Running head: HEALTH DISPARITIES BALTIMORE CITY

Health Disparities Among African Americans in Baltimore City Hollis Misiewicz Nursing 674

HEALTH DISPARITIES BALTIMORE CITY Health Disparities Among African Americans in Baltimore City

The study of health disparities in the United States has gained momentum as advances in health care have failed to close the gap between health outcomes of white Americans and other ethnic minorities. Health disparities can be defined as differences in the incidence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups (Maryland Department of Health and Mental Hygiene, 2006, page 64). Currently in the United States, cancer is the second leading cause of death. (American Cancer Society, 2011). In the 1990s African Americans had the highest incidence of cancer with a higher mortality rate than any other racial group (Maryland Department of Health and Mental Hygiene, 2006). This trend continues even today within the confines of Baltimore City (Johns Hopkins Urban Health Institute, 2010). The purpose of this paper is to identify health outcomes and health disparities that might contribute to the increased incidence of cancer and other chronic diseases in the African American population of Baltimore City and identify health priorities in relation to Health People 2020 objectives. The Population The population that is the focus of this paper are African Americans who reside within the boundaries of Baltimore City. Specifically I am interested in the adult population but some consideration needs to be given to certain characteristics of the home and school environment that influences ones development as an adult and therefore limited evaluation of these circumstances involving children will also be included. As an oncology nurse practitioner in an inner city hospital-based chemotherapy clinic a large proportion of my patients are African American. Often it is these patients who present with more advanced disease and exhibit poorer outcomes to treatment than their Baltimore City white counterparts. A population health assessment of African Americans in Baltimore

HEALTH DISPARITIES BALTIMORE CITY City might give clues as what could be done to rectify this disparity in outcomes for African Americans diagnosed with cancer. Health Outcomes

In order to determine whether health disparities exist, epidemiological data must be considered in relation to a populations health status. Life expectancy for an African American baby born in Baltimore is 70.2 years compared to the life expectancy of a Caucasian baby of 76.2 years. Despite a decrease in the number of low birth weight babies born in Baltimore between 2006 and 2008, African American women are still more apt to deliver a low birth weight infant than white mothers (15.1% vs. 7.4%). A black baby has nine times more chance of dying before his first birthday than a white baby in Baltimore (Johns Hopkins Urban Health Institute, 2010). In Baltimore City African Americans have the highest rate of death in comparison to other racial groups within the city and to African Americans outside Baltimore City. Baltimore African Americans are twice as likely to die as a result of homicide than their counterparts in Maryland. Blacks in Baltimore die from homicide at a rate of 55.2 per 100,000 population compared to whites in Baltimore who die at a rate of 7.0 per 100,000 population. HIV infection among the studied population in 2006 was 175 new cases per 100,000 people compared to the national average of 23.2 per 100,000 people. Baltimore City whites had 50.2 new HIV cases per 100,000 population. Blacks were also eight times more likely to die as a result of AIDS than whites in Baltimore (Johns Hopkins Urban Health Institute, 2010). Compared to the average in Baltimore and Maryland, African Americans in Baltimore have the highest rate of death from cardiac diseases of all racial groups. Heart disease is the number one killer of African Americans in Baltimore City. Mortality was 279.3 per 100,000 population for heart disease and 60.6 for stroke. The same statistics for whites in Baltimore disclosed a mortality rate per 100,000 population of 253.1 and 41.0 for heart disease and stroke respectively. Diabetes causes significantly

HEALTH DISPARITIES BALTIMORE CITY more deaths among Baltimore City African Americans than whites ,at a rate of 44.5 per 100,000 population compared to 23.8 per 100,000 population (Johns Hopkins Urban Health Institute, 2010). Baltimore African Americans are twice as likely to be obese as their Caucasian counterparts

