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. Different health problems, in both mental and physical health, are present in all races but are not always equally treated. Health care professionals show "implicit bias" in the way that they treat patients. In America, racism consists of stereotypes mainly that are political and economic. While this article focuses mainly on racism towards African Americans in the health field, it covers various other backgrounds including racism towards Native Americans, Asian Americans, and others while drawing comparisons between various incomes and ages. Race and health in the United States is a topic that has been researched many times over the years. There are various specific diseases that are more present among various races as well as different means for life expectancy.
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. According to the Census Bureau in 2000, race refers to one's self-identification with a certain racial group. The Bureau also specifies that race is a social concept, and has no relation to science or anthropology. 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. According to the Journal of Behavioral Medicine, America continues to become more diverse. Although the population is increasingly less homogeneous, healthcare is unequally distributed among these five racial groups. The 2000 U.S. Census further specifies the amount of Americans who identified with each racial group; in 2000, 34.6 million identified as African American, 10.2 million as Asian American, and 35.3 million as Hispanic or Latino. It is important to consider that the 2000 U.S. Census 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. 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. Bias stems from racism, creating stress on the race that is being discriminated against, leading to issues with a person's bodily and mental health. Repeated stress overtime on one’s body can lead to health problems such as depression, anxiety, insomnia, heart disease, skin rashes, and gastrointestinal problems, which are also more likely to develop in children. Racism has many detrimental effects on the health of Americans across the entire country, arising mainly from limited access to healthcare, mental health resources, and support. There are a wide range of patterns of health disparities that are caused by different levels of income across ethnic groups. Anthony Ong, a professor at Cornell University’s College of Human Ecology conveyed that this regular treatment of discrimination and backlash can have detrimental effects to a person’s self-esteem and can take opportunities of individuals. It can also cause individuals from being able to receive a full nights sleep.
Mental Health
Stress can be derived from many individualistic factors or experiences,has multiple effects on health. Stress is also associated with chronic diseases. Stress that is derived from racism has specific contextual factors, which adds a daily burden to African-Americans and other demographic groups that are discriminated against. These demographic groups do not often realize that these stressors may be contributing to the state of their mental health. Groups of people are also affected in ways that may not be outward acts of racism by another person, but through education, economics, the justice system, and largely through law enforcement. It is also possible that people who hold racist ideals have mental health problems as well, such as self-centeredness, inability to empathize, and paranoia over groups of people they are discriminating against. Individuals can develop complexes about ethnic groups and races, automatically displaying emotions without learning about the people themselves, and will cut off all friendliness to them.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.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. Today, Asian Americans live the longest (87.1 years), followed by Latinos (83.3 years), whites (78.9 years), Native Americans (76.9 years), and African Americans (75.4 years). Where people live, combined with race and income, play a huge role in whether they may die young. A 2001 study found large racial differences exist in healthy life expectancy at lower levels of education.
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.
During the 20th century, the difference in life expectancy between black and white men in the United States did not decline.
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.- Asian-Americans, average per capita income of $21,566, have a life expectancy of 84.9 years (However Filipino Americans are slightly lower at 81.5 years);
- Northern low-income rural Whites, $17,758, 79 years;
- Middle America (mostly White), $24,640, 77.9 years;
- Low-income Whites in Appalachia, Mississippi Valley, and Texas $16,390, 75 years;
- Western Native Americans, $10,029, 72.7 years;
- Black Middle America, $15,412, 72.9 years;
- Southern low-income rural Blacks, $10,463, 71.2 years;
- High-risk urban Blacks, $14,800, 71.1 years.
