonder how itcould've happened.
i have, let's see, i have thepleasure of walking my country, the owner of all there is in it, examining at very closerange what i could not and did not have before. i can say sugar cane. i can say mountain. i can say army. army say, now mineforever and yours, ours, and the vast splendor of thesun bean, the star, the flower.
i have, let's see, i have thepleasure of going, me a peasant, a worker, a simple man. i have the pleasure of going,just an example, to a bank and speaking to the managernot in english, not in sir, but in companero, aswe say in spanish. i have, let's see, that beingblack i can be stopped by no one at the door of a dancing hallor bar or even at the desk of a hotel, have someone yellat me there are no rooms, a small room and notone that's immense.
a tiny room where i might rest. i have that having theland, i have the sea. no country clubs. no high life. no tennis and no yachts, butfrom beach to beach and wave on wave, gigantic, blue, open,democratic, in short; the sea. i have, let's see, that i havelearned to read, to count. i have that i have learned towrite and to think and to laugh. i have that now i havea place to earn and work
and earn what i have to eat. i have, let's see, i havewhat was coming to me. thank you. >> while our speakers join usat the dais, i would just like to say again toecho mariana's comment; welcome to our publichealth ethics symposium. this is the second oneand we are very excited to have the secondannual symposium. my name is jo valentine andi am the associate director
for health equity in thedivision of std prevention and it is great, with greathonor and privilege that i get to speak to you this morningand act as a moderator for a very distinguished panel,which i won't do too much about the moderating, excepttry to remember them about time. that will be my main role. so in the interest oftime, what i'm going to do is introduce everybodyinitially and sort of disappear from the dais andleave it to our speakers
to move through the program. i would first like tointroduce dr. leandris liburd. i ask, you know what wouldi say about each of them when i was introducingthem and i don't like really readingbios to people. you can read those for yourself, but at least i can say i havea very personal relationship with most of the folks here. so i'm very excited to beable to say that working
with leandris hasbeen an incredible and wonderful opportunity. i've known her for a longtime and i'll tell you, she's a true champion ofhealth equity and the reduction of health disparities. so it is really anhonor to introduce her. dr. ruben warren, i knew hisname long before i ever knew him and now i'm reallyprivileged and honored to be the project officerfor his project looking
at the apology commemorative andexpanding public health ethics at tuskegee university and i just think it's awonderful opportunity again to work with himon this new effort of the public healthethics symposium that we have nowbeen planning for, like i said the second year. so welcome dr. rubenwarren to the cdc or, because he is returning.
he's retired cdc, sowelcoming him back to cdc. and then dr. fermin, who i havenot, just met this morning so i don't get to havemuch to say here in terms of a long term relationship, but i know that the workgoing forward at tuskegee, we will have much morecontact and again, i want to welcome you to cdc. and he is a professorat tuskegee university. and finally, but certainlynot least, miss carmen veare,
whom i first met when she wasan intern at the center for hiv, std, and tb preventionand we found out we were social workers. so yes, cdc does hiresocial workers [laughter]. we're sort of undercoverand people don't really know that we're around, butlook at where we are. i'm a social worker andcarmen is a social worker and that we bondedimmediately that way. so it's really excitingto see her now.
she's the chief of staff forour agency and for dr. fermin and it's a great honor andprivilege you're with us today. so again, i'm going to turnit over now to dr. liburd and please speakersif you'll just come to podium accordingto the program. >> thank you jo andgood morning again. i'm so glad to see all of youhere and on behalf of the office of minority health and healthequity, we are very excited to welcome you to the secondpublic health ethics forum
that's co-sponsored by ouroffice, by tuskegee university, by morehouse school ofmedicine, the division of sexually transmitted diseasesand the national center for hiv and aids, viral hepatitis,std, and tb prevention. the cdc atsdr latino/hispanichealth work group and also our national partners that are the hispanic servinghealth profession schools, the national alliancefor hispanic health, and the national hispanicmedical association.
the hispanic servinghealth profession schools, and the national hispanicmedical association have long histories working with cdcand other federal agencies who advance hispanic health. these national organizationshave been at the forefront for decades in advocatingfor greater attention to many of the issues that will beaddressed and raised today as well as working to ensurethat there is a diverse, culturally competent, andwell prepared public health
and healthcare workforce. i also want to acknowledgeand thank dr. ruben warren and the role that he andtuskegee university play in leading the workon behalf of racial and ethnic minority populationsto achieve health equity as well as ensuring that thereis an ethical practice of public health. many of you are on ourcampus for the first time and we are honoredby your participation
in this historic forum. we want to especiallyacknowledge and greet the minister ofinternational relations for the dominican republic, dr.sanchez-cardenas and dr. fermin who is the provost at tuskegeeuniversity and you will hear from both of them today. today's forum is also part of our national minorityhealth month celebration. this year's theme for nationalminority health month is
accelerating healthequity for the nation. health equity is definedby the department of health and human services as theattainment of the highest level of health for our people. but there's a subtext to that, which i think is particularlyimportant to highlight and that is that achievinghealth equity requires valuing everyone equally with focusedand ongoing societal efforts to address avoidableinequalities.
historical and contemporaryinjustices and the elimination of health and healthcaredisparities. the contributionof public health in attaining thehighest level of health for all people is grounded inour ability to collect, analyze, interpret, and reportaccurate and useful data, which is then used to informdecisions about how to protect and promote the population'shealth. and so as our nation is becomingincreasingly more diverse,
the data that wecollect must keep pace with not only changingdemographics, but also be sensitiveto the historical and contemporaryexperiences of communities that help shape opportunitiesfor the best health possible. so why are we here? well last year cdc releasedits first hispanic health vital signs report andyou will hear more about this report during oneof the panel discussions.
we were able to documentdifferences in health profiles between hispanic and latinopopulations in the us. today we hope to build upon thisexperience by exploring data and its implications forthe promotion and protection of hispanic health through thelens of public health ethics. at the end of the day, we hopethe information exchanged will broaden opportunities to reducehealth disparities among latinos and hispanics and then eachof you will take away ideas for specific contributions yourrespective organizations can
make to advance andaccelerate the achievement of health equity in the us. seated among you todayare representatives from federal health agencies,academic institutions, community based organizations,foundations, and cdc programs. please don't leave today withoutmeeting at least 10 people that you didn't knowbefore you came. they might just be thepartner you've been looking for to take your work toimprove hispanic health
to the next level. while our focus todayis on hispanic health, i believe that working togetherin this way across racial and ethnic groups, we allcan attain the highest level so thanks for being here andi look forward to meeting you. >> good morning again. i put my folder down onthis high tech technology and the slides start flowing. so forgive me, youcan take them back.
thank you so much for being hereand i want to, in the interest of time, just take a fewminutes, maybe seconds, to tell you why we'rehere, why i'm here. one hundred and one years ago, a man called booker twashington looked at the health of black americans throughoutthe country and said to himself and to others we need tofocus on the health of those in greatest need and atthis point in time, 1915, it happened to beafrican americans.
one hundred years later,as we sat and talked about this wonderful monthcalled minority health month, this wonderful month callednational public health month, we looked and saidwhat populations are disproportionately suffering theburden of preventable diseases, conditions, and guess what? the african americanpopulation is still disproportionately suffered. not only did that populationsuffer, other populations
of color suffered fromneedless preventable diseases and conditions. so i, we decide tocelebrate 100 years of booker t washington'slife and legacy and at tuskegee we said we'll do that by retracing whatbooker t washington did over his lifetime. not honoring his death,but honoring his life and we picked a differentvenue, a different activity
where he made his contributionsand low and behold, health was one of them. so we've reached out to cdc because that reallyis the agency that promotes healthpromotion, disease prevention, in my view more than the other,and we talked with a colleague, dr. excuse me, missjo valentine. and we decided, idecided to work with her to celebrate that month.
she said that's not big enough. so we contacted dr. liburdand now we've got a forum that really celebrates minorityhealth month, every population that fits within that rubric. and what we're here to dotoday, as we did last year, was to give you a differentlens to look through. we've looked through the lensof epidemiology, biostatistics, health services and industries,all of those disciplines in public health trying toeliminate health disparities
so that we can then fullycelebrate health equity. and it hadn't workedregardless of what you say, the data tell usit has not worked. so we're here to lookthrough those same issues through a different lens, a lenscalled public health ethics. not bioethics, whichis an important part of this conversation,but public health ethics. how do we look atpopulation issues? how do we look at issues
of not just justice,but social justice? how do we look at issues of notbenevolence, but magnificence? how do we do that? this conversation is tofurther that exploration. last year we hada wonderful time. we had a wonderfulconversation and some of the audience said well whatabout other people of color? we said you're right. we had planned it, but quitefrankly the message came
from the community whereit should always come from. and so this year wedecided to work every week to make this forum possible. so you're going tohear some things that you haven't heardbefore or some things that you heard beforeand maybe didn't believe or some things you'veheard before, believed, and wanted to hear again. you'll hear all of thosethings today plus even more.