(43.5% vs. 23.3%). Black high school students in Baltimore have a 31% higher prevalence of obesity than all other high school students in Maryland. Tobacco use is also more common among African Americans in Baltimore in comparison to whites. Statistics show there are 45% more current smokers among blacks in Baltimore than whites. It is estimated that 60,000 residents of Baltimore City abuse illegal substances, most frequently crack and heroin and many of these residents are African Americans. Approximately 17% of Baltimoreans have no health insurance (Johns Hopkins Urban Health Institute, 2010). Cancer is the second most common cause of death for African Americans in the United States and this is true of those in Baltimore as well (American Cancer Society, 2011). For African Americans as a whole in Baltimore city, the death rate from cancer is 236.7 deaths per 100,000 population compared to 219.4 for Baltimore whites and 180.8 for all races in the United States (Johns Hopkins Urban Health Institute, 2010). African American males in Baltimore have an 8% greater chance of being diagnosed with invasive cancer than a white male (Baltimore City Health Department, 2008). One measure of premature death in a population is years of potential life lost (YPLL). Cancer accounts for 10-16% of YPLL in predominantly African American neighborhoods in Baltimore (Baltimore City Health Department, 2008). Health Determinants Certain risk factors have been shown to correlate with an increased incidence of cancer. Low socioeconomic status (SES) is closely linked to increased cancer risk. A low SES is associated with poorer outcomes along the entire trajectory from prevention of cancer to end-of-life care. Certain risk

HEALTH DISPARITIES BALTIMORE CITY behaviors, such as smoking and little physical activity are more common among people of low SES. Obesity is also associated with increased cancer risk (U.S. National Institutes of Health, 2010; American Cancer Society, 2011). The environment of the lower socioeconomic population can contribute to this. Unsafe neighborhoods discourage walking as exercise. Food sources that dont offer healthy choices tend to be more common in poorer neighborhoods. A low SES is associated with problems accessing the health care system and 29.2% of African American families live below the poverty level in Baltimore City (U.S. Census Bureau, 2010). An assessment of the environment of the African American in Baltimore City to determine risk factors for cancer will follow. U.S. Census Bureau Data for Baltimore City (2005-2009) At the time of the census there were 405,112 African Americans in Baltimore City, comprising 63% of the total population. Of these, 23.4% were below the poverty level as compared to 13.4% of

Caucasians. 20.2% of families were below the poverty level compared to 7.6% of white families. Marital status of African Americans was as follows; 21.6% married, 8.3% widowed, 11.2% divorced and 52.7% never married (U.S. Census Bureau, 2010). Neighborhood Data The Office of Epidemiology at the Baltimore City Health Department publishes vital statistics of all of the neighborhoods that comprise Baltimore City. For the purposes of this analysis I have chosen ten predominantly African American neighborhoods (95-98% black) and compared them to three predominantly white Baltimore neighborhoods (92-94% white) that are geographically in close proximity (Baltimore City Health Department, 2008). I have taken an average of the vital statistics presented between the neighborhoods. The African American neighborhoods are Cherry Hill, Greater Rosemont, Greenmount East, Madison/East End, Midway/Coldstream, Pimlico/Arlington/Hilltop, Sandtown-

HEALTH DISPARITIES BALTIMORE CITY Winchester/Harlem Park, Southern Park Heights, The Waverlies, and Upton/Druid Heights. The white neighborhoods are Highlandtown, Morrell Park/Violetville and South Baltimore. Life expectancy for the African American neighborhoods ranged from 62.5-66.5 years. In the white neighborhoods life expectancy was 69.6-75.6 years. Years of potential life lost was 1,980-2,597 per 10,000 population for the black communities as opposed to 1,021-1,602 in the white communities. Age adjusted mortality was 139.2-177.6 and 98.6-120.7 per 10,000 population in the black and white neighborhoods respectively (Baltimore City Health Department, 2010). Statistics that Reflect SES and Living Conditions Violent crime rate (1 offense per 1000 people) averaged 23.3 offenses in the black

