Part 3 Reducing Racial and Ethnic Health Disparities

By Michael Caso

Biopharmaceutical companies pride themselves on conducting comprehensive research activities. These research initiatives could be clinical programs to determine the viability of a new chemical entity to satisfy an unmet medical need, market access programs, or more recently, patient-centric needs of targeted populations.    Why then have these same companies virtually ignored the medical, social and cultural needs of the fastest growing segment of the U.S. population? 
Ethnic and racial minorities currently comprise over 30 percent of the U.S. population and will grow to 50 percent by 2050. In fact, in many geographical areas, minority populations represent an “emergent majority” — a collective majority of minorities. Additionally, this population can have unique responses to medications and are differentially impacted by a number of common disease states for which they are diagnosed later and have poorer control or survival rates than majority populations. 

It would appear that there exists here a nexus of needs and opportunities that should appeal to the biopharmaceutical industry, where a focus on a medical need can result in a healthier population and a healthier bottom line.

This is the first of a three-part posting that will provide supportive data that identifies the need, demonstrates targeting opportunities and provides specific strategies and tactics designed to positively impact complementary health disparity reduction and business goals.

Opportunities for Targeting: Disease States and Geography
Disease States
Disparities in healthcare are evident in the diagnosis and treatment of specific health conditions, in the utilization of preventive services and in health outcomes. These disparities may be caused by unique reactions to medicines, cultural or social factors. In fact, the majority of published research indicates that minorities are less likely than whites to receive needed services. In Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the Institute of Medicine (IOM) of the National Academies, reports: African-Americans and Hispanics tend to receive a lower quality of healthcare across a range of disease areas; disparities are found across a range of clinical settings; and the disparities in care are associated with higher mortality among minorities. 

Any institution that impacts public health — academia, medicine and social services, etc. — has a role to play in reducing disparities in healthcare; pharmaceutical companies are no exception. It would be challenging to find a pharmaceutical company without a product in at least one of the core six disease states identified by the U.S. Department of Health and Human Services (HHS) Office of Minority Health (OHM), in which racial and ethnic minorities experience serious disparities in health access and outcomes, as well as other diseases which differentially impact minority populations:

• Infant mortality: African-American, American Indian and Puerto Rican infants have higher death rates than white infants.
• Cancer screening and management: African-American women are more than twice as likely to die of cervical cancer than are white women and are more likely to die of breast cancer than are women of any other racial or ethnic group.
• Cardiovascular disease (CVD): Heart disease and stroke are the leading causes of death for all racial and ethnic groups in the United States. In 2000, rates of death from diseases of the heart were 29 percent higher among African-American adults than among white adults, and death rates from stroke were 40 percent higher. The future for African-Americans in managing CVD is not positive, as the incidence of risk factors for diabetes, obesity and high blood pressure are higher with African-American children than with white children of the same age. For example, 13.8 percent of African-American children have high blood pressure versus 8.4 percent of white children.
• Diabetes: In 2000, American Indians and Alaska Natives were 2.6 times more likely to have diagnosed diabetes compared with non-Hispanic Whites, African-Americans were two times more likely, and Hispanics were 1.9 times more likely.
• HIV infection/AIDS: Although African-Americans and Hispanics represented only 26 percent of the U.S. population in 2001, they accounted for 66 percent of adult AIDS cases and 82 percent of pediatric AIDS cases reported in the first half of that year.
• Immunizations: In 2001, Hispanics and African-Americans aged 65 and older were less likely than non-Hispanic whites to report having received influenza and pneumococcal vaccines.

In addition, the following diseases and conditions disproportionately impact racial and ethnic minorities:

Disease Disparities
Mental health

• American Indians and Alaska Natives appear to suffer disproportionately from depression and substance abuse.
• Less access to mental health services for minorities.
• Poorer quality of care for minorities.
• Minorities are underrepresented in mental health research.

Hepatitis

• 50 percent of those infected with Hepatitis B in 2002 were Asian-Americans and Pacific Islanders.
• Black teenagers and young adults become infected with Hepatitis B three to four times more often than those who are white.
• Higher incidence in black people than white people.

Syphilis

• Infection rate for African-Americans is 5.6 times the rate for whites.

Tuberculosis (TB)

• Almost 80 percent of reported cases were in racial and ethnic minorities.
• Asian-Americans and Pacific Islanders accounted for 22 percent.

Lupus

• Three times more common in black women than in white women.
• More common in Hispanic/Latina, Asian  and American Indian women.
• African-American and Hispanic/Latina women develop symptoms earlier.
• African-Americans have more severe organ problems.
• Death rates three times higher for African-Americans than for whites.

Asthma

• African-Americans have the highest asthma rates.
• Puerto Ricans may have higher asthma prevalence rates than non-Hispanic whites and any other Hispanic subgroup.