look around, find somebody newor somebody you didn't know, find somebody you already knewand have that conversation. we're going to have a good time. this is a time to learn anddo and have a good time. i'm excited and i lookforward to talking with you throughout the day. welcome and thankyou for being here. i stepped away and step back. that's how spirit works.
when i, when we, when i talkedwith my friend and colleague, dr. fermin about thisyear's effort in latino/hispanic health,he went on to tell me about the many, manythings that's he's doing, he's been doing andwanted to do. and i said just don't tell me,dr. fermin, let's tell the world and the best place to talkabout health promotion, disease prevention, andinteraction is at cdc and that's just my bias.
so i said why don't we come andhave you come and share some of the exciting thingsthat you're doing because this is anopportunity and i might talk about what's goingon in this country, but what's going on globally. an opportunity to talkabout health promotion, disease prevention globallyin opposed to talking about disease, which isa globally phenomenon. so dr. fermin said i'd beexciting about doing this
and a matter of facti have a colleague who may also be interested incoming, but let me put the hat on that he wears or thehats on that he wears. professor of biology, well accomplishedbiomedical scientist, provost vice presidentand most importantly, cesar fermin is a friend. dr. fermin, please join us. >> good morning.
time to wake up. as dr. warren just saymy name is cesar fermin and it gives me greatpleasure to be here. first of all, to thanksuzie for hosting this. i know that bioethicshas a lot to do with it, but you've made it possible forthis and appreciate that and i bring you greetings onbehalf of our seventh president, brian johnson from tuskegeeuniversity, which after eight and a half years there, i cometo learn that it is a shrine,
that university, it's a shrineof knowledge and a beacon of hope for the world. and those of us whoare inside is better, no offense to thosewho are outside. so i've been in theunited states, i'm from the dominican republic,and so is vice minister sanchez. i've been here over fouryears hacking the system, working like crazy toget tenure and so on, but this is probablythe most exciting day
of my life even though as you know i was justcommencement speaker at a very large university, but this is really theconsummation of my sacrifice. to be at a place where ourpeople, hispanics, are seen as, not as a victim,but as a population that is being overlooked. now dr. warren and i have oftenheated discussions and arguments and many people think i'mtough, because i am tough.
i don't take excuses,but we agree on one thing and that is we like things thathelp our brothers and sisters. he challenged me, as hesaid a few minutes ago, a little bit more than he say, to start a conversationthis morning. so i am not goingto be telling you that i'm a philosopher,because i'm not. as he says, i biologist. i don't mean to be a preacherbecause i've never been one,
but i want to show you a fewthings that i think are going to start a conversation andthe first thing that i'm going to show you is that i assumethis is, oh it says right here. i assume that the challenge isgoing to be to convince those of you who are notchallenged yet, to understand what dr.warren just said, it's real. it's with us. it's not just a utopia. now someone he knows very well,
his name is dr. delorisalexander, the director of our very successfulintegrated bioscience phd program send thisto me and i love it because it just showsthe problem. we know clearly and those ofyou who remember separate, but equal can quickly seethe problem right here. alright? and god knowsthat we're equal. as you know, only 1% of the genome determines whetherwe are white, black, yellow,
blue, have kinky hair, straighthair, blue eye, brown eye, 1%. the rest 99% join us asbrothers and sisters, but we always ignore the 99%. so i start my conversation withthis and what you can read, which i'm not goingto read to you; it's okay to understandthe problems and if you can afford it,you can have a choice, but the problem is whenyou don't have a choice and you can afford it.
now what qualifies meto be talking to you and challenging youthis morning? well this little house thatyou see here are the ends, this works? anyway, as i sayaqui vivio cesar. it says cesar lived here. we were eight children, twoparents, and that house is less than 200 square feet of space. no running water.
no lights and that fellow on theright hand side is sitting next to the only latrine that we had. that's what i went tojunior high school. so that is my qualification. it's not my five patents,my three diplomas, and all the othergarbage that i've done, but the fact i know what i'mtelling you because i lived it. and as you will hear frommy colleague and friend, which is my lostand found brother,
i just met him lessthan a year ago. he is going to showyou statistics, how the government is finally, and i feel so exhilarated isaddressing these issues. so i'm not showing you this soyou could feel bad about me, because you've seen whati've done, i'm provost at one of the most prestigiousuniversities in the world and i didn't buythat by the way. but to show you that i'mqualified to talk to you
about the problems thatwe are addressing today in this conference. now, you might say butwe are all educated. we know what the problems are. of course we are. anyone of you remember this? how many years it tookfor us to accept the fact that cigarettes cause cancer? so that doesn't have to berepeated anymore, right?
yet business, theadvertisement on some of the most prominentmagazines of the time and i didn't show youeverything, but there are many from famous people such aspresident regan, smoking and say if you don't smokeyou're not important. so the point is, that knowingthe issues, which you do and i thank the cdc forputting out all the stuff that it's putting out, is not yet addressing thematter at the heart of it.
and the reason is becauseby the time that the people who are affected learn whatthe problem is, it passed and has already damaged, done. i don't know how manyof you agree with that? alright? so whathas happened to us? and again, i'm not aphilosopher, but i want, my hobby is followingthis topic for many years and my source is consumerreports because for 35 years that i bought it, i havenever seen them providing any
bias reports. now this is from a book thati read when i was 14 years old that i found in thetrash in spanish, that is called salud y vigor porla alimentacãon, which is health and strength and biggerfor, by nutrition. this is 1956 and the bookis about 100 pages long and it tells you everythingyou need to do to stay healthy and the bottom line is eatwell, drink a lot of water, and stay away from trouble.
so on the right,what do we have? is it, last week sunday'snewspaper, alright and please understand thatwe know that there are people that cannot control weight forhormonal issues and hereditary matters, that's not an issue, but what has happenedbetween 1956 and 2006? you see this recruit beingand the army being screened and you have a brother onthe, the only brother up there and he doesn't lookoverweight and none
of the other[inaudible]looks overweight. now look on the right. so what happened to us? the issue that we areaddressing today here, we are not reaching the peoplewho are suffering even though, thanks to god, wealso have our director of health disparities institutestarting a whole new wave of attacking the problems. but we are not reachingthe masses and why?
well because the messageis hidden, convoluted and sometimes not, isintentional but it is targeted and i'm going to use twoexamples to demonstrate to you my theory, which maybe crazy and you can say that guy shouldn't be provost because he doesn't knowwhat he's talking about. the first one is how aninternational decision can lead to such a mess. when i came here in 1974,our peso was almost equal
to one dollar and thatwas based exclusively on sugar cane production. then enter corn syrupand corn subsidies. now, what do you have? we have now the developmentof the fastest and the most dangerousdiabetes causing agent in this country; corn syrup. why? because it is a straightsubstance that can be absorbed through the mucous membrane ofthe gi from the time you put it
in your mouth to thetime it goes out. the mucous can absorbit and in doing so, it doesn't use any energy. we're not going through abiochemistry class here, but you know that there issomething called energy; atp and to break thingsup, you need to use atp. so you can look it up. walk to wikipedia [laughter]. so now our peso isdevaluated to the point
that it took the government, thanks god to the newgovernment, a huge measures and policy, public policy, social justice changes [inaudible] to bring this about. meanwhile, the damage isdone, which is what i say. so now our peso is devaluated,all of the dominicans that have stayed thereand worked, get a family, and get education has togo to new york and miami to clean toilets and dr.sanchez is going to talk
about it this afternoon,so don't miss it. and again, now you go to the dominican republicand what do you find? take a guess, in the streets? burger king, mcdonalds,jack in the box, and what is demonstratedright here. you can buy this, you canget this at cdc and nah, it's up to 10, but youcan see what happened. what i just say.
so refined sugar which comes from sugar cane was slowlycoming down and syrup goes up and with it goes diabetes,obesity, and all the issues that we see now with childrenless than 10 years old already with type two diabetes. so are we reachingthe target population? no and here it is,the same issue. obesity percentagein direct proportion to the productionof high corn syrup.
