Americans are all too familiar with many of the current problems that continue to plague U.S. Healthcare: the high number of uninsured Americans, certain drawbacks of managed care, and the large-scale efforts necessary to ensure patient privacy and safety. What most Americans are either unaware of or unwilling to believe is the fact that a marked number of healthcare disparities currently exist among racial and ethnic minority groups living in the United States. Numerous diseases and medical conditions have been repeatedly documented to exist at higher rates among such minority groups. The statistics are discouraging, the reasons for the disparities even more disappointing. While certain groups remain at risk for these medical problems, efforts to combat these disparities are the only dependable way to reduce both incidence and mortality rates among minorities. In particular, African American males and females are notably at risk for a number of health conditions and, when treated, result in vastly different outcomes when compared with the rest of the U.S. population.

In 1999, per request of U.S. Congress, the Institute of Medicine began to assess healthcare disparities which exist across minority groups. In total, over one hundred separate studies were reviewed in order to determine the quality of healthcare received by minority patients. Studies controlled for numerous factors such as age, gender, and care facility. Reviews of the studies found that minority groups were indeed "less likely to receive needed services, including clinically necessary procedures" [1]. Among the African-American population, recent studies have suggested that type II diabetes is rapidly becoming one of the leading causes of death among African American men and women.

The National Center for Cultural Competence at Georgetown University cites diabetes as the seventh leading cause of death in the United States [2]. However, among African Americans, diabetes is the fourth leading cause of death in women and the sixth in men.3 Compared to the overall U.S. population, African Americans are twice as likely to have diabetes and have a twenty-seven percent higher death rate. The table below, created by the Centers for Disease Control and Prevention, compares the death rate among African Americans with diabetes to the rate among the U.S. population with diabetes [3].

Age-Adjusted Death Rate Per 100,000 Population With Diabetes
As Any Listed Cause 1990 vs. 1995

Population                   1990                 1995

US                           39.8                 41.6

US African American          71.7                 76.2

Source: CDC/NCCDPHP, Division of Diabetes Translation Surveillance Section.

A staggering thirteen percent of African Americans are currently living with diabetes. Among this minority group, between ninety and ninety-five percent of those with diabetes have type II diabetes. This form of the disease typically develops in adults as a result of resistance to insulin action. A direct consequence of type II diabetes is the possible development of complications such as diabetic retinopathy (ultimately leading to blindness) and end-stage renal disease (also known as kidney failure). African American patients are seen to experience higher numbers of these diabetes complications as compared to white Americans[4]. The figure below shows the frequency of diabetes found among African Americans and is based on a 1988-94 survey by the NHANES III.

Prevalence of diagnosed and undiagnosed diabetes in African Americans, U.S., 1988-94.

Source: National Diabetes Information Clearinghouse (NDIC) [4].

The factors that put African Americans at risk for type II diabetes are generally the same factors that lead to this disease in all populations. Both genetics as well as lifestyle play a part in the chance of acquiring diabetes. Recent evidence has been found to support the existence of genes responsible for type II diabetes. One such gene, termed NIDDM1, is located near one end of chromosome 2. A mutation in just one base pair in the region of intron 3 seems to result in greater risk of acquiring diabetes [5]. Aside from genetics, other risk factors play an important role in diabetes, many of which can be controlled by an individual. Exercise is one of the best ways to protect against type II diabetes. A lack of physical activity seems to put people at high risk for diabetes. Another risk factor associated with lifestyle is obesity. In a National Health and Nutrition Survey, African Americans with diabetes were found to have significant rates of obesity as compared to those without the disease. Additionally, African Americans were seen to have a higher rate of obesity compared to white Americans when examining certain groups of men, women, and adolescents at various time intervals . These results are illustrated in the figure below:

Time trends in the percentage of adolescents and adults in the U.S. who are overweight, U.S., 1988-94.

Source: National Diabetes Information Clearinghouse (NDIC) [4].

This health disparity is intensified even more as a result of various socioeconomic factors and issues dealing with accessibility to healthcare. The American Medical Association reports that one out of every four African Americans does not have health insurance. Additionally, thirty-nine percent of African American adults don't have a regular doctor, a rate which is significantly higher than the twenty-six percent of whites who don't have a regular doctor.6 These facts make it clear that one of the main reasons for such disparities is the reduced accessibility to care that is prevalent among African Americans. Without health insurance and regular physician visits, disease among minorities is unlikely to be discovered early on. Preventative care is also highly unlikely [7].

In order to combat health disparities in the United States, nationwide programs must be implemented to educate, prevent, and treat minority groups such as African Americans. A number of such programs are currently in existence, both in urban and rural settings across America. One program in particular is The Secretary's Diabetes Detection Initiative: Finding the Undiagnosed, which has recently been unveiled by Health and Human Services Secretary Tommy Thompson. The goals of this program are to 1) increase blood testing for high-risk individuals and 2) increase rates of diagnosis for individuals who are currently unaware that they have diabetes. This program will be implemented in a number of communities that have been previously identified as high-risk areas for individuals with diabetes. Secretary Thompson stresses the urgency of implementing a program such as this, stating that "diabetes cost the U.S. $132 billion in 2002." He adds that "Through programs like the Diabetes Detection Initiative, we're working at the community level to find Americans who have type 2 diabetes but do not know it....It is vitally important that we reach the undiagnosed sooner rather than later." 8

Detection methods are indeed a vital component to any program interested in treatment of diabetes. However, prevention tactics should also be used by healthcare workers when implementing a program such as this in targeted communities. The very reason certain city neighborhoods have been selected for the pilot program is because not only are many inhabitants currently undiagnosed, but younger generations being raised there are also placed at continually higher risk. In order to combat the progression of type II diabetes among these generations, prevention methods should be targeted towards all age groups within these communities. Within an African American community, people need to be educated regarding type II diabetes, the health risks involved, and the lifestyle changes necessary for improved health. A program such as that being implemented by Health and Human Services lacks the major components of education and prevention targeted towards both older and younger generations within these communities. A combination of education, prevention methods, and the detection methods as outlined by Secretary Thompson would form a more substantial and potentially more successful program aimed at reducing type II diabetes among African Americans.

Starting with older generations, diagnosis of diabetes in patients should be accompanied by efforts to educate these individuals on how to improve the lifestyle habits of their families. Younger people should in turn be educated on prevention methods such as incorporating sensible diets and physical exercise into their lifestyle. This will allow younger and older generations to jointly assist each other in preserving good health and encouraging the use of treatment and healthcare options. Recent studies have shown what a dramatic effect lifestyle changes can have in terms of diabetes prevention. The 1996 NIDDK Diabetes Prevention Program resulted in participants reducing their risk of acquiring type II diabetes by fifty-eight percent due to enhanced physical activity. Interestingly enough, slightly less than half the participants belonged to minority groups such as African Americans.4 These findings show how effective such lifestyle changes can be in reducing risk and thus decreasing ethnic disparities in America.

Type II diabetes can potentially be prevented or delayed within all ethnic groups by incorporating the very same strategies into peoples lifestyles. However, a dramatic ethnic disparity still exists within the United States when comparing African Americans to the overall U.S. population. Type II diabetes is just one example of a disease which is strikingly prevalent within the African American community, and unfortunately is on the rise. In order to reduce the occurrence rate of type II diabetes in African Americans and thus diminish this health disparity, implementation of programs targeting high-risk groups in the United States needs to continue. At the same time, such programs need to enhance their focus to include detection components as well as prevention and educational mechanisms. Only then can we be assured that the health status of Americans, regardless of race and ethnicity, is equal for all.