HERBERT W.NICKENS 1947–1999

The health section of America Becoming: Racial Trends and Their Consequences is dedicated to the memory of Herbert W.Nickens, M.D., M.A., who passed away on March 22, 1999. In his all too brief lifetime, Dr. Nickens devoted his academic and professional interests toward improving the health status of racial and ethnic minorities in the United States. After serving on the staff of the landmark Secretary’s Task Force on Black and Minority Health, Dr. Nickens became the first director of Department of Health and Human Services’ Office of Minority Health. In that role, he was pivotal in crafting the programmatic themes for that office—many of which continue to this day. As the first Vice President for Community and Minority Programs for the Association of American Medical Colleges (AAMC), Dr. Nickens devoted much of his professional energy to increasing the number of underrepresented minority applicants to medical school. His passion for social justice brought forth the Project 3000 by 2000, which reignited the institution’s long-standing commitment to increasing minority representation in medicine. Dr. Nickens’s interests did not, however, focus solely on the educational pipeline. He continued to maintain his focus on eliminating minority health disparities in his scholarly writings, such as the co-authorship of one of the chapters in this report, and in AAMC programming, such as the Health Services Research Institute for Minority Medical School Faculty. Herbert W.Nickens will be remembered for many things—but most importantly for his pursuit of equity in health.



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America Becoming: Racial Trends and Their Consequences - Volume II HERBERT W.NICKENS 1947–1999 The health section of America Becoming: Racial Trends and Their Consequences is dedicated to the memory of Herbert W.Nickens, M.D., M.A., who passed away on March 22, 1999. In his all too brief lifetime, Dr. Nickens devoted his academic and professional interests toward improving the health status of racial and ethnic minorities in the United States. After serving on the staff of the landmark Secretary’s Task Force on Black and Minority Health, Dr. Nickens became the first director of Department of Health and Human Services’ Office of Minority Health. In that role, he was pivotal in crafting the programmatic themes for that office—many of which continue to this day. As the first Vice President for Community and Minority Programs for the Association of American Medical Colleges (AAMC), Dr. Nickens devoted much of his professional energy to increasing the number of underrepresented minority applicants to medical school. His passion for social justice brought forth the Project 3000 by 2000, which reignited the institution’s long-standing commitment to increasing minority representation in medicine. Dr. Nickens’s interests did not, however, focus solely on the educational pipeline. He continued to maintain his focus on eliminating minority health disparities in his scholarly writings, such as the co-authorship of one of the chapters in this report, and in AAMC programming, such as the Health Services Research Institute for Minority Medical School Faculty. Herbert W.Nickens will be remembered for many things—but most importantly for his pursuit of equity in health.

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America Becoming: Racial Trends and Their Consequences - Volume II 11 Racial and Ethnic Differences in Health: Recent Trends, Current Patterns, Future Directions Raynard S.Kington and Herbert W.Nickens The volume of research addressing racial and ethnic differences in health has grown dramatically in recent decades as more and better data have become available. Health results from the interaction of intrinsic genetic and biological factors with environmental and social factors distributed throughout every facet of life. Health also influences every facet of life: it affects one’s ability to work, to socialize, to think, to learn, to communicate, to reproduce. Because of the complex causal pathways and widespread influences, no single discipline is sufficient to address the problem of racial and ethnic differences in health status. All of the behavioral and social sciences—anthropology, psychology, sociology, economics, and demography—have contributed to the understanding of racial and ethnic health differentials. The public health and medical sciences provide different and often complementary perspectives. Researchers grounded in epidemiology, genetics, molecular biology, physiology, and clinical medicine have all described aspects of health and disease that differ by race or ethnicity and have posited theories to account for those differences. In attempting to synthesize these data into a coherent whole, we have decided against presenting our findings within a single theoretical framework. Instead, we chose an ecumenical approach, accepting core insights from multiple disciplines to understand the evidence on why racial and ethnic groups differ in health status and what can be done to address the disparities.

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America Becoming: Racial Trends and Their Consequences - Volume II HISTORICAL PERSPECTIVE Over the past century, a series of reports have addressed the health of minorities in the United States: from the health-related papers in the Atlanta University Series (1896, 1906), to the comprehensive review by Dorn (1940) on the health of Blacks written as a background paper for Gunnar Myrdal’s An American Dilemma, to the groundbreaking 1985 Report of the Secretary’s Task Force on Black and Minority Health (U.S. Department of Health and Human Services, 1985). Until the 1960s and 1970s, minority health studies in the United States focused on Blacks. The exception was an extensive body of anthropological literature on American Indian health, dating from the 1920s (see the review in Young, 1994, pp. 25–28). Much of it suggests that the introduction of infectious diseases from European colonists led to a significant decline in the American Indian population; that decline did not begin to reverse itself until the end of the nineteenth century. Other studies of the health status of non-Black minorities in the nineteenth and early twentieth centuries were likely carried out, but probably limited to a single locale. Systematic registration of deaths in the nation began only about 50 years ago when all of the United States was included in the Death Registration Area1 (Ewbank, 1987), and all of the historic studies show that Black death rates were substantially higher than those for Whites. Disparities lessened somewhat, however, when Blacks and Whites at similar socioeconomic position (SEP) were compared (e.g., Holland and Perrott, 1938). In the nineteenth century, Black death rates decreased along with those for Whites. Although Black death rates remained at a higher level, there were fewer deaths overall from infectious diseases because of improvements in factors such as water and sanitation and in child care. Ewbank (1987) concludes that in the second half of the nineteenth century, declines in Black mortality were minimal, but life expectancy increased from about 35 to 54 years between 1900 and 1940; thus, life expectancy for Blacks in 1940 was approximately equal to what life expectancy was for Whites in 1920. Race as a Concept in Health Studies Race as a factor in health care and health outcomes is increasingly being recognized and addressed by researchers. The modern concept of 1   Begun in 1880, the national Death Registration Area included only Massachusetts, New Jersey, and the District of Columbia. The other states were gradually included; and by 1933 all 48 contiguous states and the District of Columbia were included; Alaska and Hawaii were added when they became states.

