Minority Health Series

Quinton Baker was never much for exercise, but a Nordic track now occupies center stage in his Hillsboro home. A few years ago, Baker discovered he had diabetes. He changed his diet and began this morning ritual. The exercise helps the body use the sugar and use insulin so that it makes it easier to control the diabetes. In North Carolina, diabetes is almost twice as likely to kill blacks as whites. But given its long list of consequences, including heart disease and stroke, that figure may be conservative. There's also more undiagnosed diabetes in African-Americans, so a glucose test for the condition would seem to be a natural part of an African-American's medical exam. I was definitely overweight at the time. I mean, I told him of the history of diabetes in my family, but my physical didn't include a glucose test. Baker is the coordinator of the Chatham County Community-Based Health Initiative, a program

that seeks to narrow the minority health gap. His undiagnosed diabetes mushroomed into a crisis just two months after a visit to his doctor. I didn't really realize that it was awful until I went to the airport and realized that I couldn't read the signs, that everything was totally blurred. But the reality is that for two years, I had been living with small signs of diabetes and not knowing it. Signs such as limb pain and fatigue about which Baker says he received no information. Nor was he told that exercise and weight control can diminish the risk of developing the disease. JD Lewis is another diabetes sufferer who agrees doctors fall short of the mark. The long-time triangle radio and TV personality, now retired, adds doctors should stress more than just symptoms. They say, well, you've got sugar, you should go to high. And I've had that told them, yeah, but they usually don't attach to look, this will

kid you. You know, they don't attach these significance to it. Lewis says the minority community itself must take responsibility in areas such as exercise and diet. But there's a more disturbing, more complicated obstacle to minority health, says Lewis. It's found not on the dinner plate, but in the psyche. It's there that an attitude of fatalism can reside. After a certain age, they all expect certain kinds of things to happen to them. The fatalist approach exists among black people as a whole. The arthritis is going to be on diabetes, it's going to affect them in some way or another. And so they sort of suffer to a large degree in silence. But getting people to talk about a health problem, Quinton Baker says, is the first step in solving it, especially in the often village-like atmosphere of a minority community. The assumption is that at risk communities get the information from their doctors, from professionals, not true.

They come back to the community and check it out with those people they know and trust. The expectation is too simple. If the doctor says you should do this, this is going to happen. It doesn't happen. See, I was camouflaging. And when I go back to them, of course, I would do right just before I go back to the doctor. Mary has diabetes, but she doesn't like to advertise her condition, so she's asked her real name not be used. Mary discovered she had the disease 15 years ago, but for almost all that time, the Orange County resident denied it. Quoting the Bible, she says, a man is what he claims. So by ignoring the disease, she hoped it would simply go away. It wasn't her doctor who persuaded her otherwise, but a friend. She's talking to her, and you better take better care of yourself, blah, blah, blah. And then I have a sister. She takes her answer just like clockwork, and so I just decided, you know, it ain't going to go away. So go ahead and admit it and start taking care of yourself. And now, Mary does much more than that. She encourages friends to get glucose tests.

Out of the 10 siblings in Mary's family, nine have diabetes, and the 10th, the sister, has symptoms. She was saying, oh God, I feel so bad. I just can't handle it unless you got sugar. I should've come by my house. This evening, I'll check it. The urine test showed Mary's sister did have a dangerously high sugar level. But Mary isn't allowing her sister to indulge in denial. She had a doctor's appointment the next day. That's an example of the kind of peer encouragement, stressed in some diabetes intervention programs aimed at African Americans. And it's an approach that's also being used with one of the state's most intractable minority health problems, a black infant mortality rate more than double its white counterpart. Theresa Jones isn't getting much response from Sam. Her pet cockatiel, a small gray bird with orange spots on its cheeks. Sam will probably have to take a back seat when Theresa's child is born in a few weeks.

