UNNATURAL CAUSES is inequality making us sick? HEALTH EQUITY research topics and resources to learn more
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Race / Racism

Background: More than 100 studies now link racism to worse health. Many people of color experience a wide range of serious health issues at higher rates than do whites, including breast cancer, heart disease, stroke, diabetes, hypertension, respiratory illness and pain-related problems. On average, African Americans, Native Americans, Pacific Islanders and some Asian American groups live shorter lives and have poorer health outcomes than whites. But why?

According to the Centers for Disease Control, African American men die on average 5.1 years sooner than white men (69.6 vs. 75.7 years), while African American women die 4.3 years sooner than white women (76.5 vs. 80.8 years). Vietnamese American and Korean American women suffer some of the highest rates of cervical cancer in the nation; Vietnamese American men die from liver cancer at a rate seven times that of non-Hispanic white men.

Class certainly plays a role. Because of historical discrimination and structural racism, people of color are likely to be less wealthy, to have less education and to live in segregated communities with underfunded schools, insufficient services, poor transportation and housing, and higher levels of exposure to toxic and environmental hazards. A wide body of evidence has shown that wealth predicts health: the higher you are on the class pyramid, the better your health. Every step down corresponds to slightly worse health, from top to bottom. Inequitable distribution of resources helps explain why.

Yet socioeconomic status doesn't account for the whole picture. In many instances, African Americans and other groups fare worse than whites at the same income levels. In fact, infant mortality rates among babies born to college-educated African American women are higher than those of white Americans who haven't finished high school. Recent Latino immigrants, though typically poorer, are healthier than the average American; yet the longer they're here, the more their relative health status declines even as their socioeconomic situation improves. Racism has proven to be a factor affecting health "upstream" and independent of class.

Could there be a genetic reason? Researchers funded by the National Institutes of Health, for example, have spent 40 years and several millions of dollars studying Native Americans in southern Arizona, trying to discover a biological reason for their high rates of Type 2 diabetes. Yet their findings remain inconclusive. Hypotheses like the "salt retention gene" explanation for high rates of hypertension among African Americans have also long been debunked scientifically, although they continue to hold currency in the popular press and public imagination.

In fact, studies comparing birth outcomes among white and Black American women showed that more low birth-weight babies are born to African Americans, but birth outcomes among white Americans and African-born immigrants to America were comparable. Moreover, the daughters of the African immigrants gave birth to low birth-weight babies at the same rate as African Americans.

One risk factor researchers are investigating is how the lived experience of racism can increase chronic stress levels and thus worse health among people of color. According to their thinking, addressing unequal birth outcomes, for example, requires more than just better prenatal care; it also requires that we change the social conditions that produce negative experiences over a lifetime. African Americans have among the worst hypertension rates not because of their genes but because of difficulties they face in their lives.

As sociologist Troy Duster explains, the impact of race on disease is not biological in origin but in effect. Anxiety, anger, or frustration from racist experiences trigger the body's stress response, which over time, creates wear and tear on the body's organs and systems. Dr. Camara Jones, a leading expert on racism and health at the Centers for Disease Control, puts it this way: "It's like gunning the engine of a car, without ever letting up. Just wearing it out, wearing it out without rest. And I think that the stresses of everyday racism are doing that." Dr. Jones and others are studying three kinds of racism - institutional, interpersonal and internalized - and how each contributes to health.

Whether it takes the form of overt discrimination or structural disadvantage, racism continues to influence how people are treated, what resources and jobs are available, where we are likely to live, how we perceive the world and our place in it, what environmental exposures we face, and what chances we have to reach our full potential. Important policies to address racism and its impact on health include more equitable school funding, better enforcement of anti-discrimination laws, housing mobility programs, better transportation, affirmative action, tax policy and land use, as well as economic revitalization, business investment and wealth accumulation in communities of color.

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Image Thumbnail Cultural Loss - Impact on Native American Health E-mail to a friend

Dr. Donald Warne talks about how cultural loss impacts the health of Native American tribes in Arizona. The damming of rivers plunged local tribes into poverty, dependence and ultimately poor health. Deprived of their language, land, livelihood and traditions, many Native Americans have developed a fatalistic view about  diseases like diabetes.

