Beyond the Medicine: Reducing Breast Cancer Deaths in African-American Women

Introduction

According to the American Cancer Society, a third of all women in the US will develop cancer during their lifetime. 1 in 8 women will develop invasive breast cancer, making it the second most common type of cancer in women. African-American women are 41% more likely than white women to die from the disease despite their similar rates of disease occurrence (Susan G. Komen). The disproportionate number of deaths could be due to a number of factors, including the ineffectiveness of treatments such as chemotherapy, radiation, and surgery. Looking beyond the traditional realms of medicine, the disproportionate death rates could also be due to healthcare prejudices, mistrust in biomedicine as an institution, or African-American women’s choices to seek alternative types of treatment. This is obviously a multifaceted issue, but underlying all of these causes for the disparity are the divides between science, religion, and culture that go beyond just the traditional health care setting. This paper will analyze several of the broader reasons for the disproportionate number of deaths. Following an analysis of the causes for disparity, the paper will connect these reasons to their underlying commonality—the divides between science, religion, and culture—and ultimately explore whether these ideas can be reconciled.

Breast cancer is a malignant tumor that begins in the breast tissue and metastasizes, spreading to other parts of the body (American Cancer Society, par. 1). According to the Cancer Research Center UK, cancer is dangerous because it can disrupt the body’s chemical balance, which makes the body unable to maintain its own homeostasis. (Cancer Research UK, par. 4). Cancers can also take over essential parts of the body like the lungs, liver, or digestive tract, causing vital organs to be unable to function—ultimately resulting in potential death (Cancer Research UK, par. 2-3). Researchers have identified some of the general risk factors that contribute to breast cancer, but like many other cancers, an exact cause of the disease has yet to be discovered. The BRCA1 and BRCA 2 gene mutations can increase a women’s chance of getting breast cancer to up to 80%. Having an immediate family member with breast cancer also doubles a women’s risk for getting breast cancer. Other non-genetic factors include having children after age 30, recent oral contraceptive use, hormones, alcohol consumption, and being overweight/obese (American Cancer Society, par. 2). These risk factors explain the rates of disease occurrence. The risk factors, however, don’t explain why African-American women are more likely to die from breast cancer than white women are.

Current Knowledge

The fact that African-American women are dying more frequently from breast cancer is not a new phenomenon. On their website, the Susan G. Komen for the Cure organization discusses several factors that contribute to the increased death rate for African-Americans including biological and genetic differences in tumors. They claim that African-American women are more likely to be diagnosed with more severe tumors and later stage cancers, and that African-American women are more likely to have a recurrence of cancer even when given chemotherapy. Komen for the Cure has also attributed the disproportionate number of deaths to a number of health behaviors and other risk factors including higher body mass index and obesity (Susan G. Komen, par. 21). Another huge factor that Komen for the Cure suggests impacts the disproportionate death rates is socioeconomics. This suggests African-American women are dying more often because they can’t afford the same types of treatment (Komen). 44% of African-Americans use employer-sponsored insurance, 28% rely on Medicaid, and 20.8% are uninsured, according to the US Department of Health and Human Services Office of Minority Health. Clearly, there are obvious disparities in terms of socioeconomics that very well may impact the disproportionate death rate. Additionally, a lack of socioeconomic status contributes to other factors such as lack of education, lack of transportation, and increased familial obligations, which could also contribute to the increased death rate (US Department of Health and Human Services).

However, this attribution of the healthcare disparity to a socioeconomic factor appears to be a shallow reading of the problem and doesn’t quite account for the entire story. A survey of studies by Griffith, Newman, Simon, et al. sought to study how much socioeconomics actually affects the increased death rates. By completing a meta-analysis of 20 different studies done on race/ethnicity and death by breast cancer, the study concluded that “African American ethnicity is a significant and independent predictor of poor outcome from breast cancer, even after accounting for socioeconomic status by conventional measures” (Griffith, par. 4). This example shows how there clearly are other factors that affect the disproportionate death rate that haven’t been identified or aren’t as commonplace as the factors previously identified by the Komen for the Cure organization. There must be some underlying difference in race that contributes to the disproportionate number of deaths.

There are obviously issues in the healthcare system as a whole. In a study by the Commonwealth Fund, researchers found that a third of breast cancer patients didn’t receive supplementary treatments that could have increased their chances of survival due to “‘system failures’—a breakdown that occurs despite the surgeon’s recommendation for treatment and patient’s willingness to receive it.” These system failures are particularly detrimental to minority women (Bickell et al, par. 2-3). System failures clearly do affect the disproportionate death rates. But why are minority patients more vulnerable systematic failures than white women are? What are the differences in race that ultimately lead to more African-American women dying from breast cancer?

