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Minority Health

Minority health

Definition

Minority health addresses the special medical and health needs associated with specific ethnic and other minority groups.

Description

The United States, along with many other countries, experiences cultural diversity. This fact poses health issues that are specific to ethnic and other minority groups. Additionally, the propensity for certain diseases or illnesses is of concern in certain minority groups. These specific health issues include infant mortality rates, cancer , cardiovascular disease, diabetes, HIV infection , and immunizations. The primary minority groups in the United States are Hispanics, African Americans, Native Americans and Native Alaskans, Native Hawaiians and other Pacific Islanders, and gays and lesbians.

One of the major health problems in the United States is overweight and obesity , which lead to increased risks for a wide variety of conditions, including cardiovascular disease, diabetes, hypertension , and cancer. A 2003 study by the Agency for Healthcare Research and Quality shows that African-American and Hispanic children face much higher odds of being overweight than non-Hispanic white or Asian-American and Pacific Islander children. African-American children ages six to 11 are more than twice as likely as non-Hispanic white children to be overweight, and Hispanic children are roughly twice as likely. The odds change dramatically when children become teenagers. For example, as children, Asian Americans and Pacific Islanders have the lowest prevalence of being overweight, but once they reach adolescence , the reverse is true. As teens, they have the highest prevalence of being overweightmore than four times that of non-Hispanic white teenagers. African American children have the highest rate of being overweight, but once they reach their teen years, they are no more likely than white children to be overweight. Hispanic teens are one-and-a-half times more likely than white or African American teens to be overweight.

Researchers and policymakers have attributed the poorer health of minority Americans in part to their reduced access to medical care and the lower quality of primary care they receive. Indeed, when asked about the primary care they receive, minority patientsparticularly Asian Americansgive the primary care they receive lower marks than white patients do, according to a 2001 report by the Agency for Healthcare Research and Quality. After adjustment for socioeconomic and other factors, Asian Americans gave their primary care significantly lower scores (out of 100 total) than whites for communication (69 versus 79) and comprehensive knowledge of patients (48 versus 56), as well as all other areas of primary care except continuity of care and integration of care. African American and Hispanics reported significantly less financial access to care than whites (60 and 56, respectively, versus 65), and African Americans reported significantly less continuity of care than whites (74 versus 78), but their assessments of other aspects of primary care did not differ significantly from whites. This study agrees with others which show that Asian Americans tend to be the least satisfied with quality of care. However, this study was limited by the small number of Asian and Hispanic patients surveyed, as well as the lack of patient's country of origin and physician's ethnicity, factors that may affect patient evaluations of primary care.

Infant mortality rates

Infant mortality rates (IMRs) in the United States and in all countries worldwide are an accurate indicator of health status. They provide information concerning programs about pregnancy education and counseling, technological advances, and procedures and aftercare. IMRs vary among racial groups. Infant mortality among African Americans in 2000 occurred at a rate of 14.1 deaths per 1,000 live births. This is more than twice the national average of 6.9 deaths per 1,000 live births. The leading causes of infant death include congenital abnormalities, pre-term/low birth weight, sudden infant death syndrome (SIDS), problems related to complications of pregnancy, and respiratory distress syndrome . SIDS deaths among Native American and Alaska Natives is 2.3 times the rate for non-Hispanic white mothers.

Cancer

Cancer is a serious national, worldwide, and minority health concern. It is the second cause of death in the United States, claiming over 500,000 lives each year. Approximately 50 percent of persons who develop cancer die of the disease. There is great disparity among the cancer rates in minority groups. Across genders, cancer death rates for African Americans are 35 percent higher when compared to statistics for Caucasians. The death rates for prostate cancer (two times more) and lung cancer (27 times more) are disproportionately higher when compared to Caucasians. There are also gender differences among ethnic groups and specific cancers. Lung cancers in African American and Hawaiian men are evaluated compared with Caucasian males. Vietnamese females who live in the United States have five times more new cases of cervical cancer when compared to Caucasian women. Hispanic females also have a greater incidence of cervical cancer than Caucasian females. Additionally, Alaskan native men and women have a greater propensity for cancers in the rectum and colon than do Caucasians.