Specific diseases
Health disparities are well documented in minority populations such as African Americans, Native Americans, and Latinos. When compared to European Americans and Asian Americans, these minority groups have higher incidence of chronic diseases, higher mortality, and poorer health outcomes.Minorities also have higher rates of cardiovascular disease, HIV/AIDS, and infant mortality than whites. U.S. ethnic groups can exhibit substantial average differences in disease incidence, disease severity, disease progression, and response to treatment:
- African Americans have higher rates of mortality than does any other racial or ethnic group for 8 of the top 10 causes of death. The cancer incidence rate among African Americans is 10% higher than among European Americans;
- U.S. Latinos have higher rates of death from diabetes, liver disease, and infectious diseases than do non-Latinos;
- Adult African Americans and Latinos have approximately twice the risk as European Americans of developing diabetes;
- Asian Americans are 60% more likely to being at risk of developing diabetes in comparison to European Americans and are more likely to develop the disease at lower BMIs and lower body weights. South Asians are especially more likely to developing diabetes as it is estimated South Asians are four times more likely to developing the disease in comparison to European Americans;
- Native Americans suffer from higher rates of diabetes, tuberculosis, pneumonia, influenza, and alcoholism than does the rest of the U.S. population;
- European Americans die more often from heart disease and cancer than do Native Americans, Asian Americans, or Hispanics;
- White Americans have far higher incident rates of melanoma of the skin or skin cancer than any other race/ethnicity in the US. In 2007 incident rates among white American males were approximately 25/100,000 people, whereas the next highest group (Hispanics and natives) has an incidence rate of approximately 5/100,000 people;
- Asian Americans are at higher risk for hepatitis B, liver cancer, tuberculosis, and lung cancer. The subgroup of Filipino Americans suffer health risks similar to that of African Americans and European Americans combined;
- According to the NIH, African Americans are more likely to develop diabetes. Usually, type 2 diabetes is more prominent in middle-aged adults. Being obese or having a family history can also affect this. Over the past 30 years in the US, "black adults are nearly twice as likely as white adults to develop type 2 diabetes." Besides this difference just being between black and white adults, we see the greatest margin of comparison between black and white women;
- Sickle cell disease is more susceptible to be found in those of descent from places such as those in the Mediterranean, Italy, Turkey, and Greece, as well as Africa and regions of South and Central America. The disease affects how oxygen is delivered to the red blood cells and is often diagnosed at a young age, discovered through a diagnosis of anemia.
Women and Infants
African American women are three to four times more likely to die in childbirth than white women, while their babies are twice as likely to die than white babies, even when controlled for many factors such as education, income, and health. “White racism” is the highest cause of unrest in communities, pushing them further apart, and causing more black women and infants to die because of it. Racism in education has decreased significantly over the past century, however this does not help increases in income for blacks, and increased incomes don’t provide better health opportunities, especially for mothers and infants. Higher education and income levels for black mothers does not effect this mortality rate. There are also higher chances that a complication will occur during birth. The ‘toxin’ of these rates is racism, which has created a toxic environment for minority groups to live in with multiple stressors that effect health.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. 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. 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. Even though African-American health status and outcome is slowly improving, black health has generally stagnated or deteriorated compared to whites since 1980.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. Indications of the effect of these social forces on black-white differentials in health status have begun to surface in the research literature.
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. 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.
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. Racism is a key determinant of socioeconomic status (SES) in the United States, and SES, in turn, is a fundamental cause of racial inequities in health. 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.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. 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."
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.
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.
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. 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.Compared with white women, black women are twice as likely and Hispanic women are nearly three times as likely to be uninsured. However, a survey conducted in 2009, which examined 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.
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. 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, renal failure, bladder cancer, and pneumonia. 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.
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. Recently a study was conducted by the KFF, the Henry J Kaiser Family Foundation, in order to learn more about the infant mortality rate throughout the United States. All fifty states were surveyed. Different distributions of racial categories used in the study includes, "Non-Hispanic White, Non-Hispanic Black, American Indian or Alaska Native, Asian or Pacific Islander, or Hispanic". The infant mortality rate was compiled by the number of infant deaths per one thousand live births. In 2015, on an average nationwide, the United States reported that for Non-Hispanic white had a infant mortality rate of NSD meaning there as not enough sufficient data, Non-Hispanic black's rate was 11.3, Indian or Alaska Native's was 8.3, Pacific Islander was 4.2, and the infant mortality rate on average for Hispanic was 5.0.
