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America Becoming: Racial Trends and Their Consequences: Volume II (2001)

Chapter: 14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects

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Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

14
Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects

David R.Williams

In compliance with Article One of the U.S. Constitution, the first U.S. census, conducted in 1790, enumerated Whites, Blacks (as three-fifths of a person), and only those Indians who paid taxes. Over time racial categories have been added and altered to track new immigrants. Guidelines laid out by the federal government’s Office of Management and Budget (OMB) for categorizing race and ethnicity currently stipulate five racial categories—White, Black, American Indian or Alaska Native, Asian, Native Hawaiian, or other Pacific Islander—and one ethnic category— Hispanic (Tabulation Working Group, 1999). These categories do not capture race in any biological sense; they are socially constructed (American Association of Physical Anthropology, 1996; Williams, 1997) and reflect, in fact, ethnicity: common geographic origins, ancestry, family patterns, language, values, cultural norms, and traditions. “Race,” however, as it is popularly understood, does predict variations in health status in the United States.

This paper provides a brief overview of racial differences in health trends in the United States based on selected health-status indicators. The emphasis is on trends in specific causes of death because of the availability of national data for the major racial groups. Discussed are the limitations of the available data and priorities for research; outlined are possible future trends based on current racial data. Given the arbitrary nature of racial categorization, in the interest of economy of presentation, I will use the term “race” to refer to all six OMB categories.

In many of the tables provided in this chapter, the basis for comparison will be Whites. It should be noted, however, that U.S. Whites do not

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

have optimal or ideal levels of health either. International comparisons of infant mortality and life expectancy rates show that the White population of the United States lags behind populations of most major industrialized countries on these health-status indicators—e.g., in 1994, life expectancy for White females in the United States ranked behind that of women in 15 other countries (National Center for Health Statistics, 1998). Nevertheless, because we live in a racially stratified, color-conscious society, where being White can confer significant privileges that non-Whites do not have, Whites can serve as an appropriate, if imperfect, group for comparison with more socially disadvantaged groups.

RACIAL DIFFERENCES IN HEALTH STATUS

This section considers differences in age-adjusted death rates from major chronic diseases, infectious diseases, and external causes (murder and suicide) for the various racial groups. For Blacks and Whites, data are available from approximately 1950 to the present, 1980 for American Indians or Alaska Natives and a combined Asian and other Pacific Islander category, and 1985 for Hispanics. Despite the usefulness of mortality data, it must be remembered that they do not provide the same information as data for disease incidence (the number of new cases in a given period) and prevalence (the total number of cases at a given time). Moreover, death certificates are not uniformly accurate in recording either the cause of death or the race of the deceased.

Major Chronic Diseases

Heart Disease

Heart disease is the leading cause of death in the United States. In 1996, it claimed the lives of 733,361 U.S. citizens. Table 14–1A presents age-adjusted death rates1 by race for heart disease between 1950 and 1995. Other than Blacks, all racial groups had death rates lower than those of Whites; Asians and other Pacific Islanders had the lowest rates. Since 1950, there has been a consistent pattern of declining rates from coronary heart disease for both Blacks and Whites. A similar pattern is

1  

Age-adjusted rate: weighted average for age-specific rates, where the weights represent the fixed population proportionate by age. For example, comparing the 1980 death rates for Whites and Blacks, the age-adjusted formula would account for the fact that a certain percentage of Whites were 75 years of age or older, where significantly fewer Blacks were in that age group.

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

TABLE 14–1 Trends in Heart Disease Mortality, 1950–1995

 

1950

1960

1970

1980

1985

1990

1995

A. Age-Adjusted Death Rates per 100,000 Population

White

300.5

281.5

249.1

197.6

176.6

146.9

133.1

Black

379.6

334.5

307.6

255.7

240.6

213.5

198.8

American Indian

131.2

119.6

107.1

104.5

Asian or PI

93.9

88.6

78.5

78.9

Hispanic

116.0

102.8

92.1

B. Minority/White Ratios

B/W

1.26

1.19

1.23

1.29

1.36

1.45

1.49

Am. Indian/W

0.66

0.68

0.73

0.79

Asian or PI/W

_

_

_

0.48

0.50

0.53

0.59

Hispanic/W

0.66

0.70

0.69

 

SOURCE: NCHS (1998).

evident in available data for the other racial groups. With the exception of Asians and other Pacific Islanders between 1990 and 1995, heart disease mortality declined for all racial groups.

Table 14–1B shows the minority/White ratios for heart disease. In 1950, Blacks were 1.3 times more likely than Whites to die of heart disease compared to 1.5 times more likely in 1995. Thus, although rates declined for both groups, Whites experienced a more rapid decline than Blacks, so that the gap between the two groups widened. In fact, the reduction in heart disease rates for Whites has been relatively larger than that for all other racial groups. Although these groups still have markedly lower rates of heart disease than Whites, the gap was narrower in 1995 than in the first year for which data were available.

Cancer

Cancer is the second leading cause of death in the United States. In 1996, 539,533 people died from cancer. Table 14–2A presents trends in age-adjusted cancer death rates. Similar to the pattern observed for heart disease, Blacks had the highest death rates from all cancers in 1995. All the other racial groups had cancer death rates that were about 35 percent lower than Whites. Unlike the pattern for heart disease, however, for which there was a general trend of declining rates for all groups, data in Table 14–2A show that through 1990, cancer death rates had been rising for all racial groups. There was a slight downturn between 1990 and 1995 for the White, Black, and Hispanic populations, while there was a consistent upward trend for the Native American or Alaska Native and Asian

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

TABLE 14–2 Trends in Cancer Mortality, 1950–1995

 

1950

1960

1970

1980

1985

1990

1995

A. Age-Adjusted Death Rates per 100,000 Population

White

124.7

124.2

127.8

129.6

131.2

131.5

127.0

Black

129.1

142.3

156.7

172.1

176.6

182.0

171.6

American Indian

70.6

72.0

75.0

80.8

Asian or PI

77.2

80.2

79.8

81.1

Hispanic

75.8

82.4

79.7

B. Minority/White Ratios

B/W

1.04

1.15

1.23

1.33

1.35

1.38

1.35

Am. Indian/W

0.54

0.55

0.57

0.64

Asian or PI/W

0.60

0.61

0.61

0.64

Hispanic/W

0.58

0.63

0.63

 

SOURCE: NCHS (1998).

or Pacific Islander populations. Table 14–2B data show that, although Black-White differences in cancer were negligible in 1950, they became more marked over time. That is, the cancer death rate for Whites increased only slightly, while the rate for Blacks increased greatly. Although the changes are less marked, available data for the other racial groups show a similar pattern of more rapid increases in cancer deaths than the White population, with a correspondingly narrower differential in 1995 than in the earliest available data.

Diabetes

Diabetes mellitus describes a group of diseases characterized by high blood-sugar levels resulting from defects in insulin secretion, insulin action, or both. In 1996, diabetes was the seventh leading cause of death in the United States, claiming 61,767 lives. Table 14–3A shows that in 1995 Blacks, Native Americans or Alaska Natives, and Hispanics had higher death rates than Whites, and the rate for Asians or Pacific Islanders was slightly lower than that of Whites. Mortality rates for Whites were fairly stable over time, declined in the 1980s, then increased in the 1990s. Rates for the Black population rose between 1950 and 1970, and, after a slight decline in the 1980s, began to rise in the 1990s, going from 17.2 per 100,000 in 1950 to 28.5 per 100,000 in 1995. Rates for Native Americans or Alaska Natives, Asians or Pacific Islanders, and Hispanics also show a pattern of rising rates in recent years. Increases for the Black, Native American or Alaska Native, and Hispanic populations were somewhat higher than

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

TABLE 14–3 Trends in Diabetes Mortality, 1950–1995

 

1950

1960

1970

1980

1985

1990

1995

A. Age-Adjusted Death Rates per 100,000 Population

White

13.9

12.8

12.9

9.1

8.6

10.4

11.7

Black

17.2

22.0

26.5

20.3

20.1

24.8

28.5

American Indian

20.0

18.7

20.8

27.3

Asian or PI

6.9

6.1

7.4

9.2

Hispanic

12.8

15.7

19.3

B. Minority/White Ratios

B/W

1.24

1.72

2.05

2.23

2.34

2.38

2.44

Am. Indian/W

2.20

2.17

2.00

2.33

Asian or PI/W

0.76

0.71

0.71

0.79

Hispanic/W

1.49

1.51

1.65

 

SOURCE: NCHS (1998).

increases for the White population, leading to a larger overall minority/ White ratio in 1995. Table 14–3B shows that the Black/White ratio in 1995 was 2.44:1 compared to 1.24:1 in 1950, the Native American or Alaska Native/White ratio was 2.33:1 in 1995 compared to 2.20:1 in 1980, and the Hispanic/White ratio was 1.65:1 in 1995 compared to 1.49:1 in 1985.

