Race and health in the United States

Research on race and health in the United States shows many health disparities between the different racial/ethnic groups. The possible causes, such as genetics, socioeconomic factors, and racism, continue to be debated.

Background

Health ratings in US by race.

In biomedical research conducted in the U.S., the 2000 US census definition of race is often applied. This grouping recognizes five races: black or African American, White (European American), Asian, native Hawaiian or other Pacific Islander, and American Indian or Alaska native. However, this definition is inconsistently applied across the range of studies that address race as a medical factor, making assessment of the utility of racial categorization in medicine more difficult.

Life expectancy

The twentieth century witnessed a great expansion of the upper bounds of the human life span. At the beginning of the century, average life expectancy in the United States was 47 years. By century's end, the average life expectancy had risen to over 70 years, and it was not unusual for Americans to exceed 80 years of age. However, although longevity in the U.S. population has increased substantially, race disparities in longevity have been persistent. African American life expectancy at birth is persistently five to seven years lower than European Americans.[1]

The vast majority of studies focus on the black-white contrast, but a rapidly growing literature describes variations in health status among America's increasingly diverse racial populations. Where people live, combined with race and income, play a huge role in whether they may die young.[2] A 2001 study found large racial differences exist in healthy life expectancy at lower levels of education.[3]

A study by Jack M. Guralnik, Kenneth C. Land, Dan Blazer, Gerda G. Fillenbaum, and Laurence G. Branch found that education had a substantially stronger relation to total life expectancy and active life expectancy than did race. Still, sixty-five-year-old black men had a lower total life expectancy (11.4 years) and active life expectancy (10 years) than white men (total life expectancy, 12.6 years; active life expectancy, 11.2 years) The differences were reduced when the data were controlled for education.[4]

Socioeconomic and regional factors

A study by Christopher Murray contends the differences are so stark it is "as if there are eight separate Americas instead of one." Leading the nation in longevity are Asian-American women who live in Bergen County, N.J., and typically reach their 91st birthdays, concluded Murray’s county-by-county analysis. On the opposite extreme are Native American men in swaths of South Dakota, who die around 58.

The risks for many diseases are elevated for socially, economically, and politically disadvantaged groups in the United States, suggesting that socioeconomic inequities are the root causes of most of the differences.[5][6]

Specific diseases

Health disparities are well documented in minority populations such as African Americans, Native Americans, and Latinos.[7] When compared to European Americans and Asian Americans, these minority groups have higher incidence of chronic diseases, higher mortality, and poorer health outcomes.[8]

Minorities also have higher rates of cardiovascular disease, HIV/AIDS, and infant mortality than whites.[8] U.S. ethnic groups can exhibit substantial average differences in disease incidence, disease severity, disease progression, and response to treatment.[9]

African-Americans

History

Disparities in health and life span among blacks and whites in the US have existed since before the period of slavery. David R. Williams and Chiquita Collins write that, although racial taxonomies are socially constructed and arbitrary, race is still one of the major bases of division in American life. Throughout US history racial disparities in health have been pervasive.[21] In a 2001 paper, Williams and Collins also argued that, although it is no longer being legally enforced, racial segregation is still one of the primary causes of racial disparities in health because it determines socioeconomic status by limiting access to education and employment opportunities.[22] Clayton and Byrd write that there have been two periods of health reform specifically addressing the correction of race-based health disparities. The first period (1865–1872) was linked to Freedmen's Bureau legislation and the second (1965–1975) was a part of the Civil Rights Movement. Both had dramatic and positive effects on black health status and outcome, but were discontinued. Although African-American health status and outcome is slowly improving, black health has generally stagnated or deteriorated compared to whites since 1980.[23]

Demographic changes can have broad effects on the health of ethnic groups. Cities in the United States have undergone major social transitions during the 1970s 1980s and 1990s. Notable factors in these shifts have been sustained rates of black poverty and intensified racial segregation, often as a result of redlining.[24] Indications of the effect of these social forces on black-white differentials in health status have begun to surface in the research literature.[25]