that's not the only reason, but it's certainlyone of the main one. so why is this happening? because it is a drivenby profits, not driven by publicpolicy and social justice. that's why it's happening andi'm not saying that we're going to forget money because wecan't do anything without money. i just drove here from tuskegeeand i had to put gas in the car and so how many of you rememberuntil michelle obama got
in the case and got the adson out of the television just about a year ago there was abunch of ads; sugars is sugars, it doesn't matter what they are. do you remember that? it was all over thenewspapers, all over the news. but it's not, look atthe sweetened level of each one of these sweeteners. it's not the same and again,it says there the sucrose, which is sugar cane andhigh fructose are the same,
but i just told you it takes twoatp molecules to break sucrose into fructose and [inaudible]. okay? and you can lookit up on wikipedia. now, you don't believe me? there's a store intuskegee, a main street of tuskegee is a discount store. there are two, two grocery storeand dr. [inaudible] can attest to this, that sells greenstuff that grows in the ground. the rest is this,which is the color,
sugar water that gives youa high of about 10 minutes and then you have togo and get some more because there's nomore energy to go. so that is my conclusionfor my first point on how we have profit,drive the message that we don't reach the targetpopulation, and we do reach them when it's already too late. my second point is, youalready saw this, is i'm going to talk about my own issue.
i was diagnosed three yearsago with prostate cancer, which will happento every old man. you get something calledhyperplasia dysplasia and then the uro justwant to rip you apart because it will makeyou feel better. well, this on the left isthe number of documents, you can see how thick it is. look at cesar's,from top to bottom, that i as a scientist read fromthe nih, wikipedia, anywhere,
cdc and after reading more than10,000 pages the conclusion was that no, i don't have asolution to make on this case because none of thisinterventions offer any hope. so why was so hard for meto read all that stuff? because the way in which we try to teach the populationis convoluted. look at this, advil, two pills. the same pill, the samecontent, two different colors, and they have different prices.
so what is the target? is the pain of the patient oris the profit of the company? here it is another example. so you finish working twohours digging holes in the yard for a rich person goes geton the train, go to mcdonalds and see these choices and youonly have five bucks to spend. what are you going to do? and dr. sanchez cardenas is goingto talk to you a little bit about the governmentis doing down there
to make sure this doesn't happen down there even though we cannotstop mcdonalds from going there. and then i inviteeach one of you to read this most incrediblywork because it's very, very challenging and youmight think the guy is crazy, but it has a verygood point and that is that we are sanitizingthe message that is[inaudible]straight and sanitize. good example fromconsumer report; viagra.
what does viagra do? it stimulates somethingcalled nitrous oxide that expands the blood vesselin organs like the penis that makes it large whenyou have circulation and you know whatdoes the same thing? a very high [inaudible] of arginine amino acid. one can be patent, theother one cannot be patent. and then the last problem, i'malmost finished don't worry, is what we tell people andwhat the health system think.
i'm working 35 yearsin hospital. i'm not an md, but i'min hospital 35 years. you see here what the doctorthink and what a patient think. when consumer report asks thepatients the same question and asked the doctor,you can see how the start of the disparityis at that level. what they think they areaccomplishing is not what they're accomplishing. and then of course, this is mylast slide, you can see i am 65.
so i'm now getting readyfor medicare stuff. listen, it was easyfor me to get a phd to understand all this stuff,so how come my mom or my brother who doesn't even understandwhat hmo is make an informed decision? and there i feel sorryfor the, now the director of health disparity because howcan he possibly reverse this in a short time? it's going to take some times.
so what have we, thecurrent state is basically that our educationalis convoluted. the messages are verysanitized and is wrong. what we learn is that itwould be critical for us to begin reachingthe k-12 pipeline. it has to start that early. we cannot wait until theguy is 15 to tell him that having sex is goingto make a person pregnant and also infected.
it has to start when theyare six or seven years old. now what is missing? well we're going to have toadopt and adopt some practices that we might not wantto do and with that, i conclude my challengeto the audience to begin this conferenceand i hope that i didn't bore you to death. and do we have timefor questions? we don't have time forquestions, but we can --
okay, you want me tosummarize the talk? okay. i didn't know -- i didn't know i wassupposed to give my talk in spanish, but i could. if you want me to do itagain, i can do it in spanish. [ laughter ] >> thank you dr. fermin forthat great presentation. i want to say again,i'm carmen veare
and i'm the chief ofstaff here at cdc. i grew up in losangeles and will say that i have never seena waffle taco before in my life nor eaten one. so that was reallyenlightening for me. anyway, thank you. i have two jobs today; oneis to welcome you to cdc and the second is to introduceour honorable speaker today. so let me welcomeyou formally to cdc.
thank you for coming on a fridayto visit us here in atlanta, if you're not from here. we, i am so excitedabout today's event. i have to say that thepartners have been thanked. i want to thank them allagain, especially tuskegee for helping us bring thewhole group together. we have the nationalhispanic medical association. we have hispanic serving healthprofessional service schools and the national alliancefor hispanic health
and tuskegee universityand morehouse. i really do want to saythat this, for me personally and for the agency, isreally an exciting day. so thank you. thank you all. i also want to bringgreetings from dr. fredin, who i know if he was herewould be jumping up in his seat and asking a lot of questions,not only about diabetes and obesity and things thatwere just touched upon,
but also i know whatwe're going to hear from our guest speakerin a second. so i bring greetings from him. i also just want to say todr. liburd and her office that i have worked atcdc now for a long time, i'm not going to, as youheard from jo and the things and efforts that sheis pulling together in her office are historicalin nature for this agency and i really just wantto say thank you to her
and her leadership and toall of you who are not, some of you i know are partof her office, but part of cdc for supporting herin that endeavor and really giving usthis space, i think, for all of our scientistsand folks who are invested in these issues to reallycome forward and allow some of this good work to happen. we still have a long way to go. we know that and that's one
of the main reasonswhy we're here today. i have to say, when i came tocdc, omb was in the process of trying to figure out how to change their datacollection categories for race and ethnicity and coming fromthe west coast, i have to say that i really grew up and i didn't really knowwhat a hispanic was. i had never really heardthat word and when i came out here i had to look itup because i was americana
or a chicana or latina. i had all of those labels, buti had never heard this word. so great, it makes it alot easier in some regards to group us all together,but i think as we saw and as dr. liburdmentioned in our vital signs on hispanic health, which reallyyou're going to hear from some of the authors andcoordinators of that piece and i really do need togive a shout out to them, not only did they do a greattime on a first ever publication
on hispanic health, but theyalso just a few weeks ago won a cdc honor award fortheir efforts and so i think we should -- anyway, but what we did see from that report arethere are differences in our outcomes, obviously because we'reall a little bit different from different places. we may have grown up in notonly different countries,
but different partsof the united states with different values. in my case, i also have ajapanese mother, so i identify as hispanic, but alsoidentify as asian and what does that make me when we thinkabout data collection? i will tell you my raceofficially could be white or could be asian and wheni fill out those forms, i'm not ever sure whatto do and i'm sure i mess up the statistics becausei check multiple boxes
and i'm sure people arevery, very confused, but this is why we're here and this is why theseissues are so important. we, i have the honor andthe pleasure of being at many importantmeetings in my job. i get to meet really cool peopleand really highly educated and high achievers all the time. and it's a privilegeand an honor and i have to say i see dr. richardson here,she's on our advisory committee
to the director and we were justin all day meeting yesterday with some of the best leaders inpublic health that i've ever met and the most inspiringpeople that are out there doing publichealth work, but today, for me personally andi think for this agency and when we think about healthfor hispanics, but for everyone. especially as itrelates to social justice and social welfare, we,today is more exciting than yesterday was,for me personally
because these are hard issues that we don't alwaystake time to address. and it's really easy whenwe're publishing a paper or we're collectingdata or we are trying to make a statementto look at hispanics. it makes it's easier that way,but we're not all the same. the health outcomes we knownow are not all the same and this is our challenge;how do we do this in a way that makes sense,that delineates
and identifies the problemsso that folks at universities or other places in the communitycan target their research or their interventionsappropriately? how do we do this in a waythat is fair and ethical? and i really want to thank allof you for being here today to address these criticalissues in public health and health more broadly. so thank you for being here. thank you for the opportunityto greet you and my second job,
as i said when i started, isto introduce our guest speaker. i haven't had the pleasureof meeting dr. pã©rez-stable, but i do want to saycongratulations on his position and that he is our directorof the national institute of minority health andhealth disparities at nih. probably more so than cdc andnih collects a lot of data and these issuesare critical to how that data gets not onlylooked at and analyzed, but presented to the public.