Liver Disease/Cirrhosis

Chronic liver disease, or cirrhosis (a term used to describe a number of different liver disorders), was the tenth leading cause of death in the United States in 1996, accounting for some 25,047 deaths. In 1950, the death rate from cirrhosis was higher for Whites than for Blacks. By 1995, the rate was slightly lower for Whites, but rates for this group had changed little during this period. Table 14–4A shows that in 1995, Blacks, Native Americans or Alaska Natives, and Hispanics all had higher age-adjusted death rates than Whites. Asians or Pacific Islanders had rates that were markedly lower than all other groups, whereas Native Americans or Alaska Natives had rates that were markedly higher. Their rates declined between 1980 and 1990, but an upward trend was evident from 1990 to 1995. Asian or Pacific Islander and Hispanic populations show a small but consistent decline in cirrhosis rates over time. In 1995 the Native American or Alaska Native and the Hispanic rates were slightly lower than at the earliest noted time points for each, and the advantage of Asian or Pacific Islanders over Whites slightly increased. The rate for Blacks increased remarkably from 1960 to 1970, but began to decrease thereafter; in 1995, it was slightly higher than in 1950.

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

TABLE 14–4 Trends in Cirrhosis Mortality, 1950–1995

 

1950

1960

1970

1980

1985

1990

1995

A. Age-Adjusted Death Rates per 100,000 Population

White

8.6

10.3

13.4

11.0

8.9

8.0

7.4

Black

7.2

11.7

24.8

21.6

16.3

13.7

9.9

American Indiar

38.6

23.6

19.8

24.3

Asian or PI

4.5

4.2

3.7

2.7

Hispanic

16.3

14.2

12.9

B. Minority/White Ratios

B/W

0.84

1.14

1.85

1.96

1.83

1.71

1.34

Am. Indian/W

3.51

2.65

2.48

3.28

Asian or PI/W

0.41

0.47

0.46

0.36

Hispanic/W

1.83

1.78

1.74

 

SOURCE: NCHS (1998).

Infectious Diseases

Pneumonia/Influenza

Pneumonia/influenza was the sixth leading cause of death in the United States in 1996, accounting for 83,727 lives. Table 14–5 shows that Blacks and Native Americans or Alaska Natives had higher pneumonia/ influenza death rates in 1995 than Whites, while Asian or Pacific Islander and Hispanic groups had lower rates. Between 1950 and 1980, there were

TABLE 14–5 Trends in Flu and Pneumonia Mortality, 1950–1995

 

1950

1960

1970

1980

1985

1990

1995

A. Age-Adjusted Death Rates per 100,000 Population

White

22.9

24.6

19.8

12.2

12.9

13.4

12.4

Black

57.0

56.4

40.4

19.2

18.8

19.8

17.8

American Indian

19.4

14.9

15.2

14.2

Asian or PI

9.1

9.1

10.4

10.8

Hispanic

12.0

11.5

9.9

B. Minority/White Ratios

B/W

2.49

2.29

2.04

1.57

1.46

1.48

1.44

Am. Indian/W

1.59

1.16

1.13

1.15

Asian or PI/W

0.75

0.71

0.78

0.87

Hispanic/W

0.93

0.86

0.80

 

SOURCE: NCHS (1998).

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

marked declines in rates for both Blacks and Whites, but fluctuations occurred after 1980 for both groups. In 1995, the rate for Whites was slightly higher than it was in 1980, but the rate for Blacks was slightly lower. The overall pattern of Black-White rates from 1950 to 1995 shows a decline, and more rapid declines for Blacks than Whites. Data for Native Americans or Alaska Natives and Hispanics also show a general pattern of declining rates, with the Native American or Alaska Native/ White ratio in 1995 (1.15:1) smaller than it was in 1980 (1.59:1). For Hispanics the rate of decline between 1985 and 1995 was greater than for the White population, so that the Hispanic advantage over Whites increased during 1980 to 1995. For Asians or Pacific Islanders, mortality rates from the flu and pneumonia were considerably lower than for Whites throughout 1980 to 1995, but the rates increased so that the Asian or Pacific Islander/White ratio was closer to parity in 1995 (0.87:1) than in 1980 (0.75:1).

HIV/AIDS

In recent years, acquired immune deficiency syndrome (AIDS), and the human immunodeficiency virus (HIV) that causes AIDS, emerged as a major infectious disease—the eighth leading cause of death in the United States. In 1996, it claimed 31,130 lives. Table 14–6 presents age-adjusted death rates from HIV/AIDS for selected years between 1990 and 1996. For Whites, during 1993 through 1995, death rates increased from the 1990 level; but 1996 shows a decrease—7.2 per 100,000 as opposed to 8.0

TABLE 14–6 Trends in HIV/AIDS Mortality, 1990–1995

 

1990

1993

1994

1995

1996

A. Age-Adjusted Death Rates per 100,000 Population

White

8.0

10.5

11.2

11.1

7.2

Black

25.7

41.6

49.4

51.8

41.4

American Indian

1.8

4.6

5.4

7.0

4.2

Asian or PI

2.1

2.8

3.5

3.1

2.2

Hispanic

15.5

20.1

23.6

23.9

16.3

B. Minority/White Ratios

B/W

3.21

3.96

4.41

4.67

5.75

Am. Indian/W

0.23

0.44

0.48

0.63

0.58

Asian or PI/W

0.26

0.27

0.31

0.28

0.31

Hispanic/W

1.94

1.91

2.11

2.15

2.26

 

SOURCE: NCHS (1998).

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

per 100,000 in 1990. Data show a pattern of increasing death rates between 1990 and 1995 for the other racial groups as well, and for them, also, a decrease in 1996. Rates for Blacks and Hispanics, however, are considerably higher than those for Whites, while rates for Native Americans or Alaska Natives and Asians or Pacific Islanders are considerably lower. In 1996, the Black/White death rate ratio for HIV/AIDS deaths was 5.75:1 and the Hispanic/White ratio was 2.26:1, both considerably higher than they were in 1990. The impact of AIDS on the Black population is revealed by the fact that in 1996, while HIV was the eighth leading cause of death in the United States overall, it was the fourth leading cause of death in the Black population and the third leading cause of death among Black males.

External Causes

Homicide

In 1996, homicide was the eleventh leading cause of death for the U.S. population overall, but it was the seventh leading cause of death for Blacks and Hispanics, the ninth leading cause of death for Asians or Pacific Islanders, and the tenth leading cause of death for Native Americans or Alaska Natives (National Center for Health Statistics, 1998). Among males, homicide is the fifth leading cause of death for Blacks and Hispanics and the ninth leading cause of death for Native Americans or Alaska Natives and Asians or Pacific Islanders. In 1996, firearms were used in 70 to 80 percent of homicides of White, Black, and Hispanic men age 25 to 44 and between 50 and 60 percent of homicides of women (National Center for Health Statistics, 1998). Age-adjusted death rates from homicide in Table 14–7A show that in 1995, Blacks, Hispanics, and Native Americans or Alaska Natives had mortality rates considerably higher than those of Asians or Pacific Islanders and Whites. For Whites, homicide death rates rose progressively between 1950 and 1980, then declined slightly but remained relatively stable between 1985 and 1995; however, the rate in 1995 was 2.5 times higher than it was in 1950. Homicide rates for Blacks were 11 times higher than rates for Whites in 1950 and rose to a peak of 46.1 per 100,000 in 1970. Between 1970 and 1980, rates declined for Blacks but increased for Whites. By 1995, the homicide death rate for Blacks (33.4 per 100,000) was six times higher than it was for Whites. Homicide rates for Native Americans or Alaska Natives declined from 1980 to 1995 to a rate 2.16 times higher than that of Whites. Homicide rates for Asians or Pacific Islanders fluctuated between 1980 and 1995, with the 1995 rate being very close to that of the White population. Homicide death rates for Hispanics hovered at around three times higher than those of Whites, with the rate in 1995 only slightly lower than it was in 1985.

