Taking care of America's new majority

Editor’s note: Thomas Tseng is director of marketing at Cultural Access Group, a Los Angeles research firm.

If there is one thing the most recent census tells us, it is that the ethnic complexion of the United States is changing in an unprecedented, dramatic fashion. In fact, if the growth of ethnic populations continues to soar according to projections, then the term “minority” - commonly used to denote people of color in this country - will increasingly become a misnomer. Like other industries seeking to respond to the sweeping demographic changes occurring among American consumers, it is imperative that pharmaceutical companies and health organizations understand the increasingly multi-ethnic dimension of health care, as ethnic populations are poised to become a new majority over the next several decades.

The changing complexion of America

According to Census 2000, ethnic populations currently comprise 32 percent of the overall U.S. population, or approximately 88 million people. Hispanics now represent the largest segment of this multi-hued American population, recently overtaking African-Americans to become the largest ethnic minority group in the country. Overall, the composition of the three largest ethnic populations is: Hispanics at 12.5 percent, African-Americans at 12 percent, and Asian-Americans at 4 percent of the U.S. population.

All three of these ethnic communities have exhibited astounding growth in the past decade, due to rising immigration and natural birth rates. Asian-Americans grew at the fastest clip - 42 percent between 1990 and 2000, while Hispanics grew at an equally impressive 39 percent rate during the same period. The African-American population grew at a more modest pace at 14 percent but was still at a considerably higher level compared to the white population, which only grew 7.3 percent. These contrasting growth patterns reveal broad divergence in growth between minority and non-minority populations.

Moreover, these numbers only represent the official figures; although the Census Bureau has markedly improved its survey responses, it is widely understood that ethnic populations are significantly undercounted in the decennial census. As a result, a substantial group of ethnic minority populations are under-represented in the official results.

Thus, not only are the actual numbers of ethnic groups larger than the official count, ethnic populations are projected to continue their rapid ascent into the immediate future. Hispanics and Asian-Americans are anticipated to grow approximately 260 percent by 2050 while African-Americans are expected to grow over 80 percent in the same period. As it has in the past 30 years, the bulk of this growth will occur mostly in America’s sunbelt regions and major metropolitan areas. According to most prognostications, ethnic communities will constitute a majority of the U.S. population in the next 25 to 30 years, as they already do in such states such as California.

Today’s ethnic markets, tomorrow’s mainstream customers

Not only are ethnic populations making significant strides in population growth, they are also positioned to redefine mainstream consumer trends due to their considerable and escalating purchasing power. According to the Selig Center for Economic Growth at the University of Georgia, buying power soared for all ethnic groups between 1990 and 2001. Their findings among the three largest ethnic groups reveal that:


  • African-American buying power grew from $308 billion to $572 billion.
  • Hispanic buying power grew from $208 billion to $542 billion.
  • Asian-Pacific-American buying power grew from $113 billion to $254 billion.

Among these three groups, spending power rose astronomically, doubling in the last decade from $628.2 billion to $1.3 trillion. This purchasing potential is projected to top $4 trillion in another 15 years, as record numbers of Hispanics, African-Americans, and Asian-Americans will transition from secondary schools and colleges into the labor force. These gains demonstrate that ethnic populations are only now beginning to make their presence felt in the marketplace. As these consumer segments really begin to demonstrate their spending potential in the not-too-distant future, they will cast an indelible mark on the economic mainstream.

This will have far-reaching ramifications for pharmaceutical companies who count on a growing base of consumers to drive their sales. Of the currently estimated $100 billion per annum pharmaceuticals market, $25 billion is driven by ethnic consumers - with very little in the way of ethnic marketing and advertising strategies directed towards them. Hence, as these ethnic customer segments grow, the untapped opportunity represented by culturally-relevant ethnic marketing rise with every passing year.

The ethnic health care divide

Despite the impressive population and economic strides made among ethnic communities in the U.S., significant health challenges exist that may define the health care marketplace for decades to come. Although U.S. health care is widely considered the most advanced in the world, there are significant health disparities within U.S. ethnic populations. These health gaps have only recently begun to receive broad national attention in the past several years - exemplified by the launch of a five-year presidential initiative in 1999 via the U.S. Surgeon General’s office with a mandate to eliminate health inequities among racial and ethnic groups.