Cardiovascular disease

Cardiovascular disease is the leading cause of disability and death, about equal to the rate of death from all other diseases combined. Cardiovascular disease can affect the patient's lifestyle and function in addition to having an impact on family members. The financial costs are very high. Among ethnic and racial groups cardiovascular disease is the leading cause of death. Stroke is the leading cause of cardiovascular-related death, which occurs in higher numbers for Asian-American males when compared to Caucasian men. Mexican-American men and women and African-American males have a higher incidence of hypertension. African American women have higher rates of being overweight, which is a major risk factor of cardiovascular disease. African Americans are 13 percent less likely to undergo coronary angioplasty and one-third less likely to undergo bypass surgery than are Caucasians.

Diabetes

Diabetes, a serious health problem among Americans and ethnic groups, is the seventh leading cause of death in the United States. The prevalence of diabetes in African Americans is about 70 percent higher than Caucasians. The burden of diabetes is much greater for minority populations than the white population. For example, 10.8 percent of non-Hispanic blacks, 10.6 percent of Hispanics, and 9 percent of Native Americans and Native Alaskans have diabetes, compared with 6.2 percent of whites. Certain minorities also have much higher rates of diabetes-related complications and death, in some instances by as much as 50 percent more than the total population. Diabetes-related mortality rates for African Americans, Hispanic Americans, and Native Americans and Native Alaskans are higher than those for white people. Asians and Pacific Islanders have the lowest diabetes-related mortality of any racial/ethnic group in the United States.

HIV and AIDS

HIV infection/AIDS is the most common cause of death for all persons age 25 to 44 years old. Ethnic groups account for 25 percent of the U.S. population and 54 percent of all AIDS cases. In addition to sexual transmission there is an increase in HIV among ethnic groups related to intravenous drug usage. African Americans with HIV infection are less likely to be on antiretroviral therapy, less likely to receive prophylaxis for Pneumocystis pneumonia , and less likely to be receiving protease inhibitors than other persons with HIV. An HIV infection data coordinating center, under development in 2004, will allow researchers to compare contemporary data on HIV care to determine whether disparities in care among groups are being addressed and to identify any new patterns in treatment that arise. Among children, the disparities are dramatic, with African-American and Hispanic children representing more than 80 percent of pediatric AIDS cases in 2000. Approximately 78 percent of HIV-infected women are minorities and most become infected through heterosexual transmission.

In 2002, African Americans accounted for 50 percent of all new AIDS cases, while Hispanics accounted for 20 percent, according to the Centers for Disease Control and Prevention (CDC). Although the virus is still most likely to be passed on by gay and bisexual males, as of 2004 more than 25 percent of AIDS cases are women, most of whom are African American or Hispanic. According to the National Center for Health Statistics, black females age 15 and older are 15.5 times more likely to die of AIDS than whitesa figure even more dramatic than the one presented in the vice presidential debates, according to an article in the October 16, 2004 Los Angeles Times.

Immunizations

Data show that in 2000 children living below the poverty level have lower immunization coverage rates. Although significant progress has been made in improving childhood immunization rates, some disparities in overall immunization coverage rates among racial and ethnic groups continue. This disparity is of great concern in large urban areas with underserved populations because of the potential for outbreaks of vaccine-preventable diseases.

Demographics

The overall health of the U.S. population improved during the last decades of the twentieth century, but all Americans have not shared equally in these improvements. Among nonelderly adults, for example, 17 percent of Hispanic and 16 percent of black Americans report they are in minimally fair or poor health, compared with 10 percent of white Americans.

Causes and symptoms

Most IMRs are correlated with prenatal care. Women who receive adequate prenatal care tend to have better pregnancy outcomes when compared to those who receive little or no care. Women who receive inadequate prenatal care tend to have increased chances of delivering a very low birth weight (VLBW) infant, which is linked to risk of early death.

Cancer is related to several preventable lifestyle choices. Diet and tobacco and sun exposure can be shaped by lifestyle modifications. Additionally many cancers can occur due to lack of interest in and/or lack of availability for screening and educational programs.

Cardiovascular diseases are higher among persons with high blood cholesterol and high blood pressure. Certain lifestyle choices that may increase the chance for heart disease include lack of exercise , overweight, and cigarette use. Cardiovascular disease is responsible for over 50 percent of the deaths in persons with diabetes.

