EDITORIAL Race, Poverty, and Cancer Harold Freeman*
Poverty in Relation to Cancer Poverty, in contrast, is associated with low educational level, substandard living conditions, an inadequate social-support network, unemployment, poor nutrition, risk-promoting lifestyle, and diminished access to health care. Diminished access is often manifested by low quality and inadequate continuity of health care, as well as insufficient access to methods of disease detection, diagnosis, and treatment and to rehabilitation. Moreover, poor people tend to concentrate on day-to-day survival, often develop a sense of hopelessness and powerlessness, and may become socially isolated. Evidence indicates that poor Americans have an increased incidence of cancer and 5-year survival rates 10%-15% lower than those for other Americans.
Interrelationships of Race, Poverty, and Cancer While neither race nor poverty is an absolute indicator of cancer incidence and survival rates, each is a surrogate of predictable conditions and circumstances. Setting aside historical considerations, the significance of race with respect to cancer is generally limited to race as an indicator of a specific culture and lifestyle. We conclude, however, that economic status, irrespective of race, prevails as a more powerful surrogate of human conditions and circumstances. We theorize that poverty acts through the prism of culture—a factor that can either diminish or accentuate poverty's negative effects. For example, poor people belonging to a culture whose members do not smoke, do not drink alcoholic beverages, and have a low-fat, high-fiber diet will have diminished risk factors
Race in Relation to Cancer Race may be seen in relation to its historical, cultural, and genetic meanings, any or all of which may have significant implications.
526
Received February 28, 1991; accepted March 4, 1991. *Correspondence to: Harold Freeman, MD, Department of Surgery, Harlem Hospital Center, 506 Lennox Ave, Room 11-104, New York, NY 10037.
Journal of the National Cancer Institute
Downloaded from http://jnci.oxfordjournals.org/ at Northern Arizona University on June 3, 2015
Some Americans suffer a higher cancer incidence and mortality than the mainstream of American society and, in general, do not enjoy the same health status. If we could accurately identify subgroups of Americans who do not fare as well and determine the precise underlying reasons for the disparity, it might be possible to design and implement specifically targeted interventions that could lead to correction of the disparity. Since the early 1970s, the scientific community, focusing mainly on black and white differences, has documented racial disparities in cancer incidence, mortality, and survival (7). Data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute, as an example, have consistently shown that black Americans experience higher cancer incidence rates and lower survival rates than white Americans. The accuracy of these findings is not in question. Of substantive importance, though, is whether or not race, in and of itself, is the fundamental determinant of the disparities in cancer incidence and outcome. In this issue of the Journal, Baquet and associates, correlating cancer incidence rates for blacks and whites with data related to socioeconomic status, have concluded that the disproportionate distribution of blacks at lower socioeconomic levels accounts for much of the excess cancer burden among blacks. The authors correctly suggest that several cancer sites could be targeted for interventions in black and white populations with low income and high population density (2). The results of a number of studies are in agreement with the findings of Baquet et al. One such study is a major report issued in 1986 by the American Cancer Society, which concluded that controlling for socioeconomic status greatly reduces, and sometimes nearly eliminates, the apparent mortality and incidence disparities between ethnic groups. The report further concluded that ethnic differences are largely secondary to socioeconomic factors in contributing to these disparities (5). For a better understanding of the issues raised and conclusions reached in the article by Baquet and colleagues, it is important to define the meanings of race and economic status in relation to cancer incidence and outcome.
The history of a given racial group can be a powerful determinant of the current socioeconomic status of that group. As a dramatic example, consider the fact that, historically, black Americans have been legally free in this country for only 25 years, having prior to that experienced 250 years of slavery and 100 years of legalized segregation. The negative socioeconomic effect of this nation's long history of legalized segregation and slavery is believed to be a key factor in explaining many of the health disparities between races that still persist, including those related to cancer. Viewed from another perspective, race may be seen as a gross variable for culture. If, for example, a population designated by race has common ancestors, similar social and physical environment, and a shared communication system, its members will tend to have a similar tradition, value system, belief system, and world view. These shared elements lead to common lifestyle, attitudes, and behavior. Such cultural factors deeply influence health status, and any successful intervention must necessarily take these powerful cultural realities into account. To date, there is no known genetic basis to explain the major differences in cancer incidence and outcome between races.
compared with those in a culture whose members smoke and drink heavily and consume a high-fat, low-fiber diet. On the other hand, irrespective of culture, poor people have diminished access to health care (Fig 1) (4).
Poverty in America An estimated 34 million Americans are poor by the national standard of poverty («=$12 000/year for a family of four). Two thirds of the poor are white, but only 12% of white Americans are poor. In contrast, one third of the poor are black and one third of black Americans are poor. We suggest that the disproportionate cancer burden shared by black Americans is, for the most part, an indication of the health consequences that befall a racial group representing one third of the poor, one fourth of the unemployed, but little more than one tenth of the population.