his institute is, has abudget of $281 million and they conduct researchand support in training and enhance researchcapacity and infrastructure for public health andpublic health education. the most intriguing partabout dr. pã©rez-stable to me is that he comes from sanfrancisco prior to this position where i also spent agood chunk of my life and he was the professorof medicine and chief of the division of generalinternal medicine at ucsf.
so i know we are running behind,so without further ado i'd like to welcome dr. pã©rez-stableto the stage and thank you. thank you, my pleasure. >> good morning and thankyou for the invitation. it's a real honor to be atcdc this morning and to talk about the topic thatis very much close to my heart and my brain. i realize the title of theconference is on ethics and i will try to makereferences to that
because i don't think i reallyhave a lot of emphasis on that. i wanted to start byexplaining a little bit about where in nimhd is at. our institute isonly six years old. it was initially an office andthen became a center in 2000 and in 2010 as part of the acabecame an institute and all that time was led by dr. johnruffin who was, i think, a constant leader inthat aspect that nih. in 2014, he retired and afterthat dr. maddox was acting
for a year and a half. i started september 1, so thisis my eighth month on the job. our mission is to focuson research, as you know. nih is about science andour mandate is to look at minority health as definedby racial ethnic groups in the us census andunderstand causes and reduce health disparitiesin specific populations and i'll expand on this. we're also interested intraining a diverse work force,
an issue that has becomemuch more urgent in 2016, although we do, weourselves do not have a lot of training programs,but i am working closely with hannah valentinein the diversity, the chief diversity officerat nih to look at this, these issues, both inside thenih as well as nationally. so minority health from ourperspective is, we're defining as the characteristicsattributed to the minority groupsin the us.
as defined by omb, we're notreinventing the wheel there and we are interested inissues that are relevant to each of those groups. within the group incomparison to whites across an org comparisonto each other. whether the outcome or theresults are better or worse. so in this regards, itemphasizes the study of the minority groups. there is that general theme
of social disadvantageamongst all minorities. frequently based in beingsubject to discrimination. it varies. the historical legacy ofslavery in the united states and the african americancommunity is unprecedented, but each of the minoritygroups have experienced, in some aspect, this adversity. in addition to that, minorities in the us are historicallyunderrepresented
in all biomedical research,that has not been resolved and almost always in thescientific work force. so these are issues that unifyus more than separate us. health disparities on theother hand really implies to me an outcome that's adisadvantage, an adverse outcome by comparison toa reference group. in a population that has beenhistorically disadvantaged. generally speaking, when werefer to disparity populations at nih, nimhd, we're referring
to race ethnic minoritygroups and/or persons of low, socioeconomic status or lessprivileged socioeconomic status. we're also legislated toinclude rural residents. these are almost uniformlyrelated to being poor or people of color, but there is anunderserved component to being in a remote ruralgeographic location that i think needsto be considered. but we believe thereis this other subject to being discriminated againstis a central theme of what leads
to a disparity populationand there are other proposals for including disparitypopulations that have not been, to this date yet,endorsed by the secretary of health and human services. and the main one is thesexual gender minority group that has been for discussion. excuse me. so a health disparity isdefined as health difference that adverse the effectsa typically disadvantaged
population based on one or morehealth outcomes and i'll try to create the categoriesof outcomes that we're interested in. then our science at nimhd isdevoted to advancing knowledge about what influencesthe different factors, health determinants that indefining mechanisms that lead to these health outcomedifferences. develop and testinterventions to reduce and ultimately hopefullyeliminate these health
disparities when we can. i emphasize this inpart because at nih, nimhd has not beenlooked at necessarily as a scientific instituteand/or the perception has been that nimhd is aboutsocial determinants only. and i believe that over thecourse of these 20 years, 25 years that this wentfrom an office to a center to an institute, a robustcommunity of scientists outside of nih has developedof which i was part
of in multiple disciplines;in clinical medicine, in public health, in behavioralhealth, and in some branches of basic science and i thinkthis is our time to capture this and channel this and createthe discipline that would be, that would createcredibility at nih. i may have gone backwardsthere, yeah thanks. these are the healthdisparity outcomes that we are interestedin looking at. it starts with higher incidentsof prevalence, that's a given.
also premature orexcessive mortality in areas where populations differ. i like using a globalburden of disease measure, disability adjustedlife years is one that has been usedextensively in global health and it allows us to compare theburden of illness of something like back pain that doesn'tnecessarily kill anybody, as well as depression, cardiovascular disease,and cancer.
and the forth categoryis that anything related to how people feel, whetherit be health related quality of life, daily functioning suchas activities of daily living, or other measures as long asthey're standardized and valid. and emphasize the latter point. we're also very, i've thought and considered what arethe mechanisms that lead to these disparitiesand we've framed these and this working document onhealth disparity risk outcomes.
the first category is thewellbeing related to behavior, stress, environmentalconditions, racism, and social factorsincluding things like limited englishproficiency and violence, exposure to violence,not being a victim only. in the last 15 years,there's been an explosion of biological informationand science, perhaps started by the human genome project. it really has continued toincrease at a very sharp,
high slope and ithink understanding where the biology fits intothe social factors and lead to differences isvery important area. so earlier age of onsetwhether it be gene variance that get discovered,metabolic differences. we heard about the sugar issue, does that affect differentrace/ethnic groups differently because of metabolismdifferences? susceptibility to one or anothertoxin, faster progression,
greater severity of the illnessoften driven by some interaction between biology,environment, and social factors. in nih, the clinical worldis not a front and center and having been a primarycare general internist for over 35 years, ivery close to feeling that disparities do happenin the healthcare setting. so i want to focuson clinical events and utilization of healthcare. so things that impact health
in the clinical settinginclude conventional treatments, patient/doctor communication,differences in adverse events to medications, to, that areprescribed and also events that don't quite have adiagnoses like a fall. and similarly, health servicesresearch looking at access and abuse of services andexcess hospitalizations are all important areas that nimhdwould like to focus more on. i like to use a simple diagram to emphasize minorityhealth disparities overlap,
but that are notcompletely overlapped. there are minority groupsof which latinos are one, where the leadingcauses of death or disability areactually low than expected. lower than the referencegroup; the whites and what is that about? so because there areno health disparities in those leading causesof death and disability, do we say they'renot disadvantaged?
well that's not the case, butunderstanding why that may be, i think is important scientificquestion that we need to address at the same time that we'relooking at issues related to disadvantage forthe conditions that are disadvantaged. and this is how the two relate. our program scientists developedthis framework, it's still, i would say, a work in progressalthough to try to capture all of these differentelements in a visual way.
not to be comprehensive, butto emphasize the importance of the biology, thebehavior, the physical and social cultural environment,and as these interact with the healthcaresystem to lead to differential healthoutcomes and then at the levels of influence, theindividual's social network or interpersonal activitiesthat occur, the community and the societal factors. and you can see
in our perspective thefundamental factors being race, ethnicity, low socioeconomicstatus, and the rural populations, whichare mostly of the other two. let me finish thissegment of the talk to clarify an importantconfusing point, at least at nih, whereasminority health has often been labeled as study that includesminorities in a significant way. so investigators whosubmit grants are asked to say how many peopleare you going to recruit
in human studies and they wouldsay well we have 25% african americans, 10% latinos,and the rest white. and so that was over 25%minorities, so somebody decided that some years ago thatwould be minority health because there wereminorities in the study. we need to correctthat flawed mechanism, that flawed method i should say. to me it's a different,it's a different topic. it's inclusion, it's animportant topic that we need
to promote and emphasize, but is not to be confusedwith minority health. a good example isdiabetes prevention trail. fantastic clinical trial,has changed clinical practice in many ways, 40% of theparticipants were minorities. that is not minority health. it is a trail about interventionto prevent diabetes. that is very importantto minorities as well as to all populations.
so where this comes in atnih is that we are tasked with an annual evaluation oflooking at the nih portfolio on minority health and healthdisparities and not only to look at the content andtopics by institute, but also a dollar amount thatgets reported to congress and the number thathas been used, i think, is not based on a valid method. most of us think it's overestimate, but we'll see when we do it rightwhat happens.