HIV occurs at a higher frequency among gay males (the number of African-American males who have AIDS through sex with men has as of 2004 increased). Additionally unprotected sexual intercourse and sharing used needles for IV drug injection are strongly correlated with infection.

Vaccinations are an effective method of preventing certain disease such as polio , tetanus , pertussis, diphtheria , influenza , hepatitis b , and pneumococcal infections. Approximately 90 percent of influenza-related mortality is associated with persons aged 65 and older. This is mostly due to neglect of vaccinations. About 45,000 adults each year die of diseases related to hepatitis B, pneumococcal and influenza infections.

When to call the doctor

Parents of minority children should contact their family physician or other healthcare provider when they have any concern about their child's health.

Diagnosis

The diagnosis of VLBW occurs when newborns are weighed. Infants who weigh 52.5 ounces (1,500 grams) are at high risk for death. For cancer, the diagnosis can be made through screening procedures such as mammography (for breast cancer), PAP smear (for cervical cancer). Lifestyle modifications such as avoidance of sun, cessation of cigarette smoking , maintaining a balanced diet, and adequate nutrition , all positively affect one's health. Other specific screening tests (PSA, prostate surface antigen) are helpful for diagnosing prostate cancer. Cardiovascular diseases can be detected by medical check-up. Blood pressure and cholesterol levels can be measured. Obesity can be diagnosed by assessing a person's weight compared to the person's height. Diabetes and its complications can be detected by blood tests, indepth eye examinations, and studies that assess the flow of blood through blood vessels in the legs. HIV can be detected through a careful history and physical examination and analysis of blood using a special test called a western blot. Infections caused by lack of immunizations can either be detected by conducting physical examination and culturing the specific microorganism in the laboratory.

Treatment

Treatment should be directed toward the primary causes(s) that minorities have increased chances of developing disease(s). Cancer may require treatment using surgery, radiotherapy, or chemotherapy . Cardiovascular diseases may require surgical procedures for establishing a diagnosis and initiating treatment. Depending on the extent of disease, cardiovascular management can become complicated requiring medications and daily lifestyle modifications. Treatment usually includes medications, dietary modifications, andif complications arisespecific interventions tailored to alleviating the problem. HIV can be treated with specific medications and more often than not with symptomatic treatment as complications arise. Diseases caused by lack of immunizations are treated based on the primary disease. The best method of treatment is through prevention and generating public awareness through widespread education on the topic.

Alternative treatment

Alternative therapies do exist, but as of 2004 more research is needed to substantiate available data. Most physicians say the diseases that relate to minority health are best treated with nationally accepted standards of care.

Prognosis

Generally the prognosis is related to the diagnosis, patients' state of health, age, and the presence of another disease or complication in addition to the presenting problem. The course for IMRs is related to educational programs and prenatal care, which includes medical and psychological treatments. The prognosis for chronic diseases such as cardiovascular problems, high blood pressure, cancer, and diabetes is variable. As of 2004, these diseases are not cured, and control is achieved by standardized treatment options. Eventually complications, despite treatment, can occur. For HIV the clinical course as of 2004 is death, even though this process may take years. Educational programs with an emphasis on disease prevention can potentially improve outcomes concerning pediatric and geriatric diseases.

Prevention

Prevention is accomplished best through educational programs specific to target populations. IMRs can be prevented by increasing awareness, interest, and accessibility for prenatal care that offers a comprehensive approach for the needs of each patient. Regular physicals and special screening tests can potentially prevent certain cancers in high-risk groups. Educational programs concerning lifestyle modifications, diet, exercise, and testing may prevent the development of cardiovascular disease and diabetes. Educational programs for illicit IV drug abusers and persons who engage in unprotected sexual intercourse may decrease the incidence of HIV infection.

Parental concerns

All children should have regular well-child check ups according to the schedule recommended by their physician or pediatrician. The American Academy of Pediatrics (AAP) advises that children be seen for well-baby check ups at two weeks, two months, four months, six months, nine months, 12 months, 15 months, and 18 months of age. Well-child visits are recommended at ages two, three, four, five, six, eight, ten, and annually thereafter through age 21. Parents can take some precautions to ensure the health of their children. Childproofing the home, following a recommended immunization schedule, educating kids on safety , learning cardiopulmonary resuscitation (CPR), and taking kids for regular well-child check-ups all help to protect against physical harm. In addition, encouraging open communication with children can help them grow both emotionally and socially. Providing a loving and supportive home environment can help to nurture an emotionally healthy child who is independent, self-confident, socially skilled, insightful, and empathetic towards others.