Theresa lives in a mobile home in rural Scotland County near the South Carolina border, a large Bible, a baseball trophy, and a certificate from a tractor-trailer school adorn her simple living room. While her husband is out driving an 18-wheeler, something Theresa also did until a few months ago. The 31-year-old is without a car or a telephone. But she does have had a brown. And let's spend some time with you, and they sense that you really care for them. You become the best of friends because they know you are for real. Brown is Theresa's maternal outreach worker, and part of an army of local women in 24 counties throughout the state. These health department employees, help clients, usually low-income women, have healthy, full-term babies. Her duties were on the gamut, drive a woman to the doctor, provide nutrition information, and even, as Brown did for Theresa, bargain for time against a bank for closure notice. She's like a mama, you know, I can talk to her, and I mean, me being a new mother to this, you know, there's a lot of things I didn't know, and she gave me insight, and I couldn't

have made it financially, emotionally, or any other way without their health. It may be easy to imagine why Theresa is considered an at-risk mother, considering her limited resources. But the dismal minority infant mortality rate in North Carolina holds true regardless of education or income. In 1993, that rate stood at over 16 deaths per 1,000 births. If Theresa were rich and college educated, she would still, as an African-American, have more than twice the chance of losing her baby in the first year of its life, compared to a white mother. Even black women working in the health field are not immune. Both Brown and another maternal outreach worker, Linda Kuchin, have sisters who lost babies, and Kuchin has her own story to tell. My son was 4 pounds 16 ounces, and was 4 months premature, so for me, you know, I went to the doctor religiously and ate right and did all the things that I was supposed to do.

But she was lucky. Her son survived, but does suffer from asthma, a common ailment among children born prematurely. Kuchin doesn't hesitate to venture an explanation for her experience. For me, it was just a matter of stress. It was a matter of being a black woman, having to reach those goals. And so even though I got the prenatal care, it's how you live, too. It's a controversial explanation that racism and its accompanying stress can result in babies born too small and too soon. Last year, the state legislature funded a project to search at the community level for explanations behind the minority infant death rate, explanations that allude the professionals. But a former staff member of the governor's commission on infant mortality subscribes to the racism theory. 13 years ago, Vanessa Davis gave birth to a daughter three months too soon. The infant lived just seven minutes. Davis, who now works with adolescent parents, warns against underestimating the pressure

of being black in America. I don't want to say that in sounding like a victim, but something that I usually used to bring it home to people that don't have to function that way on a routine basis is think about in the past 24 hours, if at any time you've had to remember that you're white. And then you can ask just about every African-American in a 24-hour period, they have been reminded by an action or a deed or by having to state it or by someone making it recognizable that they are African-American, so it's the intangibles. I tell you what, between 11, between 10 and 11. Back in Scotland County, Hattie Brown makes arrangements to drive Teresa to an appointment. Teresa says she's seen friends suffer the death of a child, and she doesn't want to go through that. But she says she puts her baby's health in the Lord's hands, and in Hatties. All right, get you some rest. I know you, ever you can't retire. You can say you're not.

I know you all. This is Diane Tumey reporting. A study by the State Center for Health Statistics shows that the highest AIDS mortality rates are in the state's eastern counties. That may sound alarming, but what it means is that the number of AIDS deaths has compared proportionately to the minority population. In Scotland County, for instance, 10 blacks and 5 whites died of the disease in a 5-year period. The county's overall population is 34,000, and less than half of those people are African-American. Nevertheless, those seemingly small numbers mean that blacks are twice as likely to die of AIDS than whites in that county. But a Scotland County physician says HIV is more prevalent than the numbers reveal. Dr. Charles Stewart, who calls himself the region's lone HIV doctor, says the county isn't equipped to handle the crippling effects of the virus. We don't have from shelters.

We don't have homeless shelters. We don't have housing programs. So there are many resources in a metropolitan area to care for individuals, you know, challenge with the HIV virus there that we don't have access to here. Stewart says indigent and drug-infested communities are like petri dishes where in the virus can grow. He says he links the spread of the virus with crack cocaine's chokehold on low-income African-American communities. Even in these little remote, off-throwed checks, it's out there. So people can't get a telephone, but boy, I tell you, the drug is so powerful that it totally, you know, alters people's judgment. It's not the drug itself. Crack is normally smoked, not injected. If the crack culture, the puts drug users in the high-risk category. Sexual favors are often traded for the drug, and a drug user may unknowingly infect his or her spouse or partner.