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America Becoming: Racial Trends and Their Consequences - Volume II race was developed during a period of intense global exploration and European colonialism. Hierarchical schemes of classification rooted in dubious theories of biology and genetics were invented to classify individuals as both foreign and inferior. This strategy served as a scientific and moral enabler of colonial economic activity, for which enslaving people was accepted as an economic expedient. The concept of race, however, has been under increasing assault in the last half of the twentieth century from at least two different fronts. First, the Civil Rights Movement and its aftermath led to the end of legal segregation. Subsequently, since the 1960s, there has been increasing racial integration in the U.S. mainstream. Second, intense and sustained immigration has led to a more diverse U.S. population, resulting in a society so multiracial, simplistic racial classification and hierarchies are no longer sustainable. The concept of “race” as it has been typically used in health research, however, has at least five flaws: “Race” does not reflect meaningful biological or genetic distinctions. Race classifications are based on an individual’s appearance; and although physiognomic differences are genetic, the vast proportion of genetic variation is not so visible, and occurs within races, not between them (Lewontin, 1972). Race classification schemes are highly imprecise (LaVeist, 1994; Williams et al., 1993; Williams, 1996). In the case of determining the race of a child, such a classification may rely on arbitrary rules based on factors such as race or nationality of the mother, race or nationality of the father, or the race the mother or father if either was non-White, etc. In determining race on a death certificate or health record, judgment is often made visually by a clerk or a funeral director. Our current concept of race is distorted by America’s Black-White experience. This is especially problematic with regard to trying to classify “Hispanics,” who may be either Black or White, though the vast majority of Hispanics self-describe as White (U.S. Bureau of the Census, 1999). The idea of a pure race is problematic. Each human being more than likely embodies a variety of racial groups. U.S. citizens who self-identify as Black, for example, are likely genetic admixtures of White, American Indian, and African in widely different proportions. The widespread analysis of data by race may steer investigators away from thinking more deeply about actual underlying variables of interest such as SEP, disenfranchisement, and cultural values. In an examination of the use of “race” in the journal Health Services Research over a 25-year period, Williams (1994) noted that about 66 percent of empirical studies included “race,” but only 13 percent defined the term or had a justifiable reason for using it.

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America Becoming: Racial Trends and Their Consequences - Volume II Quality of Health and Health-Care Data One of the primary challenges in research addressing racial and ethnic health disparities is the quality of data on the health status and health care of many minority populations. Data accuracy is especially problematic for Hispanics, Asian and Pacific Islanders, and American Indians and Alaska Natives. In the 1980s, fewer than half of the states recorded Hispanic ethnicity on death certificates. By 1996, the District of Columbia and all states except Oklahoma reported Hispanic ethnicity on death certificates (National Center for Health Statistics, 1998). Sorlie and colleagues (1992a) compared reported race and ethnicity from study data with death certificate data for 21,000 deaths in the National Longitudinal Mortality Survey and found that while agreement on race was 99.2 percent for Whites and 98.2 percent for Blacks, agreement for American Indians and Alaska Natives was 73.6 percent and for Asians and Pacific Islanders 82.4 percent. Agreement for ethnicity was 89.7 percent for Hispanics. Hahn and Eberhardt (1995) analyzed 1990 death certificate data, correcting for both census undercount and race misclassification. Changes in the estimates of American Indian and Alaska Native mortality were particularly striking; estimated life expectancy at birth decreased from 73.8 years to 71.0 years for men and from 81.6 years to 79.4 years for women. The change resulted in this population going from having a reported health advantage compared to Whites to having a disadvantage. Mortality rates that are not adjusted for misclassification underestimate the mortality of these populations and lead to overestimates of life expectancy. Protocols for collecting racial and ethnic data also change over time. Kovar and Poe (1985) considered changes in data collection for the National Health Interview Survey (NHIS). From its inception in 1957 until 1976, NHIS racial categorization depended on interviewer observation, and all racial and ethnic categories other than Black and White were identified as “Other Races.” In 1976, in addition to interviewer-observed race, the NHIS added a single question allowing the respondent to identify one of the following categories as his or her national origin or ancestry: countries of Central or South America, Chicano, Cuban, Mexican, Mexicano, Mexican-American, Puerto Rican, Other Spanish, Other European (such as German, Irish, English, or French), Black/Negro/Afro-American, American Indian/Alaskan Native, and Asian and Pacific Islander (such as Chinese, Japanese, Korean, Filipino, Samoan). In 1978, to comply with guidelines established by the U.S. Office of Management and Budget (OMB) Directive 15, that question was then changed to two parts: the first addressed Hispanic ethnicity; the second addressed race. Persons who self-identified as being of Hispanic ancestry could report any of the following groups: Puerto Rican, Cuban, Mexican/Mexicano,