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. Diabetes and obesity are more common among Native Americans living on U.S. reservations than among those living outside reservations. The number of Native Americans diagnosed increased by 29% just between the years of 1990 and 1997. The prevalence of this among women and men shows that women more often have diabetes than men, especially in communities of Native American people.
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. 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."
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. 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.
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. 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. Personal experiences of racist behaviors increase stress and blood pressure.Although the relationship racism and health is unclear and findings have been inconsistent, three likely mechanisms for cardiovascular damage have been identified:
- Institutional racism leads to limited opportunities for socioeconomic mobility, differential access to goods and resources, and poor living conditions.
- Personal experiences of racism acts as a stressor and can induce psychophysiological reactions that negatively affect cardiovascular health.
- Negative self-evaluations and accepting negative cultural stereotypes as true (internalized racism) can harm cardiovascular health.
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. 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.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.
Environmental racism
Environmental racism is the intentional or unintentional targeting of minority communities for the siting of polluting industries such as toxic waste disposal, through the race-based differential enforcement of environmental rules and regulations and exclusion of people of color from public and private boards and regulatory bodies, resulting in greater exposure of the community 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.Environmental racism stems from the environmental movement of the 1960s and 1970s, which focused on environmental reform and wildlife preservation and protection, and was led primarily by the middle class. The early environmental movement largely ignored the plight of poor people and people of color who, even in the mid-20th century, were increasingly exposed to environmental hazards.
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. This may have an indirect affect health since young people have fewer places to play and adults have fewer opportunities for exercise.
Although impoverished or underdeveloped communities are at greater risk of contracting illnesses from public areas and disposal sites, they are also less likely to be located near a distinguished hospital or treatment center. Hospitals relocate to wealthier areas where the majority of patients are privately insured, thus reducing the number of low-income patients. Whereas hospitals were previously established in the areas with the greatest need, most are now focused on economic gain from private insurance companies, and are threatened by Medicare funding cuts.
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. 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.
Institutionalized racism
A major downfall of the U.S. healthcare system is the unconscious racial biases held by many white American doctors, often resulting in decreased quality of care for African American patients. One such example is the discrepancy in cardiovascular surgical procedures between white and black patients. Compared to their white counterparts, black patients are less likely to receive necessary coronary bypass surgeries and lipid-lowering medications upon discharge from the hospital. This means that black patients leave treatment centers with a significantly different health outcome.One potential cause of this discrepancy in treatment is the systematic racism present in the medical field that targets the work of African American scientists. Research shows that doctors and scientists of color are significantly underfunded in the medical community, and are less likely than their white colleagues to win research awards from the National Institute of Health (NIH). Since patients of color are often treated by white doctors, miscommunication is common; research shows that many Americans feel their doctors do not listen to their questions or concerns, or are too uncomfortable to ask certain medical questions.
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. 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.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.
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. Moreover, segregation strongly influences premature mortality in the US.
Racism towards doctors and health care professionals
Many healthcare professionals have experienced hate and racist remarks towards them at work. Whether it be at a hospital, a walk-in clinic, or a family doctor's office, people are hit with bias based comments concerning "general bias, ethnicity / national origin, race, age, gender, accent, religion, political views, weight, medical education from outside the US, sexual orientation, and more". This study conducted by WebMD and Medscape features the races of "African American/Black, Asian, Caucasian, and Hispanic" Training for doctors to handle this type of prejudice at their work is very low.Homicide
Homicide plays a significant role in the racial gap in life expectancy. In 2008, homicide accounted for 19% of the gap among black men, though it did not play a significant role in the decline in the gap from 2003 to 2008. 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." Research by Robert J. Sampson indicates that the high degree of residential segregation in African American neighborhoods is responsible for the high homicide rate among African Americans.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%. 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.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. 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.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. Some studies include this as a "race", whereas 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.