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

TABLE 14–7 Trends in Homicide, 1950–1995

 

1950

1960

1970

1980

1985

1990

1995

A. Age-Adjusted Death Rates per 100,000 Population

White

2.6

2.7

4.7

6.9

5.4

5.9

5.5

Black

30.5

27.4

46.1

40.6

29.2

39.5

33.4

American Indian

16.0

12.2

11.1

11.9

Asian or PI

5.6

4.2

5.2

5.4

Hispanic

15.7

17.7

15.0

B. Minority/White Ratios

B/W

11.73

10.15

9.81

5.88

5.41

6.69

6.07

Am. Indian/W

2.32

2.26

1.88

2.16

Asian or PI/W

0.81

0.78

0.88

0.98

Hispanic/W

2.91

3.00

2.73

 

SOURCE: NCHS (1998).

Suicide

Suicide was the ninth leading cause of death in the United States in 1996, claiming some 30,903 lives that year. Table 14–8 shows that, in 1995, Native Americans or Alaska Natives had a suicide rate slightly higher than that of Whites, with Blacks, Asians or Pacific Islanders, and Hispanics having rates considerably lower. The table also shows that there was remarkable consistency in suicide rates over time for the White population, with the rate changing from 11.6 in 1950 to 11.9 in 1995. The highest

TABLE 14–8 Trends in Suicide, 1950–1995

 

1950

1960

1970

1980

1985

1990

1995

A. Age-Adjusted Death Rates per 100,000 Population

White

11.6

11.1

12.4

12.1

12.3

12.2

11.9

Black

4.2

4.7

6.1

6.4

6.4

7.0

6.9

American Indian

12.8

12.1

12.4

12.2

Asian or PI

6.7

6.4

6.0

6.6

Hispanic

6.1

7.3

7.2

B. Minority/White Ratios

B/W

0.36

0.42

0.49

0.53

0.52

0.57

0.58

Am. Indian/W

1.06

0.98

1.02

1.03

Asian or PI/W

0.55

0.52

0.49

0.55

Hispanic/W

0.50

0.60

0.61

 

SOURCE: NCHS (1998).

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

rate (12.4) was in 1970. Rates were similarly high, and stable, for Native American or Alaska Native populations. In contrast, for Asians or Pacific Islanders, Blacks, and Hispanics, the pattern was of lower but generally increasing rates of suicide. Accordingly, although Asians or Pacific Islanders, Blacks, and Hispanics consistently had lower rates of suicide than Whites and Native Americans or Alaska Natives, rates were closer in 1995 than they were in the earliest available data.

Summary

The tables provided in this section show that the association between race and health is complex, and varies with the health-status indicator and the particular racial group under consideration. With the exception of suicide, Blacks consistently have higher death rates than Whites for the leading causes of death in the United States. Asians or Pacific Islanders consistently have lower death rates than Whites. Native Americans or Alaska Natives and Hispanics generally have lower death rates than Whites for the two leading causes of death in the United States (coronary heart disease and cancer) but higher death rates from several other causes.

Because there are extensive data for Blacks and Whites, trends become evident in comparisons of differences over time; and it is easy to see that among the groups considered, overall, Black-White differences are the most pronounced. For multiple causes of death (heart disease, cancer, cirrhosis of the liver, diabetes) the Black-White gap was wider in 1990 than in 1950. For heart disease, the Black-White difference has widened as a result of more rapid improvements in the health of the White population compared to that of the Black population. For cancer and diabetes, there were stable or declining rates for Whites but increasing rates for Blacks. For cirrhosis of the liver, between 1950 and 1970, there were increases for both Blacks and Whites, but more rapid increases for Blacks. For influenza and pneumonia, the Black-White difference narrowed as a result of more rapid improvements in the health of Blacks compared to Whites. Declines in influenza and pneumonia deaths for Blacks were especially significant between 1960 and 1980; these declines coincided with the heyday of some of the gains of the Civil Rights Movement. Evidence suggests that the Civil Rights Movement had a positive effect on the health of the Black population overall (Mullings, 1989). One study found that Blacks experienced a more significant decline in mortality rates than Whites, both on a percentage basis and an absolute basis, between 1968 and 1978 (Cooper et al., 1981a). We need a better understanding of the reasons for this success.

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

Patterns, Caveats, and Limitations

Patterns

To put these data into perspective, several issues must be considered. First, the lower rate of suicide for Blacks compared to Whites is consistent with other mental health data and reflects a well-documented paradox in the health literature. Blacks tend to rate higher than Whites on indicators of physical health problems, and Blacks rate lower than Whites on indicators of subjective well-being, such as life satisfaction and happiness (Hughes and Thomas, 1998); but Blacks have comparable or better rates than Whites on other indicators of mental health. Community-based studies using measures of psychological distress show an inconsistent pattern of Black-White differences. Some studies show that Blacks have higher rates of distress compared to Whites, while other studies show higher rates of psychological distress for Whites compared to Blacks (Dohrenwend and Dohrenwend, 1969; Neighbors, 1984; Williams, 1986; Vega and Rumbaut, 1991; Williams and Harris-Reid, 1999).

The Epidemiologic Catchment Area study (ECA), the largest study of psychiatric disorders ever conducted in the United States, is based on interviews of some 20,000 adults in five communities. ECA estimated the prevalence and incidence of specific psychiatric disorders in the general population in the five communities—people both in treatment and not in treatment (see Table 14–9; Robins and Regier, 1991). Data show that there are few differences among the groups in rates of either current or lifetime psychiatric disorders. Especially striking is the absence of a substantial racial difference in drug-use history or alcohol and drug abuse. On the other hand, anxiety disorders, especially phobias, stand out as one area in

TABLE 14–9 Rates of Psychiatric Disorder for Blacks, Whites, and Hispanics: Epidemiologic Catchment Area Study

 

Current

Lifetime

Disorders

Black

White

Hispanic

Black

White

Hispanic

Affective disorder

3.5

3.7

4.1

6.3

8.0

7.8

Alcohol abuse

6.6

6.7

9.1

13.8

13.6

16.7

Drug history

29.9

30.7

25.1

Drug abuse

2.7

2.7

1.9

5.4

6.4

4.3

Schizophrenia

1.6

0.9

0.4

2.1

1.4

0.8

Generalized anxiety

6.1

3.5

3.7

Phobic disorder

16.2

9.1

8.1

23.4

9.7

12.2

 

SOURCE: Robins and Regier (1991). Reprinted by permission.

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

TABLE 14–10 Rates of Psychiatric Disorders and Black/White, Hispanic/White Ratios: National Comorbidity Study

Disorder

Percentage

B/W Ratio

H/W Ratio

Any affective disorder

11.3

0.78

1.38

Any anxiety disorder

17.1

0.90

1.17

Any substance abuse/dependence

11.3

0.47

1.04

Any disorder

29.5

0.70

1.11

 

SOURCE: Kessler et al. (1994). Reprinted by permission

which Blacks had considerably higher rates than Whites or Hispanics. Compared to Blacks and Whites, Hispanics had a lower rate of drug-use history and lower current and lifetime rates of schizophrenia and drug abuse, but higher current rates of alcohol abuse and affective disorder. Hispanic data, however, were limited to a sample drawn from the Los Angeles area.

Findings from the National Comorbidity Survey (NCS), the first to use a national probability sample to assess psychiatric disorders in the United States, are generally consistent with those of the EGA (see Table 14–10 ; Kessler et al., 1994). These data show that Blacks do not have higher rates than Whites for any of the major classes of disorders. Instead, lower rates for Blacks are especially pronounced for the affective disorders (depression) and the substance abuse disorders (alcohol and drug abuse). In NCS, Hispanics had higher rates of disorder than Whites. These data should be interpreted with caution because of the relatively small sample of Hispanics (n=737). Large epidemiological surveys like EGA and NCS provide no data on the mental health problems of Asians or Pacific Islanders or Native Americans or Alaska Natives.