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America Becoming: Racial Trends and Their Consequences - Volume II Mexican American, Chicano, “Other Latin American,” or “Other Spanish.” Racial categories to choose from were American Indian or Alaska Native, Asian and Pacific Islander, Black, White, or other. In 1992, NHIS expanded the subgroups of Asians and Pacific Islanders; in addition to Chinese, Filipino, Korean, and Japanese, respondents could choose Vietnamese, Asian Indian, Samoan, Guamanian, and “Other Asian and Pacific Islander.” (Beginning with the 2000 Census, all federal data systems will over several years change to comply with the revised OMB Revision directive that mandates federal agencies that collect data on race to allow persons to self-identify as being a member of more than one racial group [Office of Management and Budget, 1997].) Although data from longitudinal cohort studies or interview surveys that rely on self-report of race and ethnicity should not be subject to significant misclassification errors, these longitudinal data sets do not allow assessment of trends in differences between races and ethnic groups. Measures of Health Status “Health” extends far beyond simple measures of the risk of disease and death. It encompasses an array of quality-of-life dimensions that include physical and social functioning and mental well-being. The primary measures of health we used in this overview are life expectancy, all-cause mortality, and, when available, respondent-rated general health status. Life expectancy is the estimated average number of years of life remaining for a person at a given age, and life expectancy at birth is a good summary measure of mortality differences across the life cycle. We use age-adjusted mortality rates,2 wherever possible, to allow appropriate comparisons because the age structure varies substantially across racial and ethnic groups. We use only all-cause mortality because subsequent chapters address cause-specific rates. Respondent-rated3 general health status is measured by the response to a standard survey question that asks a person to grade his or her overall health, usually on a scale of excellent, very good, good, fair, and poor. How a respondent answers 2   Age-adjusted rate: statistically, a weighted average of age-specific rates, where the weights represent the fixed proportion by age; thus, age-specific rates provide the adjusted rates for all ages combined. 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 or age or older, where significantly fewer Blacks were in that age group. 3   We use the term “respondent-rated” rather than “self-rated” or “self-reported” because in some surveys a household respondent may answer for another individual in the household.

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America Becoming: Racial Trends and Their Consequences - Volume II that single question captures many dimensions of health including health-related quality-of-life and functional status; how a respondent answers has also proved to be a significant predictor of mortality even after accounting for standard socio-demographic factors (Idler and Benyamini, 1997). PATTERNS OF RACIAL AND ETHNIC DIFFERENCES IN MORTALITY AND GENERAL HEALTH STATUS The story of health in the United States in the twentieth century can be summarized by two central findings. First, simply and clearly, across age groups, across racial and ethnic groups, among males and females, by almost all indicators, the health of the U.S. population has improved dramatically. Second—and complex to the degree that it defies straightforward description—in spite of the improvements, there have been remarkably persistent differences in health status by race and ethnicity, with the members of many, but not all, racial and ethnic minorities experiencing worse health than the majority population but also with substantial heterogeneity within any one group. Both findings are illustrated by statistics listed in Table 11–1. Members of the largest minority group of the twentieth century, Blacks, have experienced poorer health compared to Whites throughout the century. Members of the fastest growing minority group in absolute numbers, Hispanics, have enjoyed relatively good health by some measures but contain within their ranks substantial variation—e.g., health of TABLE 11–1 Age-Adjusted Death Rates, 1980–1996 (per 100,000 person years)   1980 1990 1996 White 559.4 492.8 466.8 Black 842.5 789.2 738.3 Hispanic – 400.2 365.9 American Indian/ Alaska Native 564.1 445.1 456.7 Asian or Pacific Islander 315.6 297.6 277.4   SOURCE: National Center for Health Statistics (1998).

