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Racial and Ethnic Disparities in
Healthcare: A Background and History
W. Michael Byrd, M.D., M.P.H.
Linda A. Clayton, M.D., M.P.H.1
Division of Public Health Practice
Harvard School of Public Health
INTRODUCTION
Despite steady improvement in the overall health of the United States’
population, the health of America’s racial and ethnic minorities varies
from the mainstream. For example, the health status of African Ameri-
cans—a racial-ethnic group already burdened with deep and persistent
history-based health disparities—has been recently characterized as stag-
nant or deteriorating (Byrd and Clayton, 2000, 2002; Collins, Hall, and
Neuhaus, 1999; National Center for Health Statistics, 1998a; Sullivan, 2000;
Williams, 1999). A body of nearly 600 scientific publications documenting
racial and ethnic disparities in healthcare provides ample evidence of this
problem (Geiger, 2000; Mayberry, Mili, and Ofili, 2000). Though it is well
known that these disparities reflect socioeconomic differences and inad-
equate access to quality healthcare, contemporary evidence suggests that
in addition to racial, ethnic, class, and gender bias, direct and indirect dis-
crimination are also important factors (Geiger, 2000; Mayberry, Mili, and
Ofili, 2000; U.S. Commission on Civil Rights, 1999a, 1999b; Williams,
1999).
Following the lead of the legislation and committee reports, this Insti-
tute of Medicine (IOM) study is one part of a multifaceted effort by the
United States Congress to understand and eliminate racial and ethnic dis-
parities in healthcare. The IOM report explores, analyzes, and offers cor-
rective action for factors linked to racial and ethnic health and healthcare
1 The authors extend their appreciation to Joe Feagin, Ph.D., Augustus A. White III, M.D.,
Ph.D., and Ricardo Guthrie, M.A., who served as consultants on this paper.
455
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456 UNEQUAL TREATMENT
disparities, including American racial, ethnic, and immigrant relations;
“racism;” “historic racial discrimination” and bias; biased clinical deci-
sion-making; a health system structured on the basis of race, ethnicity, and
class; and access barriers caused by shortages of racial and ethnic minority
providers (Byrd and Clayton, 2000, 2002; Section of House Committee
Report to Accompany H.R. 3064, 2000; Sullivan, 2000).
Differences in population characteristics such as race, ethnicity, class,
culture, and gender are at the root of many of the present health and health
system problems in the United States. From the perspective of racial and
ethnic relations, such differences have generated group identities and self-
awareness, racial mythology, group interaction, stereotyping, competi-
tion, conflict, a corpus of critical theory, accommodation, and in some
instances, assimilation and integration. A number of academic disciplines
and formidable bodies of scientific literature have grown around each of
these subjects and in many instances African Americans serve as surro-
gates for racial and ethnic minority groups in the United States. This is not
only by design, but based on the fact the overwhelming majority of the
research, published literature, and data on racial and ethnic disparities
before 1985 was focused on that group. Moreover, the chronicle of Afri-
can Americans, alongside Native Americans, epitomizes the depth,
breadth, and intensity of the American racial and ethnic minority experi-
ence (Burns and Ades, 1995; Byrd and Clayton, 2000, 2001a, 2002; Feagin
and Feagin, 1999; Outlaw, 1990; Smedley, 1999; Stuart, 1987).
Though viewed by many as recent occurrences, racial- and ethnic-
based health disparities are centuries-old phenomena. They are outcomes
that reflect medical-social values and policies in Western (and later U.S.)
medicine and healthcare, which paralleled the values and policies in the
larger societies. Could it be that these differences, and the biases and dis-
crimination they both generated and reflected, have dictated or even dis-
torted how the U.S. health system functions? If so, what are the character-
istics and profile of this dysfunction? What are the origins, bases, and
evolution of the biases and inequities that contribute to persistent racial
and ethnic health and healthcare disparities? Their persistence represents
a major challenge and an affront to the genius of the American health
system, while serving as the driving force behind this IOM study. As we
acquire the knowledge to begin answering these questions, we can start to
understand the nature of the problems, to perform objective analyses, and,
eventually, to craft fact-based, logical interventions and solutions for the
problems (Byrd and Clayton, 2000, 2001a, 2002; Feagin and Feagin, 1999;
Section of House Committee Report to Accompany H.R. 3064, 2000;
Smedley, 1999; The Healthcare Fairness Act of 1999, 1999; U.S. Department
of Health and Human Services, 1985a).
