Blacks live to the suburbs (Wilson, 1987; Kasarda, 1993); consciously or subconsciously, beliefs about racial groups and explicit racial discrimination may reinforce and accentuate these larger patterns (Hajnal, 1995). If one believes that a potential workforce is likely to be disproportionately unintelligent and lazy, it is a fairly rational decision to take initiatives to avoid such undesirable workers.

In addition to its effects on individual health and economic well-being, segregation can also create pathogenic neighborhood and community conditions. Residential segregation creates communities characterized by unequal access to municipal services and medical care, lower levels of social participation, higher levels of undesirable land uses, higher rates of crime, and poor housing quality (Alba and Logan, 1993; Roberts, 1997; Shihadeh and Flynn, 1996; LeClere et al., 1997; Greenberg and Schneider, 1994). Studies have found a correlative association between residential segregation and mortality for Blacks, independent of measures of SES (Polednak, 1997; LaVeist, 1989). One recent study found that cities high on two indices of segregation have higher levels of mortality for both Blacks and Whites compared to cities with lower indices of segregation (Collins and Williams, 1999). Thus, beyond some threshold of poor living conditions, residential segregation appears to be costly for Whites as well as for Blacks.

Institutional discrimination can also affect health by determining exposure to environmental pollution, toxins, and pathogens in both residential and occupational contexts. Even after adjusting for job experience and training, Blacks are more likely than Whites to be exposed to occupational hazards and carcinogens at work (Robinson, 1984). Research on the location of hazardous waste sites indicates they are more likely to be located in poor, minority urban and rural communities than in other residential areas (United Church of Christ Commission for Racial Justice, 1987). Exposure to lead poisoning and other toxic materials is also disproportionately high for racial minorities.

Institutional discrimination affects access to desirable goods and services in society, and health care is no exception. Given the link between employment and health insurance, the high levels of unemployment, instability of employment, and the overrepresentation of racial minorities in jobs that do not provide adequate benefits, Blacks and Hispanics have lower levels of health insurance coverage than Whites. National data reveal that Blacks and Hispanics are disadvantaged compared to Whites on indicators of both access to ambulatory medical care and the quality of care received (Blendon et al., 1989; Council on Ethical and Judicial Affairs,