Image Thumbnail Data Set Directory of Social Determinants of Health at the Local Level (pdf) E-mail to a friend
DATA SETS  REFERENCE, Social Determinants of Health Work Group at the Centers for Disease Control and Prevention

The directory contains an extensive list of existing data sets that can be used to address the need for improved conceptualization and availability of data on how the social environment impacts the health of populations. The data sets are organized according to 12 dimensions, or broad categories, of the social environment. Each dimension is subdivided into various components.

This directory grew out of a project based at the University of Michigan School of Public Health and funded by the Centers for Disease Control and Prevention (CDC).

Image Thumbnail David Williams Interview (pdf) E-mail to a friend

In this original interview, David Williams, Harvard professor and executive director of the Robert Wood Johnson Foundation Commission to Build a Healthier America, discusses how race and class relate, how poor circumstances cluster geographically, and why political power is good for your health.

Image Thumbnail Diabetes and Health Disparities: Community-Based Approaches for Racial and Ethnic Populations E-mail to a friend
Leandris C. Liburd, PHD

Type 2 diabetes and its principal risk factor, obesity, have emerged as twin epidemics in communities of color. This book investigates the epidemiology of diabetes in these minority communities, arguing that the determinants of diabetes include not only personal choices, but also broader social and contextual factors, such as community racism, residential segregation, and cultural patterns.

This book includes in-depth analyses of many community-based interventions which serve African-American, Hispanic/Latino American, Asian American, and Native American populations. The author also provides suggestions for community-based initiatives to reduce the "obesogenic" environment many minorities live in.

Image Thumbnail Diabetes Industry and Native American Health E-mail to a friend

Competing agendas drive the distribution of resources when it comes to diabetes care and prevention. We spend most of our dollars on late-stage care, which not coincidentally is highly profitable to companies that provide those services. To reduce diabetes rates among Native Americans and other populations, we have to advocate for policies that will invest more resources in primary prevention and underlying social conditions.

Image Thumbnail Differences in the self-reported racism experiences of US-born and foreign-born Black pregnant women E-mail to a friend

Differential exposure to minority status stressors may help explain differences in United States (US)-born and foreign-born Black women's birth outcomes.  Self-reported prevalence of personal racism and group racism was significantly higher among US-born than foreign-born Black pregnant women, with US-born women having 4.1 and 7.8 times the odds, respectively, of childhood exposure. Differential exposure to self-reported racism over the life course may be a critically important factor that distinguishes US-born Black women from their foreign-born counterparts.

Image Thumbnail Differing Birth Weight among Infants of U.S.-Born Blacks, African-Born Blacks, and U.S.-Born Whites E-mail to a friend
SCHOLARLY ARTICLE by Richard J. David and James W. Collins, New England Journal of Medicine, 1997

The David and Collins article, cited in When the Bough Breaks, that finds that African-born Black women living in the U.S. had similar delivery outcomes to white American women, while U.S.-born Black women gave birth to babies of significantly lower average birth weight. This relationship still existed when other socioeconomic factors were controlled for.

Image Thumbnail Differing Intergenerational Birth Weights among the Descendants of US-born and Foreign-born Whites and African Americans in Illinois E-mail to a friend
James W. Collins, Jr., Shou-Yien Wu, and Richard J. David in the American Journal of Epidemiology

The authors analyzed Illinois vital records to determine the intergenerational birth weight patterns among the descendants of US-born and foreign-born White and African-American women. Among the descendants of generation 1 European-born White women,  generation 3 females had a birth weight 45 g more than that of their generation 2 mothers . Among the descendants of generation 1 US-born African-American women, generation 3 females had a birth weight 17 g more than that of their generation 2 mothers. Among the descendants of generation 1 African/Caribbean-born women, generation 3 females had a birth weight 57 g less than that of their generation 2 mothers; generation 3 females had a 40% greater moderately low birth weight rate than did their generation 2 mothers: 9.6% percent versus 6.7% percent. Maternal age and marital status did not account for the birth weight trends. The authors conclude that the expected intergenerational rise in birth weight does not occur among the direct female descendants of foreign-born African-American women.