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RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE
It is clear that health and healthcare in the United States are multi-
racial, multi-ethnic, immigrant stories. A brief examination of racial
and ethnic relations in this country from its colonial past to the present
provides the context for the larger examination of health and health-
care as social processes and problems. And since virtually all modern
health policy decisions are based on the collection of accurate demo-
graphic, health, and health-related data, it is essential to have a better
understanding as to how data regarding America’s various racial and
ethnic groups are collected. An examination of the intricacies of the
process, its standardization, and its evolutionary phases is both a pre-
requisite and a necessity, especially as it has related to health and
healthcare. A factual chronology about data and its collection is pro-
vided in order to appreciate and learn from the past experiences, to
dispel assumptions and mythologies, and as a preparation for future
fact-based policy-making.
America is a nation of immigrants. A discussion built around appreci-
ating the nation’s health experience as an immigrant story, thus, provides
a window on the present racial and ethnic health disparities. Following is
an examination of the major U.S. racial and ethnic groups, both European
and people of color, focusing on their health and the variables that affect
their health. This lends a broader and much needed health policy per-
spective on where we have been and where we need to go.
Recurrent themes resonate throughout the document. For example,
as racial and ethnic minorities become larger percentages of our total
population, the health and healthcare of minority Americans become na-
tional public policy issues of the first rank—in both relative and absolute
terms. Another theme is that healthcare is presently conceptualized as a
human right.
Obtaining a background regarding the roles of race, ethnicity, gender,
culture, and class in U.S. society and healthcare is requisite to deciphering
the message inherent in the racial and ethnic health and healthcare dis-
parities. In order to acquire a deeper understanding of the present racial
and ethnic health and healthcare disparities, one must gain an under-
standing of the origins, evolution, and perpetuation of racial and ethnic
bias, inequities, and disparities in health and healthcare in the United
States and its earlier Western predecessor cultures. Because of the varia-
tion in opinions and usage of certain terms emanating from this wide
range of disciplines, a glossary has been included that contains terms the
IOM Committee thought would be useful to readers (Byrd and Clayton,
2000, 2001a; Feagin and Feagin, 1999; Fee, 1997; Fluss, 1997; Section of
House Committee Report to Accompany H.R. 3064, 2000; The Healthcare
Fairness Act of 1999, 1999).
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458 UNEQUAL TREATMENT
American Racial and Ethnic Relations: The Context
Racial and ethnic diversity is a basic tenet in the evolution of this
society. Neither health nor healthcare is an exception. “The development
of social and economic inequalities based on race and ethnicity has been
a central theme—and a central dilemma—of the history of the United
States [and the Western World], shaped over many generations by the
European conquest of indigenous peoples and by massive waves of both
coerced and uncoerced immigration from all over the world” (Pedraza
and Rumbaut, 1996, xvi). Moreover, racial and ethnic relations have al-
ways been tumultuous in the United States. The use of terms such as
dominant group and subordinate group in the study of American racial and
ethnic relations suggest—and has often been linked to—racial and eth-
nic hierarchy, stratification and substantial inequality among groups.
Disparate outcomes between European Americans and racial and ethnic
minority Americans in many spheres of social life, health, and health-
care—as all are viewed as social processes—are not new and should not
be unexpected (Byrd and Clayton, 2000, 2001a, 2002; Feagin and Feagin,
1999; Jaco, 1979; Kosa and Zola, 1975; Pedraza and Rumbaut, 1996;
Smedley, 1999). Founded more than 200 years ago after a revolution
that cut colonial ties with Europe, the creation of the United States was
based on Enlightenment principles of freedom and equality. A vigorous
nation of great racial and ethnic diversity emerged. However, racial and
ethnic prejudices, biases, oppression, and conflict were embedded in the
colonial antecedents, the founding period, and central documents of the
new republic (Brinkley, 1993; Feagin, 2000; Omi and Winant, 1994). Fur-
ther, as Rumbaut notes, “[I]mmigration and conquest—by hook or by
crook—have been the originating processes by which American ethnic
groups have been formed and through which, over time, the United
States itself has been transformed into arguably the world’s most ethni-
cally diverse society” (Pedraza and Rumbaut, 1996, xvi). The European
(predominantly English) colonists often took land from Native Ameri-
cans (American Indians) by force or collusion. By the late-seventeenth
century, the colonists had established an economy strongly based in
African-American chattel slavery in the South and on the slave trade in
the North. Moreover, throughout succeeding centuries a tradition of
oppressing non-English (e.g., Irish and Italian) and non-European (e.g.,
Chinese, Japanese, and Mexican American) immigrants was also estab-
lished (Brinkley, 1993; Burns and Ades, 1995; Feagin, 2000; Feagin and
Feagin, 1999; Stuart, 1987). At first, liberty and justice were provided
only for males of British descent, and inequality in life chances along
racial, gender and ethnic lines became a fundamental fact of the new
nation’s institutions. As Flexner observed, “Whatever their social station,
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RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE
under English common law, which became increasingly predominant in
the colonies . . . women had many duties, but few rights” (1975, 7). Con-
flict between Anglo-Protestant Americans and Indians varied from out-
right warfare to separate coexistence. Though the promotion of non-
English immigration had coincided with English mercantile and colonial
aims and intensified in the nineteenth century, new white immigrants
(“foreigners”) often met hostility and found themselves less than equal
socially or under law. Women struggled continuously for their rights
(Flexner, 1975). Racial tension and conflict was a constant between
Anglo-Protestant Americans and African Americans under 246 years of
brutal and exploitive chattel slavery, followed by 100 years of social
segregation, physical oppression, political subjugation, and economic
exploitation. As English domination was modified over the next two
centuries by the challenges and occasional ascendancy of other northern
Europeans, southern, and eastern Europeans as well as other non-Euro-
pean groups trying to move up socially, economically, and politically,
the United States became an unprecedented and uneasy mix of diverse
peoples (Brinkley, 1993; Burns and Ades, 1995; Feagin, 2000; Feagin and
Feagin, 1999; Omi and Winant, 1994; Shipler, 1997; Stuart, 1987).