One 30-year-old woman found out she and her boyfriend of 13 years were infected with the HIV virus. We'll call her Melinda to protect her real identity. Melinda, who's originally from New Jersey, lives with her boyfriend and their three children in his hometown of Lauren Berg. It feels that African-Americans living in rural, low-income communities have a culture that allows for certain harmful behaviors. Women are very loose down here, and majority of them are on drugs down here, and that's more of a reason for them to be so free with their body. Women now account for almost half of Scotland County's 47 reported HIV cases. It's important to note that state health data comes from health departments, where African-Americans make up a large percentage of the clientele. In a bigger town, such as Durham, where about 450 people are reportedly infected with HIV, a third of those cases are women. Durham has among the highest rates of HIV infections and AIDS mortality in the state, and thriving

heroin and cocaine trades are mostly to blame. Lily Gage manages Durham County's early intervention clinic. She says many African-American women are caught by surprise when they find out they've got HIV. Women come in late in the disease frequently because they don't perceive themselves at risk, and they don't test until they get sick frequently. Gage says indigent African-American women face a different set of challenges when they're infected. In many cases, the virus adds another social strike against already existing disadvantages, those of being black, poor, and female. Though Gage says she and her staff are often the only ones who know that some women are infected. African-American women are isolated. They don't have the history of a decade of perception of risk that gay men or IV drug users have. This is something that's new for them. This is something that shouldn't have happened to them.

What I see is they frequently feel like there's nowhere that they can go for support. And as soon Gage says no one will be able to hide their identities when they want to get tested for HIV. Three years ago, the General Assembly decided to phase out anonymous testing. The measure will go into effect this June. Kathy Kerr oversees Durham County's Project Straight Talk, a community-based AIDS prevention program funded by the CDC. She says the move may scare away people who are at risk for HIV. Anonymous testing has worked in that regard that people at least come to the system. They start to get the education, the information, we're able to counsel them and to ask them about notifying their partners so it still can help break the cycle without anonymous testing. I'm afraid that we may lose people that are most critical to accessing the system. Kerr says anonymous testing works. At some state health officials worry that drug addicts may not be reliable in practicing safe sex.

Therefore, keeping tabs on people who have tested for HIV could be a way to control the virus's spread. Meanwhile, outreach workers try to give the safe sex message to a community that hasn't been significantly responsive. Tim Moore is an outreach worker for Project Straight Talk. His 40-ish tall and casually dressed in jeans and a sweater. He manages to slip in and out of homeless shelters, jails and detox centers where he talks to people about AIDS prevention. This thing, Moore has come to the Imperial Barbershop where he visits regularly to fill and refill large jars of condoms. Moore says it's his job to trumpet the safe sex message to a community that sometimes offers a deaf ear. I think I have to take responsibility of helping people understand this virus because we still realize that four years of people still don't understand this virus. The customer flow churns in the Durham Barbershop on Fayetteville Street.

Barbers clippers hum, hair cutting shears, pop loudly and a radio blasts gospel music toward every corner of the shop, including the checker table where four old men are playing. Victor Hughes is among several beauty and barbershop managers who have agreed to display a jar of free condoms in their shops and why not, he says, when the shop is full of men sex is often the topic of conversation. But Hughes says many of his customers aren't getting the safe sex message. He uses, he finds his male customers resistant to the idea of using condoms, he says, once when he brought up the subject, Hughes said one customer retorted, you don't eat

hamburger with the plastic on it. And what's most dangerous about their attitude says Hughes is that it may take more people dropping like flies before the community takes aid seriously. I'm Sharon Corpening reporting. A contractor puts the finishing touches on a new kitchen sink at the Garden Street Department, a public housing complex in Lee County. The stainless steel sink and shiny white appliances in this apartment are just part of the extensive renovations ongoing at the Sanford site, thanks in part to something called the Community-Based Public Health Initiative, a consortium of educators, community agencies and citizens.

Funded by a grant from the W. Kellogg Foundation, the three-year-old group posed this question to Lee County's public housing residents. What are your most important health needs? Well it wasn't that I need to get my blood pressure checked, that's for sure. John at Henderson is a social worker with the Lee County Health Department. If you don't have food on your table, if your housing conditions are a substandard, thinking about your blood pressure, your high cholesterol, that's second, you're not concerned about that up front. The Garden Street apartment complex is made up of one and two-story orange brick buildings built about two decades ago. The top halves are painted in what must have been the most dreary, dark green available at the time. Almost all the residents here are African-American. Daisy Adams is one of them. The 65-year-old stands on the dirt lawn outside her apartment. Adams is the president of the Garden Street Resident Association. She wears a flowery blue dress, but it's her sneakers that hint at her energy. The mother of 10 is a long-time fighter for better conditions in the complex.