It is also important to attend to racial differences in the severity and course of disease. Mortality rates in a given year are a function not only of the number of persons who die because of a disease but also of the severity and the progression of that disease. Higher death rates for minority populations tend to reflect both higher levels of ill health and greater severity of disease. Higher rates may also reflect differences in access to medical care and racial disparities in the modalities of treatment. Data in Table 14–11 illustrate the pattern in differential outcomes of cancer survival. Five-year survival rates are shown for all sites and for the three most common cancers for both genders and for Blacks and Whites from 1974 to 1994 (National Center for Health Statistics, 1998). For males, the data indicate that during 1974 to 1979, 43 percent of White males had a five-year survival rate compared to 32 percent of Black males. Over time

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

the level of survival has increased for both Blacks and Whites, but the increase has been more rapid for Whites than Blacks; thus, the racial disparity has widened. White males, during 1989 to 1994, had a 60 percent survival rate compared to 45 percent of Black males. There is some variation by specific type of cancer, with the racial disparity being greater for colon and prostate cancer than for lung cancer.

The racial difference in cancer survival for females is similar to that observed for males. During 1974 to 1979, there was a 10-point difference in cancer survival, which increased to a 14-point difference during 1989 to 1994. During the latter period, Black females had a 49 percent, five-year survival rate compared to 63 percent for White females. This pattern is similar to that of males, both in the magnitude of the difference and the widening gap in survival rates over time. Also, mirroring the pattern observed for males, Black females have a very small survival rate difference for lung cancer, with much larger differences for colon and breast cancer. The increasing racial disparity in survival is especially striking for colon cancer, with the Black-White difference being almost three times as large in the early 1990s as it was in the 1970s. The racial difference in survival rate for breast cancer is also instructive. Breast cancer stands out as one of the few physical health outcomes for which the incidence rate is higher for Whites than for Blacks. Yet in spite of the fact that Black females are less likely to get breast cancer, they are more likely to die from it. It is well documented that there are racial differences in cancer staging, with Black females more likely to have more advanced cancer at the time of detection than White females. Some research suggests that Black females have even poorer stage-specific survival rates than their White counterparts (Hunter et al., 1993).

Caveats

A third factor that needs to be kept in mind, to put these data into perspective, is the dramatic heterogeneity that exists within each of the major racial categories. Subgroup variations within the major racial categories tend to predict variation in sociodemographic and socioeconomic characteristics in access to and use of medical care and in health status.

For example, the Native American or Alaska Native category consists of more than 250 federally recognized tribes; 209 Alaska Native villages; 65 communities that have been recognized as tribes by the states in which they are located, but not by the federal government; and several dozen other communities that have not received any formal recognition (Norton and Manson, 1996). Although these tribes and communities share a common history of exploitation and oppression, there is great diversity in cultures, socioeconomic circumstances, and health. The Indian Health

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

TABLE 14–11 Five-Year Relative Cancer Survival Rates for Blacks and Whites: SEER Cancer Registry

 

Percent of Patients Surviving

 

All Sites

Colon

Years

White

Black

Diff.

White

Black

Diff.

Males

1974–1979

43.3

31.9

–11.4

50.8

44.9

–5.9

1980–1982

46.6

32.4

–14.2

56.0

46.4

–9.6

1983–1985

49.1

34.7

–14.4

59.9

48.3

–11.6

1986–1988

52.8

37.7

–15.1

64.1

52.0

–12.1

1989–1994

60.0

45.1

–14.9

64.6

51.4

–13.2

Females

1974–1979

57.2

46.7

–10.5

52.4

48.6

–3.8

1980–1982

57.0

45.9

–11.1

55.4

51.3

–4.1

1983–1985

59.1

45.5

–13.6

58.5

50.0

–8.5

1986–1988

61.9

47.8

–14.1

61.7

53.4

–8.3

1989–1994

63.1

48.8

–14.3

63.1

53.1

–10.0

aFor men, prostate cancer; for women, breast cancer.

Service (IHS) is a federal agency responsible for providing medical care to those who live on or near reservations. IHS estimates that it serves about 60 percent of the Native American or Alaska Native population. IHS data reveal that death rates for this population vary considerably from state to state, with rates being higher in states that have larger concentrations of Native Americans or Alaska Natives (IHS, 1997). In addition, there is considerable tribal-specific variation within a given state.

Similarly, the Hispanic category consists of more than 25 national-origin groups that share a common language, religion, and traditions, but vary dramatically in terms of the timing of immigration, regional concentration, incorporation experiences, and socioeconomic status. It is not surprising that there is also considerable variation in health status within the Hispanic group (Sorlie et al., 1993; Vega and Amaro, 1994).

The Asian or Pacific Islander population in the United States consists

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

Lung

Gender-Specifica

White

Black

Diff.

White

Black

Diff.

11.6

9.9

–1.7

70.0

60.5

–9.5

12.2

11.0

–1.2

74.5

64.7

–9.8

12.2

10.4

–1.8

77.7

64.0

–13.7

12.7

11.9

–0.5

85.2

69.2

–16.0

13.0

9.7

–3.3

95.1

81.2

–13.9

16.7

15.4

–1.3

75.2

63.1

–12.1

16.2

15.4

–0.8

77.1

65.9

–11.2

17.1

14.2

–2.9

79.7

63.7

–16.0

15.9

11.6

–4.3

84.6

69.6

–15.0

16.5

13.9

–2.6

86.7

70.6

–16.1

of persons from some 28 Asian countries and 25 Pacific Island cultures (Lin-Fu, 1993). Each of these subgroups has its own distinctive history, culture, and language. Table 14–12 presents 1990 census data that show percentages of poverty and median income levels for subgroups of the Asian or Pacific Islander population (U.S. Bureau of the Census, 1993). Overall median income and aggregate poverty level mask the tremendous heterogeneity within that population, and it is these differences that predict variations in health status. Table 14–13 presents incidence rates for four frequently diagnosed cancers among females in Asian or Pacific Islander subgroups (Miller et al., 1996). (Rates for Blacks and Whites are included for comparison purposes.) These data reveal that there is considerable variation in cancer incidence rates for the six ethnic groups considered and that the risk of cancer varies by group and by cancer site.

The considerable cultural and ethnic diversity of the Black population

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

TABLE 14–12 Selected Socioeconomic Indicators for Asians in the United States, 1990

Ethnic Groups

Median Family Income, 1989

Percentage Persons in Poverty

Asian

$41,583

14.0

Japanese

$51,550

7.0

Chinese

$41,316

14.0

Filipino

$46,698

6.4

Korean

$33,909

13.7

Asian Indian

$49,309

9.7

Vietnamese

$30,550

25.7

Cambodian

$18,126

42.6

Hmong

$14,327

63.6

Laotian

$23,101

34.7

 

SOURCE: U.S. Bureau of the Census (1993).

TABLE 14–13 Age-Adjusted Incidence Rates (per 100,000 population) for Select Cancers Among Females, 1988–1992

Group

Breast

Cervix

Colo-Rectal

Lung

Chinese

55.0

7.3

33.6

25.3

Filipino

73.1

9.6

20.9

17.5

Hawaiian

105.6

9.3

30.5

43.1

Japanese

82.3

5.8

39.5

15.2

Korean

28.5

15.2

21.9

16.0

Vietnamese

37.5

43.0

27.1

31.2

Black

95.4

8.7

45.5

44.2

White

111.8

13.2

38.3

41.5

 

SOURCE: SEER Cancer Registry; Miller et al. (1996).

is an important factor to consider in health outcomes, also. Distinctive cultural and geographical regions predict variations in the economic and social experience of Blacks (Green, 1978). Health researchers have documented variations in morbidity and mortality based on region of birth (Fang et al., 1997). Considerable ethnic variation also exists among Black immigrants from the Caribbean region and the African mainland and islands in terms of both culture and language. For example, a Black person born and raised in the U.S. South, a Kenyan, a Jamaican, a Haitian, and a Black person born and raised in the U.S. North are likely to differ in beliefs, behaviors, and even biology. Some limited research suggests that

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

ethnicity predicts variations in health within the Black population (David and Collins, 1997; Fruchter et al., 1985).

The U.S. census also collects data on White ethnic subgroups, but the extent to which ethnicity predicts variations in health for the White population has not been systematically explored in recent health research.

