Exploring the Relationship Between Oral Health and Systemic Health Within the African American Population Enhancing Oral and Systemic Health 4

Much published research documents continuing racial and ethnic disparities in health, particularly for African Americans, which apply to both oral and systemic diseases. Current research suggests biologically plausible associations between oral and systemic diseases; however, clear causeand-effect relationships have not been substantiated. Some researchers and health care providers have noted anecdotal associations between oral and systemic health, as well as compounding adverse effects of oral and systemic diseases and dysfunctions. Historically, African American physicians, dentists, and pharmacists have bonded together under one organizational umbrella to combat discrimination, prejudice, and racism directed at them and their patient populations. This coming together has resulted in a more comprehensive clinical, behavioral, economic, and public health decision-making process related to the general health and well-being of their patient populations, such as maximizing health care visits, treatment plans, reimbursements, and oral and systemic health care followups. According to the 1985 Secretary’s Task Force Report, the six causes of excess deaths among African Americans were: cardiovascular disease and stroke; cancer; diabetes; cirrhosis; homicide and accidents; and infant mortality. In 1991, HIV/AIDS became the seventh cause of excess deaths. This article summarizes salient information about cardiovascular diseases, diabetes, cancer, and the social and behavioral factors related to oral and systemic health. After reading this article, the reader should be able to: • discuss some of the major morbidities and mortalities that disproportionately affect African American and other minority populations. • list the seven leading causes of “excess deaths” among African Americans. • summarize the major risk factors for cardiovascular diseases, diabetes, and cancer and discuss how these risk factors may also apply to oral diseases. • describe some of the barriers to health and health care experienced by African Americans and other minority populations. Learning Objectives: Rueben C. Warren, DDS, MPH, DrPH Research Chair, National Dental Association Foundation Adjunct Professor Department of Behavioral Sciences and Health Education Rollins School of Public Health Emory University Atlanta, Georgia Clinical Professor Department of Community Health/Preventive Medicine Morehouse School of Medicine Atlanta, Georgia Adjunct Professor Department of Preventive Dentistry/Community Health School of Dentistry Meharry Medical College Nashville, Tennessee CE1 Compendium / Special Issue Vol. 22, No. 3 4 and/or to prevent, treat, and/or cure disease, disability, dysfunction, and premature death. Oral health disparities among select groups of people in the United States include those groups with the poorest oral health status—generally ethnic and racial minority populations, particularly African Americans.1-5 Ethnic and racial disparities also exist in general or systemic health. In the 1985 federal publication, “Report of the Secretary’s Task Force on Black and Minority Health,” the former Secretary of the US Department of Health and Human Services, Margaret Heckler, writes: There is a continuing disparity in the burden of death and illness experienced by Black and other minority Americans as compared to our Nation as a whole. That disparity has existed ever since Federal record keeping began more than a generation ago and although our health charts do itemize steady gains in the health of minority Americans, the stubborn disparity remains.an affront to both our ideals and to the ongoing genius of American medicine.6 In response to this problem, in December 2000, the National Dental Association Foundation, the National Dental Association, Inc. (NDA), the National Institute of Dental and Craniofacial Research, and the ColgatePalmolive Company cosponsored a symposium entitled, “Exploring the Relationship Between Oral Health and Systemic Health Within the African American Population. ” The symposium addressed oral and systemic health, oral and systemic diseases, dysfunctions and premature deaths, and the relevant behavioral and socioeconomic factors that disproportionally affect the health of African Americans and other underserved populations.7 This article reviews salient issues on the health status of ethnic and racial populations. It also summarizes several presentations from the symposium that specifically focused on systemic diseases and on the social and behavioral barriers and enablers that influence oral and systemic health. Some of the other presentations at the symposium targeting oral health and diseases are also published in this issue. “Excess deaths” are additional deaths experienced by African Americans beyond what one would expect if their death rates were the same as those for the non-Hispanic white population. Excess deaths are one of