As we note above, low socioeconomic status is one of the most important predictors of adverse changes in health status (Anderson and Armstead, 1995; Williams, 1990; Williams and Collins, 1995), though the specific mechanisms by which low status compromises health have yet to be adequately elucidated (Anderson and Armstead, 1995; Clark et al., 1999). Similarly, all the mechanisms by which discrimination limits economic and social opportunities still need to be fully accounted for (Williams and Collins, 2001), but that it has historically had an effect on minority socioeconomic status is unquestioned.

Second, discrimination could lead to differences in access to and quality of health care (Blendon et al., 1989; Council on Ethical and Judicial Affairs, 1990; Institute of Medicine, 2002), a possibility we examine in Chapter 10. Third, the experience of specific incidents of unfair treatment on the basis of race or ethnicity may generate psychic distress and other changes in physiological processes that adversely affect health (Clark, 2004; Clark et al., 1999; Landrine and Klonoff, 1996; McNeilly et al., 1996). Fourth, some of the coping strategies that people use as they grapple with inequitable living conditions and a hostile psychosocial environment, such as internalizing negative stereotypes (White et al., 2000) or using drugs and alcohol (Jackson and Ramon, 2002), may also impair physical and psychological functioning (Clark, 2004).

We focus in the rest of this chapter on the third effect, with some reference to the fourth.

Early literature on black health, especially mental health, reflects a clear consensus that racism and discrimination have adverse effects (e.g., McCarthy and Yancey, 1971). That some degree of discrimination continues is clear: for example, audit studies continue to document discrimination in housing and employment (Fix and Struyk, 1993). However, there have been comparatively few attempts to explore empirically the health effects of such discrimination among blacks, whether on children, adolescents, or adults (Jackson et al., 1996; Landrine and Klonoff, 1996; Thompson, 1996; Utsey and Ponterotto, 1996). There have been even fewer empirical studies of any kind on other racial and ethnic groups (Williams et al., 2003). Researchers have continued to note that discrimination is an important factor in understanding black health status, and some suggest that it may account for particular patterns of association (Landrine and Klonoff, 1996). Fernando (1984) even proposed that racial discrimination does not just add to stress; it is an actual pathogen. Nevertheless, these constructs and arguments have received limited empirical attention (Harrell et al., 1998; Krieger, 1999), especially as they relate to the life course and aging.

The evidence that the experience of discrimination affects health outcomes is therefore spotty. The majority of reports that have looked at this issue do document an association between the experience of unequal treat-

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