Basic documents of the new republic reflect its patterns of racial sub-
ordination, ethnic discrimination, and gender difference. Neither the
Articles of Confederation, nor the Declaration of Independence, nor the
Naturalization Law of 1790 extended the doctrines of freedom and equal-
ity to African Americans (Brinkley, 1993; Feagin and Feagin, 1999; Omi
and Winant, 1994). One provision of the Naturalization Law of 1790 was
that only “white” persons could become citizens (Takaki, 1993, 273). After
a failed campaign by southern slaveholders to count black slaves for ap-
portioning states’ legislative representation though not for direct taxation
(Brinkley, 1993, 150), enslaved Americans were counted as three-fifths of
a person in the U.S. Constitution. Women were not allowed suffrage until
1920, Native Americans until 1924, and most African Americans until
1965. First-generation Asian Americans could not become U.S. citizens
until 1952 (Brinkley, 1993, 576-577, 816; Feagin and Feagin, 1999, 209, 391;
Office of Research on Women’s Health, 1998, 17). Slavery was not only
legal with blacks designated as chattel, the slave trade was allowed to
continue until 1808, and a fugitive slave provision was incorporated by
the 1850s that required the return of runaways to their owners. Neither
the Declaration of Independence’s famous statement that “all men are cre-
ated equal” nor the Constitution’s Bill of Rights applied to African Ameri-
cans (Higginbotham, 1978, 1996). The Alien, Sedition, and Naturalization
Acts compromised the rights and citizenship status of immigrants as early
as the late 1700s and early 1800s. The Page Act of 1875 restricted the immi-
gration of Chinese women, while the Chinese Exclusion Act of 1882 pro-
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460 UNEQUAL TREATMENT
hibited the group as a whole (Brinkley, 1993; Feagin, 2000; Feagin and
Feagin, 1999; Takaki, 1993).
By adopting the English language and accommodating to English-
oriented institutions, white non-British immigrant groups have gained
substantial power and status in the United States. However, voluntary
and involuntary immigrants from Africa, Asia, and Latin America, as well
as Native Americans have remained subordinate to white Americans in
political, cultural, and in most instances, economic terms. For example,
despite their arrival as agricultural laborers recruited in the 1880s, Japa-
nese Americans could not become naturalized citizens until the passage
of the McCarran-Walter Act of 1952 (Omi and Winant, 1994, 81). Though
racial and ethnic diversity, inequality, and oppression continue to be part
of the foundation of U.S. society, Americans of color continue to challenge
their subordinate status (Feagin and Feagin, 1999; Omi and Winant, 1994).
In many ways, the continuing story of racial, ethnic, class, and gender
biases and conflicts in the United States is evidence of the system’s dyna-
mism—the promises and sorrows of the American dream. America’s
troubled past has profoundly affected its health system. Likewise, the poor
health status and outcomes of African American and other minority popu-
lations are inextricably linked to historical racial and ethnic discrimina-
tion (Byrd and Clayton, 2000, 2001b, 2002; Stuart, 1987; Williams, 1999). If
current demographic trends continue and people of color become the
majority of the U.S. population by the middle of the twenty-first century,
dramatic institutional changes will be necessary—including changes
within the nation’s health system (Brinkley, 1993; Byrd and Clayton, 2000,
2001a, 2002; Collins, Hall, and Neuhaus, 1999; Feagin, 2000; Feagin and
Feagin, 1999).