Health challenges for ethnic populations exist in the following areas:

1. Access to health insurance
Although, some improvements have been observed in recent years, health care access continues to be a central challenge among most ethnic minority populations. In this country, 34 percent of the foreign-born population is without health insurance compared to 14.4 percent of the native-born population

More than a third of the U.S. Hispanic population does not have health insurance. They compose the largest segment of the uninsured at 36 percent - compared to 23 percent for African-Americans, 22 percent for Asian-Americans, and only 14 percent for whites. Additionally, they are the smallest segment to be covered by private insurance (either privately purchased or employer-based) at 45 percent. A larger proportion of African-Americans and Asian-Americans are covered by private insurance - 54 percent and 69 percent respectively - but is still significantly below the 79 percent private insurance coverage of whites. The great majority of the uninsured among Hispanics are from working families.

Even more alarming is that the lack of health care access for Hispanics has been steadily increasing. For instance, between 1977 and 1996, Hispanics who stated they have “no usual source of medical care” grew from 20 percent to 30 percent of the overall population - while they remained constant for whites and African-Americans. Likewise, Latino children are three times more likely to be uninsured at 29 percent - compared to 12 percent of Asian-American, 10 percent of white, and 10 percent of African-American children.

2. Increased risk factors
In addition to a lack of health care access, ethnic populations also face certain risk factors at greater levels than the general population. Although the leading causes of illness and of death among ethnic groups do not differ significantly from each other, their incidence rates among Hispanics, African-Americans, and Asian-Americans are considerably higher (i.e., heart disease, certain varieties of cancer, etc.). Because of these disparities and the unique incidence levels for some ethnic populations, different forms of therapeutic treatment are necessary.

Among the most distressing risk factors for ethnic populations include:


  • Heart disease – Heart disease is the leading cause of death among all groups, and is particularly high in the Hispanic population. Over one-quarter of all deaths among Latinos are attributed to heart disease, while among Hispanic females, the rates climb to 34 percent. Among Hispanic sub-groups, Cuban-Americans face the highest rates of heart disease.

In general, ethnic minorities experience higher rates of hypertension and tend to develop it at an earlier age. Despite these alarmingly high incidences, ethnic populations are less likely to undergo treatment to control high blood pressure than the general population, according to the National Heart, Lung and Blood Institute.


  • Diabetes – Ethnic populations - particularly African-Americans and Hispanics - are far more likely than the white population to develop diabetes. Diabetes strikes the Hispanic community at twice the rate of the white population. On a national level, approximately one-quarter of all Hispanics of Mexican and Puerto Rican descent have diabetes, according to the Center for Disease Control.
  • HIV/AIDS – HIV/AIDS cases are higher among ethnic populations in the U.S. than the white population in general and are rising to alarming levels among the Hispanic and African-American populations in particular. Nationally, ethnic groups comprise approximately 54 percent of all AIDS cases. In California, of all new HIV cases diagnosed between 1985 and 1995, Latinos jumped from 11 percent to 24 percent of total cases.
  • Cancer – Cancer is the second leading cause of death of all groups, although ethnic populations make up a disproportionate number of its mortality and incidence rates. Among Hispanics, rates of occurrence for lung, breast, and prostate cancer are low but rates for cervical cancer are high.

3. Cultural factors
In obvious ways, cultural factors among different ethnic populations play a tremendous role in shaping perceptions and attitudes about lifestyle choices, healthy practices, and overall wellness — all of which determine healthy outcomes. Assumptions about diet, stress management, lifestyle, religious beliefs, relationships, and trust are all derived from our cultural upbringing and play substantial roles in determining the type of health practices people will adopt.

Since these factors vary widely, a concerted effort to understand the assumptions behind the attitudes and behaviors of ethnic groups in governing personal health is critical to achieving greater levels of medical awareness, ensuring the seeking of proper therapeutic treatment, and encouraging patient compliance. If the direct-to-consumer efforts of many pharmaceutical companies are to achieve any cultural efficacy, it is essential for them to consider and incorporate these assumptions into their strategies.

