Treating the Troops: A Model for Battling Health-Care Disparities
There are many characteristics that set the military apart from the general population. But there was one particularly appealing characteristic: It is an equal-access-to-care culture. Of course, in a country as large and diverse as America, we can't expect to replicate the equal-access model of the US military. But we can try.
In 2004, I was appointed Chief of the Division of Urologic Surgery at Duke University Medical Center in Durham, North Carolina. Duke has a venerable heritage in prostate cancer research, and as urologic oncologist I am privileged to be associated with one the country's top urology programs. The long road from medical school to my current position at Duke began in a place that I never dreamed of visiting: A US Army recruiting station.
I came from a family of modest means, and when I was accepted into medical school the euphoria was tempered by the daunting costs. I had heard that the military offered medical scholarships. So on a whim, I visited a local recruiter who explained about the Army's Health Profession Scholarship Program. I knew nothing about Army life and I'd never considered it an option. But I ended up enlisting. In return for my service, the US Army would pay for my full medical education.
After 5 years in the Medical Corps at Walter Reed, I was contemplating leaving the military for private practice when the Army offered to sponsor a urologic oncology fellowship for me at Duke University. I seized the opportunity.
By the time I completed my fellowship, I was fully intrigued by the therapeutic possibilities of treating prostate cancer. Back at Walter Reed, I was the only fellowship-trained urologic oncologist in the Army who had a special interest in prostate cancer. At that time, during the late 1980s, prostate cancer awareness was well off the radar screen. It was a subject that men were still culturally reticent about. That changed, however, with the advent of PSA testing and the subsequent cancer diagnosis of Bob Dole and several other prominent DC politicians. These powerful new poster boys used their political clout to push for prostate cancer research. Suddenly, it seemed, prostate cancer was out of the closet. It was a good thing.
The military, with its built-in male screening population, offered a perfect venue for the kind of studies that I felt could produce reliable data in this emerging field of inquiry. By this time, it had been widely recognized that there are observed differences in prostate cancers in white and black men. I became interested in studying racial differences in prostate cancer within the military health-care system. To that end, I was fortunate to have been given the opportunity to serve as Director of the Department of Defense Center for Prostate Disease Research (CPDR).
In 1995, we were the first researchers to show that African-American men with newly diagnosed prostate cancer had higher PSA values than white men, even after adjustment for age at diagnosis and grade and clinical stages. We also discovered that African-American men had significantly greater cancer volume. In our studies, focusing on PSA levels in both black and white men, we demonstrated that previously accepted serum values were too high in screening black men.
There are many characteristics that set the military apart from the general population. But there was one particularly appealing characteristic: It is an equal-access-to-care culture. So finding this diagnostic disparity launched an important question: What factors account for the greater cancer burden in African-American men in the Army who have the same access to screening as their white counterparts?
Although the full explanation for this disparity remains elusive, subsequent studies have indicated several potential biologic factors contributing to faster-growing tumors in black men. Moreover, research has shown that young black men have up to 15% higher testosterone levels than white men of the same age. This, plus some new findings in genetic variation might help clarify this clinical intrigue. However, one fact is clear: Black men in the civilian population are not screened at the same rate as white men, and they're dying at a greater rate for it.
I am proud of my 26-year career in the Army--grateful, too. I'm certainly a better doctor for having practiced medicine in an environment in which unbiased treatment is standard operating procedure. Today's oncologists struggle with a number of conflicts, one of which can be the inability to provide high-quality care to all of their patients. Of course, in a country as large and diverse as America, we can't expect to replicate the equal-access model of the US military. But we can try.
-Judd W. Moul, MD