Limitations

In creating mortality statistics, the numerator for death rates for any given group comes from absolute counts based on death certificates. An undercount in the numerator suppresses death rates for the subject group. A growing body of evidence indicates that funeral home directors and other officials who record racial status on death certificates misclassify a relatively high proportion of Native Americans or Alaska Natives, Hispanics, and Asians or Pacific Islanders as White. This has serious implications for the quality and accuracy of mortality data trends for these populations (Hahn, 1992). Miscategorization undercounts death rates for these groups and slightly inflates rates for Whites.

Sorlie et al. (1992) compared race as self-reported during personal interviews for the Current Population Survey with race as recorded on the self-reporter’s death certificate. They found very high agreement for Blacks and Whites; however, 26 percent of Native Americans or Alaska Natives, 18 percent of Asians or Pacific Islanders, and 10 percent of Hispanics were classified as another racial category on the death certificate; most were classified as White. A study of mortality data for American Indian infants found that 28 percent were misclassified as another race on the death certificate (Kennedy and Deapen, 1991). Another study of data in a cancer surveillance registry found that 40 percent of cancer patients registered with IHS as Native Americans or Alaska Natives were identified as another race in the registry (Frost et al., 1992). For Native Americans or Alaska Natives, misclassification on the death certificate also appears to vary by cause of death; Native Americans or Alaska Natives who die alcohol-related deaths are more likely to be correctly coded than those who die as a result of some other major chronic illness (Frost et al., 1994).

The denominator for mortality statistics comes from census data. Obviously, inaccuracy in those data also limits the quality of these health-related statistics (Notes and Comments, 1994). A denominator based on an undercount inflates the rate in exact proportion to the undercount. Although the overall undercount for the U.S. population is relatively small, it is much higher for Blacks than it is for Whites. Evaluations based on demographic analyses suggest that there is a net census undercount of 11 to 13 percent for all of the 10-year age groups for Black males between the ages of 25 and 64 (National Center for Health Statistics, 1994a). Thus,

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

all the officially reported morbidity and mortality rates for Black males in these age groups are 11 to 13 percent too high. For the 1990 census, in addition to demographic analysis, the Bureau of the Census conducted a postcensus enumeration survey (PES) in which the undercount was estimated on a case-by-case matching of census records with those obtained by PES of 165,000 households. According to PES, the undercount rates for Hispanics and for American Indians residing on reservations were even higher than the undercount for Blacks (Hogan, 1993). Future research must give greater attention to the magnitude and size of the undercount and of its impact on the quality of health data.

UNDERSTANDING THE SOURCES OF RACIAL DIFFERENCES IN HEALTH STATUS

Health is socially embedded in the larger conditions in which individuals and groups live and work (Amick et al., 1995; Engels, 1984). Biological differences do exist between human population groups, but the existing racial categories do not capture those differences (American Association of Physical Anthropology, 1996; Montagu, 1965). About 75 percent of known genetic factors are innate and identical in all humans; about 95 percent of human genetic variation exists within racial groups (Lewontin, 1974, 1982). Thus, there is more genetic variation within races than between them, and, at best, genetic and biological differences play a minor role in accounting for the observed racial disparities in health (Kaufman and Cooper, 1995).

A prominent hypothesis in the health literature is that racial differences in socioeconomic status (SES) account for the racial variations in health. A robust inverse association persists between SES and health across a broad range of health outcomes in both the industrialized and the developing worlds (Antonovsky, 1967; Bunker et al., 1989; Williams, 1990). Moreover, some research suggests there is a stepwise progression of diminished risk with each higher level of SES (Adler et al., 1993; Marmot et al., 1991). Race is strongly associated with SES, and adjusting Black-White disparities in health for SES sometimes eliminates, but always substantially reduces, these differences (Williams and Collins, 1995; Lillie-Blanton et al., 1996). It is frequently found, however, that even when education and income level are held constant, Blacks have higher levels of ill health than Whites (Williams, 1996b). Some studies find that Black-White differences in health status actually increase with rising SES (Schoendorf et al., 1992; Singh and Yu, 1995).

Greater attention to the construct of racism can serve to inform and structure our understanding of racial inequalities in health (Cooper et al., 1981b; Hummer, 1996; Krieger et al., 1993; LaVeist, 1996; Williams, 1996c,

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

1997). “Races” are socially meaningful groupings linked to the structure of society; different races have differential access to societal resources and rewards. Although there is considerable overlap between race and SES, race reflects more than SES; and fully understanding racial differences in health will require researchers to explicitly consider the role of racism in health and society. Racism incorporates ideologies of superiority, negative attitudes and beliefs toward racial outgroups, and differential treatment of members of those groups both by individuals and by social institutions. Racism has been a fundamental organizing principle within American society and has played a major role in shaping major social institutions and policies (Omi and Winant, 1986; Quadagno, 1994).

Table 14–14 presents data from the 1990 General Social Survey (GSS) based on White Americans’ prejudgments and perceptions about other White and non-White groups—Blacks, Hispanics, Asians, Jews, and Southern Whites (Davis and Smith, 1990). The Black column indicates that substantial proportions of Whites endorsed negative stereotypes of Blacks. Forty-four percent of the White population responding to the survey believe that most Blacks are lazy; 56 percent believe most Blacks prefer to live off welfare, and 50 percent believe most Blacks are prone to violence. Relatively small percentages of Whites were willing to endorse positive stereotypes of Blacks. Only 17 percent believe most Blacks are hard working, only 20 percent believe most Blacks are intelligent, only 13 percent believe most Blacks prefer to be self-supporting, and only 15 percent believe most Blacks are not prone to violence. Twenty-eight to 45 percent opted for the “Neither” category for each choice. It is impossible to know the extent to which the desire to give socially acceptable and nonracist answers contributed to this pattern of response. It is instructive, though, that a large percentage of Whites view Blacks so much more negatively than they view themselves. Hispanics tend to be viewed twice as negatively as Asians; Jews tend to be viewed more positively than Whites in general; and southern Whites tend to be viewed more negatively than non-southern Whites. In general, the data show that a significant percentage of Whites view other groups more negatively than themselves and view Blacks more negatively than any other group.

Historically, ideologies and attitudes about racial groups have been translated into policies and societal arrangements that limit the opportunities and life chances of stigmatized groups. The disproportionate representation of minority groups at the low end of the socioeconomic spectrum in the United States reflects the successful implementation of social policies designed to limit societal benefits to socially marginalized groups.

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

TABLE 14–14 White Americans’ Stereotypes: Percent Agreeing That Most Group Members…

 

Blacks

Whites

Hispanics

Asians

Jews

Southern Whites

Are Unintelligent

Unintelligent

28.8

6.1

29.1

13.2

7.0

14.3

Neither

45.0

33.3

42.6

38.0

25.9

44.9

Intelligent

20.0

55.4

18.4

37.3

58.8

31.5

DK/NA

6.2

5.2

9.8

11.5

8.3

9.4

Are Lazy

Lazy

44.3

4.9

33.5

15.0

4.7

17.9

Neither

34.0

36.4

33.7

27.7

21.9

41.2

Hardworking

16.8

54.5

23.9

47.2

65.5

32.0

DK/NA

4.9

4.2

9.0

10.1

7.9

8.9

Prefer to Live Off Welfare

Prefer welfare

56.1

3.7

41.6

16.3

2.4

12.9

Neither

26.5

21.5

30.5

31.6

14.6

35.2

Prefer self-support

12.7

70.5

18.3

40.6

75.7

41.4

DK/NA

4.7

4.3

9.7

11.5

7.3

10.5

Are Prone to Violence

Violence prone

50.5

15.7

38.3

17.2

10.1

17.9

Neither

28.3

42.3

34.0

41.1

33.3

45.5

Not violence prone

15.2

36.6

17.8

29.6

46.6

25.9

DK/NA

5.9

5.5

9.8

12.1

10.0

10.7

Note: DK/NA-don’t know or no answer.

SOURCE: Davis and Smith (1990).

