However, when the poorest group is compared with all other groups, it is clear that the size of the racial/ethnic disparities is much smaller than the size of the income disparities. It is not enough, then, to look at racial and ethnic differences; socioeconomic differences should also be considered. Braveman explained that without considering both, the long-term effects of the experience of racism are not captured.

Braveman noted that institutionalized racism, independent of socio-economic differences, also affects health. The effects of institutionalized racism may mean that a child born to an African American family is far more likely to grow up in a neighborhood with fewer opportunities and more adverse effects on health. Residential segregation systematically tracks certain racial and ethnic groups into worse living and working conditions. The effects of crime, toxic hazards, a lack of safe areas to play or exercise, a lack of access to healthy foods, and an environment filled with despair are all a part of an important potential pathway through which disparities are played out, Braveman said.

From a historical perspective, the focus on disparities in health care at the beginning of the disparities movement, Braveman explained, has had both positive and negative effects. One unfortunate outcome of this focus is that it has fed into racial and ethnic stereotypes and led to unfounded assumptions about the basis of racial and ethnic health disparities. For example, a common assumption is that disparities are based on the construct of “culture.” The problem with this construct is that it implies that culture is something that people freely choose.

More measurement work is needed, said Braveman, to enable the field to do a better job of tracing the pathways by which different social factors contribute to the creation of health disparities. A better understanding of those factors, how they operate, and how they perpetuate and exacerbate health disparities is needed.

Figure 6-2 from the Karolinska Institute in Sweden (Burstrom et al., 2010) outlines a simple way to demonstrate how health inequities are created. Differential exposure is related to social position, and social position is reflected by racial/ethnic group. (Social position can also be reflected by sexual orientation, disability status, or any number of other characteristics that define the likelihood that an individual will experience discrimination on the basis of that social position.) Furthermore, social position determines the extent to which a person is exposed to either factors that promote health or factors that have adverse effects on health.

Differential vulnerability should also be considered; that is, social position also affects the extent to which a given level of exposure is likely to result in a given level of damage to health outcomes. For example, increasing knowledge about the physiology of stress—and, particularly, of chronic stress—demonstrates how experiences associated with a lower social position



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