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America Becoming: Racial Trends and Their Consequences - Volume II Puerto Ricans is comparatively poorer, whereas health of Mexican Americans and Cubans is comparatively better. For Asians and Pacific Islanders the picture is varied as well, though many Asian and Pacific Islander subgroups have comparatively good health. American Indians and Alaska Natives, like Blacks, continue to experience poorer health than Whites, though in recent periods the health gap between Whites and American Indians and Alaska Natives has narrowed considerably. Black Americans Over the course of the twentieth century, life expectancy at birth for Blacks has more than doubled; for Whites it increased by about 60 percent. In 1900, life expectancy for a Black person was 33 years and 47.6 years for a White person; by 1950, life expectancy had risen to 60.7 years for Blacks and 69.1 years for Whites (National Center for Health Statistics, 1998). The Black-White gap had decreased to its lowest point, 5.8 years, around 1984, and then began to increase due to high death rates among Blacks from HIV, homicides, diabetes, and pneumonia. (A decrease in life expectancy was extremely unusual for a large subpopulation in a developed country.) Another factor in the increased differential was that mortality from heart disease decreased at a much faster rate for Whites than for Blacks (Kochanek et al., 1994). By 1989 the gap was at 7.0 years, where it remained until 1995. By 1996 life expectancy increased to 70.2 years for Blacks and 76.8 years for Whites (National Center for Health Statistics, 1998). Comparison of age-adjusted all-cause mortality rates for Blacks presents a similar picture. In 1950, the mortality rate for Blacks was 1,236.7 per 100,000; the rate for Whites was 800.4. As shown in Table 11–1, by 1996, the rate for Blacks had fallen by almost 40 percent to 738.3; the rate for Whites was 466.8 (National Center for Health Statistics, 1998). One fact is true for all groups: women live longer than men. Relative gains in mortality and life expectancy have not been experienced equally, however, by Black men and women. In 1900, the life expectancy at birth of Black females was 1 year greater than for Black males; for White females life expectancy was 2.1 years longer than for White men. Among Blacks the differential increased to 3.8 more years for females in 1950,8.3 more in 1970, and peaked at about 9.2 years in 1991. In 1996 it decreased to 8.1 years. Among Whites the differential peaked in 1970 at 7.6 years and has steadily declined since then, primarily because of reductions in cardiovascular disease among men (National Center for Health Statistics, 1998; Waldron, 1993). National survey data on respondent-reported general health status also suggest a poorer health-related quality of life for Blacks compared to Whites. The age-adjusted percentage of Blacks who reported “fair” or

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America Becoming: Racial Trends and Their Consequences - Volume II “poor” health in 1995 was 15.4 percent compared to 8.7 percent for Whites (National Center for Health Statistics, 1998), and it has remained around 15 to 17 percent during the last decade. Among the elderly age 75 or older, the Black-White gap in the percentage reporting “fair” or “poor” health narrowed from 18.8 percent to 13.1 percent between 1987 and 1995. Among Black persons age 75 and older the percentage dropped from 52.4 to 44.4; among Whites, from 33.2 percent to 31.2 percent. Although the Black population is often thought of as a culturally distinctive, homogenous group, there are in fact significant differences among subgroups. Several studies have described wide variation in mortality rates among Blacks in different parts of the county, with some areas far behind others in recent improvements in health (McCord and Freeman, 1990; Geronimus et al., 1996). A growing literature has also described differences in health between Blacks who were born in the South and Blacks born in other parts of the country (Fang et al., 1996; Schneider et al., 1997; Kington et al., 1998). Most, but not all, of this literature has found worse health for Blacks born in the South even if they have migrated. These findings may be related to poor early-life health conditions in the South or perhaps to more subtle psychosocial factors (Schneider et al., 1997). A related body of literature is now describing the health of recent immigrants of African descent, most notably those from the Caribbean but more recently those from sub-Saharan Africa. In 1980, approximately 3.1 percent of Black Americans were foreign born. It is estimated that by 2010, over 10 percent of the Black population in the United States will be recent immigrants or their descendants (Reid, 1986). We know of no national studies of West Indian or African immigrants, but Fang and colleagues (1997) analyzed data on mortality in New York and found that U.S.-born Blacks had between 1.5 and 2 times the age-adjusted mortality rate of foreign-born Blacks (67 percent of whom were from the West Indies, 12 percent from South America, and 5 percent from Africa). David and Collins (1997) analyzed data on the birth weight of infants, a potent indicator of infant mortality risk, and found that among infants born in Chicago between 1985 and 1990, those born to African-born Black women were likely to have a birth weight more similar to infants of U.S.-born White women rather than to babies born to U.S.-born Black women. Literature on the relatively good health of foreign-born Blacks in the United States has been used to dispel the idea that Black health status is genetically based. Comparisons across Black subgroups may provide important additional insights into the causes of racial and ethnic differences in health.

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America Becoming: Racial Trends and Their Consequences - Volume II Hispanic Americans By some measures of general health status, Hispanics experience relatively good health, but closer scrutiny of the data reveals a more complicated pattern. Life expectancy at birth for Hispanics in 1990 was estimated to be 79.1 years, 3 years longer than the 76.1 years estimated for Whites (Erikson et al., 1995). That 79.1 years, however, is almost certainly an overestimate because it is based on data that exclude several states, including New York, where over 40 percent of Puerto Ricans live, and this group generally has poorer health status than other Hispanic subgroups. NCHS mortality data also suggest that the health of the Hispanic population has improved. Between 1985 and 1994–1996, the age-adjusted mortality rate for Hispanic males decreased from 524.8 to 501.1, and for Hispanic females from 286.6 to 270.34 (National Center for Health Statistics, 1998). For non-Hispanic White males over this period, the mortality rate dropped from 669.7 to 602.8 and for females from 385.3 to 365.5. Analyses by Sorlie et al. (1993) and Liao et al. (1998) of longitudinal data on national sample cohorts revealed a similar pattern of lower mortality rates for Hispanics compared to non-Hispanic Whites. In 1990, Mexican Americans comprised the largest subpopulation of Hispanics, 63 percent, Puerto Ricans comprised 11 percent, Cubans, 5 percent, and a combined category of “all other Hispanics” including immigrants from Central and South America comprised the remaining 21 percent (US. Bureau of the Census, 1991). Analyses of data sets that have included a sufficient number of members of each subgroup to compare have found substantial differences across the Hispanic subgroups. For example, Sorlie and colleagues (1993) analyzed data from the National Longitudinal Mortality Study and compared the age-adjusted mortality rate of Hispanic subpopulations and the non-Hispanic population; they found that the ratio for Hispanics compared to non-Hispanics was 0.74:1 for men and 0.82:1 for women (ratios less than 1 indicate better health than Whites), but the ratio varied substantially across age groups. For example, among men older than age 65, Mexicans, Puerto Ricans, Cubans, and a final category of “all other Hispanics” each had substantially lower mortality rates than non-Hispanics. In contrast, among those aged 25 to 44, no Hispanic subgroup had a mortality risk significantly different than Whites. Liao and colleagues (1998) analyzed linked mortality data from the 1986–1990 NHIS and describe a similar pattern of overall lower 4   Again, these trend data must be viewed with caution because the 1985 rates are based on data from 17 states and the District of Columbia (90 percent of the Hispanic population) while the 1994–1996 rates are based on data from 49 states plus the District of Columbia (99.6 percent of the Hispanic population) (National Center for Health Statistics, 1998).