Bias Hypothesis, Preference Hypothesis, and Communication Hypothesis

Though most research on the topic focuses on the immediate healthcare reasons for why African-American women are dying more frequently, there has been some research that pushes the question further. Even though the most commonplace reasons are those identified by Komen, other research has been done, and is united in the common theme of the divides between science, religion, and culture, which if reconciled, could ultimately help reduce the death disparity.

One of the possible reasons for the increased death rates is doctor’s biases—perhaps African-Americans aren’t getting the same types of treatment. This could be due to doctor’s conscious or unconscious judgments regarding their patients: a theory known in medical anthropology as “bias hypothesis” (Ashton, par. 5). This hypothesis suggests that doctors don’t give their minority patients the same types of treatments as they give their white patients. According to the American Medical Association, in 2008, 54.5% of physicians were white. The ethnic group with the second most physicians in the field was Asians, who consisted of only 12.2% (American Medical Association). A study done by KA Schulman et al. measured the effects of race and sex on a physician’s recommendation for cardiac catheterization. The study found that women and African-Americans were less likely to be referred to for cardiac catheterization than their male and white counterparts were. Black women were the group least likely to be referred for catheterization (Schulman et al, par. 3). Perhaps, in this case, the physicians’ beliefs about culture and race affected their delivery of science; their conscious or even unconscious beliefs about minorities’ differences in culture or religion could have impacted their scientific treatment. The doctors may think the patients have different beliefs or are incompetent, making them unable to complete the assigned regiment. This underlying difference in culture and religion that comes with a difference in race impairs doctors’ judgments on the delivery of their science.

The Schulman study has its flaws however. It is difficult to measure whether a doctor is blatantly choosing to not give a minority patient and a white patient the same type of treatment, and surely, most doctors would not openly admit that they’ve treated a patient differently on the basis of race. And while one can measure trends, as in the Schulman study, correlation is certainly not causation. It’s unclear whether or not doctors are actually treating their patients differently, but what more obvious is that minority patients certainly feel as if they are not receiving the same types of treatment. African-Americans tend to rate their visits to the doctor as less participatory than whites do. However, doctor-patient race concordance correlates to an increased number of patients rating their doctors’ decision-making styles as more participatory (Cooper-Patrick, par. 5). Another study reinforced these findings, revealing that African-Americans, if given the choice, prefer to see African-American doctors, and doctor-patient race concordance is associated with greater patient satisfaction with care (LaVeist 302). Minority patients want race concordance, along with which come greater similarities in religion and in culture, providing a better delivery of science for the minority patient. It clear that this lack of comfort and security is problematic in the healthcare system; but it is encouraging that Commonwealth Fund plans to improve the overall healthcare system by adding to the number of minority healthcare providers (McDonough et al, par. 1).

Another avenue that could affect the greater number of deaths in African-American women is “preference hypothesis,” which suggests that patients’ choices affect healthcare disparities. Patients choose to not seek out the same types of treatments due to personal preferences. In African Americans, the patients’ choices could be driven by the medical mistrust in white biomedical doctors. The Tuskegee Syphilis Experiment, done from 1932-1972, studied the progression of untreated syphilis in African-American males (Spencer). The inherent assumption of this study was the belief that African-Americans were different than whites. Today, many people consider the Tuskegee Syphilis Experiment to have been driven by racism. As Spencer discusses, Tuskegee is the primary reason that African-Americans cite for being less likely to be vaccinated and participate in clinical trials for fear of conspiracy, sterilization, and harm (Spencer, par. 5-7). Other experiments performed on African-Americans that have also increased their mistrust in biomedicine include the injection of live cancer cells into twenty-two chronically ill African-American patients without their consent, the collection of blood of young African-American children to test for criminal activity, and the use of radiation ten times more powerful than the safe amount on African-American women, which resulted in twenty-five deaths (Randall, par. 7). These examples show how racist intentions were masked as “science” in order harm or objectify the African-American community. This disconnect between biomedical cultural and African-American culture to this day continue to affect African-American’s seeking of biomedicine.