neighborhoods and 12 in the white neighborhoods. Domestic violence incidents (#911 calls for domestic violence per 1000 people) averaged 51 in African American neighborhoods compared to 29 in white neighborhoods. Juvenile arrests for violent crime (# arrests for violent offenses per 1000 youths, ages 10-17) averaged 21.6 and 11.6 in black and white communities respectively (BNIA, 2010). A significant difference in the crime rate between neighborhoods reflects an unsafe environment for the African American population in Baltimore. This could influence the walkability of these neighborhoods resulting in less physical activity for the residents. The U.S. Census Bureau (2000) recorded the average median annual household earnings of African Americans in Baltimore as $22,800 compared with the earnings of Baltimore whites of $33,300. The unemployment rate for African Americans in the aforementioned neighborhoods was 19.9% versus 6% in the white neighborhoods. Only 28.6% of blacks in these communities had any education beyond high school compared to 56.6% of whites. The high school dropout rate for blacks was 10% of all students while only 4.7% of white students left high school prior to graduation. The teen birth rate (ages 15-19 per 1000 teens) was 89 for the African American neighborhoods and 82 for the white

HEALTH DISPARITIES BALTIMORE CITY neighborhoods. Early prenatal care was received by 68% of black women as opposed to 81% of white women in their respective neighborhoods. Black women had babies of satisfactory birth weight 84% of the time compared to 90% of white women (BNIA, 2010). Eleven percent of commercial properties in black neighborhoods had permits for rehabilitation compared to 16% in white neighborhoods. Of residential properties, 4.7% had permits to undergo rehabilitation in black neighborhoods compared to 6.3% in white neighborhoods. The percentage of

businesses that were at least four years old was similar between the neighborhoods with 54.6% in black communities and 58.7% in white communities. The average price of a home for sale in the African American neighborhoods was $78,700 in contrast to $219,000 in the predominantly white areas. One of the most telling factors about these neighborhoods is the percentage of vacant buildings. In the African American neighborhoods 19.5% of residences are vacant and abandoned. In the white neighborhoods only 1.3% of housing was abandoned. Two other statistics which reflect conditions within a neighborhood are rat incidents (per 1000 people) and dirty street and alley incidents (per 1000 people). In the African American neighborhoods the range of rat incidents was 0.52-200.02 with an average of 99 incidents. In the white communities the average was 50 incidents. There was an average of 128 dirty street and alley incidents in black neighborhoods compared to 83 in white neighborhoods (BNIA, 2010). Of the ten African American neighborhoods, five have community gardens. Two of the neighborhoods are involved in a Healthy Neighborhood Initiatives program. This initiative is dedicated to revitalization of undervalued neighborhoods. It supports residents who wish to purchase their homes and provides support for rehabilitation of residences. The Healthy Neighborhoods Initiative receives federal grants for assisting in rebuilding the local economy and helping to stabilize neighborhoods (Healthy Neighborhoods, 2010). The two neighborhoods involved in the Healthy Neighborhood

HEALTH DISPARITIES BALTIMORE CITY Initiatives are adjacent to each other and share a farmers market. A Giant supermarket has recently located here. The area also has a YMCA and a large recreational park (Healthy Neighborhoods, 2010). Food Stores in Baltimore Four different types of food stores predominate in the city of Baltimore. There are supermarkets that are large and carry a variety of fresh and prepared foods. Convenience stores are part of a nationally recognized chain and are smaller in size than supermarkets. Corner stores are not owned by chains but usually are operated by their owners, friends or family members. They are known only locally. Another type of store found in Baltimore is the behind-glass store. These have Plexi-glass walls that separate the customer from merchandise and the person working at the store. A study of food stores in Baltimore revealed the distribution of supermarkets to be more numerous in predominantly white neighborhoods. Supermarkets that are in poorer areas tend to have less healthy foods available than their counterparts in more affluent neighborhoods. Corner stores and behind-theglass stores were distributed unevenly among neighborhoods, more frequently seen in black communities. These stores generally do not sell fresh produce, skim milk or whole grain products (Haering & Franco, 2010). Parks and Recreation Baltimore City has about 6,000 acres of parks within the city borders. Three of these are large landscape parks that are greater than 50 acres in size. These offer a variety of amenities, such as athletic fields and walking trails. Clifton Park which is 117 acres and has a golf course in situated within a predominantly white area. Patterson Park is 55 acres in size and has 2 ice rinks in addition to athletic parks. This is situated in a neighborhood that is 51% African American. Druid Hill Park is the largest of the landscape parks with 745 acres and a zoo. This is situated near a low income African American neighborhood that has the highest incidence of violent crime of all the communities assessed in this