Race has played a decisive role in shaping systems of medical care in the United States. The divided health system persists, in spite of federal efforts to end segregation, health care remains, at best widely segregated both exacerbating and distorting racial disparities.[26] Furthermore, the risks for many diseases are elevated for socially, economically, and politically disadvantaged groups in the United States, suggesting to some that environmental factors and not genetics are the causes of most of the differences.[27][28]

Racism

Racial differences in health often persist even at equivalent socioeconomic levels. Individual and institutional discrimination, along with the stigma of inferiority, can adversely affect health. Racism can also directly affect health in multiple ways. Residence in poor neighborhoods, racial bias in medical care, the stress of experiences of discrimination and the acceptance of the societal stigma of inferiority can have deleterious consequences for health.[29] Using The Schedule of Racist Events (SRE), an 18-item self-report inventory that assesses the frequency of racist discrimination. Hope Landrine and Elizabeth A. Klonoff found that racist discrimination was frequent in the lives of African Americans and is strongly correlated to psychiatric symptoms.[30]

A study on racist events in the lives of African American women found that lifetime racism was positively correlated to lifetime history of both physical disease and frequency of recent common colds. These relationships were largely unaccounted for by other variables. Demographic variables such as income and education were not related to experiences of racism. The results suggest that racism can be detrimental to African American's well being.[31] The physiological stress caused by racism has been documented in studies by Claude Steele, Joshua Aronson, and Steven Spencer on what they term "stereotype threat."[32]

Kennedy et al. found that both measures of collective disrespect were strongly correlated with black mortality (r = 0.53 to 0.56), as well as with white mortality (r = 0.48 to 0.54). A 1 percent increase in the prevalence of those who believed that blacks lacked innate ability was associated with an increase in age-adjusted black mortality rate of 359.8 per 100,000 (95% confidence interval: 187.5 to 532.1 deaths per 100,000). These data suggest that racism, measured as an ecologic characteristic, is associated with higher mortality in both blacks and whites.[33]

Princeton Survey Research Associates found that in 1999 most whites were unaware that race and ethnicity may affect the quality and ease of access to health care.[34]

Inequalities in health care

There is a great deal of research into inequalities in health care. In 2003, the Institute of Medicine released a report showing that race and ethnicity were significantly associated with the quality of healthcare received, even after controlling for socioeconomic factors such as access to care.[35] In some cases these inequalities are a result of income and a lack of health insurance a barrier to receiving services. Almost two-thirds (62 percent) of Hispanic adults aged 19 to 64 (15 million people) were uninsured at some point during the past year, a rate more than triple that of working-age white adults (20 percent). One-third of working-age black adults (more than 6 million people) were also uninsured or experienced a gap in coverage during the year. Blacks had the most problems with medical debt, with 61 percent of uninsured black adults reporting medical bill or debt problems, vs. 56 percent of whites and 35 percent of Hispanics.[36]

Compared with white women, black women are twice as likely and Hispanic women are nearly three times as likely to be uninsured.[37] However, a survey conducted in 2009 examining whether patient race influences physician's prescribing found that racial differences in outpatient prescribing patterns for hypertension, hypercholesterolemia, and diabetes are likely attributable to factors other than prescribing decisions based on patient race. Medications were recommended at comparable rates for hypercholesterolemia, hypertension and diabetes between Caucasians and African Americans.[38]

It has been argued that other cases inequalities in health care reflect a systemic bias in the way medical procedures and treatments are prescribed for different ethnic groups. Raj Bhopal writes that the history of racism in science and medicine shows that people and institutions behave according to the ethos of their times and warns of dangers to avoid in the future.[39] Nancy Krieger contended that much modern research supported the assumptions needed to justify racism. Racism underlies unexplained inequities in health care, including treatment for heart disease,[40] renal failure,[41] bladder cancer,[42] and pneumonia.[43] Raj Bhopal writes that these inequalities have been documented in numerous studies. The consistent and repeated findings that black Americans receive less health care than white Americans—particularly where this involves expensive new technology—is an indictment of American health care.[44]