I didn't know who would have turned because I told him I said, well I'm too old, I can't do it. So they trained me to do what I'm doing now because I didn't know anything about it. Social workers from the program helped tenants organize and send complaints in the right direction. For the first year and a half, the project dealt solely with problems not traditionally considered health-related, drug dealers, potentially deadly gas leaks, and aging infrastructure. In the result, a grant for an on-site police satellite station, repaired gas leaks, and the renovation of the entire complex. They didn't tell us what you ought to do. They said, what can we do to be the happiest? You tell them now what they need to be in search of, so I appreciate them being here. The coalition then felt tenants might be ready to deal with some conventional health problems. Residents had their cholesterol and blood pressure tested at an on-site health fair. The health department also let workshops on a number of topics, and the community, say the social workers, is now listening. Daisy Adams says a few years ago, those same residents wouldn't have bothered.

When they came in, they showed us the need of it. They brought it into the community to us. A lot of people are using it, and the ones that missed this time they said they're going to be sure, when they come back again, they're going to be sure to be there. But Ms. Daisy, as she's known around Garden Street, hasn't finished her work yet. Right now, she's after the housing authority to install speed bumps in the complex, and to eliminate large puddles of standing water, a danger, she says, to small children. We just began. We just getting off the ground. But we're getting together. If the barrier to good health at Garden Street was a poor housing environment, and other communities that can be a lack of health insurance, or a lack of the English language, some health departments are even providing transportation to their clinics. The knee jerk reaction, why people can't get anywhere, it's transportation. Williams Smith is the health department director in Robinson County, a poor region with two-thirds of its population, either African or Native American. You know, I was going to make it, but I couldn't get transportation.

Yet, half our after they should have been at a clinic, they were downtown at Family Dollar. So they got transportation one way or another. And what we've gotten to the point of saying is, if it's a priority, then they'll find a transportation to get there. Now it's up to us to educate them and make it a priority. One area Robinson County has made a priority is childhood immunizations. Three years ago, using state funds, the major immunization providers in the county, including the health department, combine records to form a single immunization database. In that way, a faulty parental memory or an immunization record left at home wouldn't prevent a child from receiving the appropriate shots. The database also includes county birth certificates, so parents can be notified when a shot is due. But oftentimes, parents in this county must be convinced to bring a child into a clinic. And since the days of the polio epidemic are long gone, images of children and leg braces won't scare a parent into action.

One that we like to stay around is measles, because everybody sees measles and they think, well, that's nothing. That one in six requires hospitalization and winds up with permanent ear damage. That's very easy to sell to people, because they see the measles. The polio's an adder kind of go along with the ride. However, Smith says there's still an entrenched attitude that pervades his county, one born out of the fatalism and hard life of poverty. Their mentality, as I heard said one time, is it's not whether your arm is broken or not. It's whether it has fallen off before they go the emergency room. So if you think about that extreme, just imagine where a shot would fit into the whole spectrum of health. To advertise the importance of immunization, the health department rented space on billboards to make it easier, clinic hours were extended. An immunization was even made profitable. Welcome. Do you understand how to use this coupon, girl? OK.

This coupon is good for any Wal-Mart store. OK. A health department worker hands a certificate worth $7 to a young mother, her reward for completing all of her two-year-olds vaccinations on time. The health department also raffles off of VCR, television or microwave monthly, to a parent who's vaccinated their child on time that month. All right. Good luck. But this mom didn't know about the Wal-Mart coupon or the raffle, and neither did a number of other mothers at the clinic today. These moms were here because they said they understood the importance of on-time vaccinations. And for those who don't, the best strategy, maybe to go where there's a captive audience, with literally needle in hand. Once a month, this meeting room in the Fairmont Fire Department, a few miles south of Lumberton, fills with women and children. Mothers enrolled in the Women Infants and Children Federal Nutrition Program sit on metal folding chairs as they wait to receive their food certificates.

