Karen Bankston, PhD, MSN
Professor Emerita, College of Nursing
Member, University of Cincinnati Cancer Center

The incidence of cancer and cancer deaths continue to ravage our communities. About 224,080 new cancer cases and 73,680 cancer deaths are expected to occur among Black people in 2022. Black people have the highest death rate and shortest survival of any racial/ethnic group in the United States for most cancers. While the Black population is the third largest ethnic group in the U.S., following Whites and Hispanics, this trend continues. It is, however, important to point out that Black immigrants, those arriving from the Caribbean or Africa, have a lower mortality rate than U.S. born Blacks who are descendants of slaves. This indicates the importance of understanding where someone lives in addition to race and ethnicity.

An underlying source of health disparities among people of color is structural racism, defined as discrimination perpetuated through interconnected institutions and reinforced through culture, history, ideology, and sanctioned practices. Structural racism impacts all facets of life to limit the accumulation of wealth and overall standard of living through unequal access to work, education, housing, healthy food, and quality health care.  This has been demonstrated by the historical diversion of resources from Black neighborhoods. Specifically, access to public transportation, grocery stores, and public green spaces, all of which limit the availability of affordable healthy food and opportunities for physical health, has historically been challenging in some neighborhoods. Additionally, this resource-poor environment increases the prevalence of chronic stress, infectious disease and other exposures that contribute to poor health.

During 2019-2020, 19% of Black people were living below the federal poverty level compared to 7% of White people, and only 28% had completed four years of college compared to 41% of Whites. However, regardless of race/ethnicity, cancer risk and mortality increase with decreasing socio-economic status. Additionally, access to health care influences the use of prevention and early detection services, like tobacco cessation counseling and cancer screening, followed by receipt of cancer treatment and survivorship. The American Cancer Society estimates that 42% of all cancer cases and 45% of cancer deaths in the US are attributed to potentially modifiable risk factors, including cigarette smoking, excess body weight, alcohol intake, poor diet, physical inactivity, and exposure to cancer-associated infectious agents. Subsequently, exposure to early detection and prevention is imperative, along with adequate resources.

Unfortunately, a lack of trust in the system persists. Studies have shown that Black people have higher mistrust in the medical system compared to Whites, with one-quarter expressing high mistrust of physicians. This is likely due in part to a long history of racial bias and discrimination in the US health care system, including exploitation of Black people for medical advancement, unequal treatment at segregated hospitals, and provider bias. Sadly, some of this treatment was seen locally.

By the 1850s, Cincinnati had become the sixth largest city in the United States, with a population of about 115,000. Its African American population also had increased to about 3,200, making it one of the largest Black American communities in the nation during the antebellum era. Unfortunately, African American Cincinnatians lives turned into a nightmare. During most of the 19th century, African Americans in the city began to fully comprehend that although Cincinnati was in a free state, most of its African American residents had very limited rights and freedoms. This showed itself in such activities like the practice known as "redlining," which singles out predominantly Black neighborhoods as high risk, limiting homeownership opportunities and, subsequently, resources required for living healthy lives. While Cincinnati's numerous public facilities were not segregated legally, clearly most local African Americans knew that there were customs that existed that unofficially reinforced the wishes of White private property owners who sought to prevent African Africans from entering their hotels, restaurants, and amusement parks. The consequences of this segregation led to generations of Black families that had the inability to own real estate, grow wealth and improve their lot in life.

Between 1960 and 1972, the Department of Defense funded research on radiation exposure to humans, some of which occurred locally at Cincinnati General Hospital. Their research subjects were cancer patients with life expectancies, at the most, of two years, and primarily indigent, and poorly educated, with a majority being African American. The patients were told that the radiation was for the benefit of their cancer treatment and were not told that the radiation dosage was determined by the experimental design of the research "to study the effects of massive doses of radiation on human beings in preparation for a possible nuclear war." No consent forms were used for the first five years. When consent forms came into use, the risk of radiation exposure to the patients was not stated. This incidence has influenced the trust factor that many African American families in Cincinnati have with the health care system and can be a barrier to ensuring health equity.

Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health. Achieving this requires ongoing societal efforts to address historical and contemporary injustices, as well as develop ways to overcome economic, social, and preventable health disparities. Furthermore, to achieve health equity, we must engage in initiatives that change the systems and policies that have resulted in these generational challenges that have led to racial and ethnic health disparities. One way to begin the journey towards health equity is to engage the community in developing strategies for change.

Community engagement starts by understanding that a person’s social and community context includes their interactions with the places they live, work, learn, play, and worship and their relationships with family, friends, co-workers, community members, and institutions. Then by engaging with trusted leaders known by the community, work jointly to address misinformation, myths, and lack of access to appropriate resources. Additionally, be intentional in delivering all health-related services in a culturally appropriate way and according to the needs of patients. Establishing and developing cultural competence training for health care professionals will support an intentional focus on skills and knowledge that value diversity, understand, and respond to cultural differences, and increase awareness to facilitate improvement of cancer care provided to our patients.

 
Dr. Karen Bankston is a professor emeritus at the University of Cincinnati College of Nursing and a cancer prevention, control and population science research program member at the University of Cincinnati Cancer Center.