The concentration of resources on high-risk groups is an accepted medical principle in the attempt to achieve substantially
Risk-pwnoling litsstyls. attitude behavior
References (/)
HENSCHKE UK, LEFFALL LD JR, MASON CH, ET AL: Alarming increase of
cancer mortality in the U.S. black population (1950-1967). Cancer 31:763-768,1973 (2)
BAQUET CR, HORM JW, GIBBS T, ET AL: Socioeconomic factors and cancer
incidence among blacks and whites. J Natl Cancer Inst 83:551-557, 1991 (i)
(4)
SUBCOMMITTEE ON CANCER
IN THE ECONOMICALLY DISADVANTAGED.
AMERICAN CANCER SOCIETY: Special report on cancer in the economically disadvantaged. New York: American Cancer Society, 1986 FREEMAN HP: Cancer in the socioeconomically disadvantaged. CA 39:266-288,1989
Fig 1. The interrelationships of race, poverty, and cancer. Poverty acts through the prism of culture (race) [from Freeman (4)].
Vol. 83, No. 8, April 17,1991
EDITORIAL 527
Downloaded from http://jnci.oxfordjournals.org/ at Northern Arizona University on June 3, 2015
Conclusions
improved survival rates, whether one is dealing with infectious disease, neoplastic disease, or other forms of illness. Convincing evidence has accumulated to show that low socioeconomic status, regardless of race, is a major determinant of higher cancer incidence and lower survival. Poor Americans, therefore, constitute a high-risk group for developing and dying of cancer. Accordingly, substantial resources should be directed toward prevention, detection, diagnosis, and treatment of cancer in the economically disadvantaged. In 1983, the war against cancer took on a new approach when the National Cancer Institute set a goal to diminish the mortality rate from cancer by 50% by the year 2000. The achievement of such a goal requires, among other things, the dramatic narrowing or elimination of the gap in cahper incidence and survival between the socioeconomically disadvantaged and other Americans. To accomplish this year 2000 goal, we must declare and conduct a new kind of war against cancer—a guerrilla war to tear down the economic and cultural barriers to prevention, early detection, and treatment of cancer. This hand-to-hand combat must be carried out in the neighborhoods of America where people live and die. Therefore, the designated battlegrounds for waging such a guerrilla war should include geographically and culturally delineated areas of high cancer incidence and mortality. Such areas should be targeted with an intense approach to providing culturally relevant education, control of tobacco use, appropriate access to early diagnosis and treatment, and an improved social-support network. It is important to see things in perspective. If in fact the human condition of poverty, irrespective of race, is the key underlying cause of increased cancer incidence and mortality, it follows that we, as a humane society, armed with cultural sensitivity, must aim our preventive and therapeutic guns to destroy trie disproportionate cancer burden of those Americans who can pay for neither the guns nor the ammunition.
Poverty in Relation to Cancer Poverty, in contrast, is associated with low educational level, substandard living conditions, an inadequate social-support network, unemployment, poor nutrition, risk-promoting lifestyle, and diminished access to health care. Diminished access is often manifested by low quality and inadequate continuity of health care, as well as insufficient access to methods of disease detection, diagnosis, and treatment and to rehabilitation. Moreover, poor people tend to concentrate on day-to-day survival, often develop a sense of hopelessness and powerlessness, and may become socially isolated. Evidence indicates that poor Americans have an increased incidence of cancer and 5-year survival rates 10%-15% lower than those for other Americans.
Interrelationships of Race, Poverty, and Cancer While neither race nor poverty is an absolute indicator of cancer incidence and survival rates, each is a surrogate of predictable conditions and circumstances. Setting aside historical considerations, the significance of race with respect to cancer is generally limited to race as an indicator of a specific culture and lifestyle. We conclude, however, that economic status, irrespective of race, prevails as a more powerful surrogate of human conditions and circumstances. We theorize that poverty acts through the prism of culture—a factor that can either diminish or accentuate poverty's negative effects. For example, poor people belonging to a culture whose members do not smoke, do not drink alcoholic beverages, and have a low-fat, high-fiber diet will have diminished risk factors
Race in Relation to Cancer Race may be seen in relation to its historical, cultural, and genetic meanings, any or all of which may have significant implications.
526
Received February 28, 1991; accepted March 4, 1991. *Correspondence to: Harold Freeman, MD, Department of Surgery, Harlem Hospital Center, 506 Lennox Ave, Room 11-104, New York, NY 10037.
Journal of the National Cancer Institute
Downloaded from http://jnci.oxfordjournals.org/ at Northern Arizona University on June 3, 2015
Some Americans suffer a higher cancer incidence and mortality than the mainstream of American society and, in general, do not enjoy the same health status. If we could accurately identify subgroups of Americans who do not fare as well and determine the precise underlying reasons for the disparity, it might be possible to design and implement specifically targeted interventions that could lead to correction of the disparity. Since the early 1970s, the scientific community, focusing mainly on black and white differences, has documented racial disparities in cancer incidence, mortality, and survival (7). Data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute, as an example, have consistently shown that black Americans experience higher cancer incidence rates and lower survival rates than white Americans. The accuracy of these findings is not in question. Of substantive importance, though, is whether or not race, in and of itself, is the fundamental determinant of the disparities in cancer incidence and outcome. In this issue of the Journal, Baquet and associates, correlating cancer incidence rates for blacks and whites with data related to socioeconomic status, have concluded that the disproportionate distribution of blacks at lower socioeconomic levels accounts for much of the excess cancer burden among blacks. The authors correctly suggest that several cancer sites could be targeted for interventions in black and white populations with low income and high population density (2). The results of a number of studies are in agreement with the findings of Baquet et al. One such study is a major report issued in 1986 by the American Cancer Society, which concluded that controlling for socioeconomic status greatly reduces, and sometimes nearly eliminates, the apparent mortality and incidence disparities between ethnic groups. The report further concluded that ethnic differences are largely secondary to socioeconomic factors in contributing to these disparities (5). For a better understanding of the issues raised and conclusions reached in the article by Baquet and colleagues, it is important to define the meanings of race and economic status in relation to cancer incidence and outcome.