we know that proportionallypopulation is minorities almost 40%, so inclusionis really an issue of social justiceand common sense. these are the people whowe're taking care of. on the other hand, aforth area is work, biomedical work force diversity, which is almost, isin a crisis mode. the profession and i'm referringto me as a clinician as well as a scientist, cannot look sodifferent from the population
and in clinician clinicalmedicine, about 10-12% of physicians are latinoor african american, american indiansbarely register, pacific islanders arenot that many either. and in the big, in thebiomedical work force of scientists, they'relooking at predominately phds, we're looking at about 5%-6%. currently in 2015, a little over2% of principle investigators at nih are africanamerican, the funded ones
and about not quite4% are latino. so we have a long ways togo and this is another area that i'm involved withas director of nimhd that we don't particularlyfocus on this in our, but working with hannahvalentine and the leadership. so let me switch to moretopics on latino health. we're all familiarwith this question. this is the question thatis used in the 2010 census. it was also used in 2000.
i think it was based on datacollected in part by the cdc, but omb decided that at onepoint to ask ethnicity first in order to get amore accurate count of latino/hispanicpopulation in the us. we fill, i fill this outand you put your country. i think it achieved amore accurate count, but i think it alsoled to confusion because there was an option,there was question number two; respond to this race andthese are the categories
that you are all familiar with. i emphasize a coupleof minor points here. we should not be usingthe term caucasian in any scientific publication. it's an antiquated termof physical anthropology from the 19 century andthe anthropologists gave up on it over 100 years ago. you know the caucus are in areaof western, i guess western asia or eastern europe and russia.
so it really doesn't reflectmuch of anything related to white individuals in the us. the asian population isextremely heterogeneous. asian advocates are pushinghard for more desegregation and i'll refer to thiswith latinos as well. there's clearly heterogeneityin regards to diversity issues as well because filipinos andvietnamese and southeast asians in general are underrepresentedand often underprivileged. so as opposed to asian indiansare people from northeast asia.
pacific islanders are adifferent race and time and time again i see datafrom nih that lumps asian and pacific islanderstogether and this is again, the pacific islandersare a very small number. they're like american indians inthat regards, except of course, in the state of hawaii andsome areas of california. and then we have the famousmix for more than one race. this audience is familiarwith this question and in the year 2000,what was the proportion
of people who checked that box? somebody here must knowthe answer to that? it was 3%, 3.2% i believe. we know that's not correct. now the bay area, of course youknow, is a very multi ethnic, multi-racial, 6%in the bay area, in the san francisco bay area. so clearly people are stillidentifying predominantly as you hear earlierwith one group,
although they couldcheck different boxes. 2010 actually thenumber of multi-racial, people who checkedmulti-racial went down to 2.3%. so we're still not in a societythat that has been embraced, although that's an idea that people are aimingfor at some point. the question doesn'twork for these reasons; david [inaudible] made, showedme this data a few years ago. so in the 2010 census whenlatinos answered the questions
about race, a littleover half checked white. you can see that black is2.5%, american indian at 1.4%, the column on the rightis the national data. asian is a smallnumber, pacific islander, but almost 40% eithersaid some other race or actually left it blank and the response was welli already said my race is latino [laughter]. so why should i, shouldi give you another race?
they didn't understandthe question. it didn't get, sopart one was right. we got a good countbecause you asked it first, so you always get the goodcount when you ask it first. part two didn't work andwhen, and the census decided to do this, i go ohthat's interesting. in california we never did that because we wouldjust ask the question as a single questionand gave the options.
and nobody ever had anytrouble self-identifying. the main group that had issueswith the question of race or ethnicity were oftenforeign born whites, europeans who would sayi'm german, i'm this and so getting country oforigin gets at the granularity. i hear that the censusis very much considering, omb is very much consideringgoing back to a single question for 2020 and possiblyadding a new ethnic group; middle eastern, north african.
i suspect some ofthese changes will need congressional approval. so i don't know whatwill happen with that for 2020, but we'll see. latin america is a uniquegeographic population in the world. to some extent india is likethat, although we know less of that history andit's much older. and hawaii is more recentexample of this add mixture.
there were 500 years of historyin latin america and populated by the native people, the indigenous peoplethat came from asia. although the genetic link isquite remote at this point. the europeans weknow came in 1492 and six million africans wereforcibly brought to the americas over the course ofabout 300 years. four million went to southamerica or the caribbean. mostly brazil and the islands,
but two million cameto the united states. so we have this shared heritageamongst the african americans and the latinos in that history. but this add mixtureis 20 generations of add mixture have led to aunique population structure and i think this isone of the things that makes latinosso fascinating. from a variety of perspectives,both advancing knowledge in science as wellas you can say social
and for other reasons. the mixtures arevariable as you well know and our expressedphenotypically typically as well as reflected genome typically. so i often, i don't hesitateto say that, you know cubans and dominicans are different. i'm from cuba, puerto ricans,you know we're all part of the caribbean,argentina, columbia. so we can emphasizedifferences, but my position is
that in the united states,latinos have more similarities than differences despite thesenational origin differences. we have a mix of cultureand themes that unify us. there is a central role ofthe spanish language, not to, one also has to acknowledge morerecent immigrants particularly from central americaand southern mexico who do not speak spanish orspeak spanish very, very poorly. this racial mixture,these 500 years have led to this unique mix and ithink there is interesting,
not just social, cultural,and political history there, but potentially biologicalconsequences that i think are worth studying. we also have a shared heritageof the catholic church, which has been a very powerfulinstitution in latin america. you know that abortion isillegal in every country in latin america exceptcuba and puerto rico. so that's an exampleof the power of the catholic church eventhough there had been quote
"less disseverments in powerin much of south america over the last 10-15 years." so i'm a very much a lumper,not a splitter when it comes to latino populations. i'm all for looking atdifferences by national origin, but not to diminish theimportance of the group. this is an example of astudy on asthma in children to exemplify some ofthe genetic add mixture. mexican/americans areon average about 50/50,
but it goes full spectrum. in this sample, puerto ricansyou can see have a higher proportion of european addmixture surprisingly high contribution of indigenousmixture and african. and of course, that willvary also considerably in populations driven inpart by socioeconomic status, but not exclusivelyacross the island and across the population. this is taken fromthe vital signs report
that was referredto, which is great. this is looking atsome highlights of social demographiccharacteristics to give you a snapshot of thegroups by national origin, number of persons who have lessthan a high school education, less than 10% of us adultsin general among whites and even among africanamericans, the number is low, but look at mexican population. look at central american,even the cubans were quote
"the more middle classimmigrants" supposedly, 21% have not finishedhigh school. limited english proficiencyis a critical variable that we don't do a very good jobof collecting that information in our healthcare systems. and you can see among whites,it's just a very small number as expected, but it variesfrom 17% for puerto ricans where presumably they dolearn english in puerto rico to as high as almost halfin the central americans
and i think this is a criticalfactor, always in latinos. and then the percent poverty,it is on average double that of whites ormore, even again, among the more latinogroups, the cuban americans. and so there are thedifferences; cubans are older, the puerto ricans aswe know are citizens, the undocumented burden ispredominately among mexican and central american to lesserextent among caribbean latinos and so forth.
so i think this is a beginningto look at this; however, i will also challenge usthat one of the challenges is to understand why these outcomesare better than expected. if one looks at these scsperimeters of education and poverty, you would notexpect outcomes to be better. you would expect that theparadigm in public health of your poor, your health isgoing to be worse, but hold. the fact that for latinos andfor what we know about asians, it appears to be similar.
they're worse, they're worseoutcomes of, they're worse scs, lower scs and education does nottranslate the worse outcomes, is an important observationthat needs to be studied. these are also data that, published by thecdc a few years ago. we've heard a lotabout life expectancy in the last couple of, lastfew months regarding what's happening to poor whites. and remember it's poor whites,
poor and lower middle classwhites, not all whites, where the mortalityrates are going up. but latino women have thelongest life expectancy in the us. in those same data thatlooked at the changes that have happened among whites, african american mortalityrates have dropped faster than any other group. unfortunately theystarted off much higher,
so they're still higher,but they are moving in the right direction. that's good news. for latinos, their mortalityrates look like germany and then the charts ofthe high income countries, the us or how the us hasflattened with regards to white mortalityparticularly the, first coming down with women and then with,and now with both men and women. but with latino mortalityrates, and no one is a;
talking about that or understanding whythat is the case. and i think that weshould talk about it and really try to understand it. the more recent study aboutthat if you're poor and live in san francisco, manhattan,or birmingham and you're poor, you live three years longerthan if you lived in detroit or in rural areas in the us. now what is that about?