Children's height and weight are being measured here today as well. The health department also brings the children's immunization records to this WIC satellite clinic. Some of these children know this routine only too well. Are you ready to go to Canada? Are you? And I want to get you to one of those shops where you've got to have a shop. Bradwick McCann's mother has made sure her four-year-old received all of his immunizations on time. A noteworthy achievement, even for a WIC mother, must attend these clinics twice a year. OK, help Mama Sam with your other hand, OK? They did what they did. We're still. They did what? Ah, ah! Ah! See, there's all over. See, that's it. Ah, I'm finished. I'm finished. You finished. I'm finished. You finished. I'm finished. Donna Love It is a health department immunization nurse. She says many women don't know about the discount coupons or raffle incentives, and only occasionally does a child come into the clinic simply for immunization. Whenever we haven't come in the first time, we always, always stress, please come back

in eight weeks. So, for your money, that one-on-one interaction with them, when you're here for WIC. Yeah, that's 100% of it, just that reminder, hey, get back in here. And where one-on-one isn't possible, the Robinson County Health Department has mailed or phone parents' immunization reminders, a strategy officials admit that hasn't resulted in many on-time vaccinations. After three years of billboards, emergency room flyers and discount coupons, Health Director William Smith says the program has had some success. The number of 15-month-olds receiving their final tetas vaccination on time increased by 118%. But that's just one shot. A recent analysis of Robinson County Health Department records showed that the children it serves only about 53% were up to date on their immunizations. The national average is only a few points higher.

But minority children in Robinson County fared worse. Only half of them had been vaccinated on time. Although he may not be able to reach them, Smith believes he knows where some of these children are. The group that we can't get to are those that the grandmother keeps during a daytime or a neighbor. And they stay outside the system. The mothers work early wages. So it's that group in between what we kind of call the medically indigent crowd. They don't have insurance, therefore they're not used to access and cared for anything. This crowd only shows up under a dire emergency. And that's the population, in my opinion, that is not being immunized because they're totally out of the health loop. Despite the fact that vaccinations are free to any child at the health department, I'm Diane Tumey reporting. Hello, lady. It's mid-morning on this particular Saturday in Wilmington.

Camille Alexander is taking two elderly women to the new Hanover Medical Mall on the other side of town. As a lay health advisor for the Save Our Sisters breast cancer screening program, Camille volunteers to educate her peers about the importance of early cancer detection. And sometimes, that includes driving women like Mrs. Woods to the hospital. Save Our Sisters, or SOS, is holding its fifth mammography day since the program began in 1990. The program was started by a professor at the UNC School of Public Health who discovered that African American women in Wilmington were reluctant to get mammograms. lay health advisors are former teachers or postal workers who may also had their churches stewardess board. They're known as natural leaders, opinion-formers within their community. The idea is that they make the best liaisons between their contemporaries and the health

care system. You would always start at the top using your three fingers, using the palm of those three fingers, using circular motions, rubbing. Cindy Meredith, a new Hanover County health educator, demonstrates the procedure for a self-brest exam, while women wait for their mammograms. Meanwhile, X-ray technologists explain the mammography procedure, assuring women that the discomfort from the machine's imaging compressor can be lessened if they relax. During most of the process, from signing in and filling out insurance forms until the patients complete their evaluations, about a dozen lay health advisors help to navigate the breast cancer screening process. The reason for the kid glove treatment is to make the trip to the hospital a pleasant one.

Lay advisors Camille Alexander and Diane Bennett say that fears, based on myths, as well as on bad real-life experiences with mammography, are hard to dispel. There's still a lot of fear, a lot of women still haven't been able to reach because they're a friend. It's hard to talk to them, oh boy, you can talk for days. And there is, you give the mammogram hurting soul, you know, all the things you can do. This is an ideal situation, and that compared with a bad episode at a mammography center, and you'll never see them again. Several years ago, New Hanover's Health Department noticed African American women weren't getting breast cancer screenings as often as white women. And although African American women aren't as likely to get breast cancer as white women, they tend to die from it because they don't get treatment until it's too late. After learning this, Dr. Jeannie In, a professor at UNC School of Public Health, started the SOS program.

Being says she discovered that older black women are still apprehensive of a system that once discriminated against them. These women also remember a health care system during the period of segregation. And so you go to a doctor only when you had a serious problem. And you don't go to a doctor when you don't have a problem. And so the traditions between the older African American women and the health care system still continue today. So after setting up a focus group, Ang learned that older African American women often talk to other women, especially their daughters, when it comes to female health issues. Part-time SOS coordinator, Jackie Smith, says black women tend to understand each other's needs. So many older women, especially in this area, that don't ask questions, you know, I think maybe they're embarrassed to ask some questions, some of our good, sweet ladies cannot read. And they don't want you to know that.

