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James C. Robinson Disparities In Health: Expanding The Focus Health Affairs, March/April 2008; 27(2): 318-319. [Extract] [Full Text] [PDF] [Reprints & Permissions]

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Racism By Commission Or Omission?

Milton E. Hammerly   ( 3 April 2008 )

Racism By Commission Or Omission? 3 April 2008
Milton E. Hammerly, VP, Medical Operations and Integrative Medicine Catholic Health Initiatives Send letter to journal: Re: Racism By Commission Or Omission? milthamerly{at}catholichealth.net Milton E. Hammerly	Heightened attention is justifiably focused on the important topic of racial disparities in health care. The IOM’s report Unequal Treatment has increased awareness in the medical community, and the new four-part series, “Unnatural Causes,” airing on PBS (www.unnaturalcauses.org), should raise consciousness in the general public regarding racial disparities in health care. The magnitude of the disparities is breathtaking. Over a 10-year period there were 886,000 more deaths than predicted in African Americans compared with Caucasians. [1] That’s more than 88,000 potentially avoidable deaths per year! Every health care provider, administrator, and policymaker should be losing sleep over this. Nearly all discourse on this topic focuses on the social determinants of health. There is now persuasive evidence that another critical factor has been ignored. Because greater amounts of melanin pigment in the skin of African Americans reduce ultraviolet penetration, less Vitamin D is produced with sun exposure.[2,3] Research shows that African Americans (men [4,5], women [6,7], children[ 8,9], adolescents [10], adults [10], and seniors [11]) have dramatically lower blood levels of Vitamin D. While Vitamin D deficiency is known to cause rickets, over the last several years understanding of the profound physiologic importance of Vitamin D has increased considerably. Numerous studies now link suboptimal Vitamin D levels to a host of ailments including breast cancer [12], prostate cancer [13], colon cancer [14], diabetes [15], hypertension [16], and heart disease [17,18], to name just a few. One study estimates that 150,000 cases of colon and breast cancer could be prevented per year if optimal Vitamin D levels were achieved in the U.S. population.[19] Given the greater prevalence and severity of suboptimal Vitamin D levels, along with earlier, more aggressive disease and higher mortality than Caucasians, as many as two-thirds (100,000) of the lives changed by Vitamin D optimization would be African Americans. Similar arguments can be made about prostate cancer and most of the killer diseases with a higher incidence and poorer outcomes among African Americans. Ignoring biologically based, epidemiologically documented, pathophysiologically significant racial differences is a form of racism by omission. Treating all patients the same despite proven physiologic differences promotes inequity of clinical outcomes and perpetuates societal injustice. Regardless of race, individualized care is a basic human right. Recognizing the relevance of suboptimal Vitamin D levels in African Americans is a golden opportunity for us to reduce racial disparities by individualizing care. Much work is needed to address the social determinants of health and their contribution to racial disparities. This complex work will take time and yield results over generations. Promoting the safe upper limit of daily Vitamin D intake (2,000 IU daily, per the IOM) for every African American is a safe, simple, and inexpensive biologic intervention that could produce more dramatic improvements in less time. By tackling the former, we will reduce racism by social commission. We must also embrace the latter to prevent racism by biologic omission. References 1. Woolf SH et al. Resolving racial disparities: an analysis of US mortality data. Am J Public Health, 2004;94:2078-2081 2. Norman AW. Sunlight, season, skin pigmentation, vitamin D and 25-hydroxyvitamin D: integral components of the vitamin D endocrine system. Am J Clin Nutr, 1998;67:1108-1110. 3. Harris SS. Vitamin D and African Americans. J Nutr, 2006;136:1126-1129. 4. Akhter N, et al. Vitamin D insufficiency is associated with lower hip bone density in African American men. J Clin Densitometry, 2007;10(2):S210-S-211. 5. Platz EA et al. Racial variation in prostate cancer incidence and in hormonal system markers among male health professionals. J Natl Cancer Inst, 2000;92(24):2009-2017. 6. Harris SS, Dawson-Hughes B. Seasonal changes in plasma 25-hydroxyvitamin D concentrations in young American black and white women. Am J Clin Nutr, 1998;67:1232-1236. 7. Nesby-O'Dell S et al. Hypovitaminosis D prevalence and determinants among African-American and white women of reproductive age: third National Health and Nutrition Examination Survey, 1988-1994. Am J Clin Nutr, 2002;76:187-92. 8. Willis CM et al. A prospective analysis of plasma 25- hydroxyvitamin D concentrations in white and black prepubertal females in the southeastern United States. Am J Clin Nutr, 2007;85(1):124-130. 9. Kumaravel R et al. Vitamin D insufficiency in preadolescent African-American children. Clinical Pediatrics, 2005;44(8):683-692. 10. Looker AC et al. Serum 25-hydroxyvitamin D status of adolescents and adults in two seasonal subpopulations from NHANES III. Bone, 2002;30(5):771-7. 11. Harris SS et al. Vitamin D insufficiency and hyperparathyroidism in a low income, multiracial, elderly population. J Clin Endocrinol Metab, 2000;85:4125-30. 12. Lin J et al. Intakes of calcium and vitamin D and breast cancer risk in women. Arch Intern Med, 2007;167(10):1050-1059. 13. Ahonen MH et al. Prostate cancer risk and prediagnostic serum 25 -hydroxyvitamin D levels (Finland). Cancer Causes Control, 2000;11(9):847–852. 14. Feskanich D et al. Plasma vitamin D metabolites and risk of colorectal cancer in women. Cancer Epidemiol Biomarkers Prev, 2004;13(9):1502–1508. 15. Mathieu C et al. Vitamin D and diabetes. Diabetologia, 2005;48(7):1247-57. 16. Scragg R, Sowers MF and Bell C. Serum 25-hydroxyvitamin D, Ethnicity, and Blood Pressure in the Third National Health and Nutrition Examination Survey. Am J Hypertens, 2007;20:713–719. 17. Arroyo M et al. Micronutrients in African-Americans with decompensated and compensated heart failure. Transl Res, 2006;148(6):301-8. 18. Scragg R et al. Myocardial infarction is inversely associated with plasma 25-hydroxyvitamin D3 levels: a community based study. Int J Epidemiol, 1990;19(3):559-63. 19. Garland CF et al. What is the dose-response relationship between vitamin D and cancer risk? Nutrition Reviews, 2007;65(S1):91-95.