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



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America Becoming: Racial Trends and Their Consequences - Volume II 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

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America Becoming: Racial Trends and Their Consequences - Volume II 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.

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America Becoming: Racial Trends and Their Consequences - Volume II 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

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America Becoming: Racial Trends and Their Consequences - Volume II 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

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America Becoming: Racial Trends and Their Consequences - Volume II 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.

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America Becoming: Racial Trends and Their Consequences - Volume II 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).

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America Becoming: Racial Trends and Their Consequences - Volume II 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).

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America Becoming: Racial Trends and Their Consequences - Volume II 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.

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America Becoming: Racial Trends and Their Consequences - Volume II 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).

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America Becoming: Racial Trends and Their Consequences - Volume II 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.

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America Becoming: Racial Trends and Their Consequences - Volume II 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.

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America Becoming: Racial Trends and Their Consequences - Volume II 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. 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.

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America Becoming: Racial Trends and Their Consequences - Volume II 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). 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. 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

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America Becoming: Racial Trends and Their Consequences - Volume II 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. REFERENCES Adler, N., T.Boyce, M.Chesney, S.Folkman, and S.Syme 1993 Socioeconomic inequalities in health: No easy solution. Journal of the American Medical Association 269:3140–3145. Alba, R., and J.Logan 1993 Minority proximity to Whites in suburbs: An individual-level analysis of segregation. American Journal of Sociology 98(6):1388–1427. Amaro, H., N.Russo, and J.Johnson 1987 Family and work predictors of psychological well-being among Hispanic women professionals. Psychology of Women Quarterly 11:505–521. American Association of Physical Anthropology (AAPA) 1996 AAPA statement on biological aspects of race. American Journal of Physical Anthropology 101:569–570. Amick III, B., S.Levine, D.Walsh, and A.Tarlov, eds. 1995 Society and Health. New York: Oxford University Press.

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