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America Becoming: Racial Trends and Their Consequences - Volume II mortality for Hispanics, but with a pattern of significantly higher mortality among young Hispanic men and lower mortality among older Hispanics. Mortality data present a picture of relatively good health for Hispanics on average; however, survey data on respondent-reported general health present a different picture. Data from the 1992–1994 NHIS revealed that Hispanics were more likely to report “fair” or “poor” health (14.7 percent) than non-Hispanic Whites (10.4 percent). Among Hispanic subgroups, Puerto Ricans were more likely to report “fair” or “poor” health (17.4 percent) than Mexicans (15.3 percent) or Cubans (13.3 percent). A similar pattern of relatively poor respondent-rated health status for Hispanics was found in the 1987–1988 National Survey of Families and Households (Ren and Amick, 1996). American Indians and Alaska Natives Much of the data on the health of American Indians and Alaska Natives comes from the Indian Health Service (IHS), which provides healthcare services primarily to the American Indian and Alaska Native populations living on or near reservations (Indian Health Service, 1996; Kunitz, 1996) —about 60 percent of all Native Americans residing in the United States. The consensus is that American Indians and Alaska Natives have significantly poorer health than Whites, and data from the IHS, which generally provides a reasonable picture of its service population, corroborate that consensus. Their data also suggest that the gap between American Indians and Alaska Natives and Whites is narrowing.5 In 1940, life expectancy at birth for American Indians and Alaska Natives was 51 years compared to 64.2 years for Whites, a gap of 13 years (Indian Health Service, 1991). By the period of 1972 to 1974, life expectancy for the IHS population had increased to 63.5, leaving about an 8-year gap. By 1991– 1993, the gap had narrowed to about 3.3 years, with a life expectancy of 73.2 years for the IHS population (Indian Health Service, 1996). Although more than half of American Indians live in urban areas, IHS provides services in relatively few urban areas (Indian Health Service, 1996). Because the IHS data are the primary source of high-quality data on the health of American Indians, little is known about the health of urban American Indians and Alaska Natives. In one of the few studies of urban American Indians, Grossman and colleagues (1994) compared health indicators among urban American Indians, Blacks, and Whites in 5   Even IHS data probably underestimate mortality and overestimate life expectancy for American Indians and Alaska Natives (Indian Health Service, 1991).

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America Becoming: Racial Trends and Their Consequences - Volume II Dorn, H. 1940 The Health of the Negro, A Research Memorandum. Carnegie-Myrdal Study. New York: Schomburg Center for Research in Black Culture. Dowd, J., and V.Bengston 1978 Aging in minority populations: An examination of the double jeopardy hypothesis. Journal of Gerontology 33(3):427–436. Dressler, W. 1993 Health in the African American community: Accounting for health inequalities. Medical Anthropology Quarterly 7:325–345. DuBois, W.E.B. 1899 The Philadelphia Negro: A Social Study. Philadelphia: University of Pennsylvania Press. English, P., M.Kharrazi, and S.Guendelman 1997 Pregnancy outcomes and risk factors in Mexican Americans: The effect of language use and mother’s birthplace. Ethnicity and Disease 7:229–240. Erikson, P., R.Wilson, and I.Shannon 1995 Years of healthy life. Statistical Notes No. 7. Hyattsville, Md.: Centers for Disease Control and Prevention, National Center for Health Statistics. Escarce, J., K.Epstein, D.Colby, and J.Schwartz 1993 Racial differences in the elderly’s use of medical procedures and diagnostic tests. American Journal of Public Health 83:948–954. Ettner, S. 1996 New evidence on the relationship between income and health. Journal of Health Economics 15:49–66. Evans, R., M.Barer, and T.Marmor, eds. 1994 Why Are Some People Healthy and Others Not? The Determinants of Health of Populations. New York: Aldine De Gruyter. Ewbank, D. 1987 History of Black mortality and health before 1940. Milbank Memorial Fund Quarterly 5:100–128. Fang, J., T.Madhavan, and M.Alderman 1996 The association between birthplace and mortality from cardiovascular causes among Black and White residents of New York City. New England Journal of Medicine 335:1545–1551. 1997 Nativity, race and mortality: Influence of region of birth on mortality of U.S.-born residents of New York City. Human Biology 69(4):533–544. Farrer, L., L.Cupples, J.Haines, B.Hyman, and W.Kukull 1997 Effects of age, sex, and ethnicity on the association between apolipoprotein E genotype and Alzheimer disease: A metaanalysis. Journal of the American Medical Association 278:1349–1356. Feinstein, J. 1993 The relationship between socioeconomic status and health—A review of the literature. Milbank Memorial Fund Quarterly 71:279–323. Ferraro, K., and M.Farmer 1996 Double jeopardy to health hypothesis for African Americans: Analysis and critique. Journal of Health and Social Behavior 37:27–43. Fiscella, K. 1995 Does prenatal care improve birth outcomes? A critical review. American Journal of Obstetrics and Gynecology 85(3):468–479.