So they'll just, oh, that's a nice literature, and leave it alone, you know. But sometimes we can pick up on these little signs, and so we'll kind of just talk to them about it. And it seems to work. Smith says SOS is successful in using the traditional relationships that exist between African American women to help close the racial gap in breast cancer screenings, and the concept of natural helpers is now spread to other communities. I didn't want to have a mammogram. I just kept saying no, you know, until finally the doctor said you go. Nellie Council is one of eight women taking the first of three classes on how to become a lay health advisor in Martin County. After hearing several speakers, the class is involved in a discussion. And so I went, since then, I've talked about, because it didn't hurt me, and I've talked about it to other people, and hopefully I've helped someone see that it doesn't necessarily have to hurt as much as they've heard.

This class is part of the North Carolina breast cancer screening program. It's modeled after save our sisters in Wilmington, and the founder of the program, Dr. Joe Ann Earp, is also a colleague of Dr. Genie Ng. The breast cancer screening program focuses on five Eastern counties, Martin, Washington, Terrell, Beaufort, and Bertie counties. But Dr. Joe Ann Earp says the most significant difference is that the breast cancer screening program has an added component. The outreach effort extends to hospitals and health department staff in order to make sure medical staff does their part. We are working with the health departments in our intervention called EnReach, reaching in and trying to reduce the bureaucracy that says, oh, I'm sorry, we have a waiting list, and we're doing outreach trying to bring many people in who have never trusted the health departments or who have never found support there. Both Dr. Joe Ann Earp and Genie Ng are working on ways to improve on the community-based models used in save our sisters and the breast cancer screening program.

Dr. Ng says the next step for SOS is training African-American nurses, both retired and semi-retired, to help reach underserved women that will help broaden the base of women trained to preach early detection. The hope is that those women will tell others and so on and so on until thousands of rural African-American women, over 50, are reeled into the healthcare system. I'm Sharon Corpening, reporting. The death rates from liver and kidney disease, diabetes, and stroke are all significantly higher for African-Americans, and in North Carolina, blacks die of AIDS and astounding five times more often than whites. These statistics appear in North Carolina Insight, the magazine of the Center for Public Policy Research.

Its editor is Mike McLaughlin, who found no simple explanation for the health disparity between whites and minorities. Researchers look at a number of different causes. Think some of it is biological, some of it is behavioral, and some of it is failure to connect non-preventive care, so the causes I think are rather complex. While gathering numbers for the study, the center's researchers also found programs that did indeed address these problems, attacking preventable diseases head on. There's the five a day program concentrated in several black churches in eastern North Carolina that teaches people to eat five servings of fruit and vegetables a day as a way to prevent cancer. Project assist, helping people quit smoking to reduce heart and lung disease, and Wake County's Project Direct campaign to control diabetes among African-Americans. The center recommends that the legislature appropriate $750,000 in the next biennium to strengthen preventive health programs in the state. We did recommend that the state fund a number of those programs that give them enough

resources to try to really make a difference, and also measure the outcome. Don't just throw money at it and walk away from it, measure the outcome, and see if we can obtain some results, and if we can, what lessons will that give us to apply to other areas of the state? Should we be discussing this in terms of racial divisions or economic divisions among populations? Just talking about poor people here, are we talking about diseases that cut across economic divisions? Well, I think it's both Kevin and our next recommendation really goes straight to that, which is to target a little more in the area of infant mortality. Here we see African-American infant mortality rate that is twice that of quite infants. In this particular case, when you control for education and some other of those socioeconomic factors that you mentioned, the rate still remains quite high. It does seem there's a racial component in some of these issues in infant mortality,

certainly is one of them. We'd like to see the state focus a little more there. The state division of maternal and child health plans to expand a maternal outreach workers program that has lowered infant mortality statistics in some areas of the state. But infant mortality statistics include only children up to age one year. The maternal outreach workers responsibilities end at the child's first birthday. The center recommended the legislature appropriate $550,000 to extend oversight until age three. One reason is because accidents and abuse are very serious issues among children of that age group one to three. Another issue is that these workers can help coach mothers and encourage more birth spacing. Interestingly, this is a big issue in it from mortality. If you have your children very close together, it increases the chances of a low birth white infant and increases the chances of infant death, so if these outreach workers can

