WASHINGTON -- A robust economy and years of government pressure have helped move minority groups closer to the mainstream. But when it comes to health, studies show a stubborn, daunting and in some respects growing disparity between black and white Americans.
For decades, blacks have suffered higher death rates from nearly all major causes. Although life expectancy has increased for all groups, differences persist. And government and academic research shows a widening gap between blacks and others in the incidences of asthma, diabetes, major infectious diseases and several forms of cancer.
The federal Centers for Disease Control and Prevention reports that from 1980 to 1994 the number of diabetes cases rose 33 percent among blacks, three times the increase among whites. The gap in cases of infectious diseases has grown by the same magnitude.
With breast cancer, the CDC reports that from 1990 to 1995 the death rate for all women fell 10 percent, from 23.1 per 100,000 to 21. But black women's higher rate did not budge from 27.5 per 100,000.
The erosion of black Americans' health in relation to the health of Americans at large stands in stark contrast to blacks advances in areas like jobs, education and housing that three decades of civil rights laws have helped promote.
In the economy of the 1990s, poverty among blacks has shrunk, and gaps in income have narrowed. Sociological barriers to economic progress like a high teen-age pregnancy rate have receded, too.
But blacks often receive less, and worse, health care than whites, analysts say, meaning that they are sicker than whites and typically die at about age 70, six or seven years earlier than whites.
"We have a two-tiered health care system," said Dr. Randall Morgan, an orthopedic surgeon and a former president of the predominantly black National Medical Association.
Limited education, violence and addiction remain partly to blame. But Clinton administration officials and analysts of health systems say they are finding growing evidence that race, discrimination and social and cultural factors influence the care people receive and, consequently, their health.
The chief White House adviser on health issues, Chris Jennings, said economic status was a big source of the gap. "But even if you control for that, race is huge," Jennings said. "If you pull out education, race is still huge."
The White House is grappling with new ways to address the problem, most likely in the president's budget proposal early next month. In response to a White House request, officials of the Department of Health and Human Services and the Health Care Financing Administration said they were compiling proposals to try to eliminate the gap after 2000.
Dr. Donald M. Berwick, a pediatrician in Boston and a member of President Clinton's commission on health care quality, said: "Tell me someone's race. Tell me their income. And tell me whether they smoke. The answers to those three questions will tell me more about their longevity and health status than any other questions I could possibly ask. There's no genetic blood test that would have anything like that for predictive value."
The growth of managed care, experts said, has had little effect. "The more we hear about the problems in the health care delivery system and managed care, the more the issues of minorities stand out," said Bailus Walker, health policy director for the Joint Center for Political and Economic Studies, which focuses on blacks.
Administrations since the '60s have been aware of the gap and have started dozens of programs, committees and conferences to tackle it.
The Department of Human Services has an Office of Minority Health, which among other activities publishes a newsletter, Closing the Gap. The department compiles ambitious annual reports on progress toward goals for 2000 to prolong healthy lives and reduce the disparities.
But the results are mixed. For many conditions that disproportionately touch blacks, including asthma, obesity, homicide, maternal mortality, diabetes and fetal alcohol syndrome, the report published in October shows the incidences not only falling short of the goals but also slipping in relation to the conditions in the late '80s and early '90s, on which the goals were based.
Morgan said government attempts to reduce the gap were modest and subject to sporadic financing. "We get a program, and then it's over," he said. "We can't get a sustained effort. The tragic thing is it's costing America more and more every day to have the premature babies -- not the ones who die -- who go on to drain the health system's resources."
Public health programs begun in Clinton's tenure have made little more headway against the gap than those of prior administrations, including Medicaid, the insurance program for the poor, and Medicare, the program for the elderly.
Programs that pay for prenatal care for mothers and nutrition and immunization for children have helped many additional children survive infancy. But deaths of black mothers in childbirth, although rare, jumped 48 percent from 1987 to 1995 (the rate soared in the late 1980s), compared with 7.6 percent for all mothers. And blacks still have two times the infant mortality rate of whites, a gap that has not changed in at least a decade.
Since the early '60s, the American Cancer Society said, black men's death rate from cancer rose 62 percent, compared with 19 percent for all American men. A gap in the incidence of prostate cancer has narrowed. But the incidence is 30 percent higher for black men, and 66 percent survive for five years, compared with 81 percent of white men.
In general, the nation has realized declining death rates from leading killers like heart attack, stroke and cancer. But blacks still suffer those and other disabling conditions sooner than whites.