Racial and Ethnic Data Collection and Definitions
Racial and ethnic minority groups are among the more difficult de-
mographic categories to categorize because there is no simple scheme for
defining these groups or classifying the categories’ subgroups (U.S. De-
partment of Health and Human Services, 1985a). As will be discussed
later, attempts at categorization are further complicated by the complex
histories and chronologic layers of definitions and classifications related
to racial and ethnic concepts in Western culture (Byrd and Clayton, 2000,
2002; Smedley, 1999). Imprecise and changing definitions of race and
ethnicity emanating from the federal government, anthropologists and
other social scientists further complicate the issue of definitive categories
or classifications (American Anthropological Association, 1997;
Thernstrom, Orlov, and Handlin, 1980; Zenner, 1996). Nevertheless, in
order to assess the health status, outcomes, and services utilization of vari-
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RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE
ous racial and ethnic groups in the United States, data must be collected
with some type of category system. Although current data collection sys-
tems are both imprecise and do not adequately collect data for all the
important U.S. racial or ethnic minority groups, the federal government
does attempt to perform this task in a systematic manner (U.S. Office of
Management and Budget, 1997).
The U.S. government provides a standard classification system for
record keeping, collection, and presentation of data on race and ethnicity
in federal program administrative reporting and statistical activities. The
five racial and two ethnic categories are: American Indian or Alaskan
Native, Asian, Native Hawaiian or Pacific Islander, Black, White, Hispanic
or Latino, Not Hispanic or Latino [Box 1-1, Introduction, this volume],
and originate from a 1977 Office of Management report (Haynes and
Smedley, 1999). Depending on the data source, these racial or ethnic clas-
sifications are based on self-classification or on observation by an inter-
viewer or other person filling out the questionnaire (National Center for
Health Statistics, 2000).
Before 1980, the National Vital Statistics System for newborn infants
and fetal deaths tabulated the race of the fetus or newborn according to
the race of both parents. If the parents were of different races and one
parent was White, the child was classified according to the race of the
other parent. When neither parent was White, the child was classified
according to the father’s race, with one exception: if either parent was
Hawaiian, the child was classified as Hawaiian. Since 1989, newborn in-
fants and fetal deaths are tabulated according to the race of the mother
(National Center for Health Statistics, 1998a). In spite of these efforts, most
existing sources of health data, with the exception of those derived from
the census and from the vital registration system (birth and death certifi-
cates), permit examination of only the three largest racial and ethnic cat-
egories: non-Hispanic White persons, non-Hispanic Black persons, and
persons of Hispanic or Mexican origin (National Center for Health Statis-
tics, 2000).
The gathering of racial data by the U.S. Census Bureau is symbolic of
its centrality in the nation’s culture (Omi and Winant, 1994). As the U.S.
health system developed, these data sets profoundly affected health policy
and health services delivery. Race has been such an important character-
istic in this country that census takers have tallied the racial composition
of the population since the first U.S. Census taken in 1790: “[T]he U.S.
Census has always included a question about race. Whites were normally
distinguished from nonwhites” (Thernstrom, Orlov, and Handlin, 1980,
869). However, “[t]he racial categories used in census enumeration have
varied widely from decade to decade” (Omi and Winant, 1994, 3). Until
the 1850 census, African Americans were tabulated as either “Slave” or
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462 UNEQUAL TREATMENT
“Free Colored,” with the latter term sometimes including detribalized
Native Americans. Though the 1850 and 1860 censuses collected data for
free persons in “White,” “Black,” or “Mulatto” categories, the main tables
continued to designate the overall population as “White,” “Slave,” and
“Free Colored.” The 1860 census also counted “Civilized Indians” (who
were required to pay taxes because they did not live on reservations) and
Chinese. In 1870, Japanese were added, and the “Civilized Indian” cat-
egory was divided into “Pure Indians” and “Half-breeds” designations.
The first reliable statistics tabulated for Native Americans “are those for
1890, the year in which the Bureau of the Census and Bureau of Indian
Affairs made a concerted effort to report accurately the Indian population
and the occurrence of vital events” (Stuart, 1987, 96). Census Bureau offi-
cials grouped mulattos with Negroes under “Colored” in 1880, but made
finer distinctions in 1890, counting 6.3 million Negroes, 957,000 mulattos,
105,000 quadroons, and 70,000 octoroons. Finally admitting these divi-
sions were valueless for analytical purposes, they grouped them all to-
gether with the Chinese, Japanese, and Indians under the general heading
“Colored” (Thernstrom, Orlov, and Handlin, 1980).