On a broader scale, biomedicine’s assertion of superiority may also contribute to African-American’s medical mistrust. As Richard C. Keller cites in his article Geographies of Power, Legacies of Mistrust: Colonial Medicine in the Global Present, biomedicine’s legacies during colonialism still deter people away from the institution (Keller 26). Biomedicine has always claimed scientific neutrality and a universal nature. Yet biomedical circumstances humiliated Native Americans and African-American slaves by using them as objects of experimentation. In fact, this objectification and use of subordinate people as objects of medicine seem to have helped perpetuate biomedicine into the institution that it is today. Slaves were used as subjects of experimentation in procedures ranging from surgery, to vaccination, to pouring gallons of boiling water onto people (Randall, par. 6). Furthermore, biomedicine doesn’t allow for other forms of healing: a rain doctor can pull on many different practices for his healing methods, but a biomedical doctor will only call on his own paradigm for treatment. The domineering attitude of biomedicine often clashes with the cultural and religious practices of not only African-Americans, but those of other racial and ethnic groups as well.

It is also evident that often times biomedicine sees culture and religion as barriers that must be overcome for effective curing. Perhaps African-American women are being pushed away from biomedicine because there’s a communication barrier between doctor and African-American patients, not only in terms of linguistics, but in ideologies as well. This theory is known to medical anthropologists as the “communication hypothesis” (Ashton, par. 6). A study done by Mitchell, Mathews, and Mayne explored fear and fatalism in the African-American female population. The study found that there was fear in the population of being diagnosed with breast cancer, but these women would have rather risked the other consequences than to actually know they had cancer. Fatalism also added to this fear: many of the individuals in the study believed that all things were fated, and thus, had no reason to fight what was happening to them, which also ties into the religious component of the disparity. The study overall, showed that these women feared, rather than understood, breast cancer. They only focused “on the subjective idea of being healthy rather than the epidemiological risk factors.” This ultimately led them to a poorer decision about healing because these women were opting for other types of healing (Mitchell). These attitudes of fear and fatalism are most likely culturally and religiously based, and clearly affect the delivery of science.

Another example of the more fatalistic outlook on death is exemplified by the Jazz Funeral, which is commonly associated with New Orleans and the African-American population. The main procession of the funeral to the cemetery plays solemn hymns, but after the burial, the band plays happy and celebratory music. While this may seem like a contradiction to some, these actions are due to underlying belief that death is a celebration of life—that a funeral is not a farewell, but “a celebration of that person’s life and a time for rejoicing” (Shelemay 228). This practice also parallels to the Edwards study, in which researchers found that 81% of African-American women agreed with the statement “If it’s meant to be, I will stay healthy,” compared to only 65% of their white counterparts (Edwards). This culturally based attitude of fatalism influences African-American women’s choices to not seek biomedicine, which could greatly contribute to the increased death rate.

The outlooks on life are not the only disconnects between the female African-American population and biomedicine. The modes of healing chosen are often based on the attribution of the cause of the sickness: if an individual thinks that germs or bacteria caused the sickness, a person will seek out treatment through drugs and vaccinations. On the other hand, if an individual thinks a supernatural force caused the sickness, they may opt to seek religious healing instead of biomedical treatment. Perhaps African-American women have attributed “cancer” to something besides a pathological abnormality. Maybe African-American women have ascribed cancer to a more religious or spiritual cause—a personalistic mode of affliction, one in which the sick is the victim of a supernatural cause (Chua). Maybe African-American women aren’t seeking out the same types of treatment because they are turning to God’s healing rather than a doctor’s. In a literature review done by Johnson, Elbert-Avila, and Tulsky, the researchers found that constant themes emerged regarding African-American’s spirituality and their treatment. These themes included “spiritual beliefs and practices are a source of comfort, coping, and support and are the most effective way to influence healing; God is responsible for physical and spiritual health; and the doctor is God’s instrument” (Elbert-Avila, par. 5). This led the women to seek more religious modes of healing rather than biomedical ones. This is problematic because biomedicine is very effective at curing, but at the expense of other realms of illness (Chua). The Mitchell, Mathews, and Mayne study, as previously mentioned, also found that misinformation about breast cancer greatly affects the treatments sought.

Another study demonstrated that there are a number of cultural beliefs that could impact the disproportionate death rate. For example, the beliefs that air causes cancer growth, a root or spell causes cancer growth, God will cure without medical treatment, and the devil causes cancer, were much more present in the African-American community than they were in the white community in both the early-stage and the late-stage cancer groups. Additionally, African-American women in the study were more likely to believe that herbs and chiropractics would cure cancers, and that surgery was less likely to cure cancer, than the white women were (Edwards). These cultural misconceptions could very well encourage African-American women to seek other modes of healing besides biomedicine, which as previously mentioned, is quite problematic.