Stroke

• African-American adults are 50 percent more likely than their white adult counterparts to have a stroke.
• In general, American Indian/Alaska Native adults are 60percent more likely to have a stroke than their white adult counterparts.
• In 2004, Hispanic men were 14 percent less likely to die from a stroke than non-Hispanic white men. 

 (Source: http://www.cdc.gov/omh/AboutUs/disparities.htm)  

While providing a tremendous service by addressing critical unmet medical needs, pharmaceutical companies will expand business opportunities by reaching minority populations. Analyzing and communicating data about these markets can improve pharmaceutical company efforts in improving outcomes and delivering assistance to the healthcare system through improved population management. The improved outcomes and population health management assistance will increase product demand, enhance relationships with growing physician and patient populations, and lead to networking opportunities within governmental health agencies, ethnic medical associations and community-based organizations.  

Geography
While a focus on specific disease states is critical, so too is the ability to impact specific population bases. In this manner, it is more likely that limited resources can have a significant and measurable impact that can then be duplicated in other areas of need.  

Historically, significant minority population bases exist in major metropolitan areas. Wikipedia, as well as government census reports provide listings of cities for black, Hispanic and Asian populations and these tables can be used for creating an initiative for a single population. However, if your goal is to have a comprehensive initiative across all three of these minority groups, a comparative analysis of metropolitan areas would be required.   A suggested list of targeted cities for initiatives impacting black, Hispanic, and Asian populations would include the following:

• New York
• Los Angeles
• Detroit
• Chicago
• Washington, D.C.

The next issue of this report will focus on strategies and tactics across a broad range of R&D, medical affairs and marketing needs that can positively impact a foundation for cooperative endeavors with minority communities leading to a reduction in health disparities. 

Developing a Plan for Engagement and Collaboration
Now that we have addressed the why, what and where, let’s review options for how. The development of any plan for engaging minority physicians and patients should exhibit a number of key characteristics:

• Demonstrate cultural competency.
  • Cultural competency has been described by Dr. Lois Margaret Nora of Rush Medical College as “the ability to understand, appreciate and work with individuals and belief systems other than one’s own.” Having this characteristic will enhance trust with targeted audiences. As products of minority populations, most minority physicians have experienced the full range of involvement with medical and pharmaceutical companies, from exclusion to exploitation. Therefore, they will evaluate any overtures from pharmaceutical companies from a dual set of perspectives.
• Have corporate sign-off/focus.
  • Product managers come and go, so even when initiatives have been developed and executed in the past, they frequently disappear when the originator moves on to any role in the organization or leaves the company. This negatively impacts the trust element previously identified.
  • In addition, any comprehensive initiative takes time to develop and execute and is accompanied by an extensive budget. A return on investment will require a broad-based program across multiple disease states that differentially impact minorities. A single product budget will probably not support the scope of an initiative required to make a significant impact.
• Have both national and local initiatives.
  • A true participant in a minority health initiative can gain benefits from opportunities to collaborate with individuals, organizations and institutions that exist at both the national and local levels. In fact, once your “advances” to these communities are recognized as real, you are invited to participate in networks with others possessing similar missions in R&D, education and community outreach that exist at both the national (federal government) and state levels. Corporate officers can participate in national initiatives, while local company representatives can benefit from engagement with local organization leadership. For example, ethnic medical associations have national organizations supported by a network of state and local groups.
  • With a rise in the need for population management, collecting data and addressing the needs of local populations becomes increasingly important.

   
Proposed Strategies and Tactics 
Having provided the characteristics listed above, the following are suggested strategies along with associated tactics:

• Identify opportunities for R&D programs that include or address issues of minority health.
  • There is a wealth of data available addressing ethnic and racial differences in response to medicines that can influence both drug efficacy and compliance. It is good science and good business to factor those issues into major clinical programs.
  • Identify opportunities to capitalize on data captured on pharmacogenomics.
• Identify opportunities for collaboration on projects of mutual interest and benefit.
  • Anyone can write a check to support an identified need with a minority health organization, but the basis for a long-term working relationship is founded in all parties benefitting. Collaborative programs for physician and patient education and community outreach are recommended
• Develop direct-to-patient programs.
  • Engage with a diverse set of patients from the very beginning of the development process all the way through commercialization to help improve your clinical trial outcomes.
  • In pre-launch, ensure minority population subgroup analyses are part of the scientific platform.
  • At launch, collaborate with local patient advocacy groups in high minority areas.

 
As the U.S. population demographics shift, so too must the focus of the pharmaceutical industry. As stated previously in this publication, there exists here a nexus of needs and opportunities with minority populations, where a focus on a medical need can result in a healthier population and a healthier bottom line.