In 1900, under the growing influence of anthropological notions of
race, census officers were determined to assess the U.S. population in
terms of the then-presumed four great races: Caucasian or White, Negro
or Black, Mongolian or Yellow, and Indian or Red. Chinese and Japanese
were designated subdivisions of Mongolian, and it was finally decided to
use the term Negro and abandon the ambiguous term “Colored.” * By 1910
census officials reverted to “Black” and “Mulatto” but avoided the term
“Colored.” The main divisions were “White,” “Negro,” “Indian,” “Chi-
nese,” “Japanese,” and “All Other” (including subdivisions for Hawai-
ians, part-Hawaiians, and other races). The Indian population was treated
separately in a special census recording both the “civilized” and those
residing on reservations, and provided details on tribes, languages and
geographic areas. This set many precedents for modern censuses. Mexi-
cans were put in the “Other Races” category in 1930 but were later counted
as Whites. Other Asian and Pacific Islander subgroups were tabulated,
but appeared only in general tables. Enumerators in 1960 were instructed
to consider how the person or family identified itself, and in 1970 self-
identification was introduced into racial and ethnic tabulations (Thern-
strom, Orlov, and Handlin, 1980).
Ethnicity is a much more recent concept. As a response to the general
movement toward self-identification and the modern notions of a plural-
* While the 1890 Census had used the term “Colored” to mean all nonwhite persons, in the
West Indies it meant part-European, part-Negro, and in the earlier censuses, in some south-
ern states, and in some other countries it meant anyone with a Negro ancestor.
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RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE
istic democratic society, the ethnic-origin category was introduced in the
Current Population Survey in 1969 and included in the U.S. Census in
1980. However, there are difficulties with this mode of distinguishing
races and ethnic origin, including sampling variation, changes in respon-
dent fashion, and the difficulties of handling racial and ethnic mixtures.
These issues are yet to be resolved (Haynes and Smedley, 1999; National
Center for Health Statistics, 2000; Thernstrom, Orlov, and Handlin, 1980).
The 1997 standards have five racial groups: American Indian or Alaska
Native, Asian, Black or African American, Native Hawaiian or Pacific Is-
lander, and White, all of which continue to offer possibilities for confu-
sion and complexity. Respondents are able to select more than one of the
five groups, which sometimes diminishes sample size, creates ambiguous
results, and increases the likelihood of not meeting the standards for sta-
tistical reliability or confidentiality. All federal data systems are required
to be compliant with this system by 2003 (National Center for Health Sta-
tistics, 2000). Whether or not one is of Hispanic origin reflects another
dimension, because the U.S. Census Bureau reiterates, “Hispanics are clas-
sified as an ethnicity, not as a race. People of Hispanic origin, therefore,
may be of any race” (U.S. Census Bureau, 2001a). Therefore, the Office of
Management and Budget outlines a more complex “combined format”
whose minimum acceptable categories are: American Indian or Alaskan
[sic] Native; Asian or Pacific Islander; Black, not of Hispanic origin; His-
panic; or White, not of Hispanic origin (Haynes and Smedley, 1999).
Distinguishing racial and ethnic groups from one another is useful in medi-
cal, health services, and epidemiologic research, provided that researchers are clear
on the nature and source of human variation (e.g., cultural and behavioral pat-
terns, environmental influences) and their relationship to health outcomes. Race
and ethnicity affect factors as varied as disease rates, health behaviors, concep-
tions of well-being and attitudes toward health maintenance and home treatment,
illness behavior, utilizations patterns, concepts of disease and illness, interac-
tions with mainstream health professionals and organizations, and ethnic inter-
est groups and medical delivery (Harwood, 1981). Using such information
applicable to distinct groups could direct appropriate and efficient bio-
medical and health services research, focus health promotion disease pre-
vention efforts, objectively redirect health services and restructure com-
ponents of the health system, and guide diversity and cultural competence
programs. However, if the “boundaries” of ethnic identity remain unclear,
continue to be perceived as more flexible rather than rigid, become agents
to defocus and fragment the nation’s health policy and political mecha-
nisms, all compounded by increased numbers of mixed ethnicity families
in this country (where individuals claim two or more ethnicities), the chal-
lenge of pluralistic ethnic-oriented data collection, analysis, research, and
program creation remains daunting. As we develop the methodology and
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464 UNEQUAL TREATMENT
science of tracking racial and ethnic health and healthcare outcomes, ur-
gent efforts should be directed toward eliminating racial and ethnic bias
in the caregivers and re-educating both caregivers and patients to elimi-
nate stereotyping, conscious, and unconscious biases. In the interim, there
can be no delay in making recommendations leading to: 1) patient and
provider education to understand the existence and dynamics of racial
and ethnic bias in the healthcare arena; 2) programs at all levels teaching
the dynamics of the stereotyping and the bias-producing processes and
how they affect healthcare; and 3) the development of measures to teach
patients and providers the specific cultural competence, diversity and
cross-cultural skills to maximize the benefits of the doctor-patient rela-
tionship (Haynes and Smedley, 1999; White, Rutledge, and Brown, 2000;
Zenner, 1996).