In conclusion, we can see that all of Ashton’s ideas—bias hypothesis, preference hypothesis, and communication hypothesis—contribute to the disproportionate death rates that African-American women experience. Though these problems are seemingly sporadic, the underlying theme of science, religion, and culture do come into play. These ideas conflict with each other, most apparently in the examples of the communication hypothesis, but are also in the examples of bias hypothesis and preference hypothesis. Perhaps if we could reconcile these ideas, we could find a mode of healing to help address these problems and reduce the disproportionate number of deaths.

Reconciling Science, Religion, and Culture

Science is using the scientific method. It’s beginning with an observation, making a hypothesis, and then deriving an experiment to test that hypothesis (Reece, 9-11). According to religious insider Robert Ingersoll, religion is a practice that teaches obedience, humility, self-denial, forgiveness, and nonresistance. Religion says that creatures should be thankful and obedient to a creator (Ingersoll, par. 1-2). Culture is the full range of learned human behavior and encompasses subcultures and cultural universes. Culture is powerful and fragile, because it is “constantly changing” and “easily lost because it exists only in our minds” (Palomar Community College, par. 1-2). The contradictions between these ideas are evident even in their definitions, but must they always be at odds as they appear in our everyday lives?

It is more apparent how science and religion clash. Science uses natural forces to explain natural phenomenon. Religion on the other hand uses supernatural forces to explain magical systems. Science is based on numerous tests, whereas religion is based on faith. Religion requires belief and worship, whereas science ignores these concepts (Brooke 17-18). Religion and science have conflicted as far back in history as Galileo and the church, to more the more recent Scopes Trial, to our present day deliberations on issues such as abortion (Linder State v. John Scopes; Linder Trial of Galileo). Though often times the symbolic content of religion conflicts with science, Einstein once said that these ideas are essential to each other, symbiotically challenging and growing off of one another (Einstein, par. 4). This is even exemplified by the greatest creative achievers of science: Sir Isaac Newton, Lord Kelvin, and Kepler, were all great scientists inspired by religion (Boyce, par. 21). Culture falls along many of the same lines, ameliorating both religion and science when all blended together.

These aspects are all blended together in the case study of Ananda Shankar Jayant—a renowned Indian dancer who fought cancer with dance. Though not of the particular demographic being addressed in this paper, Jayant’s case study shows how science, religion, and culture can be used to defeat cancer. When she was a small child, Jayant was introduced to dance through her mother, who encouraged her to perform. Jayant has traveled the world teaching and performing, and in 2007, received the Padma Shri (a high ranking civilian award) for her contribution to Indian art. However, in 2008, she was diagnosed with breast cancer, which she described using the Indian idea of emotional states. She said “As a dancer, I know the nine rasas or the navarasas: anger, valor, disgust, humor, and fear. I thought I knew what fear was. That day, I learned what fear was.” After a period of disbelief, Jayant realized that she had control over only three things: “her mind, her thought, and the actions that derive from it.” By focusing on her dancing, Jayant was able to combine her culture and religion to ameliorate the science of her treatments. The ideas worked together to create a sense of ultimate well-being, that cannot be matched with just science, religion, or culture alone. By “focusing on [her] mudras, on the imagery of [her] dance, and on the poetry and the metaphor and the philosophy of the dance itself…[she] moved out of that miserable state of mind.” Jayant allowed her experiences with cancer to help foster her dancing, and refused to let the science of it all consume her. She focused on the additional aspects of her culture and religion—manifested in her dance—in order to help her overcome the disease. Cancer can become “insignificant” when one focuses on other realms besides the science, which can ultimately make it more conquerable (Jayant. Ted Talk).

Conclusion

There are a number of reasons that underlie the healthcare disparity that African-American women are more likely to die from breast cancer than white women are. Ranging from doctors biases to patient preferences to communication barriers, these ideas are all united in that there is a clear lack of reconciliation between the ideas of science, religion, and culture. Ultimately however, as indicated by the Ananda Shankar Jayant case study, when these ideas can be reconciled and act harmoniously, an ultimate state of healing can occur.

A mode of healing that works to help bridge the divides would ultimately eliminate the disproportionate numbers for death. We’ve answered fundamental questions about the physical world using a combination of science, religion, and culture, so perhaps we can use this same methodology to address the fact that more African-American women dying from breast cancer. It is only by looking back in history and realizing these divides that we can better understand and address healthcare disparities, and greatly reduce not only breast cancer deaths in the African-American female population, but perhaps cancer deaths in all demographics.