The infant mortality rate for African Americans is approximately twice the rate for European Americans, but, in a study that looked at members of these two groups who belonged to the military and received care through the same medical system, their infant mortality rates were essentially equivalent.[45] Recent immigrants to the United States from Mexico have better indicators on some measures of health than do Mexican Americans who are more assimilated into American culture.[46] Diabetes and obesity are more common among Native Americans living on U.S. reservations than among those living outside reservations.[47]

A report from Wisconsin’s Department of Health and Family Services showed that while black women are more likely to die from breast cancer, white women are more likely to be diagnosed with breast cancer. Even after diagnosis, black women are less likely to get treatment compared to white women.[48] University of Wisconsin African-American studies Professor Michael Thornton said the report’s results show racism still exists today. "There’s a lot of research that suggests that who gets taken seriously in hospitals and doctors’ offices is related to race and gender," Thornton said. "It’s related to the fact that many black women are less likely to be taken seriously compared to the white women when they go in for certain illnesses."[49]

Krieger writes that given growing appreciation of how race is a social, not biological, construct, some epidemiologists are proposing that studies omit data on "race" and instead collect better socioeconomic data. Krieger writes that this suggestion ignores a growing body of evidence on how noneconomic as well as economic aspects of racial discrimination are embodied and harm health across the lifecourse.[50] Gilbert C. Gee's study A Multilevel Analysis of the Relationship Between Institutional and Individual Racial Discrimination and Health Status found that individual (self-perceived) and institutional (segregation and redlining) racial discrimination is associated with poor health status among members of an ethnic group.[51]

Cardiovascular disease

Research has explored the effect of encounters with racism or discrimination on physiological activity. Most of the research has focused on traits that cause exaggerated responses, such as neuroticism, strong racial identification, or hostility.[52] Several studies suggest that higher blood pressure levels are associated with a tendency not to downplay racist and discriminatory incidents, or that directly addressing or challenging unfair situations reduces blood pressure.[52] Personal experiences of racist behaviors cause physiological arousal and increase stress and blood pressure.[52]

Although the relationship racism and health is unclear and findings have been inconsistent, three likely mechanisms for cardiovascular damage have been identified:[53]

Fear of racism

It has been argued that while actual racism continues to harm health, fear of racism, due to historical precedents, can also cause some minority populations to avoid seeking medical help. For example, a 2003 study found that a large percentage of respondents perceived discrimination targeted at African American women in the area of reproductive health.[54] Likewise beliefs such as "The government is trying to limit the Black population by encouraging the use of condoms" have also been studied as possible explanations for the different attitudes of whites and blacks towards efforts to prevent the spread of HIV/AIDS.[55]

Infamous examples of real racism in the past, such as the Tuskegee Syphilis Study (1932–1972), have injured the level of trust in the Black community towards public health efforts. The Tuskegee study deliberately left Black men diagnosed with syphilis untreated for 40 years. It was the longest nontherapeutic experiment on human beings in medical history. The AIDS epidemic has exposed the Tuskegee study as a historical marker for the legitimate discontent of Blacks with the public health system. The false belief that AIDS is a form of genocide is rooted in recent experiences of real racism. These theories range from the belief that the government promotes drug abuse in Black communities to the belief that HIV is a manmade weapon of racial warfare. Researchers in public health hope that open and honest conversations about racism in the past can help rebuild trust and improve the health of people in these communities.[56]

Environmental racism

Main article: Environmental racism

Environmental racism is a form of racial discrimination where race-based differential enforcement of environmental rules and regulations; the intentional or unintentional targeting of minority communities for the siting of polluting industries such as toxic waste disposal; and the exclusion of people of color or lack thereof from public and private boards, commissions, and regulatory bodies results in greater exposure to pollution. RD Bullard writes that a growing body of evidence reveals that people of color and low-income persons have borne greater environmental and health risks than the society at large in their neighbourhoods, workplaces and playgrounds.[57]