Immigration, Racial and Ethnic Groups, Health and Healthcare
Racial and ethnic groups are viewed today as by-products of social pro-
cesses such as immigration, group interaction and conflict, group hierar-
chies and dominance, acculturation, and assimilation (Feagin and Feagin,
1999; Pedraza and Rumbaut, 1996). Acknowledgment of the effects of racial
and ethnic problems on health and disease, the health professions, and,
finally, the health system is new and indicative of an ongoing contempo-
rary cultural movement among liberal democratic governments worldwide.
These social dimensions of health and healthcare delivery serve as markers
of a growing awareness, critique, examination, and redirection that is fi-
nally committed to the notion of embracing all of the nation’s diversity
(Byrd and Clayton, 2000, 2001a, 2002; Glazer, 1997; The Healthcare Fairness
Act of 1999, 1999; Section of House Committee Report to Accompany H.R.
3064; Taylor et al., 1994). The World Health Organization has defined health
as “. . . a complete state of physical, mental, and social well-being and not
merely the absence of disease or infirmity” (Sutchfield and Keck, 1997, 3),
and has proclaimed that “health [without qualification] is a human right”
(Fluss, 1997, 377). These declarations, which are evidence of the fact that
health is viewed as a universal human need—a “primary good,” along with
income, education, religious freedom, freedom of conscience, speech, press,
and association, due process, the right to vote, and the right to hold office—
are givens (Taylor et al., 1994, 4). Another corollary of this ongoing reas-
sessment is that American health and healthcare are increasingly being
viewed as immigrant, multicultural, racial, and ethnic minority stories with
biomedical, medical historical, sociocultural and political, public health,
health policy, and medical-social dimensions (Table 1).
This is why a brief overview of North American health and healthcare
from racial, ethnic, and immigration perspectives is germane to this dis-
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RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE
cussion (Byrd and Clayton, 2000, 2001a, 2002; Fluss, 1997; Garrett, 2000;
Malone and Johnson, 1986; U.S. Commission on Civil Rights, 1999a,
1999b).
Native Americans, North America’s original racial/ethnic group, are
the indigenous people of the land now occupied by the United States.
Scholarship concerning their fifteenth through twenty-first century inter-
face with European explorers and invaders, the backdrop for America’s
racial and ethnic immigrant saga, is growing exponentially. It is becom-
ing clear that health factors such as disease transmission, epidemics, and
exposures of non-immune populations to new diseases had as much to do
with early group interaction and eventual European dominance of New
World, pre-Columbian (North, Central, and South American) people as to
political and military activity (Burns and Ades, 1995; Byrd and Clayton,
2000, 2002; Diamond, 1999; Stannard, 1992; Watts, 1997).
We know that the 105 years between Columbus’s landfall in the Car-
ibbean and English colonization in 1607 had profound health effects in
North America. Sixteenth-century Spanish colonies spreading from the
Caribbean, South America, Mesoamerica (central and southern Mexico
and adjacent areas of Central America), Mexico, and St. Augustine,
Florida, bolstered by expeditions deep into North America itself, facili-
tated the spread of Old World diseases that greatly reduced American
Indian populations. The resulting depopulation may have contributed to
the myth of an “empty” American continent ripe for European settlement
(Byrd and Clayton, 2000; Diamond, 1999; Watts, 1997). Not only does the
Native American health experience serve as the opening chapter of the
North American chronicle of racial and ethnic health, American Indian
health and healthcare have been major factors shaping both their demogra-
phy and their contact with Europeans. Prior to 1492, native people in the
New World had few serious diseases compared with people of the Old
World (Diamond, 1999; Pedraza and Rumbaut, 1996; Watts, 1997). Iso-
lated from the Old World’s domesticated animals * and diseases such as
smallpox, influenza, measles, typhus, malaria, leprosy, cholera, bubonic
plague, gonorrhea, and chancroid—even New World exposure to viru-
lent forms of tuberculosis or syphilis is questionable—95 percent of the 8
to 12 million Native Americans inhabiting the North American continent
at that time succumbed to European conquests, politics, and diseases (Dia-
mond, 1999; Pedraza and Rumbaut, 1996; Stannard, 1992; Watts, 1997). By
* Though it is not fully understood, the origins of the germs (bacteria, viruses, etc.) caus-
ing many human diseases can be traced to many animals domesticated in the Old World,
such as pigs, cows, horses, sheep, and goats. SOURCES: Diamond J. Guns, Germs, and Steel:
The Fates of Human Societies. Paperback Edition. New York: W.W. Norton and Company,
Inc., 1999; Pedraza S, Rumbaut RG. Origins and Destinies: Immigration, Race, and Ethnicity in
America. Belmont, California: Wadsworth Publishing Company, 1996.
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GLOSSARY
ACCULTURATION The modification of the culture of a group or an individual,
a process encompassing infancy onward, as a result of contact with
a different culture. This cultural assimilation, which can take two
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to three generations, moves toward the dominant Anglo-Protes-
tant culture.