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America Becoming: Racial Trends and Their Consequences - Volume II Fiscella, K., and P.Franks 1997 Does psychological distress contribute to racial and socioeconomic disparities in mortality? Social Sciences and Medicine 45:1805–1809. Flegal, K., M.Carroll, R.Kuczmarski, and C.Johnson 1998 Overweight and obesity in the United States: Prevalence and trends, 1960–1994. International Journal of Obesity 22:39–47. Ford, E., and R.Cooper 1995 Racial and ethnic differences in health care utilization of cardiovascular procedures: A review of the evidence. Health Services Research 30:237–251. Franks, P., C.Clancy, and M.Gold 1993a Health insurance and mortality. Evidence from a national cohort. Journal of the American Medical Association 270:737–741. Franks, P., C.Clancy, M.Gold, and P.Nutting 1993b Health insurance and subjective health status: Data from the 1987 National Medical Expenditure Survey. American Journal of Public Health 83:1295–1299. Freeman, V., and L.Martin 1998 Understanding trends in functional limitations among older Americans. American Journal of Public Health 88:1457–1462. Friedman-Jimenez, G., and J.Ortiz 1994 Occupational health. In Hispanic Health in the U.S.: A Growing Challenge, C.Molina and M.Aguirre-Molina, eds. Washington, D.C.: American Public Health Association. Garber, A. 1989 Pursuing the links between socioeconomic factors and health: Critique, policy implications, and directions for future research. In Pathways to Health: The Role of Social Factors, J.Bunker, D.Gomby, and B.Kehrer, eds. Menlo Park, Calif.: Henry J.Kaiser Family Foundation. General Accounting Office (GAO) 1983 Siting of Hazardous Waste Landfills and Their Correlation with Racial and Ethnic Status of Surrounding Communities. RCED-83–168. Washington, D.C.: General Accounting Office. 1992 Hispanic Access to Health Care: Significant Gaps Exist. PEMD-92–6. Washington, D.C.: General Accounting Office. Geronimus, A., J.Bound, T.Waidmann, M.Hillemeire, and P.Burns 1996 Excess mortality among Blacks and Whites in the United States. New England Journal of Medicine 335:1552–1558. Gibson, R. 1991 Age-by-race differences in the health and functioning of elderly persons. Journal of Aging and Health 3:335–351. Grossman, D., J.Krieger, J.Sugarman, and R.Forquera 1994 Health status of urban American Indians and Alaskan Natives. Journal of the American Medical Association 271:845–850. Guralnik, J., K.Land, D.Blazer, G.Fillenbaum, and L.Branch 1993 Educational status and active life expectancy among older Blacks and Whites. New England Journal of Medicine 329:110–116. Haan, M., and T.Camacho 1987 Poverty and health: Prospective evidence from the Alameda County Study. American Journal of Epidemiology 125:989–998. Haan, M., and G.Kaplan 1985 The contribution of SEP to minority health. In Report of the Secretary’s Task Force on Black and Minority Health: Crosscutting Issues in Minority Health. Washington, D.C.: U.S. Department of Health and Human Services.