HEALTH DISPARITIES BALTIMORE CITY analysis (Baltimore City Department of Parks and Recreation, 2010). This could have a negative effect

on residents willing to walk to the park to take advantage of the facilities. Figure 1 depicts a community built playground within the neighborhood of Druid Hill. Additional Data Additional data on the selected population that would assist in a thorough analysis of health disparities within the health care system would focus on actual access to health care. This would include several areas of interest. First, it would be helpful to know how much of the population is uninsured. For those that are insured, how many have private health insurance and how many are covered by Medicare and Medicaid plans. Which plan the patient has within these government insurances is also important as coverage can vary greatly. Next I would like to know the availability of health care facilities within the vicinity of these neighborhoods and if not nearby, how is public transport, patient access to a car, etc. Last I would like to know the pattern of use of healthcare facilities and whether patients have their own primary care physician who monitors their care. The above information can determine how likely a person is to enter the healthcare system for a perceived problem. It would help explain why this African American population often waits until later in the stages of a disease to obtain help. Top Three Health Priorities The top three health priorities for this population would be addressing issues related to cancer incidence, cardiac disease incidence and obesity. Heart disease is the number one killer of African Americans in the United States and Baltimore City as well. Forty-four percent of black men and 46.9% of black women over the age of twenty have cardiovascular disease (American Heart Association, 2010). Cancer is the second leading cause of mortality of blacks in Baltimore and the country (American Cancer Society, 2011). African Americans have shorter survival times after cancer diagnosis and a higher death rate from cancer than other races in the United States (American Cancer Society, 2011; U.S. Department

HEALTH DISPARITIES BALTIMORE CITY of Health & Human Services, 2011). African Americans in Baltimore city have a higher death rate from

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cardiovascular disease and cancer than any other racial or ethnic group in the city (Johns Hopkins Urban Health Institute, 2010). Seventy-one percent of African American males and 79.6% of females over the age of twenty are overweight and obese (American Heart Association, 2010). The black population in Baltimore City is twice as likely to be obese as their white counterparts (Johns Hopkins Urban Health Institute, 2010). Obesity has been linked to increased incidence of a variety diseases including cancer and heart disease (National Cancer Institute, 2010; Hubert, Feinleib, McNamara, & Castelli, 1983). An analysis of the African American neighborhoods reveals several factors which could influence the predominance of obesity within this population. Food sources in close proximity tend not to offer healthy foods (Haering & Franco, 2010). The availability of high-fat, processed foods contributes to obesity. Crime in these neighborhoods is high and this could discourage residents from walking and decreased physical activity is also linked to increased weight gain. Addressing the issue of obesity can help to improve the incidence of cardiovascular disease and cancer of the African American population in Baltimore City. Improving access to healthy foods and increasing walkability of neighborhoods needs to be addressed initially in order to provide an environment conducive to interventions that aid in weight loss. Healthy People 2020 The Nutrition and Weight Status Goal for Healthy People 2020 is to promote health and reduce chronic disease risk through the consumption of healthful diets and achievement and maintenance of healthy body weights (U.S. Department of Health and Human Services, 2010). Several objectives encompassed by this goal are very applicable to the African American population of Baltimore City. The following Healthy People 2020 objectives should be addressed; (1) Increase the number of States that have State-level policies that incentivize food retail outlets to provide foods that are encouraged by the