AMERICAN INDIAN OR ALASKAN [sic] NATIVE * A person having origins in any
of the original peoples of North America, and who maintains
cultural identification through tribal affiliations or community
recognition.
ANGLO-PROTESTANT A more accurate term for those often referred to as
White Anglo-Saxon Protestant Americans.
ANGLO-SAXON a term that originally referred to Germanic tribes, the Angles
and the Saxons, that came to the area now called England in the
fifth and sixth centuries A.D.; it was later applied to the inhabitants
of England and to those English who came to North America.
ARCHAIC MEDICAL SYSTEM Though possessing religion and magic as distinct
features, archaic medical systems were distinguished by empiri-
cism, systemization, practical organization, recording its experi-
ences and cases for future utilization, and incorporating some pub-
lic health measures into its corpus of knowledge and practice.
ASIAN OR PACIFIC ISLANDER A person having origins in any of the original
peoples of the Far East, Southeast Asia, the Indian subcontinent, or
the Pacific Islands. This area includes, for example, China, India,
Japan, Korea, the Philippine Islands, and Samoa.
ASSIMILATION An incoming group’s adoption of the cultural traits and iden-
tity of the host group or integration into the primary networks and
secondary organizations of the host group.
1. A preference or an inclination, especially one that inhibits im-
BIAS
partial judgement; 2. An unfair act or policy stemming from
prejudice.
BLACK A person having origins in any of the black racial groups of Africa.
CLASS A social stratum whose members share certain economic, social, or
cultural characteristics.
CONSTRUCTIONIST Refers to the social formed dimensions of an inquiry.
Such an inquiry includes elements such as the history, social di-
mensions, and culture shaping a subject.
CULTURE The accumulated store of shared values, ideas (attitudes, beliefs,
values, and norms), understandings, symbols, material products,
and practices of a group of people. Culture has both material and
non-material aspects.
DEMOGRAPHY The study of the characteristics of human populations, such
as size, growth, density, distribution, and vital statistics.
* This population is currently referred to as “Alaska Native.”
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Actions carried out by members of dominant groups, or
DISCRIMINATION
their representatives, that have a differential and harmful impact
on members of subordinate racial or ethnic groups.
DOMINANT GROUP A racial or ethnic group with the greatest power and
resources in a society (also called a majority group).
ETHNIC AMERICAN Historically, groups that have been designated with a
hyphenated name: “African Americans,” “Asian-Americans,”
“Native-Americans,” “Hispanic-Americans.” The hyphenation im-
plies that a second person would not recognize these individuals
as Americans unless designated as such.
ETHNIC GROUP A group socially distinguished or set apart, by others or by
itself, primarily on the basis of cultural or national-origin charac-
teristics.
ETHNICITY Ethnicity is a concept referring to a shared culture and way of
life, especially as reflected in language, folkways, religious and
other institutional forms, material culture such as clothing and
food, and cultural products such as music, literature, and art. The
collection of people who share an ethnicity is often called an ethnic
group.
EUROPEAN AMERICAN Denotes individuals usually called “white” which
need no designation (such as ethnic or hyphenated Americans) be-
cause they are recognized and presumed to be Americans.
HEALTH A state of complete physical, mental, and social well-being and
not merely the absence of disease or infirmity. [WHO definition]
HEALTHCARE Those services provided to individuals or communities by
agents of the health services or professions, for the purpose of pro-
moting, maintaining, monitoring, or restoring health. Health care
is broader than, and not limited to medical care, which implies
therapeutic action by or under the supervision of a physician.
HISPANIC A person of Mexican, Puerto Rican, Cuban, Central or South
American or other Spanish culture or origin, regardless of race.
IDENTIFICATIONAL ASSIMILATION A term involving giving up one’s ethnic
identity for that of the dominant Anglo-Protestant culture, or an
incoming group’s development of a sense of identity linked to that
of a host group.
IDEOLOGICAL RACISM An ideology that considers a group’s unchangeable
physical characteristics to be linked in a direct, causal way to psy-
chological or intellectual characteristics and that, on this basis, dis-
tinguishes between superior and inferior racial groups.
INSTITUTIONALIZED RACISM Differential access to the goods, services, and
opportunities of society by race. Institutionalized racism is norma-
tive, sometimes legalized, and often manifests as inherited disad-
vantage. It is structural, having been codified in our institutions of
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custom, practice, and law, so there need not be an identifiable per-
petrator. It is often evident as inaction in the face of need.