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

Institutional Discrimination and Health

SES is one of the strongest known predictors of variations in health; and racial differences in SES reflect, in part, the impact of economic discrimination produced by large-scale societal structures. Residential de facto segregation has been a primary mechanism by which racial inequality has been created and reinforced. Racial segregation has limited access to educational and employment opportunities, which has led to truncated socioeconomic mobility for Blacks and Native Americans or Alaska Natives (Jaynes and Williams, 1987; Massey and Denton, 1993). Moreover, racism skews the value of SES indicators, making them nonequivalent across racial groups. This makes it difficult to truly adjust racial differences in health for SES (Kaufman et al., 1997). For example, there are racial differences in the quality of education, income returns for a given level of education or occupational status, wealth or assets associated with a given level of income, purchasing power of income, stability of employment, and health risks associated with occupational status (Williams and Collins, 1995; Kaufman et al., 1997).

Evidence suggests that some White employers use racial group membership and residence in undesirable neighborhoods as criteria for refusing to hire some urban residents (Kirschenman and Neckerman, 1991). Thus, beliefs based on stereotypes are combined with Blacks’ geographic concentration to systematically reduce their employment opportunities. Empirical evidence suggests corporate executives use beliefs about minority group inferiority and data on minority group concentration to move firms away from areas that are likely to have a high proportion of minority group workers. A Wall Street Journal analysis of the Equal Employment Opportunity Commission reports of more than 35,000 U.S. companies revealed that during the economic downturn of 1990–1991, Blacks were the only group that experienced a net job loss—59,500 jobs—compared to net job gains of 71,100 for Whites, 60,000 for Hispanics, and 55,100 for Asians (Sharpe, 1993). Blacks lost a disproportionately high share of the jobs that were cut and gained a disproportionately low share of the jobs that were added.

Corporate America indicated that these job losses were the result of restructuring, relocating, and downsizing. Sears moved distribution centers from the central city to the suburbs to facilitate more convenient routing of its truck fleet. Coca Cola reduced its workforce to maintain profits, but 42 percent of those laid off were Black, even though Blacks were only 18 percent of its workforce. General Electric stopped production in two plants—39 percent of employees in one were Black, in the other, 80 percent. Clearly there are a number of structural forces driving the movement of high-pay, low-skill jobs from the urban areas where

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

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.

Discrimination and Medical Care

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,

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

1990; Anderson et al., 1986; Trevino et al., 1991). Dental services are not covered well by most insurance policies, and minority access to dental care is especially problematic. Although the use of dental services has increased over time for all racial groups, the absolute percentages of persons who see a dentist in a given year is still unacceptably low. In 1993, for example, among persons 25 years of age and over, only 64 percent of Whites, 47 percent of Blacks, and 46 percent of Hispanics had visited a dentist within the previous year (National Center for Health Statistics, 1998).

Research also reveals there are large and systematic racial differences in the quality of medical care provided, which reflects, at least in part, the role of racism. Louis Sullivan, the former Secretary of Health and Human Services, concluded that “There is clear, demonstrable, undeniable evidence of discrimination and racism in our health-care system” (Sullivan, 1991). Evidence of discrimination comes from studies that have examined Black-White differences in access to a broad range of specific medical procedures. These studies reveal that, even after adjustment for health insurance and clinical status, Whites are more likely than Blacks to receive coronary angiography, bypass surgery, angioplasty, chemodialysis, total-knee arthroplasty for osteoarthritis, intensive care for pneumonia, and kidney transplants (Giles et al., 1995; Council on Ethical and Judicial Affairs, 1990; Wilson et al., 1994). Blacks are less likely than Whites to be on the waiting list for kidney transplants and once on the list, are likely to wait twice as long to receive a kidney (Sullivan, 1991).

A recent analysis of 1.7 million inpatient discharge abstracts from a national sample of 500 hospitals revealed that for almost half (48 percent) of a broad range of disease conditions, Blacks were less likely than Whites to receive major therapeutic procedures (Harris et al., 1997). Studies of specific health conditions also document racial differences in the intensity of medical care for comparable conditions. A cohort study of 8,406 Black and White men with prostate cancer found that, with comparable disease, Black men were 2.2 times less likely than their White peers to receive aggressive therapy (Schapira et al., 1995). Similarly, a national study using randomly selected hospitals found that among patients with pneumonia, non-Whites (mainly Blacks) compared to Whites, received fewer hospital services than expected on the basis of their health status and had longer than expected hospital lengths of stay (Yergan et al., 1987). It is important to note that these racial differences were apparent not only in the aggregate, but also within individual hospitals.

Especially striking are racial differences in the Veterans Health Administration (VHA) system and the Medicare program. Among inpatients in these two large federal programs, racial differences should be eliminated by the absence of differences in insurance coverage; yet, racial

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

differences in the use of cardiovascular procedures have been documented among VHA patients (Whittle et al., 1993; Peterson et al., 1994). Similarly, a large national study of almost 10,000 Medicare patients found that patients who were Black or resided in poor neighborhoods received poorer inpatient medical care and had greater instability at discharge than other patients (Kahn et al., 1994). These differences were evident in all types of hospitals, but less pronounced in urban teaching hospitals than in rural and urban nonteaching institutions. An analysis of all inpatient Medicare reimbursement claims for 1992 revealed that Blacks were less likely than Whites to receive all of the 16 most commonly received procedures by Medicare beneficiaries (McBean and Gornick, 1994). The racial differences were especially large for the newer, elective, and referral-sensitive procedures.

These racial differences in medical care are consequential and in some cases life threatening. Among the 1992 Medicare beneficiaries, Blacks had a higher 30-day postadmission mortality rate than Whites for most of the procedures (McBean and Gornick, 1994). Moreover, additional analyses of the Medicare files revealed four procedures that Black beneficiaries received more frequently than their White counterparts—all four procedures reflect delayed diagnosis, delayed initial treatment, or failure in the management of chronic disease.

  1. Amputation of part of the lower limb, usually as a consequence of poor management of diabetes, was 3.6 times more likely to be performed on Blacks compared to Whites.

  2. Excisional debridement, the removal of tissue usually related to poor and infrequent medical care that leads to decubitus ulcers and skin infections, was performed 2.7 times more frequently on Black than on White patients.

  3. Arterial venostomy, the implantation of shunts for chronic renal dialysis, often reflective of the failure of the management of end-stage renal disease, was 5.2 times more likely to be performed on Black patients than on White.

    Bilateral orchiectomy, removal of both testes, often reflective of delayed diagnosis or initial treatment in the case of prostate cancer, was 2.2 times more likely to be performed on Black men than on White men.

Further evidence of the potential adverse effects of racial differences in medical care comes from two more recent studies. Peterson et al. (1997) studied 12,402 patients who underwent their first cardiac catherization. After adjusting for demographic factors, severity of disease, coexisting medical conditions, and access to subspeciality cardiology care, Blacks were only slightly less likely to receive coronary angioplasty but

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

markedly less likely to undergo bypass surgery. The racial difference was largest among patients with severe disease—those who would benefit the most. Moreover, compared to Whites, Blacks had a higher five-year mortality rate, which was partly explained by differences in treatment. Hannan et al. (1999) followed for three months a random sample of 4,905 patients undergoing angiography to determine racial differences in the receipt of coronary artery bypass graft (CABG) surgery. They found that among patients judged as appropriate for CABG using rigorous criteria, Black and Hispanic patients were about 1.6 times less likely than non-Hispanic Whites to receive the surgery, even after adjustment for age, gender, insurance status, and vessels diseased. Moreover, Blacks, but not Hispanics, were 1.6 times less likely than Whites to receive the surgery among patients for whom CABG surgery was judged to be necessary. In addition, the study interviewed the gatekeeper physician for a random sample of patients appropriate for CABG surgery who did not receive it. For 90 percent of this group, the physician indicated that he/she had not recommended surgery. Among those patients who were not recommended for CABG surgery, in 9 percent of the cases, the patient preferred another intervention; in 8 percent, the physician preferred another intervention first. Thus, patient preference did not play a major role in accounting for racial differences in CABG surgery.

Taken together, the research on racial differences in medical care raises uncomfortable questions about the prevalence of racial bias among America’s physicians. Health-care providers are a part of society and share, to some degree, prevailing negative beliefs about Blacks and other racial groups, as reflected in the stereotype data reviewed in Table 14–14. Consciously or unconsciously, race appears to influence the practice of medicine. In a world of finite medical resources, larger societal beliefs about the intellectual capacities, violent nature, and laziness of racial groups may creep into clinical decision making to establish the worthiness, or lack thereof, of some patients for the receipt of medical care. More research is clearly needed on provider attitudes and behaviors (King, 1996). More important is the urgent need for the organizations responsible for medical education, training, and licensure to develop and implement strategies to eradicate racial inequities in medical care. They should also establish strong countervailing influences to combat tendencies toward racial prejudice and bias (Williams, 1998).

