From the editors' desk: disparities near and far.

JGIM has cultivated a reputation for publishing important research in the field of health disparities. The reasons should be clear. The United States is a divided country, and not just politically. As Christopher Murray and colleagues reported in another journal (PLoS Medicine, 2006), there are at least “eight Americas,” each with markedly different health outcomes. For example, in 2001, Asian women had a life expectancy that exceeded that of urban black males by an entire generation (20.7 years). These disparities deserve exposition, analysis, and creative multilevel solutions. In this issue of JGIM, several articles address different aspects of health disparities. Using data from the California Health Interview Survey, August and Sorkin show that racial and ethnic minorities exercise less and eat less healthy diets than whites, particularly in middle adulthood, when risk factors for cardiovascular disease and cancer begin to accumulate. Other work reminds us not to shrug off these differences as a simple matter of individual choice; our collective failure to invest in neighborhood parks and walkways and to promote the availability of fresh produce in inner cities (among other things) has consequences. At the same time, the finding that health behavioral disparities were greatest among English-proficient minorities reminds us of the enduring role of culture. The genesis of health disparities is multifaceted, but differences in access to and quality of health care surely play a role. Numerous studies show that care differs among groups, even within the same health care system. The article by Burgess et al. adds to this profusion of evidence, showing that within the VA system, blacks were less likely to receive appropriate colorectal cancer screening than whites. However, the differences were small, and overall performance was good. But what about the way physicians and nurses interact with minority patients? A systematic review by Lie et al. examines whether cultural competency training of health professionals can improve patient outcomes. The authors are appropriately circumspect about the current state of the evidence. There are also evident disparities in the manner in which our health care system evaluates and pays for medical devices and diagnostic tests as compared with pharmaceuticals. While the Food and Drug Administration (FDA) demands evidence derived from randomized clinical trials before approving a new drug, the bar is set much lower for approval of most new medical devices and diagnostic tests. In this issue, Ollendorf et al. report on a systematic review of the diagnostic accuracy and impact on medical decision-making of multislice coronary computed tomographic angiography (CCTA), a non-invasive technology used to image coronary artery anatomy. Several manufacturers received clearance from the FDA through the 510(k) process to market multidetector CT scanners for this purpose. However, few physicians and even fewer patients know that clinical trials demonstrating safety and efficacy are not required to win 510(k) approval from the FDA. Systematic reviews of new and emerging medical devices and technology, such as the Ollendorf et al. systematic review, are essential for patients, providers, and health plans to make sound, evidence-based decisions about the appropriate role of new technology in medical decision-making and treatment. Ollendorf et al. conclude that while CCTA appears to have high diagnostic accuracy in patients with suspected coronary artery disease, its role in medical decision-making (arguably, the domain that really matters) is less certain. In Healing Arts, a recurring JGIM feature, journal authors examine human triumphs and suffering through a different lens. In a poignant essay, Siram Shamasunder recounts his experiences as a medical volunteer during the early days of rescue and recovery. The stories are harrowing, but the courage and determination of the Haitian people are inspiring. More than a year later, Haiti is easy to forget, but she still needs our help, particularly in the face of the recent cholera epidemic. JGIM readers interested in providing professional or financial assistance might contact Partners in Health (http://www.pih.org/), Doctors Without Borders (http://www.doctorswithoutborders.org/), or the Clinton Bush Haiti Fund (http://www.clintonbushhaitifund.org/).