Image Thumbnail Disparities In Infant Mortality Not Related To Race, Study Finds E-mail to a friend
Science Daily

The cause of low birth weights among African-American women has more to do with racism than with race, according to a report by an associate professor of pediatrics at the University of Illinois at Chicago.  Minority women are subject to stress caused by perceived racial discrimination, the researchers said.  They asked the mothers if they had ever been treated unfairly because of their race when looking for a job, in an educational setting or in other situations.  Those who felt discriminated against had a twofold increase in low birth weights. And for those who experienced discrimination in three "domains," the increase was nearly threefold.

Image Thumbnail Disparities in infant mortality: What's genetics got to do with it? E-mail to a friend
SCHOLARLY ARTICLE by Richard David and James Collins, American Journal of Public Health, 2007

Since 1950, dramatic advances in human genetics have occurred, racial disparities in infant mortality have widened, and the United States' international ranking in infant mortality has deteriorated. The quest for a "preterm birth gene" to explain racial differences is now under way. Scores of papers linking polymorphisms to preterm birth have appeared in the past few years. Is this strategy likely to reduce racial disparities? A review of broad epidemiological patterns contradicts the genetic theory of race and points toward social mechanisms.
A subscription is required to access the full article online.

Image Thumbnail DiversityData E-mail to a friend
DATABASE of the Harvard School of Public Health and The Center for the Advancement of Health

DiversityData is an interactive website on socioeconomic indicators in U.S. metropolitan areas.

Image Thumbnail Does Racism Make Us Sick? E-mail to a friend
WEBCAST, Minority Health Conference Panel, June 2007

* Karina L. Walters, M.S.W., Ph.D., Director, Indigenous Wellness Research Institute, and Professor, University of Washington School of Social Work
* Gilbert C. Gee, Ph.D., Department of Health Behavior and Health Education, University of Michigan School of Public Health
* Borrell N. Borrell, D.D.S., Ph.D., Assistant Professor, Department of Epidemiology, Columbia University Mailman School of Public Health and College of Dentistry, and Site Director, Kellogg Scholars for Health Disparities
* David R. Williams, Ph.D., M.P.H., Professor of Public Health, African and African American Studies, and Sociology, Harvard University

Transcript available from Kaiser Network (pdf)

Image Thumbnail Embodying Inequality: Epidemiologic Perspectives E-mail to a friend
BOOK edited by Nancy Krieger

To advance the epidemiological analysis of social inequalities in health, and of the ways in which population distributions of disease, disability, and death reflect embodied expressions of social inequality, this volume draws on articles published in the International Journal of Health Services between 1990 and 2000. Framed by ecosocial theory, it employs constructs of "embodiment"; "pathways of embodiment"; "cumulative interplay of exposure, susceptibility, and resistance across the lifecourse"; and "accountability and agency" to address the question: who and what drives current and changing patterns of social inequalities in health? The book is aimed at health professionals, policymakers, and advocates concerned with social disparities in health, including class inequalities (including occupational health), racial/ethnic inequalities, gender inequalities and women's health, and disparities involving sexuality (including lesbian, gay, bisexual, and transgender health) and disability.

Image Thumbnail Environmental Justice Resource Center E-mail to a friend

The Environmental Justice Resource Center (EJRC) at Clark Atlanta University was formed in 1994 to serve as a research, policy, and information clearinghouse on issues related to environmental justice, race and the environment, civil rights and human rights, facility siting, land use planning, brownfields, transportation equity, suburban sprawl and smart growth, energy, global climate change, and climate justice. The overall goal of the center is to assist, support, train, and educate people of color, students, professionals, and grassroots community leaders with the goal of facilitating their inclusion into mainstream decision-making.

Image Thumbnail Equal Justice Society E-mail to a friend

The Equal Justice Society is a national advocacy organization strategically advancing social and racial justice through law and public policy, communications and the arts, and alliance building.