The Subjective Experience of Racism and Health

A small but growing body of research also indicates that chronic and acute experiences of discrimination in the lives of minority group members is a source of stress that adversely affects their physical and mental

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

health. Laboratory studies reveal that exposure to discrimination leads to cardiovascular and psychological reactivity (Anderson, 1989; Armstead et al., 1989; Dion, 1975; Pak et al., 1991). Two studies of Hispanic females note that self-reported experiences of discrimination are positively related to psychological distress (Amaro et al., 1987; Salgado de Snyder, 1987). Epidemiologic studies indicate that, at least under some conditions, racial discrimination is positively related to blood pressure among Blacks (Krieger, 1990; Krieger and Sidney, 1996). Similarly, two studies using national probability samples found that self-reports of discrimination are adversely related to both physical and psychological distress (Williams and Chung, in press; Jackson et al., in press). One recent study of a major metropolitan area found that discrimination made more of an incremental contribution to racial disparities in health than SES and, in combination with SES, completely explained racial differences in physical health (Williams et al., 1997).

Widespread negative societal stereotypes can adversely affect the health status of minority group members in that the stigma of inferiority can, for some, create certain expectations, anxieties, and reactions that affect motivation, performance, and psychological well-being. Research across a broad range of societies reveals that groups that are socially unequal have lower scores on standardized tests (Fischer et al., 1996). U.S.-based studies reveal that the performance of Black students on an exam is adversely affected when the stereotype of Black intellectual inferiority is made salient (Steele, 1992). This phenomenon is so robust that the performance of females is adversely affected when told in advance that they perform more poorly than men, and White men’s performance is negatively affected when they are contrasted with Asians (Fischer et al., 1996). Health researchers have also documented that among Blacks, there is a correlative relationship between mental and physical health problems and the endorsement of the dominant society’s negative stereotypes of Blacks. Taylor found that Blacks who believe that Blacks are inferior have higher levels of psychological distress and alcohol use (Taylor and Jackson, 1990; Taylor et al., 1991). Analyses of data from the National Study of Black Americans revealed that Blacks who endorse negative stereotypes of Blacks as accurate were more likely to report poorer physical and mental health than those who rejected those stereotypes (Williams and Chung, in press).

RESEARCH NEEDS

Research is needed to identify the mechanisms and processes that link location in social structure to health outcomes. Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention (U.S.

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

Department of Health, Education, and Welfare, 1979) indicated that health behaviors and lifestyle account for more of the variation in health than medical care and genetic factors combined. Similarly, the Report of the Secretary’s Task Force on Black and Minority Health (U.S. Department of Health and Human Services, 1985) concluded that most of the major risk factors responsible for the excess level of disease and death within Black and minority populations are behavioral, and thus potentially preventable. Behavioral risk factors are typically measured at the individual level; and much research on health behaviors views them simply as individual characteristics. Research is needed that would seek to understand the constraints on individual choice and the ways in which the larger social environment is consequential in the initiation and maintenance of unhealthy practices (McKinlay, 1990; Williams, 1990).

For example, cigarette smoking and alcohol use were risk factors in five of the six causes of death responsible for the 60,000 annual excess deaths in the Black population compared to the White population (U.S. Department of Health and Human Services, 1985). Alcohol and tobacco are mood altering substances frequently used to alleviate stressful working and living conditions created by social structures and processes. Research is needed that would elucidate the ways in which the cooperative efforts of governmental and commercial interests to initiate and maintain the use of these substances within disadvantaged populations combine with their adverse living and working conditions to produce particular patterns of risk behavior. Research is also needed to rigorously assess the relative contribution of behavioral factors to racial disparities in health. One study using a national sample found that although health behaviors varied by SES, individual behaviors played only a minimal role in accounting for SES differences in mortality (Lantz et al., 1997). Some limited research suggests that although behavioral factors are related to race and SES and to health status, modification of these risk factors without changes in the larger social institutions that drive them will give rise to new intervening factors that will maintain social inequalities in health (Williams, 1997).

Research on social support and other psychosocial factors that can affect health also needs to attend to the ways in which these characteristics are shaped by social conditions. For example, marital status is a powerful predictor of health; married persons enjoy lower levels of ill health and lower rates of mortality than unmarried persons. Marriage rates, however, are shaped by economic conditions. Unemployment, declines in income, and high job turnover are all associated with increased rates of marital dissolution; female-headed households decline when male earnings rise and rise when male unemployment increases (Bishop, 1977). Rates of female-headed households within the Black population are in-

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

versely related to employment opportunities for Black males (Wilson, 1987). Lack of meaningful and adequately compensated employment can create frustration and hostility, which have emerged as important risk factors for coronary heart disease, obesity, and other health conditions. Levels of hostility, however, are patterned by SES; and residence in poor living conditions predicts the higher likelihood of hostile responses (Harburg et al., 1973).

As the findings on race and mental health status suggest, research is also critically needed to identify the reason why Blacks have lower rates than Whites on indicators of subjective well-being but comparable or better rates than Whites on other indicators of mental health. More attention needs to be focused on the resources and cultural strengths within minority communities. High levels of religious involvement, family and kin support systems, psychological resources, such as John Henryism and racial identity, and processes of attribution have all been identified as potential adaptive resources within minority populations (James, 1993, 1994; Neighbors et al., 1996; Williams, 1998).

Future research must give greater attention to comprehensively assessing racial minority status and including identifiers for ethnic variation within each of the five OMB categories. The availability of adequate data for Native Americans or Alaska Natives, Hispanics, and Asians or Pacific Islanders is still a major problem. Because of the relatively small sizes of some of these groups and their geographic distribution, standard sampling strategies for national populations do not yield adequate sample sizes to provide reliable estimates for the distribution of diseases in these groups or to explore heterogeneity within a given racial group. Surveys focused on a particular geographic area with a high concentration of a racial subgroup, as opposed to national ones, are necessary to provide data for these groups. Combining multiple years of data in ongoing surveys is another useful strategy for obtaining health information for small population groups.

Researchers also need to be more self-critical about the collection, analysis, and interpretation of racial data. Greater consideration must be given to why race/ethnicity identification is being collected, the limitations of racial data, and how the findings should be interpreted. Data on racial differences should routinely be stratified by SES within racial groups. Failure to do this may misspecify complex health risks and even lead to harmful social stereotypes and consequences. Whenever feasible, additional information that captures these characteristics should be collected. This will include the assessment of SES, acculturation, and economic and noneconomic aspects of discrimination (Williams, 1997). There are limited opportunities to collect additional information in vital-statistics systems and in record-based surveys. Even in these contexts, how-

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

ever, years of formal education, nativity status, and years of residence in the United States can be ascertained.

FUTURE TRENDS

A number of factors are likely to affect future patterns in the health status of racial minority populations in the United States. One likely trend is that increasing length of stay and greater acculturation of Hispanic and Asian or Pacific Islander populations will lead to worsening health for them (Hernandez and Charney, 1998). Across a broad range of health-status indicators, research indicates that foreign-born Hispanics have a better health profile than their counterparts born in the United States. Rates of infant mortality, low birth weight, cancer, high blood pressure, adolescent pregnancy, and psychiatric disorders increase with length of stay in the United States (Vega and Amaro, 1994). As groups migrate from one culture to another, immigrants often adopt the diet and behavior patterns of the new culture—e.g., decreased fiber consumption; decreased breast feeding; increased use of cigarettes and alcohol, especially among young females; driving under the influence of alcohol; and increased use of illicit drugs (Vega and Amaro, 1994). Early studies of acculturation found that the rate of heart disease among Japanese increased progressively as Japanese moved from Japan to Hawaii to the U.S. mainland (Marmot and Syme, 1976). The association between acculturation and length of stay in the United States and the prevalence of disease, however, is complex. Migration studies of Chinese and Japanese people show that rates of some cancers, such as prostate and colon, increase when these populations migrate to the United States, while the rates of other cancers, such as liver and cervical, decrease (Jenkins and Kagawa-Singer, 1994).

