Eliseo Pérez-Stable, MD, is director of the National Institute on Minority Health and Health Disparities (NIMHD) at the National Institutes of Health (NIH). He sat down with WebMD to discuss the field of health disparities and how his studies aim to improve interventions not only in clinical settings, but across communities.
Editor’s note: This interview has been edited for length and clarity.
WebMD: Health disparities is a relatively new field. What’s its focus and purpose?
Pérez-Stable: In health outcomes, poor people do worse than people with more resources. It was observed 40 years ago that African Americans and other groups – particularly American Indian, Alaska Native – had much worse outcomes when compared to general results or White American population. So, there’s a preventable condition, and it’s not because someone had a bad gene or behaved badly. It stems from an identity factor, a social demographic factor.
WebMD: What drew you to health disparities?
Pérez-Stable: When I was a resident about 40 years ago, I noticed my Latino/Hispanic patients reacted differently to me. I felt this connection and bond. I asked, “What is it about me being Latino? Was it because I’m fluent in Spanish?” No. There were other things involved, and that led me to research this area.
It started with this patient-clinician communication model, and although language was a big factor, it grew from there. It gradually expanded to all racial and ethnic populations – and realizing that sometimes the outcomes are actually better than the general ones.
WebMD: Your institute funded a study showing ethnic and racial disparities cost the U.S. up to $451 billion annually. Break that down.
Pérez-Stable: Most costs to societies come from premature death – people who die too early and we lose out on their productivity in their job and in their community with their family. The average U.S. woman lives to her early 80s, and males 2-3 years younger, so you get a sense of where we should be.
When people are sick and no longer able to work or their work is limited, that’s a cost. Presumably, with proper intervention, they could’ve worked another 5 or 10 years. Someone with high blood pressure doesn’t get it under control and has a stroke at 60 – they’re still in the prime of work life. Maybe thinking about retirement, but still working, and they’re not going to be the same retiree after a major stroke.
Another area is excess health care costs. When you’re sick, you need more diagnostics and treatments. Prevention costs resources, but maybe it would have cost less. Say, my kidneys fail and I need a transplant or dialysis. That’s tens of thousands of dollars on a regular basis. Well, if I had taken a certain medicine, I could have prevented kidney failure or delayed it 10-15 years.
WebMD: Do biological factors play a role as well?
Pérez-Stable: Biology is part of this because we’re all living systems with biology and behavior. One important concept is race or ethnicity. It doesn’t have a biological formula. There are components to it, and this is where people get confused.
For example, Latin America for 500 years has been this mix of people from Africa, Indigenous people from the Americas, and European colonizers. It’s been 20 generations, and now there are different mixtures.
I think biological pathways are left to be discovered that may vary by socioeconomic stressors or identity – things such as metabolic pathways leading to diabetes: Why doesn’t everyone with really high body weight develop diabetes? It’s not even 50%. Some people – we don’t know what their susceptibility is.
There are also genes that increase risks for certain cancers. The breast cancer gene is probably the most famous. But there’s actually a gene that’s protective against breast cancer, discovered only in women with Indigenous background from Latin America.
WebMD: Your work shows environmental and living conditions affect how genes express themselves. Can you explain how it works?
Pérez-Stable: This is the field of social epigenomics. It’s evolving. The epigenome concept involves changes that occur on the gene from external factors. Where this has been studied the most includes cardiovascular health, asthma, maternal health, and a little bit in cancer.
For example, if you’re under 5 and you’re really stressed – because there’s a dysfunctional family, maybe there’s lack of food, maybe violence in certain contexts – these adverse events change your epigenome in a way that maybe 30 years later you’ll get a disease. That’s a hypothesis.
We see poor housing, lack of quality food, or lack of bonding with your parents. These may have short-term effects – we can study that more easily. But what does it mean 30 or 40 years down the road? It’s really hard to study because we don’t keep that kind of data on people for all this time.
WebMD: Explain how the Community Engagement Alliance (CEAL) that you helped spearhead addressed disparate COVID-19 outcomes in underserved communities.
Pérez-Stable: In summer 2020, there was a study to test the Moderna vaccine. After the first month or so, 90% of study volunteers were White. Dr. Francis Collins (former NIH director) said we can’t allow this.