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Dietary Guidelines, (2) Increase the proportion of Americans who have access to a food retail outlet that sells a variety of foods that are encouraged by the Dietary Guideline for Americans, (3) Increase the proportion of physician office visits that include counseling or education related to nutrition or weight, (4) Increase the proportion of physician office visits made by adult patients who are obese that include counseling or education related to weight reduction, nutrition, or physical activity, (5) Increase the proportion of adults who are at a healthy weight, (6) Reduce the proportion of adults who are obese, and (7) Reduce the proportion of children and adolescents who are considered obese (U.S. Department of Health and Human Services, 2010). Conclusion The African American population of Baltimore City has a higher incidence of many chronic diseases and risk behaviors than other racial and ethnic groups within the city. Blacks are more likely to be below the poverty level and live in areas with high violence and poorer food sources. These circumstances lead to an increased incidence of obesity which then leads to increased rates of cardiovascular diseases and cancer. This population analysis revealed several issues that need to be addressed in order to reduce health disparities of the African American population. Improving neighborhoods to make them more conducive to physical exercise and increasing access to healthy food sources would be a start to reducing the incidence of obesity in the African American population of Baltimore City.

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Figure 1. Community built playground in Druid Hill. (playspace finder.kaboom.org)

HEALTH DISPARITIES BALTIMORE CITY References

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American Cancer Society (2011). Cancer facts and figures for African Americans 2011-2012. Retrieved from: http:// www.cancer.org/Research/CancerFactsFigures/index American Heart Association (2010). African American and cardiovascular diseases-statistics. Retrieved from: http://www.americanheart.org/presenter.jhtml?identifier=3000927 Baltimore City Government, Department of Parks and Recreation (2010). Recreation and parks/parks. Retrieved from: http://www.baltimorecity.gov/Government/AgenciesDepartments/RecreationandParks/Parks.a spx Baltimore City Health Department (2008). Baltimore city health status report, cancer incidence. Retrieved from: http://www.baltimorehealth.org/hsr2008.html Baltimore City Health Department (2008). Neighborhood health profiles 2008. Retrieved from: http://www.baltimorehealth.org/neighborhood.html BNIA: Baltimore Neighborhood Indicators Alliance Jacob France Institute (2010). Vital signs 8. Retrieved from: http://www.bniajfi.org Haering, S.A., & Franco, M. (Eds.). (2010). The Baltimore city food environment. Johns Hopkins Center for a Livable Future. Retrieved from: http://www.jhsph.edu/clf/PDF_Files/BaltimoreCityFoodEnvironment.pdf Healthy Neighborhoods (2010). News and publications. Retrieved from: http://www.healthyneighborhoods.org

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Hubert, H.B., Feinlab, M., McNamara, P.M., & Castelli, W.P. (1983). Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study, Circulation, 67,968-977. Retrieved from: http://www.circ.ahajournals.org Johns Hopkins Urban Health Institute (2010). Health disparities in Baltimore city: is geography destiny? Retrieved from: http://www.jhsph.edu/urbanhealthpublications/reports/healthdis_baltimore.pdf Maryland Department of Health and Mental Hygiene, Maryland Family Health Administration (2006). Cancer Disparities. Retrieved from: http://fha.maryland.gov/cancer/cancerplan U.S. Census Bureau (2000). Baltimore city, Maryland. Retrieved from: http://www.factfinder.census.gov U.S. Census Bureau (2010). Baltimore city, Maryland. Retrieved from: http://www.factfinder.census.gov U.S. Department of Health & Human Services (2010). Healthy People 2020. Retrieved from: http://www.healthypeople.gov/2020/topicsobjectives2020/ U.S. Department of Health & Human Services, The Office of Minority Health (2011). Cancer and African Americans. Retrieved from: http://minorityhealth.hhs.gov/ U.S. National Institutes of Health, National Cancer Institute (2010). Cancer trends progress report 2009/2010 update. Retrieved from: http://progressreport.cancer.gov/