For instance, some examples highlighting the ethnic differences among African-Americans, Hispanics and Asian-Americans — as it pertains to health care - include the following:


  • Among Hispanics, Spanish-speaking patients are less likely than English-speaking patients to receive sufficient preventive information or referrals from their providers. In part, this is attributed to language barriers that can result in misdiagnoses of illnesses or a physician obtaining inadequate consent.
  • Spanish-speaking Hispanic patients tend to be more open and ask more questions when seen by bilingual providers. The development of relationships and establishing trust is vital for Hispanics. A trust based on credentials and professional authority is not assumed.
  • More than any other ethnic group, Hispanics are less adherent in visiting physicians or health experts. The percentage of Hispanics that visit their doctors for annual physicals, prenatal check-ups, and mammograms is below that of the general market. There is a sensibility that visiting the doctor is simply not necessary when you feel well. Hence, a large majority of Hispanic patients often pay for medical care out of their pockets or visit free clinics and government-funded medical facilities - often when an ailment or illness has progressed beyond the initial stage.
  • A 1999 Morehouse study revealed that African-Americans were less likely than Hispanics to believe there is a cause-and-effect relationship between diet and health and were also less likely to believe generic drugs were as good as name-brand drugs.
  • There is a general lack of trust of the health care system among many African-Americans, Hispanics, and some Asian-American groups. Many participants do not trust health care professionals to adequately diagnose their problems. They believe they have to do their own research to validate their doctors’ treatment recommendations.
  • Although differences vary widely among Asian and Pacific Islander (API) populations depending on nationality (a lack of sufficient research information is available as well), API males also face numerous health care challenges stemming from lower access to health care. Some common ailments include high rates of cancer, diabetes, heart disease, tobacco use, hepatitis B, and tuberculosis.

Searching for the right physician

Because of the demographic sea change in the U.S., it will be important to establish cultural competency across all levels of the health care system - particularly among physicians and pharmaceutical companies.

According to the National Hispanic Medical Association, there are approximately 26,000 licensed physicians and 1,800 full-time Hispanic medical faculty across the country - not nearly enough to treat the more than 35.3 million members of the Hispanic market located in the United States. Finding a Hispanic doctor for each Hispanic patient is not a solution to difficulties brought on by cultural differences.

For instance, in California, the nation’s most ethnically populous state, only 3 percent of all physicians were Latino, though greater than one-third of the population in California is Latino. The remaining composition of physicians were 75 percent white, 19 percent Asian, and 3 percent Black. This means more and more non-Hispanic members of the medical industry will be treating even more Hispanic patients.

The importance of identifying and cultivating minority physicians cannot be underscored enough. Sixty one percent of Hispanics feel it’s important to be treated by someone of the same ethnicity, while 28 percent of African-Americans feel it’s important.

The role of the pharmaceutical industry: culturally competent marketing

Like physicians, the U.S. pharmaceutical industry can also play a critical role in understanding the racial and ethnic challenges in health care and cultivating these markets. As ethnic populations continue to grow, it becomes essential for drug manufacturers and distributors to target ethnic communities with effective communications to make them more aware of their treatment options, preventive practices, and available educational resources.

Identifying the avenues for reaching these potential patients can directly occur through exploring direct-to-consumer advertising or over-the-counter approaches. As direct-to-consumer approaches increase, communications must be informed through culturally compelling and relevant messages that will both educate and resonate with ethnic consumers. As providers of products that enhance health, cure diseases, and heal ailments, it is in the best interests of pharmaceutical companies to recognize and address ethnic differences and disparities in the health care system. In short, health issues addressed to the multicultural market must be done through culturally competent marketing.

The need for further research

The need for culturally relevant information about the exploding U.S. multicultural population demands continued research to understand existing health gaps. Additionally, research further illuminates the cultural assumptions, health care needs and practices that distinguish U.S. ethnic populations from each other - providing the key to achieving healthier lifestyles, better health-related decisions, and increased compliance. Research must identify the specific challenges facing America’s multicultural consumers and demonstrate the population’s growing significance to the health care marketplace. Understanding these differences has strong implications for health care marketing, administration, and public policy agendas.

The current base of knowledge serves as a solid foundation, but the need for further research will escalate as the U.S. ethnic minority population grows. These research and information needs will increase in importance as health care providers, pharmaceutical manufacturers, and other public health groups begin to deal with the challenges resulting from this growth. It will be increasingly essential for research to explore culturally competent methods of promoting disease awareness, communication mechanisms between ethnic patients and their health care providers, treatment compliance, and a sense of well-being that is culturally derived.

These research areas will determine the important differences among America’s major ethnic groups in order to improve health outcomes for the new American majority in the 21st century.