We all discussed strategies. Out of those early conversations, CEAL was born. We wanted to create an infrastructure to activate the community. Initially, it was, “Participate in this clinical trial,” because we didn’t know what the outcome was going to be. Once the vaccine was out in December (2020), we had to convince everybody to get vaccinated.
We saw how poorly Black communities were doing, the Latinos, American Indians, and Native Hawaiian/Pacific Islanders. The deaths were two to three times the average, but we saw by fall 2022, death rates had decreased across the board and the gaps narrowed or eliminated. It was a success.
We are in the middle of a transition, but CEAL will continue as an infrastructure for community engagement and partnership of community organizations with academic researchers to make a difference in those communities’ health. We now have 21 teams across the country.
WebMD: You talked about some outcomes being better. One of your areas of study shows African Americans who engage in unhealthy behaviors are more resistant to depression than White people and most Latinos. What factors might be at work?
Pérez-Stable: The fact that African Americans have less diagnosed depression and actually less suicide – that has been known for a long time. Latinos are in between. They’re not really as high as White people, but they aren’t as low as Black people.
The idea is you eat, drink, or smoke instead of being depressed. The first time I heard about this (pioneering social research being done by the University of Michigan’s James Jackson), I couldn’t buy into it, so we opted to test it in Latinos because there was no data for Latinos. The usual suspects – sedentary lifestyle, smoking, and drinking – were the main unhealthy behaviors. Probably poor nutrition was the fourth, which is harder to measure.
Among Puerto Ricans, using the (Hispanic Community Health Study/Study of Latinos) we did see a trend: that chronic stress didn’t lead to more depressive symptoms, but did lead to more unhealthy behaviors. But Mexican-Americans did not fit this model at all. (Two-thirds of Latinos in the U.S. have Mexican backgrounds.) Stress made them more depressed, and they didn’t engage in more unhealthy behaviors to cope.
It wasn’t gender specific because the sample sizes were not large enough, and we couldn’t say anything about Cubans or Central Americans.
WebMD: Another focus for you is how Latino heritage and adaptation to American culture impact smoking behavior. Can you expand?
Pérez-Stable: I’m Cuban myself. In Cuba, cigarette smoking was much more prevalent. In the U.S., Latinos smoke at lower rates. Again, the U.S. data is driven by Mexicans. The pattern for Cuban Americans and Puerto Ricans is more intense smoking and higher rates. I think that’s fairly consistent.
Well, Mexicans and Central Americans – and curiously, Dominicans – smoke at much lower rates.
Generally, it’ll be influenced by social mobility as well. In general, women, as they become more acculturated, they’re more likely to smoke and men are less likely to smoke. The traditional gender role of women in Latin American culture may be functioning as a protective factor against cigarettes and alcohol. That’s one hypothesis.
For men in the U.S., there’s the social environment where it’s not always as cool to smoke as it had been in Latin America. We see the same with Chinese males immigrating to the U.S. There were high smoking rates when they were in China. They came to the U.S., their smoking rates dropped dramatically.
WebMD: What can patients and doctors do to ensure they’re considering all factors driving health outcomes – and receiving or delivering the best care?
Pérez-Stable: What clinicians do least well sometimes – and it’s not their fault; it’s more that the system doesn’t make it easy – is understand who the patient is in their social context.
We know their age and sex. We usually know their racial and ethnic background. Sometimes people ask about birthplace. It matters where your patients were from originally – maybe not for many, but for some – so we should know they migrated to one part of the country but their family was from another part. For immigrants, that matters.
Then, socioeconomic status is often completely ignored in clinical care. Knowing at least the educational attainment of your patients helps you communicate better, understand where you have to be more concrete or more sophisticated depending on their educational background and providing a sense that you’re not threatening them when you ask, “How far did you go with school?”
WebMD: Talk about the “Understanding and Addressing the Impact of Structural Racism and Discrimination on Minority Health and Health Disparities” initiative.
Pérez-Stable: We funded 38 research grants. Most are observational, looking at associations among structures causing adverse outcomes. We’ve found, for example, areas with fewer social resources have, specifically, worse heart attack and transplantation care.
Studies to intervene take a while to develop, but NIH has committed resources to doing this using a community-based approach. Most are going to address things around access to healthy food that’s affordable, how can we impact housing, green space, community violence, health care. Also, education quality, which is harder.
Since communities don’t exist in isolation, they need good health care, and health care systems need to know about their communities, so it works both ways.
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