Image Thumbnail Falling Behind: Life Expectancy in US Counties from 2000 to 2007 in an International Context E-mail to a friend
SCHOLARLY ARTICLE , Population Health Metrics 2011 9:16

This study uses mortality data from 2000 to 2007 to assess disparities in life expectancy across US counties. Life expectancy rates for counties are compared to the life expectancies across nations in 2000 and 2007.

Image Thumbnail Federal Indian Policies and Health E-mail to a friend

Historically, federal Indian policies have been destructive to Native American communities - ranging from removal to assimilation and termination. These policies have had a negative impact on health and health-related behaviors. More recent trends towards self-determination and tribal control provide reason to hope.

Image Thumbnail Foreclosed: State of the Dream 2008 E-mail to a friend
REPORT, United for a Fair Economy, January 2008

In this year's report for Martin Luther King, Jr. Day, United for a Fair Economy found that the subprime lending crisis is causing the greatest loss of wealth to people of color in modern US history. They also estimate the difference in losses due to racial bias. The report details how and why the damage occurred, and offers solutions for what can be done.

Image Thumbnail Forum #1: Healthy Communities (pdf) E-mail to a friend

Dolores Acevedo-Garcia, Meizhu Lui, Makani Themba-Nixon, and Jack Shonkoff answer questions from Web site visitors about neighborhoods, community organizations, labor, family, and early childhood.

Image Thumbnail Forum #2: Genetics, Race, and Disease (pdf) E-mail to a friend

Troy Duster, Jay Kaufman and Pilar Ossorio answer questions from Web site visitors on how biology and genetics impact health and our ideas about race.

Image Thumbnail Forum #3: Myths About Health Inequities (pdf) E-mail to a friend

William Dow, Tony Iton, Dennis Raphael, and David Williams answers questions from Web site visitors on diet, universal health care, the economic costs of poor health, the "healthy immigrant effect," and the difference between health disparities and health inequities.

Image Thumbnail Forum #4: Divided We Fall (pdf) E-mail to a friend

Camara Jones, Nancy Krieger, and Donald Warne speak to racism, hope, diabetes, infant mortality and industry-driven health care.

Image Thumbnail Freedom on My Mind E-mail to a friend
DOCUMENTARY distributed by California Newsreel, 1994

Nominated for an Academy Award, winner of both the American Historical Association and the Organization of American Historians awards for best documentary, this landmark film tells the story of the Mississippi freedom movement in the early 1960s when a handful of young activists changed history.

This film is part of the Structural Racism sub-category of California Newsreel's African American Perspectives Collection.

Image Thumbnail From Disparity to Difference: How Race-Specific Medicines May Undermine Policies to Address Inequalities in Health Care E-mail to a friend
SCHOLARLY ARTICLE by Jonathan Kahn, Southern California Interdisciplinary Law Journal, 2005

On June 23, 2005, the U.S. Food and Drug Administration (FDA) formally approved the heart failure drug BiDil to treat heart failure in self-identified black patients. The drug itself is not actually new; it is merely a combination of two generic drugs that have been used to treat heart failure for over a decade. BiDil's newness derives primarily from its public presentation as the world's first ethnic drug.

This analysis begins with a consideration of the race-specific clinical trials that preceded the FDA approval and then moves on to elaborate upon some of the broader implications of BiDil in the context of genomic medicine and the politics of heath care. It briefly relates the story of how law and commerce played a central role in the emergence of BiDil as an ethnic drug. Then it explores the strategic reification of race as genetic in the context of BiDil and connects the drug to larger issues concerning genetics and the politics of difference in health care and perhaps beyond.

Image Thumbnail Getting Under the Skin: Using Knowledge about Health Inequities to Spur Action E-mail to a friend
RESEARCH-IN-ACTION BRIEF, Charles Hamilton Houston Institute for Race and Justice, Harvard Law School, 2009

"This brief has two purposes. The first is to translate knowledge from the so-called “social determinants of health” arena into a useable form. The second purpose is to explore how to best use this knowledge to lobby for, and create policy and programming changes on the ground in, communities of concentrated disadvantage."

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