encourage women to wait a little bit longer to have another child, that can have an impact on the right. Another way to help kids stay healthy is to make sure they get their immunization shots on time. But again, minority children fall short when compared to whites. The center recommends that the legislature appropriate $500,000 to hire workers in 20 high-minority, low-wealth counties to do the kind of job that seems to be working in new handover county. They have a person assigned to go through the files, I think she sends cards to all the people who are behind and need to get in for an immunization, call them on the phone, and essentially hand them like a bill collector. That's the model that was used to get these parents to get their children in. The center for public policy research report on minority health also suggests the need for expanding AIDS prevention and treatment in minority communities, for local health departments to make a greater effort to consult more minority clients in planning for health services,

and to expand Hispanic translation services where language barriers prevent needed services from being rendered. When we look at it, we see tremendous gaps in health outcomes between whites and minorities, and it's just a matter of targeting the problem, it's sort of like marketing, you look at the population you're not serving and you try to serve it better, and frankly I see nothing wrong with that. There's no guarantee that we can shrink these gaps, but there seems to be some need to try. I feel strongly there's a need to try, and the reason is the gap is large, it cuts across all sorts of causes of death, communicable disease rates, infant mortality, and on and on. I think it extends to preventive care areas such as immunization. And I think the state can and should do more to serve these populations that are suffering from ill health for any number of reasons.

Mike McLaughlin, editor of North Carolina Insight, the magazine of the North Carolina Center for Public Policy Research. This most recent issue contains the study of minority health in North Carolina. I'm Kevin Wolfe. In a year when leaders of both political parties have promised to cut taxes, it's difficult to imagine the legislature putting a lot of new money into any government program, but programs devoted to minority health seem especially unlikely to receive new state funds, because some lawmakers aren't convinced that minority health programs are necessary. There shouldn't be a society development where this is the minority health plan. It should be this is the North Carolina citizens of the United States health plan. Alamance County Republican Ken Miller is among a handful of house members who have been raising questions about the state's commitment to minority health initiatives, Representative

Miller, a member of the committee that studies such issues, says he's opposed to new funding from minority health and says he wonders whether it's necessary to continue the existing health programs for minorities. People are people. And I don't understand why we have to have separate, why it has to be segregated that way. And I really don't understand why folks of a minority, if that be the way they want to be called, would promote being segregated like that, because they're only putting themselves out for ridicule. I think they have a whole separate bureaucracy set up for that, that's ridiculous. Even among house members who are open to the idea of separate programs to address minority health issues, there still are questions about whether those programs should get larger budgets. Craven County Republican John Nichols, the chairman of the House Committee on Health and the Environment, says he's not likely to support increased spending from minority health programs until he gets a better accounting of how those programs are spending their existing funds. Nichols is concerned that there may be too many minority health programs spread throughout

state government, with little coordination between the programs. I think we can save a bunch of money if we would streamline some of these programs. And being a relative newcomer, it looks like to me they've been put in half-hands as you got a piece in here that went in this department. Two years later, three years later, you got a piece over here that went in this department and a piece that went over here and a piece that went over there, you know, over the last 10 to 20 years, and it's scattered to the full winds. If we could pull it all together, I think we could get a better handle on it. We know where the money was coming from, we know better where the money goes, the way that it's on us and possible. Advocates for minority health funding insist that the programs in place are necessary, and they insist that there's little duplication from program to program. Democrat Howard Hunter represents Northampton County in the House of Representatives, a county that's among the state's poorest, and a county where there's a high percentage of African Americans. Hunter, who runs a funeral home, says he often sees the results of health problems among minorities, and he's disappointed that the House leadership hasn't done more about

those problems. The other side of the aisle seems to be trying to pull all the financial legislation out of the budget, right along with the Office of Minority Health. And they're doing it real out of ignorance. Still, Hunter says obtaining money from minority health programs isn't just a partisan political problem. Indeed, before this year, when Democrats control the House of Representatives, rather than Republicans, Hunter says it wasn't much easier to get funding. He recalls his effort last year to find some money for an AIDS prevention program. Last year, we got an attitude not only in committee, but in the general assembly and the general public, they're dying anyway, why are you going to spend this kind of money? All told, Representative Hunter, who's long been an advocate for minority health initiatives, says he's not optimistic that the legislature will put much money into them this year. He says he hopes to see the day when there will be no need to have special health programs

targeted just at minorities, but he says as long as the death and illness rates for African Americans remain higher than those of whites, he'll keep fighting in the legislature to do something about it. I'm Adam Hockberg in Raleigh.