place matters. we've been saying that for sometime, but there are something about an urban environmentthat tries to take care of its most disadvantagedpopulations that appears to makea difference. a three year life expectancydifference is pretty big in a public healthperspective as we know. so these are, the healthyimmigrant, as we have called it, the paradox is probablyaccounting for a good amount
of this observation, butit's not the entire answer. people have talked aboutthe salmon hypothesis. i recently reviewed a paper fora high profile clinical journal where this was proposedto explain an observation about kidney disease in latinos. there is some misclassificationas i alluded to earlier. people will phenotypicallylook at someone and say well you're this and with latinos youcan't always be sure.
and i can tell youstories about growing up, i mean having my kids and beingthought people were talking one language or another and notassuming i wasn't latino because i wasn'tbrown in california. and that's the stereotype. so there are manydifferent, so it's a, you self-identify; you ask. and in medical recordsit's been shown, there was a study anumber of years ago
that latinos were often, most often would bemisclassified as whites. and so if someone comes inwith a heart attack, dies, and someone looks at themand say oh they're white and that you could imaginethey would be misclassification accounting for someof this information. let's run throughsome data on health, important health statistics. this is infant mortality rates.
the us gets a lot of negativepress about how badly we rank in infant mortality comparedto other high income countries, but over the last decade we'veseen improvement in all groups, particularly highlightthe 18% drop in african americans even thoughthey still have way too high infant mortality rate. and among the latino groups, the puerto rican populationhad the highest rates and it has now droppedsignificantly
down to still a little bithigher than the other groups, but not that much more. notice the cuban rate of 3%? the cubans in cuba have abouta 4% infant mortality rate. so and this is the, thisis a very sensitive measure of a global measure ofthe population health. this is causes of death takenfrom the vital signs report. latinos again, heartdisease, cancer, and stroke; the three leadingcauses of death in the us
and you see the hugegap in heart disease and cancer, globally latinos. so we'll look at one nationalorigin difference and then so forth down the list, diabetesis higher, we know that. alzheimer's disease islower and that's interesting and there's other clinical datacoming out of keiser that one of the, our post docs at ucsfis working on getting published that shows the same thing. lower mortality for alzheimer's
for all minoritygroups actually, within keiser comparedto whites. renal disease is, balances out. chronic lung disease isconsiderably lower and not all of this is related to tobacco,although it's a good amount of it and then unintentionalinjuries. these are mexicanscompared to puerto ricans, you know they have dataon dominicans and cubans and central americans,
so the vital signs reportreports these same data for all the nationalorigin groups. it's a contrast of, if you wish, the two largest latinopopulation groups in the us by national origin. mexicans are 65%, puertoricans are a little over 10%. more heart diseaseamong puerto ricans, in fact heart disease amongpuerto ricans is very similar to whites and cancer isstill lower than compared
to whites in both groups. and again, cancer is becoming, close to becoming number onecause of death in us latinos and in the us general populationas well as it is in other, some countries in latin america. as we continue to drivecardiovascular mortality down, it's one of the more remarkableaccomplishments of health, healthcare and life stylechange in the last 50 years. where you've seen a precipitous,you know,
more than a 50% decrease in mortality in cardiovasculardisease in the united states and related primarilyto behavior change, but also to somespecific therapies. and again, you see copd beinghigher among puerto ricans, so we're still far lowerthan it was for whites. and alzheimer's,diabetes about the same. i think now most people areaware that diabetes is just as common among puertoricans and other latinos
as it is among mexicans. the idea that this was anoh it's an indigenous mix, that's why you see itin mexicans is incorrect and we also see excess diabetes in all minority groups,as you know. this is prevalence ofheart disease taken from american heart association. again, latino menand women have lower. worth noting that stroke is morecommon among women in general.
latino women have higherstroke rates than latino men. this is data from sol,the study of latinos. i know larissa ended upnot being able to come, but she would go on and on aboutsol, which is a terrific study. it's a great research resource. the national heart, lung, andblood institute is 16,000 adults that they're following. they're completingwave number two. the highlight of this slideis to show by country of birth
in terms of cardiovascularrisk factors. us residents were more than 10years and language preference. and it's one of the questions,i think, that always comes up. oh is this healthadvantage going to go away? once the immigrantsget acculturated and that's a question thati will leave you with. foreign born latinos acrossthe board appear to do, to have a healthier profile. a higher proportionhave no risk factor,
a lower proportion have morethan three risk factors, and about a little less than half report having coronaryheart disease or stroke, if you look by country of birth. if you look by residentsin the us, again you see similar trends. so there is this healthyimmigrant effect appears to be present. and in terms of languagepreference,
which is the third way oftrying to get at this construct of acculturation,which is really hard to measure i would arguewith any kind of self-report. but these three arepretty good if you use them in combination or isolated. you can see a similar trend. so if you respond in spanish. keep in mind that solis 80% immigrants. it is for communities.
it's not population based. it misses out on a lotof the latino population. it's a very in-depth verticalstudy and it is very valid in and of itself, butit's not necessarily, it is population sample,but not population of, not representative of theentire latino population. cancer among women; look atwhat race does to cancer rates. if you, if someone sayswell you know we should, race doesn't matter.
we shouldn't even betalking about race anymore. show them the cancer rates. you know, they varyremarkably even more so for men and not all fully explained bybehavior and here we can look at either disparities or why let's say latinowomen have less breast cancer in incidents. i'll take you quickly one partof that story, this is a study that my colleague [inaudible]did in california.
pursuing a genetic source forpart of that explainational of why is breast cancer lesscommon using case control design, pulling togetherseveral studies from northern and southern california. in pursuing to find the gene and then using replicationanalysis with other studies. they found the genein an unexpected area in the estrogen receptorarea; esr1 there. it's a well-known gene that'sassociated with breast cancer,
but this gene waspresent only in women with indigenous americanbackground and it was not that uncommon. it was 15% of the women had it and in their analysis showedobservational protection of about 40% decreaseof breast cancer. so here is a geneticfactor that is protected, that has been preserved amonglatino populations as part of the indigenouspopulation in the americans.
not a whole lot has been donewith these kinds of research. so i think this is one ofthe areas of discovery, understanding that nih andnimhd should be interested. this was all funded bynational cancer institute. among men you seedifferences in cancer that are equally impressive. african american men have anexcess rate of prostate cancer, which is remarkable and i don'tbelieve that we really know yet. there are some geneticvariants that are associated,
but it's not the whole story. we see that amongst livercancer, i'll give you as an example, ishigher among minorities, but we don't really know whythese different groups have excess liver cancer. we believe and we think we'repretty certain that for asian and pacific islandersit's hepatitis b driven, but for african americansit's not entirely clear that hepatitis b is the answer.
and for latinos itactually probably varies by national origin group where hepatitis b isnot, is not the cause. c may be part of it, but theremay be something, maybe it's fat or inflammation provoked bydeposits of fat in the liver. so again, an area that needsto be further researched, but let me deviate,skip over this. we know a lot of the thingsthat are related to cancer. these are smoking data from sol.
again, not reflectiveof the national picture. that get that betterfrom nhanes or nhis, but the cubans you cansee smoke at higher rates. so do the puerto ricansand the puerto rican, the biggest concern for yearshas been the higher rates of smoking among the women andit has trended down slightly over the years, but notas much as it should. the second numberis the non-dailies. those people who donot smoke every day.
so clearly they're not addicted. so the paradigm of addictionin smoking is evolving. look at the dominican rates. they're very low. they actually lookmore like mexican or central american rates. so this idea that thecaribbean latinos are going to be more alikedidn't hold up here. at least not in smoking behaviorand this is the first time
that we had us baseddata on dominicans in any significant wayand that they're being, they're mostly recruitedin the bronx. and again, see the verylow rates for women. now, the national rates do notbreak down by national origin in these data, but you can seethe latino rates nationally 15% less than 10% ofwomen, similar to asian. so smoking is an area where wehave traditionally done better even though i just showed youdata with rates are higher.