As a result, new research sponsored by the National Institute for Aging shows that blacks enjoy 56 years of reasonably good health, eight years fewer than whites and Hispanic-Americans. In an institute survey, one-third of all blacks from 51-61 described their health as fair to poor, compared with one-fifth of all whites of the same ages.
Kenneth G. Manton, director of the Center for Demographic Studies at Duke University, who wrote an analysis of the survey, said: "If you look at the total population, you find a significant decline in chronic disability and institutionalization for people 65 and older. But if you break it down among blacks and whites, you find almost all the improvement is among whites."
Concern about the gap has entered White House planning for Clinton's last two years in office. It has risen with experts' doubts that the enactment last year of a five-year $24 million plan to provide care to half the 10 million uninsured children would help reduce the disparities.
Administration officials expect Clinton, in his budget message, to ask for additional money to improve minority groups' health. In addition, the officials say, he could ask for revisions of government health programs so that additional people like nurses and physicians in minority communities join in working on the stubborn roots of the gap.
The issue is also entering other arenas. The president's advisory board on race, which has been dwelling mostly on discriminatory barriers to economic opportunity, has begun soliciting testimony on health.
Berwick said he and other members of the health commission were urging the commission to include a proposal to close the gap in the panel's final report in March.
To curry support to close the gap, the president is likely to define the issue in terms of minority health, not simply black health.
Other minority groups suffer from some diseases more than blacks. American Indians have higher levels of diabetes. Hispanic-Americans tend to suffer more fatal and disabling strokes. Puerto Rican children have the highest incidence of asthma.
The CDC reports that in 1996, tuberculosis among Asian-Americans was nearly 15 times higher than among whites and nearly twice the level for blacks.
But as the largest minority group and the one with the highest death rates from most diseases, blacks arouse the most concern among experts.
"There is a minority group that is very disadvantaged with respect to health, and that's African-Americans," said Samuel H. Preston, a demographer and dean of the School of Arts and Sciences at the University of Pennsylvania. "It's not a minority problem. It's a black problem."
The intractability of the gap is stirring searches for explanations beyond the conventional one of disproportionately low income. Hispanic-Americans, too, are relatively poor and are much less likely to have health insurance than any other group. Yet the CDC finds that they stay healthy longer than non-Hispanic whites, as well as blacks.
Research has shown slight, apparently genetic, predispositions among blacks for prostate cancer, sickle cell anemia and underweight births. But analysts say the major disparities arise less from inherent differences among races than from attitudes toward the races and unequal care.
A study in October in The New England Journal of Medicine suggested something peculiarly American to being black and unhealthy beyond genes. For the study, two neonatologists in Chicago, Drs. James Collins and Richard David, surveyed the birth weights of all children born in Illinois from 1980 to 1995. They isolated the lowest-risk group of mothers, from 20 to 39, who were college educated, married to college-educated men, had prenatal care in their first trimesters and had no prior miscarriages or stillbirths.
The researchers found that 2.4 percent of the 12,361 American-born white mothers delivered underweight babies, compared with 3.6 percent of 608 mothers living in Illinois and born in sub-Saharan Africa, and 7.4 percent for American-born black mothers.
"These findings discredit the genetic theory of race as it applies to birth weight," the doctors said in a paper presented in November to the annual meeting of the American Public Health Association. "To understand this thing called race, we must turn our attention to the institutions and attitudes which perpetuate and justify unequal treatment of people on the basis of their physical appearance, language or culture."
In hospitals and clinics, said Sara Rosenbaum, director of the Center for Health Policy Research at George Washington University here, blacks often receive worse care than whites. "When you take black and white Americans," Ms. Rosenbaum said, "and exactly the same situation like being hospitalized for a heart attack and having the same insurance, the chance that the black patient will get the advanced care is much less than it is for the white patient. The medical system appears to treat them differently."
Analysts say solutions require attention to the health conditions of the very young, before the effects of poverty, toxic environments, bad diets, violence and untreated disease.
"Policy that only deals with people in their 50s is going to have a minor impact on eliminating differences because a series of health shocks has happened already," said James P. Smith, a senior economist at Rand Corp. who testified this month before the race commission.
Policy goals should also change, said Berwick in Boston.
"It isn't enough to say we're going to close the gap by equalizing services," he said. "I don't think that's the heart of the problem. It's not equality of access. It's equality of result that we should seek."
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