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America Becoming: Racial Trends and Their Consequences - Volume II Hahn, R., and S.Eberhardt 1995 Life expectancy in four U.S. racial/ethnic populations: 1990. Epidemiology 6(4):350– 355. Halperin, E. 1988 Desegregation of hospitals and medical societies in North Carolina. New England Journal of Medicine 318:58–63. Hart, C, G.Smith, and D.Blane 1998 Inequalities in mortality by social class measured at three stages of lifecourse. American Journal of Public Health 88:471–474. Hayes-Bautista, D. 1992 Latino health indicators and the underclass model: From paradox to new policy models. In Health Policy and the Hispanic, A.Furino, ed. Boulder, Colo.: Westview Press. Haynes, S., C.Harvey, H.Montes, H.Nickens, and B.Cohen 1990 Patterns of cigarette smoking among Hispanics in the United States: Results from the HHANES 1982–84. American Journal of Public Health 80(Suppl):47–54. Hazuda, H., S.Haffner, M.Stern, and C.Eifler 1988 Effects of acculturation and socioeconomic status on obesity and diabetes in Mexican Americans. American Journal of Epidemiology 128:1289–1301. Holland, D., and G.Perrott 1938 The health of the Negro. Milbank Memorial Fund Quarterly 16:5–38. Hoyert, D., and H.Kung 1997 Asian and Pacific Islander mortality, selected states, 1992. Monthly Vital Statistics Report 46(1 Suppl):1–63. Hutchins, E., J.Reitman, and D.Klaub 1967 Minorities, manpower, and medicine. Journal of Medical Education 42:809–821. Idler, E., and Y.Benyamini 1997 Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior 38:21–37. Indian Health Service (IHS) 1991 Trends in Indian Health, 1991. Rockville, Md.: Indian Health Service, U.S. Department of Health and Human Services. 1996 Trends in Indian Health, 1996. Rockville, Md.: Indian Health Service, U.S. Department of Health and Human Services. Institute of Medicine (IOM) 1999 Toward Environmental Justice: Research, Education, and Health Policy Needs. Washington, D.C.: National Academy Press. Jackson, J., T.Brown, D.Williams, M.Torres, S.Sellers, and K.Brown 1996 Racism and the physical and mental health status of African Americans: A thirteen year national panel study. Ethnicity and Disease 6:132–147. James, S. 1994 John Henryism and the health of African Americans. Culture, Medicine and Psychiatry 18:163–182. James, W., M.Nelson, A.Ralph, and S.Leather 1997 The contribution of nutrition to inequalities in health. British Medical Journal 314:1545–1549. Jarvik, G. 1997 Genetic predictors of common disease: Apolipoprotein E genotype as a paradigm. Annals of Epidemiology 7:357–362.

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America Becoming: Racial Trends and Their Consequences - Volume II John, R. 1996 Demography of American Indian elders: Social, economic, and health status. In Changing Numbers, Changing Needs: American Indian Demography and Public Health, G.Sandefur, R.Rindfuss, and B.Cohen, eds. Washington, D.C.: National Academy Press. Johnson, B., and S.Coulberson 1993 Environmental epidemiologic issues and minority health. Annals of Epidemiology 3:175–180. Kahn, K.L., M.L.Pearson, E.R.Harrison, K.A.Desmond, W.H.Rogers, L.V.Rubenstein, R.H.Brook, and E.B.Keeler 1994 Health care for Black and poor hospitalized Medicare patients. Journal of the American Medical Association 271(15):1169–1174. Karoly, L. 1996 Anatomy of the U.S. income distribution: Two decades of change. Oxford Review of Economic Policy 12(1):77–96. Kaufman, J., and R.Cooper 1995 In search of the hypothesis. Public Health Reports 110:662–666. Kaufman, J., R.Cooper, and D.McGee 1997 Socioeconomic status and health in Blacks and Whites: The problem of residual confounding and the resiliency of race. Epidemiology 8:621–628. Kaufman, J., A.Long, Y.Liao, R.Cooper, and D.McGee 1998 The relation between income and mortality in U.S. Blacks and Whites. Epidemiology 9:147–155. Keil, J., S.Sutherland, R.Knapp, and H.Tyroler 1992 Does equal socioeconomic status in Black and White men mean equal risk of mortality? American Journal of Public Health 82:1133–1136. Kennedy, B., I.Kawachi, K.Lochner, C.Jones, and D.Prothrow-Stith 1997 (Dis)respect and Black mortality. Ethnicity and Disease 7:207–214. Kessler, R., and H.Neighbors 1986 A new perspective on the relationships among race, social class, and psychological distress. Journal of Health and Social Behavior 27:107–115. Kington, R., D.Carlisle, D.McCaffrey, H.Myers, and W.Allen 1998 Racial differences in functional status among elderly U.S. migrants from the south. Social Sciences and Medicine 47:831–840. Kington, R., and J.Smith 1997 Socioeconomic status and racial and ethnic differences in functional status associated with chronic diseases. American Journal of Public Health 87:805–810. Kipen, H., D.Wartenberg, P.Scully, and M.Greenberg 1991 Are non-Whites at greater risk for occupational cancer? American Journal of Indian Medicine 19:76–74. Kochanek, K., J.Maurer, and H.Rosenberg 1994 Why did Black life expectancy decline from 1984 through 1989 in the United States? American Journal of Public Health 84:938–944. Komaromy M., K.Grumbach, M.Drake, K.Vranizan, N.Lurie, D.Keane, and A.Bindman 1996 The role of Black and Hispanic physicians in providing health care for underserved populations. New England Journal of Medicine 334:1305–1310. Kovar, M., and G.Poe 1985 The National Health Interview Survey design, 1973–1984, and procedures, 1975– 1993. Vital and Health Statistics. Series 1, No. 8. DHHS Pub. No. (PHS) 85–1320. National Center for Health Statistics. Washington, D.C.: U.S. Government Printing Office.

