States As the Laboratory for Democracy: Is Anybody Paying Attention, and Does Anybody Care?

It is important to not lose sight of the methodologically simplistic but still powerful take-home points from the report by Jemal et al, which accompanies this editorial. Between 2008 and 2010, 23,000 deaths resulting from colon cancer (50% of total) could have been prevented if all states had colon cancer death rates equal to the five states with the lowest rates for the most educated whites. An equally important point is the variation among the states; 69% of deaths could have been prevented in Mississippi, compared with only 29% in Utah. An often-repeated concept of our nation, attributed to Justice Louis Brandeis, is that the states are the laboratory for democracy. Implicit in this is that other states and the federal government should be able to learn from and adapt the successful experiments. To achieve this is complicated, and true parity is unlikely in the foreseeable future, but the lessons are out there if policymakers are willing to pay attention. Jemal et al obtained mortality data for colorectal cancer from 2008 through 2010 by age, sex, race/ethnicity, educational attainment, and state of residence from the National Vital Statistics System of the National Center for Health Statistics. For the population denominator, the authors used estimates derived from the Annual Social and Economic Supplement to the Current Population Survey. From these data, they calculated age-adjusted colorectal cancer death rates by race/ethnicity and educational level. Within each racial/ethnic category (non-Hispanic black, non-Hispanic white, and Hispanic), they calculated a rate ratio for each state, comparing those with 16 years of education with those with 12 years of education. States were ranked based on the rate ratio. To determine preventable deaths, the authors took the colorectal cancer death rates for the five states with the lowest rates among the most educated non-Hispanic whites and calculated what would happen if all other groups achieved these lower death rates. Many of the results are predictable and will come as no surprise to those who follow these data. Blacks or those with lower levels of education had higher colorectal cancer death rates than whites. Also nicely highlighted in Figure 1 of the report is that even controlling for education, blacks did worse. For example, the age-adjusted death rate for whites with 12 years of education was 11.3 per 100,000, compared with 16.7 per 100,000 for blacks. The potential reasons for all of these findings have been explored by others but include diet, exercise, obesity, lifestyle, vitamin D status, treatment differences, and health care access. The low colorectal cancer death rates for Hispanics is quite encouraging. However, this category is complicated by limited data, heterogeneity of the country of origin, and differences in immigration status (ie, new immigrant, first generation, second generation, and so on). The strength of the report is that it highlights that these disparities may not have to be as large as they are, and in fact, there are places in the United States where the differences by race or education are much smaller. For example, among non-Hispanic blacks with the lowest educational level, the neighboring states of New Jersey and New York had death rates of 16.3 versus 12.9. Similarly, Alabama and Texas had death rates of 20.3 and 21.5, respectively, compared with North Carolina, with a death rate of 14.5. Among non-Hispanic whites, Delaware had a colorectal cancer death rate for the lowest education group of 7.2, compared with neighboring Pennsylvania, with death rate of 10.9. It may not be reasonable in the near term for Texas or New Jersey to achieve parity with Utah or Minnesota, but if Texas could achieve parity with North Carolina as a start and New Jersey could achieve parity with New York, then disparities by education and race would be reduced, and lives would be saved. The question is, how can this be achieved? A partial answer lies in focusing on states like New York and Delaware and learning from what they have done. In this study, New York had the lowest death rate among blacks with the lowest level of education; it was below the US average among other education groups. In 2003, the New York City Department of Health and Mental Hygiene launched a multipronged initiative to combat colorectal cancer, including a public education campaign, an open-access colonoscopy referral system, and patient navigation. By 2007, New York was able to increase the colonoscopy rate from 40% to 60%, and among blacks from 35% to 64%, thereby eliminating the screening disparity. Similarly, the state of Delaware, which had the lowest death rate among whites with the lowest level of education, embarked on a statewide effort in 2002, with the goal of eliminating colorectal cancer health disparities. It also launched a public education effort and used patient navigation services. In addition, it committed to reimbursing for up to 24 months the cost of cancer treatment for the uninsured so that those diagnosed with cancer could actually be treated. By 2009, it was able to eliminate the incidence rate disparities between blacks and whites and had nearly eliminated the mortality disparity. What will it take for other states to take notice and act on this? Simply put, there has to be a commitment at all levels of the state to the public health of all its citizens. Both New York City and Delaware made the elimination of health disparities in colorectal cancer a priority. That was the bold step, and everything else was a detail. I fear that this commitment is not shared across the country, and the study by JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L