the measurements that reflect the problem of poorer health status among African Americans. Using data from 1979 to 1981, the analysis of excess deaths reflects 60,000 more deaths among African Americans when compared to the nation as a whole.6 The causes of excess deaths included heart diseases and stroke, homicide and accidents (unintentional injury), cancer, infant mortality, cirrhosis, and diabetes. The report also chronicled the longstanding problem of the burden of illness suffered by ethnic and racial minority populations. Since the time of the report, acquired immunodeficiency syndrome (AIDS) has become the seventh leading cause of death among African Americans.8 The Task Force Report focused on four groups: African Americans, Native Americans/Alaskan natives, Hispanics, and Asian/Pacific Islanders. The Task Force, appointed by Secretary Heckler, completed the following assignments: (1) a review of departmental programs to determine how the health problems of minorities [people of color] have been addressed; (2) a careful analysis of the range of health care resources and information available; and (3) a critique of the health status of African Americans, Native Americans, Hispanics, and Asian/Pacific Islanders. Using previously existing data, the Task Force also focused on several areas including: • an outreach campaign • patient education • delivery and financing of health services • developing strategies outside the federal sector • building capacity of the nonfederal sector to address minority health problems • improving and fully using available sources of data • a research agenda. The Task Force reviewed the existing literature, published research, government documents, and epidemiological databases. They conducted interviews and focus groups with health professionals and research scientists both inside and outside of the federal government. Other assessments were undertaken, such as reviews of conference proceedings from minority health symposiums and conferences. Even with the broad-based recommenVol. 22, No. 3 Special Issue / Compendium 5 dations from the Task Force, the restructuring of many federal, state, and local public health agencies, and more than a decade of financial support for creative research and intervention programs in both the public and private sectors, racial and ethnic health disparities remain.9 In fact, since the 1985 Task Force Report, some of the racial and ethnic health disparities are the same or have worsened. While some of the health gap is a result of socioeconomic status, race and ethnic backgrounds remain important in accounting for the disparities. Some of the disparities can be explained by inequalities in the health delivery system, such as differences in accessibility, use, quality of care, or benefit derived.10-13 Unfortunately, most of these variables can be chronicled by race and ethnicity.14-17 Regardless of the interventions to close race/ethnic health disparities, the problem remains. In “Eliminating Racial and Ethnic Disparities in Health: Report to Congress FY 1998/1999,” the US Department of Health and Human Services lists the following facts18: • Age-adjusted breast cancer mortality increased 3.9% for black women and declined 15.4% for white women between 1985–1996 (Department of Health and Human Services [DHHS], 1998). • While the number of tuberculosis (TB) cases among non-Hispanic whites actually decreased 42.9% between 1986–1997, the number of reported TB cases increased 51.1% for Asian Americans and Pacific Islanders, and 30.3% for Hispanics (Centers for Disease Control Tuberculosis Data, July 1998). • The number of cases of AIDS-opportunistic illnesses from 1991 to September 1998 increased 14% to 34% for non-Hispanic blacks, Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan natives, while the number of cases decreased 18% for nonHispanic whites. During 1997, the most recent year-end data available, the AIDS case rate was 20.5 per 100,000 for African Americans, 14.4 per 100,000 for Hispanics, and 2.5 per 100,000 for whites (CDC AIDS Surveillance Report, September 1998). • Life expectancy gaps between blacks and whites have measured from 6.0 years in 1985 to 6.6 years in 1996b (DHHS, 1998). • While infant mortality rates among blacks have decreased since 1985, it is still disproportionate. Infant mortality rates decreased by 33.7% for infants of white mothers but only 22.6% for infants of black mothers between 1985 and 1996. The disparity in infant mortality between blacks and whites, as measured by the ratio of infant mortality rates, has, therefore, increased from 2.07 in 1985 to 2.41 in 1996 (DHHS, 1998). • The same general pattern in infant mortality is seen in American Indians and Alaskan natives in the Indian Health Service’s service areas. From 1985 to 1992, infant mortality among American Indians and Alaskan natives in the Indian Health Service area declined 20.7%, while infant mortality declined 25.8% for the total US white population (Trends in Indian Health, 1997). • Between 1985 and 1996, age-