Resources

BOOKS

LaVeist, Thomas. Race, Ethnicity, and Health: A Public Health Reader. Hoboken, NJ: Jossey-Bass, 2002.

Shannon, Joyce Brennfleck. Ethnic Diseases Sourcebook: Basic Consumer Health Information for Ethnic and Racial Minority Groups in the United States. Detroit, MI: Omnigraphics, 2001.

PERIODICALS

El-Mohandes, Ayman A. E., et al. "The Effect of a Parenting Education Program on the Use of Preventive Pediatric Health Care Services among Low-Income, Minority Mothers: A Randomized, Controlled Study." Pediatrics 111 (June 2003): 132432.

Harrison, Patricia A., et al. "The Adolescent Health Review: A Test of a Computerized Screening Tool in School-Based Clinics." Journal of School Health 73 (January 2003): 1520.

Walsh, Catherine, and Lainie F. Ross. "Are Minority Children Under- or Over-represented in Pediatric Research?" Pediatrics 112 (October 2003): 89095.

Wechsler, Jill. "Health Plans Examine Minority Healthcare Gap: Research Examines Racial and Ethnic Disparities in Healthcare." Managed Healthcare Executive 13 (November 2003): 8.

ORGANIZATIONS

National Center on Minority Health and Health Disparities. National Institutes of Health. 6707 Democracy Blvd., Suite 800, MSC-5465, Bethesda, MD 208925465. Web site: <http://ncmhd.nih.gov>.

Office of Minority Health Resource Center. PO Box 37337, Washington, DC 200137337. Web site: <www.omhrc.gov/omhrc>.

WEB SITES

"Eliminating Minority Health Disparities." U.S. Department of Health and Human Services, July 12, 2004. Available online at <http://raceandhealth.hhs.gov> (accessed November 11, 2004).

"Minority Children's Health Gets Poor Report Card." Texas Health Resources. 2004. Available online at <www.minoritynurse.com/vitalsigns/jan03-3.html> (accessed November 11, 2004).

Laith Farid Gulli, M.D. Nicole Mallory, M.S. Ken R. Wells

KEY TERMS

Angioplasty A medical procedure in which a catheter, or thin tube, is threaded through blood vessels. The catheter is used to place a balloon or stent (a small metal rod) at a narrowed or blocked area and expand it mechanically.

Cardiopulmonary resuscitation (CPR) An emergency procedure designed to stimulate breathing and blood flow through a combination of chest compressions and rescue breathing. It is used to restore circulation and prevent brain death to a person who has collapsed, is unconscious, is not breathing, and has no pulse.

Cardiovascular Relating to the heart and blood vessels.

Congenital Present at birth.

Hypertension Abnormally high arterial blood pressure, which if left untreated can lead to heart disease and stroke.

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"Minority Health." Gale Encyclopedia of Children's Health: Infancy through Adolescence. . Encyclopedia.com. 22 Aug. 2017 <http://www.encyclopedia.com>.

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Minority Health

Minority Health

Definition

Minority health addresses the special medical and/or health needs associated with specific ethnic groups.

Description

The United States, as well as many other countries, experiences cultural diversity. This poses specific health issues that are specific to ethnic groups. Additionally, the propensity for certain diseases or illnesses is of concern in certain minority groups. These specific health issues include infant mortality rates, cancer, cardiovascular disease, diabetes, HIV infection, and immunizations.

Infant mortality rates

Infant mortality rates (IMRs) in the United States and in all countries worldwide are an accurate indicator of health status. They provide information concerning programs about pregnancy education and counseling, technological advances, and procedures and aftercare. IMRs vary among racial groups. African Americans had an IMRs of 14.2 per 1,000 live births in 1996, approximately 2.5 times higher than Caucasians. The IMRs among American Native Indian groups varies greatly, with some communities possessing IMRs about two times more than national rates. Additionally Hispanic IMRs (7.6 per 1,000 live births) are also diverse for separate groups, since the IMRs for example among Puerto Ricans is higher (8.9 per 1,000 live births).