we also see a great scsgradient in smoking, which is actually morecompelling than race ethnicity. less than 1% of medicalstudents smoke. nurses have quit smoking andpeople with phd is less than 5%. so you do see thisincredible gradient of lower smoking ratesamong, by education. but why are thesedifferent is by lung cancer. if i may deviate for a minute. we know that cancer takesat least 10 years to develop
after you've been exposedheavily to cigarettes. that intensity is related. if you smoke onecigarette a day your risk of cancer is probably elevatedlike it is if you're exposed to second hand smokeintensely, but it's much higher if you smoke 20 cigarettesa day. it's a very linear relationship. odd ratios go up considerably. there are other environmentalexposures
that we know are carcinogens,particularly combustion products and then there's geneticsthat have been pursued. there is an area ofchromosome 15, i believe, that has been consistentlyfound to be associated with lung cancer acrossvarious populations and whether or not there are some variationshere that are worth pursuing. this is unknown territoryright now, but the data from the multi ethnic corestudy published 10 years ago now in the new england journalof medicine have not
yet been fully clarifiedas far as i know. this is a cohortstudy, multi ethnic, california and hawaii based. so that's the populationsthat are present. respectfully identified casesof lung cancer from [inaudible] and predominately, wellmajority were in men. and used africanamericans is the referent group because they had thehighest rate of lung cancer. stratified by smokingintensity and then the numbers
on the next slideare relative risk of lung cancer by smoking level. and the amazing thing hereis that for the same level of smoking, 11-20 cigarettesjust to pick that line, african americans and hawaiian,native hawaiians were the same, were statisticallynot different. but latinos, japaneseamericans, and whites were, had hazard ratios thatwere significantly lower. same carcinogen, same intensity,
and the self-identifiedrace ethnicity led to a very different risk ofan outcome that we all care about because only 15%of people live five years after you get lung cancer. it wasn't until you got to 30that you even, the playing field or the badness of theplaying field in terms of statistical differencesbetween these hazard ratios. now why does this happen? i don't know.
one of the smoking chemists,i'm blocking on his name now, says he now has an answer as to why the african americansare higher, but he didn't figure out the latinos one, buti haven't see the paper. so i'll leave it at that. lots of explanations ongenetic factors linked to african ancestriesis one possibility, some in gene environmentinteraction. metabolism differences isone pathway that we worked
on not related to this outcome,but just had done some work on differences inmetabolism; blacks and whites, latinos were not differentthan whites in that, in our studies, blacks were. menthols always comes up becausementholated brands are smoked predominantly by africanamericans and puerto ricans and not by almost anyother group in the world. it's a start brand, you knowit has a 10-15% market share in the us, but it hasvery little uptake outside
of the united states. smoking topography, which is areference to how people smoke. so you hold it in longer,that kind of stuff, which i don't think hasbeen shown to prove much and then whether thereare protective factors. you all know that nicotineis designed in cigarettes to be absorbed in thealveoli capillary interspace. so it is, it is somethingthat is taken in by this incrediblyeffective system
of drug delivery,which is our lungs. and that's how the nicotine in electronic cigaretteswill come in as well. another example of differentialoutcomes by ethnicity that are unexplained,this is data from a keiser diabetes cohort. all patients takencare of by keiser. this is a follow up at 10 years and the paper wasactually published looking
at the asian nationalorigin groups in california. notice that for africanamerican, latino, and all asians combined the riskof a heart attack with diabetes at 10 years within keiser,so similar healthcare, is actually lowerthan for whites. so fewer heart attacks,isn't that interesting? and the chinese, japanese,and filipinos did as well. the pacific islanderswere actually higher and in south asianswere not different,
but we looked at kidney disease. it was the opposite. all the minority groups hadmore end stage renal disease and so ending up on dialysis andthis was true for the latinos, granted more predominantlylatinos in northern california, keiser are mexicanor central american. we don't have that kind ofgranularity data among cubans and puerto ricans and noticethat for chinese, japanese, filipino, and pacific islanders,
again they behavemore, increase at esrd. south asians whose backgroundancestrally actually is more white and african,some african mixture with a north/south gradientare statistically not different from whites in termsof their risk of esrd. study on generation and diabeteshave shown some mixed results. so the idea of wellwhen you come to the us and you become acculturated youget worse, you get more disease, you get, you pick up bad habits,you start eating at what was it?
that wacko taco,whatever and you get, and you lose yournatural advantage of having eaten morenatural food. so this is the[inaudible]that sacramento area, latino study on aging. all mexican 60-101years old at recruitment and they measured generation, acculturated skills,and language. that diabetes prevalenceincreased by generation
in this study from 29% to35% to 40% with an odds ratio for the third generationthat was double. so this would support thehypothesis, the proposal that you will get worse, thatmy kids will get worse health than i am, than ihave, i don't know? that is presumed. we also then did an analysisof the [inaudible] study, which is again anelderly cohort followed by dr. markelis in texas.
it's all the southwest, it'sbeen followed since 1990. again, all mexican americansand again 65 base line. you can see the parametersof the sample there. about half were immigrants. we defined being lessprivileged socioeconomic status, having less than a high school and having publicinsurance or no insurance. and 27% had diabetes at baseline, so we excluded them. all of this is by self-report.
we looked then at incidentdiabetes in this cohort over the course of 1990 to 2010,i think was the, 2005 sorry. there's my slide and foundan interesting relationship that those who continued toanswer the survey in spanish and were of low socioeconomicstatus by our definition, going from first to thirdgeneration had an increase in diabetes, in incidentdiabetes, new diabetes that was adjusted hazard ratioof 1.8, but those who responded to the survey in englishand had a higher scs.
mind you, higher scsmeans you've graduated from high school and had someinsurance that wasn't medicaid, going from first to thirdgeneration actually had a lower risk of diabetes. so these kind of data wouldimply that we really need to look at this multidimensionally with different socialfactors involved. the social class doesplay a major role in this, acculturation spectrumthat we talk about,
and there may be an advantageactually to become acculturated for some groups while there'sa disadvantage in some groups who remain un-acculturated,especially if they're poor and so i think thatsol may be a data set where this can be looked at. as mortality is excessive amonglatinos, puerto ricans have one of the highest knownmortality in diagnosis rates of asthma in the world. this is not understand why.
mexican latinos alsohave one of the lowest. so again, here heritabilityis important to understand. obesity we've talked about; 40% of latinos slightlylower than for blacks. interestingly the ratethere for puerto rico of 28%, those on the island. so on the island there's lessobesity then there is in the us. finish up with acouple of these; screening for coloncancer, latinos are behind.
limited english proficiencyis a major issue and ascertainment of english -- the proficiency in englishis an important metric that we need to look at. i won't go over all the detailsof what the importance of lep. the data on healthoutcomes is mixed. there's generally poorcommunication, but the effect on clinical outcomes varies. there's clearly ashortage of clinicians
who speak other languages and language discordanceis very common. interpreters are often notavailable and infrequently used and often used whoare not professional and this is really a problemthat needs to be addressed. we have endorsedthe census question because of the simplicity andthe fact that everybody uses it. everybody responds to it, someasure asked by the census and then if you say lessthan very well, you are lep,
but there is a group that sayswell that probably is mixed and by asking them what languagedo you prefer your medical care in? we seem to get at the group thatreally needs interpretation. we also found in analysisone of the people i work with that patientswith low literacy, if they are in a discordantrelationship in terms of language, the low literacygets trumped by the fact that they are in a discordantrelationship in terms
of communication metrics. so even in that group thatwe worry about in speaking, having language concordanceis important. there's empiric data that saysthat people who see doctors, clinicians who speak the samelanguage have been glucose control, feel better, haveless pain, better understanding of instructions, bettermedication adherence, ask more questions so it'smore patient centered care. one may even say wellthat's a no brainer,
but you need evidence to beable to pursued policy makers that somebody shouldreally pay attention to this and the quality of careof these patients needs to include professionalinterpretation. this will get people'sattention, so we say well if you don't speak english,you're high risk of readmission. that's a medicareperformance metric. money is on the table,people pay attention to this and so get interpretersinto the system.
i'll just close with this, ialluded to these questions. so will the healthprofile worsen with second, third, fourth generation? i think when i talk to people,everyone assumes this is going to happen and i challengethe community to say show me. generate data and let's lookat it, let's look at data and see what's happening tosecond, third generation. i don't necessarilyhave a strong reason to say it's not going tohappen, but i like to think
that this isn't necessarilygoing to always be the case. how does acculturationaffect health behaviors? we have a lot of dataon smoking and alcohol. how does it affect outcomes? how do we look at acculturation? how do we measure it? how do we balance itwith social class? we do need to have avery standardized method of ascertainment.
whatever it is, we need toall use the same method. it may not be your favorite. the worst thing is to have,you know one investigator in texas say i likethe question this way and another investigator incalifornia oh no i like it that way and another one is newyork says i like it this way. then how can you compare? so we just have to geton board with common use and then do we focus ondifferences by country
of origin, ancestry, region? i mean these are all factorsthat you are all familiar with. so thank you very much. hopefully, i don't know if wehave time for questions or not, but thank you foryour attention. >> hello, hello yes. thank you [inaudible],that was awesome. the data's and again,we know that. latinos know the differences.
