Eliseo Perez – StableMD, Director, National Institute on Minority Health and Health Disparities (there is nothing) at the National Institutes of Health (NIH). He sat down with WebMD to discuss the field of health disparities and how his research aims to improve clinical settings as well as interventions across communities.
Editor’s note: This interview has been edited for length and clarity.
Online MD: Health disparities are a relatively new field. What is its focus and purpose?
Perez is stable: On health outcomes, the poor fare worse than those with greater resources. It was observed 40 years ago that outcomes for African Americans and other groups—particularly American Indians, Alaska Natives—were much worse compared to general outcomes or to white Americans. So, there is a condition that is preventable and it’s not because someone has bad genes or behaves badly. It originates from identity factors and socio-demographic factors.
Online MD: What made you notice the health disparities?
Perez is stable: About 40 years ago, when I was a resident physician, I noticed that my Latino/Hispanic patients responded to me differently. I felt this connection and bond. I asked, “What does it matter that I’m Latino? Is it because I’m fluent in Spanish? No.”
It started with this model of patient-clinician communication, and it grew from there, although language was an important factor. It gradually expanded to all racial and ethnic populations, with the realization that sometimes outcomes are actually better than average.
Online MD: Your institute funded a study showing the cost of ethnic and racial disparities in America Up to $451 billion per year. Break it down.
Perez is stable: Much of the cost to society comes from premature deaths – when people die prematurely, we lose their productivity at work, in their communities and at home. The average lifespan for American women is in their early 80s and the average lifespan for men is 2-3 years, so you can get an idea of where we should be.
When people get sick and can’t work or their jobs are limited, that’s the cost. Presumably, with appropriate intervention, they could work for another 5 to 10 years. People with high blood pressure who have uncontrolled strokes at age 60 are still in their prime working years. Maybe someone is considering retirement but is still working, and they won’t be the same retiree after a big stroke.
Another area is the exorbitant cost of health care. When you are sick, you need more diagnosis and treatment. Prevention requires resources, but may be less expensive. Let’s say my kidneys fail and I need a transplant or dialysis. This is usually tens of thousands of dollars. Well, if I had taken a certain medication, I could have prevented kidney failure or delayed it by 10-15 years.
Online MD: Could biological factors also play a role?
Perez is stable: Biology is part of it because we are all living systems with biology and behavior. An important concept is race or ethnicity. It has no biological formula. It has a lot of components, and that’s where people get confused.
For example, Latin America has been a mixture of Africans, Native Americans, and European colonizers for 500 years. There have been 20 generations and now there are different blends.
I think biological pathways are still to be discovered and may vary by socioeconomic stress or status, such as metabolic pathways that lead to diabetes: Why doesn’t everyone who is very heavy develop diabetes? Not even 50%. Some people – we don’t know how sensitive they are.
There are also genes that increase the risk of certain cancers. The breast cancer gene is probably the best known. But there’s actually a gene that protects against breast cancer, and it’s only found in women of indigenous Latin American backgrounds.
Online MD: Your work shows that environmental and living conditions influence how genes are expressed. Can you explain how it works?
Perez is stable: This is the field social epigenomics. It is developing. The concept of epigenome involves changes in genes due to external factors. The most researched areas include cardiovascular health, asthma, maternal health and some cancers.
For example, if you’re under 5 years old and you’re really stressed out because of a dysfunctional family, maybe a lack of food, maybe violence in some cases, those adverse events will change your epigenome, maybe 30 years Later you will be changed by it. This is an assumption.
We see poor housing, lack of quality food, or lack of connection with parents. These may have short-term effects – something we can more easily study. But what will this mean 30 or 40 years from now? Research is really hard because we don’t keep this kind of data on people all the time.
Online MD: explain how Community Engagement Alliance (CEAL) You’ve helped lead the way in addressing the disparate consequences of COVID-19 in underserved communities.
Perez is stable: In the summer of 2020, there was a study testing the Moderna vaccine. For the first month or so, 90 percent of the study volunteers were white. Dr. Francis Collins (former director of the National Institutes of Health) said we cannot allow this to happen.