Cancer

Cancer is a serious national, worldwide, and minority health concern. It is the second cause of death in the United States, claiming over half a million lives each year. Approximately 50% of persons who develop cancer will die. There is great disparity among the cancer rates in minority groups. Across genders, cancer death rates for African Americans are 35% higher when compared to statistics for Caucasians. The death rates for prostate cancer (two times more) and lung cancer (27 times more) are disproportionately higher when compared to Caucasians. There are also gender differences among ethnic groups and specific cancers. Lung cancers in African American and Hawaiian men are evaluated compared with Caucasian males. Vietnamese females who live in the United States have five times more new cases of cervical cancer when compared to Caucasian women. Hispanic females also have a greater incidence of cervical cancer than Caucasian females. Additionally, Alaskan native men and women have a greater propensity for cancers in the rectum and colon than do Caucasians.

DR. ANTONIA NOVELLO (1944)

Born Antonia Coello was born in Fajardo, Puerto Rico, on August 23, 1944, the oldest of three children. At eight years old, she suffered two blows that she would carry all of her life. Her father, Antonio Coello, died, leaving her mother, Ana Delia Flores Coello, to raise her children alone until she later remarried Ramon Flores, an electrician. Novello was also diagnosed with a chronic condition called congenital megacolon, an illness in which her colon was overly large and not functioning properly, which required regular hospitalization. Although an operation would have helped Novello, it was not performed until she was 18 years old, and even after the surgery, complications followed her for years. Because of her childhood illness, Novello grew up wanting to be a doctor.

On October 17, 1989, President George Bush officially nominated Novello for Surgeon General. The fourteenth United States Surgeon General, Novello, sworn in on March 9, 1990, remarked that "the American dream is well and alive today the West Side Story comes to the West Wing." Novello was the first woman and the first Hispanic to be appointed Surgeon General of the United States. Noted for her philosophy of "good science, good sense" and for her approachability, Novello was dedicated to the prevention of AIDS, substance abuse, and smoking, as well as to the education of the American public. Her special concerns were for women, children, and hispanicspopulations often overlooked by public health services.

Cardiovascular disease

Cardiovascular disease is responsible for the leading cause of disability and death rates about equal to death from all other diseases combined. Cardiovascular disease can affect the patient's lifestyle and function in addition to having an impact on family members. The financial costs are very high. Among ethnic and racial groups cardiovascular disease is the leading cause of death. Stroke is the leading cause of cardiovascular related death, which occurs in higher numbers for Asian-American males when compared to Caucasian men. Mexican-American men and women and African-American males have a higher incidence of hypertension. African-American women have higher rates of being overweight, which is a major risk factor of cardiovascular disease.

Diabetes

Diabetesa serious health problem in Americans and ethnic groupsis the seventh leading cause of death in the United States. The prevalence of diabetes in African Americans is about 70% higher than Caucasians.

HIV

HIV infection/AIDS is the most common cause of death for all persons age 25 to 44 years old. Ethnic groups account for 25% of the United States population and 54% of all AIDS cases. In addition to sexual transmission there is an increase in HIV among ethnic groups related to intravenous drug usage.

Immunizations

Immunization, the reduction of preventable disease by vaccination, was lower in 1996, but the there has been a rapid increase in African Americans taking vaccinations. The coverage for immunization among African Americans and Hispanics for persons age 65 and over is currently below the general population. This may increase the death rates due to respiratory infections.

Causes and symptoms

IMRs are correlated with prenatal care. Women who receive adequate prenatal care tend to have better pregnancy outcomes when compared to little or no care. Women who receive inadequate prenatal care also have increased chances of delivering a very low birth weight (VLBW) infant, which is linked to risk of early death.

Cancer is related to several preventable lifestyle choices. Tobacco use, diet, and exposure to sun (skin cancer) can be prevented by lifestyle modifications. Additionally many cancers can occur due to lack of interest and/or lack of availability for screening and educational programs.

Cardiovascular diseases are higher among persons with high blood cholesterol and high blood pressure. Certain lifestyle choices may increase the chance for heart disease includes lack of exercise, overweight, and cigarette smoking. Cardiovascular disease is responsible for over 50% of the deaths in persons with diabetes.