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America Becoming: Racial Trends and Their Consequences - Volume II Krieger, N. 1987 Shades of difference: Theoretical underpinnings of the medical controversy on Black/White differences in the United States, 1830–1870. International Journal of Health Services 17:259–278. Krieger, N., and S.Sidney 1996 Racial discrimination and blood pressure: The CARDIA study of young Black and White adults. American Journal of Public Health 86:1370–1378. Krieger, N., D.Williams, and N.Moss 1997 Measuring social class in U.S. public health research: Concepts, methodologies and guidelines. Annual Review of Public Health 18:341–378. Kumanyika, S. 1993 Special issues regarding obesity in minority populations. Annals of Internal Medicine 119:650–654. Kunitz, S. 1996 The history and politics of U.S. health care policy for American Indians and Alaskan Natives. American Journal of Public Health 86(10):1464–1473. Kuo, J., and K.Porter 1998 Health status of Asian Americans: United States, 1992–1994. Advance Data from Vital and Health Statistics; no. 298. Hyattsville, Md.: National Center for Health Statistics. The Lancet 1995 The unequal, the achievable, and the champion. The Lancet 345:1061–1062. Lantz, P., J.House, J.Lepkowski, D.Williams, R.Mero, and J.Chen 1998 Socioeconomic factors, health behaviors, and mortality. Results from a nationally representative prospective study of U.S. adults. Journal of the American Medical Association 279:1703–1708. LaVeist, T. 1994 Beyond dummy variables and sample selection: What health services researchers ought to know about race as a variable. Health Services Research 29(1):1–16. Lavizzo-Mourey, R., and E.Mackenzie 1996 Cultural competence: Essential measurements of quality for managed care organizations. Annals of Internal Medicine 124(10):919–921. Lewontin, R. 1972 The apportionment of human diversity. Evolutionary Biology 6:381–398. Liao, Y., R.Cooper, G.Cao, R.Durazo-Arvizu, J.Kaufman, A.Luke, and D.McGee 1998 Mortality patterns among adult Hispanics: Findings from the NHIS 1986–1990. American Journal of Public Health 88:227–232. Libby, D., Z.Zhou, and D.Kindig 1997 Will minority physician supply meet U.S. needs? Health Affairs 16:205–214. Lillie-Blanton, M., P.Parson, H.Gayle, and A.Dievler 1996 Racial differences in health: Not just Black and White, but shades of gray. Annual Review of Public Health 17:411–448. Lind, M. 1998 The Beige and the Black. New York Times Magazine, August 16:38–39. Loomis, D., and D.Richardson 1998 Race and risk of fatal injury at work. American Journal of Public Health 88:40–44. Lynch, J., G.Kaplan, and S.Shema 1997 Cumulative impact of sustained economic hardship on physical, cognitive, psychological, and social functioning. New England Journal of Medicine 337(26):1889– 1895.

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America Becoming: Racial Trends and Their Consequences - Volume II MacDorman, M, and J.Atkinson 1998 Infant mortality statistics from the linked birth/infant death data set—1995 period data. Monthly Vital Statistics Report 46(6/Suppl 2). Hyattsville, Md.: National Center for Health Statistics. Malcolm S., G.VanHorne, Y.George, and C.Gaddy 1998 Losing Ground: Science and Engineering Graduate Education of Black and Hispanic Americans. Washington, D.C.: American Association for the Advancement of Science. Markides, K., and J.Coreil 1986 The health of Hispanics in the southwestern United States: An epidemiologic paradox. Public Health Reports 3:253–265. Marmot, M. 1998 Improvement of social environment to improve health. The Lancet 351:57–60. Marmot, M., H.Bosma, H.Hemingway, E.Brunner, and S.Stansfield 1997 Contribution of job control and other risk factors to social variations in coronary heart disease incidence. The Lancet 350:235–239. Marmot, M., M.Kogevinas, and M.Elston 1987 Social/economic status and disease. Annual Review of Public Health 8:111–135. May, P. 1996 Overview of alcohol abuse epidemiology for American Indian populations. In Changing Numbers, Changing Needs: American Indian Demography and Public Health, G.Sandefur, R.Rindfuss, and B.Cohen, eds. Washington, D.C.: National Academy Press. McBean, A., and M.Gornick 1994 Differences by race in the rates of procedures performed in hospitals for Medicare beneficiaries. Health Care Financing Review 15:77–90. McCord, C., and H.Freeman 1990 Excess mortality in Harlem. New England Journal of Medicine 322:173–179. McDonough, P., G.Duncan, D.Williams, and J.House 1997 Income dynamics and adult mortality in the United States, 1972 through 1989. American Journal of Public Health 87:1476–1483. McGarvey, S. 1991 Obesity in Samoans and a perspective in its etiology in Polynesians. American Journal of Clinical Nutrition 53:1586–15945. McKeown, T. 1979 The Role of Medicine: Dream, Mirage or Nemesis? Princeton: Princeton University Press. McKinlay, J., and S.McKinlay 1977 The questionable contribution of medical measures to the decline of mortality in the United States in the twentieth century . Milbank Memorial Fund Quarterly (Summer):405–428. Medicaid Access Study Group 1994 Access of Medicaid recipients to outpatient care. New England Journal of Medicine 330:1426–1430. Menchik, P. 1993 Economic status as a determinant of mortality among Black and White and older men—Does poverty kill? Population Studies 47:427–436. Morbidity and Mortality Weekly Report (MMWR) 1994 Prevalence of risk factors for chronic disease by education level in racial/ethnic populations—United States, 1991–1992. Morbidity and Mortality Weekly Report 43(48):894–899.

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