Opinion: Cancer disparities are shrinking, but the work of health equity is just getting started

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By Niasha Fray, MA, MSPH

As I read reports that the disparities in cancer incidence and survival between African-Americans and whites are shrinking, I find myself encouraged, but also thinking about a patient I worked with a few years ago as a medication adherence counselor.

This well-educated, successful African-American woman gave up her career to take care of her aging parents. After they passed away, she took a service job that required her to stand and walk all day—only to be diagnosed with breast cancer.

Radiation therapy followed, as did the side effect of extreme fatigue. Without family wealth to fall back on, and with doctors and employers not taking her ongoing symptoms seriously, when her FMLA period expired she had to choose between going back to work despite feeling physically depleted or losing her income and health benefits.

She chose to prioritize her recovery, but quickly found that she had a new, exhausting full-time job: scrambling to find the money and support to get through the 5 to 10 years of endocrine therapy she’d need to make sure her cancer didn’t return.

Stories like this remind me that, while any evidence of shrinking disparities is cause for celebration, our work is only beginning. As an African-American woman and breast cancer survivor myself, I know that battling the disease and adhering to a long-term therapy is hard enough. It’s even harder when you’re also battling the legacy of slavery, Jim Crow, redlining, and other racist institutions that have eliminated generational wealth, displaced communities, and sown mistrust of the healthcare enterprise.

Photo credit: Durham County Department of Public Health

The story of a person’s health is not just a story of doctors, insurance, and pharmaceuticals; it’s also the story of that person’s community, of the environment they grew up in, the employment opportunities they have, the food they can access, and many other social determinants of health.

If we want to find answers to our health crises, researchers and care providers can’t settle for only asking questions about treatment options and personal habits. They also need to partner with communities to ask questions about issues like violence and policing, housing, green space, air quality, and locally-sourced fresh food.

Think of it this way: If a young person is unable to access healthy foods; unable to play outside because there’s nowhere to go or because their community is unsafe or over-policed; if they are exposed to pollutants from the freeways and industrial parks often located in low-income and non-white areas, can we be surprised when they and their peers suffer disproportionately from serious disease later in life? And can we call this anything other than injustice on a massive scale?

On the other hand, the opportunities are also massive. We have the chance to capitalize on the decline in cancer rates and turn it into sustained health equity by interrogating the reasons for that decline and creating culturally appropriate, replicable methods for tackling other health issues.

Let’s consider the example of lung cancer: Dr. J. Leonard Lichtenfeld of the American Cancer Society attributes the decline mostly to changes in smoking habits. He told NPR, “I can’t say why smoking has decreased so dramatically in the black community…It has significantly narrowed the gap [in lung cancer rates] between blacks and whites and we are very grateful.”

I, too, am grateful and happy to hear this news, and I believe it represents a fantastic opportunity. We know this didn’t happen because of individual healthcare treatment—it happened through large-scale behavior change. It’s not an endpoint, it’s an urgent call to investigate what drove that change, so that we can extract lessons to customize prevention, screening, and peer-support models for African-American populations.

These kinds of tools could be invaluable in addressing future health crises—perhaps even those that will be undoubtedly be caused by the disparity in exposure to air pollution and other challenges related to our changing planet.

The American Tobacco Trail in Durham, NC.

We also need to tease out hidden disparities that the overall data obscures. For example, African American women get breast cancer less often than white women, yet they are 41% more likely to die of it. This shocking discrepancy is likely due to a myriad of factors, including the comorbidity of a disease like diabetes, which is similarly linked to diet, exercise, and education, and has higher prevalence among African-Americans.

The solutions to these problems will never be found in the healthcare industry alone. Health equity can only be accomplished through participatory, community-informed policy change that involves every major sector: government, business, education, faith, community activism, healthcare, and more.

Fortunately, communities all over the country are waking up to this idea. In Durham, North Carolina there are numerous task forces, non-profits, and community-based organizations focused on the social determinants of health and creating tangible change.

With increasing cooperation and investment, we’ve proven that we can eliminate disparities and build a community that’s healthier for everyone, supporting the disenfranchised rather than tearing them down.

Niasha Fray, MA, MSPH, is a health equity specialist in the Center for Community & Population Health Improvement at Duke University, and the Program Director of Healthy Durham 20/20, a multi-sector coalition working to address health disparities in Durham County, North Carolina.

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