HIV occurs at a higher frequency among homosexuals (the number of African-American males who have AIDS through sex with men has increased). Additionally unprotected sexual intercourse and sharing used needles for IV drug injection are strongly correlated with infection.

Vaccinations are an effective method of preventing certain disease such as polio, tetanus, pertussis, diphtheria, influenza, hepatitis b, and pneumococcal infections. Approximately 90% of influenza related mortality is associated with persons aged 65 and older. This is mostly due to neglect of vaccinations. About 45,000 adults each year die of diseases related to hepatitis B, pneumococcal, and influenza infections.

Diagnosis

The diagnosis of VLBW is by weight. Infants who weigh 1,500 g are at high risk for death. For cancer, the diagnosis can be made through screening procedures such as mammography (for breast cancer ), PAP smear (for cervical cancer), and lifestyle modifications such as avoidance of sun, cigarette smoking, balanced diets, and adequate nutrition. Other specific screening tests (PSA, prostate surface antigen) are helpful for diagnosing prostate cancer. Cardiovascular diseases can be detected by medical check-up. Blood pressure and cholesterol levels can be measured. Obesity can be diagnosed by assessing a persons weight relative to height. Diabetes and its complications can be detected by blood tests, in-depth eye examinations and studies that assess the flow of blood through blood vessels in legs. HIV can be detected through a careful history/physical examination and analysis of blood using a special test called a western blot. Infections caused by lack of immunizations can either be detected by careful physical examination and culturing the specific microorganism in the laboratory.

Treatment

Treatment is directed at the primary causes(s) that minorities have increased chances of developing disease(s). Cancer may require treatment utilizing surgery, radiotherapy, or chemotherapy. Cardiovascular diseases may require surgical procedures for establishing a diagnosis and initiating treatment. Depending on the extent of disease cardiovascular management can become complicated requiring medications and daily lifestyle modifications. Treatment usually includes medications, dietary modifications, andif complications arisespecific interventions tailored to alleviating the problem. HIV can be treated with specific medications and more often than not with symptomatic treatment as reported complications arise. Diseases caused by lack of immunizations are treated based on the primary disease. The best method of treatment is through prevention and generating public awareness through educational awareness.

Alternative treatment

Alternative therapies do exist, but more research is needed to substantiate present data. The diseases that relate to minority health are best treated with nationally accepted standards of care.

Prognosis

Generally the prognosis is related to the diagnosis, patients state of health, age, and if there is another disease or complication in addition to the presenting problem. The course for IMRs is related to educational programs and prenatal care, which includes medical and psychological treatments. The prognosis for chronic diseases such as cardiovascular problems, high blood pressure, cancer, and diabetes is variable. These diseases are not cured and control is achieved by standardized treatment options. Eventually complications, even with treatment can potentially occur. For HIV the clinical course at present is death even though this process may take years. Educational programs with an emphasis on disease prevention can potentially improve outcomes concerning pediatric and geriatric diseases.

Prevention

Prevention is accomplished best through educational programs specific to target populations. IMRs can be prevented by increasing awareness, interest, and accessibility for prenatal care that address a comprehensive approach for the needs of each patient. Regular physicals and special screening tests ca potentially prevent certain cancers in high-risk groups. Educational programs concerning lifestyle modifications, diet, exercise, and testing may prevent the development of cardiovascular disease and diabetes. Educational programs assemble to illicit IV drug abusers and persons who engage in unprotected sexual intercourse may decrease the incidence of HIV infection.

Resources

ORGANIZATIONS

Office of Minority Health. 2001. http://www.omhrc.gov/rah/3rdpgBlue/Cardio/3pgGoalsCardio.htm.

KEY TERMS

Prevalence Number of existing cases relative to time.

Propensity A greater risk for developing a disease.

Cite this article
Pick a style below, and copy the text for your bibliography.

  • MLA
  • Chicago
  • APA

"Minority Health." Gale Encyclopedia of Medicine, 3rd ed.. . Encyclopedia.com. 22 Aug. 2017 <http://www.encyclopedia.com>.

"Minority Health." Gale Encyclopedia of Medicine, 3rd ed.. . Encyclopedia.com. (August 22, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/minority-health

"Minority Health." Gale Encyclopedia of Medicine, 3rd ed.. . Retrieved August 22, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/minority-health