The history of a given racial group can be a powerful determinant of the current socioeconomic status of that group. As a dramatic example, consider the fact that, historically, black Americans have been legally free in this country for only 25 years, having prior to that experienced 250 years of slavery and 100 years of legalized segregation. The negative socioeconomic effect of this nation's long history of legalized segregation and slavery is believed to be a key factor in explaining many of the health disparities between races that still persist, including those related to cancer. Viewed from another perspective, race may be seen as a gross variable for culture. If, for example, a population designated by race has common ancestors, similar social and physical environment, and a shared communication system, its members will tend to have a similar tradition, value system, belief system, and world view. These shared elements lead to common lifestyle, attitudes, and behavior. Such cultural factors deeply influence health status, and any successful intervention must necessarily take these powerful cultural realities into account. To date, there is no known genetic basis to explain the major differences in cancer incidence and outcome between races.
compared with those in a culture whose members smoke and drink heavily and consume a high-fat, low-fiber diet. On the other hand, irrespective of culture, poor people have diminished access to health care (Fig 1) (4).
Poverty in America An estimated 34 million Americans are poor by the national standard of poverty («=$12 000/year for a family of four). Two thirds of the poor are white, but only 12% of white Americans are poor. In contrast, one third of the poor are black and one third of black Americans are poor. We suggest that the disproportionate cancer burden shared by black Americans is, for the most part, an indication of the health consequences that befall a racial group representing one third of the poor, one fourth of the unemployed, but little more than one tenth of the population.
The concentration of resources on high-risk groups is an accepted medical principle in the attempt to achieve substantially
Risk-pwnoling litsstyls. attitude behavior
References (/)
HENSCHKE UK, LEFFALL LD JR, MASON CH, ET AL: Alarming increase of
cancer mortality in the U.S. black population (1950-1967). Cancer 31:763-768,1973 (2)
BAQUET CR, HORM JW, GIBBS T, ET AL: Socioeconomic factors and cancer
incidence among blacks and whites. J Natl Cancer Inst 83:551-557, 1991 (i)
(4)
SUBCOMMITTEE ON CANCER
IN THE ECONOMICALLY DISADVANTAGED.
AMERICAN CANCER SOCIETY: Special report on cancer in the economically disadvantaged. New York: American Cancer Society, 1986 FREEMAN HP: Cancer in the socioeconomically disadvantaged. CA 39:266-288,1989
Fig 1. The interrelationships of race, poverty, and cancer. Poverty acts through the prism of culture (race) [from Freeman (4)].
Vol. 83, No. 8, April 17,1991
EDITORIAL 527
Downloaded from http://jnci.oxfordjournals.org/ at Northern Arizona University on June 3, 2015
Conclusions
improved survival rates, whether one is dealing with infectious disease, neoplastic disease, or other forms of illness. Convincing evidence has accumulated to show that low socioeconomic status, regardless of race, is a major determinant of higher cancer incidence and lower survival. Poor Americans, therefore, constitute a high-risk group for developing and dying of cancer. Accordingly, substantial resources should be directed toward prevention, detection, diagnosis, and treatment of cancer in the economically disadvantaged. In 1983, the war against cancer took on a new approach when the National Cancer Institute set a goal to diminish the mortality rate from cancer by 50% by the year 2000. The achievement of such a goal requires, among other things, the dramatic narrowing or elimination of the gap in cahper incidence and survival between the socioeconomically disadvantaged and other Americans. To accomplish this year 2000 goal, we must declare and conduct a new kind of war against cancer—a guerrilla war to tear down the economic and cultural barriers to prevention, early detection, and treatment of cancer. This hand-to-hand combat must be carried out in the neighborhoods of America where people live and die. Therefore, the designated battlegrounds for waging such a guerrilla war should include geographically and culturally delineated areas of high cancer incidence and mortality. Such areas should be targeted with an intense approach to providing culturally relevant education, control of tobacco use, appropriate access to early diagnosis and treatment, and an improved social-support network. It is important to see things in perspective. If in fact the human condition of poverty, irrespective of race, is the key underlying cause of increased cancer incidence and mortality, it follows that we, as a humane society, armed with cultural sensitivity, must aim our preventive and therapeutic guns to destroy trie disproportionate cancer burden of those Americans who can pay for neither the guns nor the ammunition.
