Moormeier [1] recently summarized the available data on the greater morbidity and mortality of black women with breast cancer. Although we agree with the need for screening and early detection in black women, we believe the problem is more complex than economics and knowledge of the disease.

We previously postulated that the poor outcome among black women was caused solely by relative unavailability of medical care and the cost of methods of detection. However, when we provided medical care and screening procedures for free, few patients belonging to a minority group participated. Because one third of black patients presenting with breast cancer to our institution have stage III or IV disease, an incomplete-sentence technique was used among patients with breast cancer to determine the reasons for this lack of participation. Most responses described elements of fatalism. Often, this fatalism had religious connotation; some of these respondents believed that one's actions cannot influence outcome or that cancer was a punishment for wrongdoings.

An instrument was developed to collect information on education, income, race or ethnicity, sex, age, and health practices; an inventory of 10 questions was also developed to quantify responses indicating fatalism. Information was collected from healthy volunteers at marketplaces and malls that were patronized by a mixture of ethnic groups. The mean age was 54 years. Data were collected from 600 persons, 68% of whom were female. Black persons had a higher mean fatalism score than whites, and women were more fatalistic than men. Age, education, and economic status were each significant factors in this survey. When white and black persons who had similar education and economic status were paired, the difference in fatalism scores based on ethnicity or race was markedly diminished. We concluded that fatalism is prevalent in poor and less educated populations and that this factor is an important reason why some persons fail to seek medical care at an early stage of disease and do not use methods for early detection of cancer. Methods of interdiction and education need further study.

Our conclusion and observations are similar to those reported by Powe [2] in the Charleston, South Carolina, area. Whether fatalism is primarily a problem in southern United States and whether it is a significant problem in other minority populations are not known.