i think it's fascinatingwhat you show. i just have my genome done by afriend of mine at the university of chicago just for theheck of it and of course in the dominican republic mypersonal id says that i'm white. well i know i'm not whitebecause my brother looks just like a brother, youknow one of my brothers. however, my mix is41% west african area, which is where my greatgrandfather came from, the canary island orsomething like that
and the moorsinvaded spain. so that's where i come from. twenty-three percent asian. i was surprised about thatbecause, you know i never saw that in me, but again,tahinos y caribes right in puerto rico and in cubawas the hibaros yeah right. so we basically share thesame indian or native heritage in some ways, but the geneticcomposition is different
and then there was, i think,28% of something else. who knows what, but thefact of the matter is that your whole talk ended up saying the samething that we all know. that is we have lack ofeducation being a contributor to how these things are -- >> the ancestry issue is animportant scientific tool. i think i'm, i believe that raceethnicity is a social construct, that self-identity is the goldstandard, but this is a tool
that we can use tolearn about mechanisms and how different thingsthat might be explained. latinos are interesting inthat regards because of that and it's right, we'reright here in the us. african americans are alsohave significant amount of racial add mixture withwhites and american indians. so we're not unique in thatcontext, although the extent of the mixture is not as much. and at nih, you know thegenetics people are like saying,
you know there was a commentaryin science earlier this year that said we should takerace out of genetic studies and it was a wellthought, well written, but i think they missed a bigpicture on, so there's some of this tension [inaudible]. yes. >> buenos dias y gracias por supresentacãon. my name is nancy lopezand i'm a sociologist. i also direct the institutefor the study of race
and social justice at theuniversity of new mexico and we recently did a studywhere we included a question of racialization among latinos;1,500 latinos nationally at the robert less johnsoncenter for health policy that included a question onwhat is your street race? if you were walkingdown the street, what race do youthink other americans who do not know you wouldautomatically assume you were based on what you look likeand what we found is that those
of us that are afro latinosor seen as arab or mexican -- >> right. >> basically some variation ofbrown, even after controlling for education, hadhigher odds of obesity, had higher odds ofvery poor health. so my question isabout what's going to be decided by the census. right now there's a lot of valueto having the two part question because not only can wedesegregate by national origin,
but also race as a master ofsocial status, i'm wondering if there is any consensus amongresearchers about the need to retain that questionbecause if i look around the room anyonehere could be latino, could be hispanic, but weall occupy different racial statuses, may have differentinteractions when we look for a house, discipline inschools, with the police, immigration, theairport [laughter]. so i'm hoping that there'ssome consensus because i think
that health disparitiesresearchers are really on the cutting edge ofdescribing the importance of not conflatingnational origin. >> with race as a mastersocial status that's based on what you look like. >> so thank you foryour comment. i look forward to seeingyour results published and send them us. so two points; i don't workfor the census, so i can't,
omb is our own, they're in theirown world, but they will dictate if they change these categories, we need to adhereto that as an nimhd. so that's why i payclose attention. i saw a presentation wherethey were proposing doing this. the basis is that that question as currently presentedis confusing in the response to race. the loss, some people say wellthe afro latinos may not check,
may not have an opportunity to say they're blackand that's an issue. that is a loss of that,but they will most likely, almost certainly identifyas latino to begin with if they're given the optionas opposed to being black. but you also broughtup a second part, the part about perceived race, which i think is acritical construct that we don't typicallyask in our studies.
it is not asked in the censusand so i think the idea of asking that inthe census leaves a, even in the americancommunity survey as an experiment wouldbe worth suggesting. nancy adler had developedthis ladder question about social status,which not only asked about where do you standand how do people see you on a social ladder? so i think it's a perceivedrace of what you are getting at,
which i kind of thinkis another construct which i think isworth exploring. so -- >> hello. >> hi. >> good morning dr. perez-stable. my name is elizabethoflee and -- >> oh hi elizabeth,i didn't see you. >> the morehouse schoolof medicine and so,
i also have researchprogram that i work with called the research centerof minority institutions, just saying that forthe group to understand where my questionis coming from. i know you are aware ofthe program and i just want to also add my thanks to you. i think this was a veryinteresting discussion and really i think expandssome of the thought process around understandingresiliency on the one hand
and disparities onthe other hand. and so that's theframework of my question. as you know, these institutionshave multi-disciplinary groups from basic science to populationhealth and when i look at the nimhd budget versusthe nih budget that's looking at disparity populations,but not necessarily i think in the comprehensiveway you're defining. i think the question for meremains in the short amount of time and the urgency thati see here, what is the role
of these existing programsthat are structured in a way that would allow us, i think,to work across disciplines in collaboration with obviouslyother scientists, how do you see that as you look at the broaderlandscape in moving forward with disparities or i shouldsay the signs of disparities? >> i'm not sure i knowwhat you're asking. the, elizabeth referredto the rcmi program and nimhd inheritedthe research centers for minority institutionsa number of years ago.
this is probably myride to the airport -- >> yes, this will have tobe the last question please. >> i'm just finishing up. thanks, alright can icall you right back? thanks. yeah. >> should i ask my question[laughter], is that on me? >> yeah i think you'rethe last question please. >> okay. >> but anyway, we are verymuch in favor of continuing
to support, as youknow, these institutions through a competitive process that will actuallygenerate not only behavioral and biological data, but alsoclinical and population data to help us understand. focused in theseinstitutions as opposed to all studies being doneat harvard and stanford and ucsf and hopkins, yes. thanks.
>> well thanks for yourpresentation dr. perez-stable. i, well i think mostof us are familiar with the hispanic paradox,at least those of us in public health and of course, the data you've shownthis morning further, i'm sorry, supports that. in fact it's quiteremarkable that all of this population baseddata sort of converges to really show the hispanicadvantage in terms of health.
given the data, i'm curiousabout your thoughts on focusing on minority status in general. meaning focusing our resourcesand research on minority status as opposed to those groups who sheer the disproportionateamount of disease in these particular areas. >> i think if i understandyour question, so we are the nationalinstitute of minority health and health disparities.
so i think i take that literallyuntil they tell us otherwise and for me, minorityhealth will imply looking at the race ethnicgroups within the groups. that allows us then toadvance our knowledge about why we see thedifferences that we see. why some group has anadvantage, has better results, i think is a worthwhilescientific question. elizabeth mentioned resiliency as a mechanism whether itrelates to social networks,
for example, as another, knowingthat and if this is a population where we observe these, thatwill actually contribute to our knowledge thatwill apply to everyone, not just that particular group. i don't want to leaveyou with the message that everything is greatfor latinos, you know? we have excess amountsof accidents in children, there is a tremendouspressure on family function, alcohol binge drinking is aproblem, particularly among men,
there's excess liver disease,i didn't bring that up. chronic liver diseaseis more common. hiv/aids is predominatelynot an epidemic of minorities of african americans andlatinos, among men who have sex with men as well asother groups with, related to other behaviors. and so i don't think that thereare a number of conditions where latinos doworse in healthcare. the quality disparities reportthat hrq produces every year,
latinos do worse onall, well majority of the metrics are noteither, they're either worse than whites or the same. very few are they better. so the processes of care and thehealthcare process latinos are also at a disadvantage. so we are, we're all part of thesame enterprise in this regards. i think the differencesand priorities in, you know is reflected often inthe funding and when you see,
you know where you see moredisparities or less disparities, but we are interested in minority healthin and of itself. not just this healthdisadvantage exclusively, so. >> please join mein thanking dr -- >> i better stop. >> so i hated to be the one sortof being the police on the time and cutting people offon their questions, but we have a littlebit of a remedy.
so the rest of the program, ifyou will pick up a little card and there are people who aredesignated in the organization, if you'll just raise yourhand for people who are going to be picking up the cards. what we're asking you todo is if you will write down your questions,give them to the folks who are collecting them, and that way we'llmake sure we get them, at least if they're notanswered within the context
of the program today, we willbe able to follow up with you and make sure you getanswers to your questions. we even have a remedyfor folks online. so if you will, ifyou're online, if you will e-mail yourquestions to x as in x-ray, g as go, v as in victory@cdc.gov those questions will be collected and they willalso be answered and again, if not in the context of theprogram today, we will be able to follow up withyou afterwards.
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