A second trend that may have implications for health is the growing income inequality in the United States between the very rich and everyone else. Since the mid-1970s there has been a growing concentration of wealth among the highest income groups and worsening economic conditions for a substantial proportion of the population (Danziger and Gottschalk, 1993). Research from both Western Europe and the United States suggests that widening health-status disparities parallel widening economic disparities (Williams and Collins, 1995). To the extent that racial minority group members are overrepresented among lower-income groups, worsening health status linked to economic inequalities will disproportionately affect these populations. The data cited earlier, and other data showing the widening of the health gap between Blacks and Whites during the 1980s, are consistent with this hypothesis (National Center for Health Statistics, 1994b; Williams and Collins, 1995).

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

A third factor that is likely to affect future trends in minority health is the high rate of childhood poverty. National data suggest that the rate of childhood poverty is disconcertingly high in the United States. One in five U.S. children, and two in five Black and Hispanic children under the age of 18, live in poverty (National Center for Health Statistics, 1998); children of the poor2 and the near poor3 combined represent 43 percent—nearly half—of all children in the United States—31 percent White, 41 percent Asian or Pacific Islander, 68 percent Black, and 73 percent Hispanic.

Health status is affected not only by current SES but by exposure to economic deprivation over one’s life course. Several studies reveal that early-life economic and health conditions have long-term adverse consequences for adult health (see, e.g., Elo and Preston, 1992). For example, some studies suggest that growth retardation during the fetal period, leading to low birth weight, is associated with elevated risk of high blood pressure in adulthood (Elo and Preston, 1992). Rates of low birth weight are twice as high for Blacks as for Whites, and rates of hypertension during adulthood are also considerably higher for Black than White populations. However, the contribution, if any, of low birth weight to the elevated rates of hypertension among Blacks has not been systematically studied.

Finally, the persistence of racism suggests the disparities in minority health may linger for some time. National data reveal that Whites are more opposed to race-targeted policies than to similar poverty-targeted policies (Bobo and Kluegel, 1993). Current debates about affirmative action reveal the absence of a reservoir of sympathy for the economic disadvantages of minority group members, despite the fact that data suggest that challenges for the Black population may be distinctive and greater than those of other minority groups. Although racial relations in the United States are much more complex than Black and White, Black-White relations have historically anchored U.S. race relations. In light of that, factors shaping future trends for Blacks in particular are not hopeful.

  1. Blacks continue to be the group most discriminated against in terms of residential segregation (Massey and Denton, 1993) and continue to have the greatest difficulties finding opportunities for socioeconomic mobility (Lieberson, 1980). The high level of segregation is not self-

2  

Households for which the annual income is at or below the poverty level—$16,000/year for a family of four.

3  

Households for which the annual income is just above but less than 200 percent of the poverty level.

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

imposed; Blacks reflect the highest support for residence in integrated neighborhoods (Bobo and Zubrinsky, 1996). Available evidence suggests, however, that instead of greater ethnic diversity leading to greater acceptance of Blacks as neighbors, greater diversity adds to the climate of resistance toward Blacks. One Los Angeles study found that Hispanics were as hostile as Whites to Black neighbors, while Asians were more hostile than Whites (Bobo and Zubrinsky, 1996).

  1. The 1990 General Social Survey (see Table 14–14) indicated that, although Whites tend to view all minority populations more negatively than they view other Whites, Blacks tended to be viewed more negatively than other minority groups. A key characteristic of racial prejudice has been an explicit desire to maintain social distance from defined outgroups; and with 25 to 44 percent of Hispanics and 25 to 50 percent of Asian or Pacific Islander subgroups marrying persons of other races (primarily White) (Rumbaut, 1994), the future trend is that Blacks are likely to be further marginalized. However, rates of Black-White intermarriage have been increasing in recent years—6 percent in 1990 compared to 2 percent in 1970.

  2. Data from around the world indicate that in virtually all cultures, the color black is associated with negative attributes (Franklin, 1968), and Blacks are darker in skin color than any other racial group. National data on Blacks reveal that skin color is a stronger predictor of adult occupation and income than is parental socioeconomic status (Keith and Herring, 1991). National data on Mexicans reveal that those who were darker in skin color and more Indian in appearance experienced higher levels of discrimination than those who were lighter in skin color and more European in appearance (Arce et al., 1987). Similarly, studies of Sephardic Jews in the United States, Israel, and Australia reveal that they experience higher levels of discrimination than their lighter-skinned peers (Rosen, 1982; Kraus and Koresh, 1992; Gale, 1994). Some research also suggests that darker skin color predicts higher levels of morbidity among Blacks (Klag et al., 1991; Dressler, 1996). Thus, although many groups have suffered and continue to experience prejudice and discrimination in the United States, Blacks have always been at the bottom of the racial hierarchy; and the social stigma associated with this group is probably greatest. The resultant unique challenges to socioeconomic mobility and, thus, health status, are likely to persist.

CONCLUSION

This chapter documents that there is a complex but persistent pattern of racial differences in health. On virtually all indicators of physical health status, at least one racial minority population experiences worse

Suggested Citation:"14. Racial Variations in Adult Health Status: Patterns, Paradoxes, and Prospects." National Research Council. 2001. America Becoming: Racial Trends and Their Consequences: Volume II. Washington, DC: The National Academies Press. doi: 10.17226/9719.
×

health status than the White population. These differences should not be ignored for at least two reasons. First, some evidence suggests that because of the economic links tying various communities together, health problems that initially are more prevalent in minority communities eventually spread to other areas and populations (Wallace and Wallace, 1997). If unaddressed, the health problems of minority populations will eventually become the health problems of the larger society. Second, given current patterns of population growth, the health problems of minority populations may soon become the statistical norm. The Bureau of the Census’ 1997 estimate of the population indicates that minority populations comprised 27 percent of the U.S. population and an even higher proportion in the most populous states—49 percent of California, 44 percent of Texas, 34 percent of New York, and 31 percent of Florida. Given current demographic trends, minority racial groups will increasingly become a larger share of the U.S. population. Thus, taking action to improve the health and social conditions of marginalized population groups is investing in our mutual future and likely to have positive health consequences for the entire society.

ACKNOWLEDGMENTS

Preparation of this paper was supported in part by grant 1 RO1 MH57425 from the National Institute of Mental Health and by the John D. and Catherine T.MacArthur Foundation Research Network on Socioeconomic Status and Health. I wish to thank Car Nosel, Clara Kawanishi, Colwick Wilson, and Scott Wyatt for assistance with the preparation of the manuscript.

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The 20th Century has been marked by enormous change in terms of how we define race. In large part, we have thrown out the antiquated notions of the 1800s, giving way to a more realistic, sociocultural view of the world. The United States is, perhaps more than any other industrialized country, distinguished by the size and diversity of its racial and ethnic minority populations. Current trends promise that these features will endure. Fifty years from now, there will most likely be no single majority group in the United States. How will we fare as a nation when race-based issues such as immigration, job opportunities, and affirmative action are already so contentious today?

In America Becoming, leading scholars and commentators explore past and current trends among African Americans, Hispanics, Asian Americans, and Native Americans in the context of a white majority. This volume presents the most up-to-date findings and analysis on racial and social dynamics, with recommendations for ongoing research. It examines compelling issues in the field of race relations, including:

  • Race and ethnicity in criminal justice.
  • Demographic and social trends for Hispanics, Asian Americans, and Native Americans.
  • Trends in minority-owned businesses.
  • Wealth, welfare, and racial stratification.
  • Residential segregation and the meaning of "neighborhood."
  • Disparities in educational test scores among races and ethnicities.
  • Health and development for minority children, adolescents, and adults.
  • Race and ethnicity in the labor market, including the role of minorities in America's military.
  • Immigration and the dynamics of race and ethnicity.
  • The changing meaning of race.
  • Changing racial attitudes.

This collection of papers, compiled and edited by distinguished leaders in the behavioral and social sciences, represents the most current literature in the field. Volume 1 covers demographic trends, immigration, racial attitudes, and the geography of opportunity. Volume 2 deals with the criminal justice system, the labor market, welfare, and health trends, Both books will be of great interest to educators, scholars, researchers, students, social scientists, and policymakers.

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