We all discussed strategy. From these early conversations, CEAL was born. We want to create an infrastructure that activates the community. Initially, it was “join this clinical trial” because we didn’t know what the results would be. Once the vaccine becomes available in December (2020), we must convince everyone to take it.
We see how poorly Black communities, Latinos, American Indians, and Native Hawaiians/Pacific Islanders are fared. The number of deaths is two to three times higher than average, but we see an overall decline in death rates by the fall of 2022, with the gap narrowing or eliminating. It was a success.
We are in the midst of a transition, but CEAL will continue to serve as an infrastructure for community engagement and partnerships between community organizations and academic researchers to improve the health of these communities. We now have 21 teams across the country.
Online MD: You talked about some outcomes being better. One of your areas of research shows that African Americans who engage in unhealthy behaviors are more resistant to depression than white people and most Latinos. What factors might be at play?
Perez is stable: In fact, it has long been known that African Americans are diagnosed with less depression and actually have lower suicide rates. Latinos are somewhere in between. They’re not as tall as whites, sure, but they’re not as low as blacks either.
The idea is to let you eat, drink, or smoke instead of feeling depressed. When I first heard about this (from James Jackson’s groundbreaking social research at the University of Michigan), I couldn’t believe it, so we chose to test it among Latinos because there was no data on Latinos. The usual suspects – a sedentary lifestyle, smoking and drinking – are the main unhealthy behaviors. A fourth, perhaps more difficult to measure, is malnutrition.
Among Puerto Ricans, through the (Hispanic Community Health Study/Latino Study), we do see a trend: chronic stress does not lead to more depressive symptoms, but it does lead to more unhealthy behaviors. But Mexican Americans simply don’t fit that mold. (Two-thirds of Latinos in the United States are of Mexican background.) Stress makes them more depressed, and they don’t engage in more unhealthy behaviors to cope.
It’s not gender specific because the sample size isn’t large enough for us to talk about Cubans or Central Americans.
Online MD: Another focus of your attention is how Latino heritage and acculturation to American culture influence smoking behavior. Can it be expanded?
Perez is stable: I am Cuban myself. Smoking is more common in Cuba. Latinos have lower smoking rates in the United States. again, The U.S. data is driven by Mexicans. Cuban Americans and Puerto Ricans have higher rates of smoking and higher rates of smoking. I think it’s pretty consistent.
Well, Mexicans and Central Americans — and, oddly enough, Dominicans — have much lower smoking rates.
In general, it is also affected by social mobility. Generally speaking, women are more likely to smoke as their education level increases, while men are less likely to smoke. Traditional gender roles for women in Latin American cultures may be a protective factor against cigarettes and alcohol. This is an assumption.
For American men, the social context for smoking wasn’t always as cool as it was in Latin America. We see the same thing among Chinese men immigrating to the United States. After they came to the United States, smoking rates dropped dramatically.
Online MD: What steps can patients and doctors take to ensure they consider all factors that influence health outcomes and receive or provide the best care?
Perez is stable: Clinicians sometimes do the worst thing – and it’s not their fault; more importantly, the system doesn’t make it easy – understand who the patient is within their social context.
We know their age and gender. We usually know their racial and ethnic background. Sometimes people ask about birthplace. Where your patients originally come from matters — maybe not to many people, but to some — so we should know that they moved to one part of the country but their family came from another. For immigrants, this is important.
Socioeconomic status, then, is often completely overlooked in clinical care. Knowing at least a patient’s education level can help you communicate better, understand where you have to be more specific or complex based on their educational background, and make them feel like you’re not a threat when you ask “how far along have you come?” Go with them to school?
Online MD: Talk about the “Understanding and Addressing the Impact of Structural Racism and Discrimination on Minority Health and Health Disparities” initiative.
Perez stable: We have funded 38 research grants. Most are observational, looking at associations between structures that lead to adverse outcomes. For example, we found that heart attack and transplant care fare particularly poorly in areas with fewer social resources.
Intervention studies take time to develop, but the National Institutes of Health has committed resources to using community-based approaches to achieve this goal. Most questions will address issues around access to affordable healthy food, how we impact housing, green space, community violence, health care. In addition, the quality of education is also more difficult.
Because communities don’t exist in isolation, they need good health care, and the health care system needs to understand their communities, so it goes both ways.