Policies related to redlining and urban decay can also acts as a form of environmental racism, and in turn affect public health. Urban minority communities may face environmental racism in the form of parks that are smaller, less accessible and of poorer quality than those in more affluent or white areas in some cities.[58] This may have an indirect affect health since young people have fewer places to play and adults have fewer opportunities for exercise.[58]

Robert Wallace writes that the pattern of the AIDS outbreak during the 80s was affected by the outcomes of a program of 'planned shrinkage' directed in African-American and Hispanic communities, and implemented through systematic denial of municipal services, particularly fire extinguishment resources, essential for maintaining urban levels of population density and ensuring community stability.[59] Institutionalized racism affects general health care as well as the quality of AIDS health intervention and services in minority communities. The overrepresentation of minorities in various disease categories, including AIDS, is partially related to environmental racism. The national response to the AIDS epidemic in minority communities was slow during the 80s and 90s showing an insensitivity to ethnic diversity in prevention efforts and AIDS health services.[60]

Segregation

Some researchers suggest that racial segregation may lead to disparities in health and mortality. Thomas LaVeis (1989; 1993) tested the hypothesis that segregation would aid in explaining race differences in infant mortality rates across cities. Analyzing 176 large and midsized cities, LaVeist found support for the hypothesis. Since LaVeist's studies, segregation has received increased attention as a determinant of race disparities in mortality.[1] Studies have shown that mortality rates for male and female African Americans are lower in areas with lower levels of residential segregation. Mortality for male and female European Americans was not associated in either direction with residential segregation.[61]

In a study by Sharon A. Jackson, Roger T. Anderson, Norman J. Johnson and Paul D. Sorlie the researchers found that, after adjustment for family income, mortality risk increased with increasing minority residential segregation among Blacks aged 25 to 44 years and non-Blacks aged 45 to 64 years. In most age/race/gender groups, the highest and lowest mortality risks occurred in the highest and lowest categories of residential segregation, respectively. These results suggest that minority residential segregation may influence mortality risk and underscore the traditional emphasis on the social underpinnings of disease and death.[62]

Rates of heart disease among African Americans are associated with the segregation patterns in the neighborhoods where they live (Fang et al. 1998). Stephanie A. Bond Huie writes that neighborhoods affect health and mortality outcomes primarily in an indirect fashion through environmental factors such as smoking, diet, exercise, stress, and access to health insurance and medical providers.[63] Moreover, segregation strongly influences premature mortality in the US.[64]

Crime

Crime plays a significant role in this racial gap in life expectancy. A report from the U.S. Department of Justice states "In 2005, homicide victimization rates for blacks were 6 times higher than the rates for whites" and "94% of black victims were killed by blacks."[65]

Trends

Based on data for 1945 to 1999, forecasts for relative black:white age-adjusted, all-cause mortality and white:black life expectancy at birth showed trends toward increasing disparities. From 1980 to 1998, average numbers of excess deaths per day among American blacks relative to whites increased by 20%.[66] David Williams writes that higher disease rates for blacks (or African Americans) compared to whites are pervasive and persistent over time, with the racial gap in mortality widening in recent years for multiple causes of death.[29]

Criticisms

The study of a genetic basis for racial health disparity in the United States is criticised for the use of a "melting pot" perspective and for neglecting to include indigenous North Americans. This is based on studies suggesting the genetic difference between "races" is greatest with populations that have been reproductively isolated for long periods of time.[67] The United States is the opposite of this with a wide variety of cultures in close proximity along with a decreasing social stigma against interracial relationships.[68]

This issue is illustrated with the example of those who identify themselves as Hispanic/Latino, typically a mix of Caucasian, Native American and African ancestry.[67] Some studies include this as a "race", where as others do not have that option and force members of this group to choose between identifying themselves as "Caucasian", "Other" or whatever group that individual identifies with. Such admixture of genetic ancestry would lend results more to cultural, environmental and socio-economic explanations of health disparity rather than a genetic explanation.

See also

References

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