INTERNALIZED RACISM Acceptance by members of the stigmatized races of
negative messages about their own abilities and intrinsic worth. It
is characterized by their not believing in others who look like them,
and not believing in themselves. It involves accepting limitations
to one’s own full humanity, including one’s spectrum of dreams,
one’s right to self-determination, and one’s range of allowable self-
determination, and one’s range of allowable self-expression. It
manifests as an embracing of “whiteness” (use of hair straighten-
ers and bleaching creams, stratification by skin tone within com-
munities of color, and “the white man’s ice is colder” syndrome);
self devaluation (racial slurs as nicknames, rejection of ancestral
culture, and fratricide); and resignation, helplessness, and hope-
lessness (dropping out of school, failing to vote, and engaging in
risky health practices).
LIFE SCIENCES An inclusive term designating all branches of science (i.e.,
biology, medicine, anthropology, epidemiology, or sociology) that
deal with living organisms and life processes.
MAINSTREAM A term that is often used to describe the “general market,”
usually refers to a broad population that is primarily White and
middle class.
MEDICINE The science and art dealing with the prevention, cure, or allevia-
tion of disease...the Western Greek model sites of activity are: the
bedside, library, hospital, community, and the laboratory.
MINORITY A group that is singled out because of physical or cultural char-
acteristics whose members become objects of discrimination; it
typically has less power and resources than the dominant group
(also called a subordinate group).
MODEL MINORITY STEREOTYPE The non-Asian stereotype that views certain
Asian American groups as uniquely exemplary in socioeconomic
and moral characteristics compared to other people of color.
PERSONALLY MEDIATED RACISM Prejudice and discrimination, where preju-
dice means differential assumptions about abilities, motives, and
intentions of others according to their race, and discrimination
means differential actions toward others according to their race.
PREJUDICE An antipathy, felt or expressed, based upon a faulty generaliza-
tion and directed toward a group as a whole or toward individual
members of a group.
1. As many physical anthropologists abandon racial taxonomies alto-
RACE
gether, race can be more objectively considered a sociocultural con-
cept wherein groups of people sharing certain physical characteristics
are treated differently based on stereotypical thinking, discriminatory
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institutions and social structures, a shared worldview, and social
myths; 2. A term developed in the 1700s by European analysts to refer
to what is also called a racial group (see racial group).
RACIAL GROUP A social group that persons inside or outside the group have
decided is important to single out as inferior or superior, typically
on the basis of real or alleged physical characteristics subjectively
selected.
REDUCTIONISM The belief, very prevalently used in science, that the whole
of reality consists of a minimal number of entities or substances.
The major methodological reductive triumph of recent years is the
demonstration that the classical unit of heredity, the gene, is a mac-
romolecule—deoxyribonucleic acid, or DNA.
SCIENTIFIC RACISM The creation and employment of a body of legitimately
scientific, or patently pseudoscientific, data as rationales for the
preservation of poverty, inequality of opportunity for upward
mobility, and related regressive social arrangement. Usually creat-
ing a myth of two distinct races of mankind—one consisting of a
small, healthy, wealthy, educable elite, while the second race is a
far larger population of poor or nonwealthy, vulnerable, and alleg-
edly uneducable by virtue of hereditarily inferior brains—scien-
tific racism has often also instituutionalized and lent scientific re-
spectability to racist dogma and practices that were all far, far older
than science itself.
SLAVE HEALTH DEFICIT The dramatic and deliterious Black/White differen-
tials in health status and outcome presumed to be the consequence
of slavery and subordinate racial status.
SLAVE HEALTH SUBSYSTEM The inconstant, inferior, alternate health system
made up of traditional healers, root doctors, granny midwives and
nurses, overseers, and planters’ wives, sometimes backed up by
formally trained physicians, provided African Americans during
slavery. Some plantation infirmaries and hospitals and slave dis-
pensaries and hospitals served as institutional sites.
STEREOTYPE A rigid, oversimplified, often exaggerated belief or image that
is applied to both an entire category of people of a racial or ethnic
outgroup and to each individual within it, usually negative, that is
false or that greatly distorts the real characteristics of the outgroup.
SUBCULTURE A subculture pertains only to those standards that are operative
when a person is acting in a particular social capacity or group. For
example, occupations and ethnic groups develop their own subcul-
tures—standards for what exists, what goals are to be valued, how
one should behave—which are relevant when one is acting either on
the job or as a member of the ethnic group but which are largely
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irrelevant outside those contexts. The medical profession and health
system are excellent examples of subcultures (see culture).
SUBORDINATE GROUP A group that is singled out because of physical or cul-
tural characteristics for differential and unequal treatment and
whose members become objects of discrimination; it typically has
less power and fewer resources than the dominant group.
WHITE A person having origins in any of the original peoples of Europe,
North Africa, or the Middle East.
WORLDVIEW A culturally structured, systematic way of looking at, perceiv-
ing, and interpreting various world realities. The Western racial
worldview holds that racial groups are by nature unequal and can
be ranked along a gradient of superiority—inferiority.
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