Race and health


Race and health

Race and health research is mostly from the United States. It has found both current and historical racial differences in the frequency, treatments, and availability of treatments for several diseases. This can add up to significant group differences in variables such as life expectancy. Many explanations for such differences have been argued, including socioeconomic factors (e.g., education, employment, and income), lifestyle behaviors (e.g., physical activity and alcohol intake), social environment (e.g., educational and economic opportunities, racial/ethnic discrimination, and neighborhood and work conditions), and access to preventive health-care services (e.g., cancer screening and vaccination) [ [http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5401a1.htm Health Disparities Experienced by Black or African Americans - United States ] ] as well as to treatment (through lack of insurance, lack of hospitals in certain areas, etc.), among other environmental differences. Some diseases may also be influenced by genes which differ in frequency between groups, such as sickle-cell anemia, which occurs overwhelmingly among some black populations, although the significance in clinical medicine of race categories as a proxy for exact genotypes of individuals has been questioned. [ [http://www.pbs.org/race/000_About/002_04-background-01-13.htm RACE - The Power of an Illusion . Background Readings | PBS ] ] [ [http://www.pbs.org/race/000_About/002_04-background-01-y.htm RACE - The Power of an Illusion . Background Readings | PBS ] ]

Background

Race and racism

There is considerable debate about the usefulness of racial categories in studies of health. Likewise, the effects of racism on social mobility, segregation and psychological well-being being of ethnic minorities is an emerging topic of study in health research. [" [http://www.bmj.com/cgi/content/extract/326/7380/65 Antiracism is an important health issue] "] David Williams writes that because race is, in his view, an unscientific, societally constructed taxonomy, racial or ethnic variations in health status result primarily from variations among races in exposure or vulnerability to behavioral, psychosocial, material, and environmental risk factors and resources. Although race has only limited biological significance, the concept of race is socially meaningful in the study of health. ["The concept of race and health status in America." Williams DR, Lavizzo-Mourey R, Warren RC.] Trevor A. Sheldon and Hilda Parker write that thought and care is needed before data are routinely categorized by race or before race is included as a variable in medical research. They write that the tendency to collect routine ethnic data and include ethnic variables in an ad hoc and uncritical way in the United Kingdom and other countries may help transform minorities into mere statistical categories and produce data and findings which reinforce stereotypes. [" [http://jpubhealth.oxfordjournals.org/cgi/content/abstract/14/2/104 Race and ethnicity in health research] "] David Williams writes that terms used for race are seldom defined and race is frequently employed in a routine and uncritical manner to represent ill-defined social and cultural factors. [ [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8063565&dopt=Citation The concept of race in Health Services Research: 1966 to 1990.] ] A. H. Goodman writes that using race as a proxy for genetic differences limits understandings of the complex interactions among political-economic processes, lived experiences, and human biologies. [ [http://www.ajph.org/cgi/content/abstract/90/11/1699 Why genes don't count (for racial differences in health)] American Journal of Public Health, Vol 90, Issue 11 1699-1702] Thomas A. LaVeist writes that while no credible scientist believes that race has any biological or genetic basis, it does have profound social meaning, rooted in history but with contemporary consequences. Racial status is a risk marker for exposure to racism, which may be a primary etiological factor in race differences in morbidity and mortality. ["On the Study of Race, Racism, and Health: A Shift from Description to Explanation" International Journal of Health Services Volume 30, Number 1 / 2000]

In biomedical research conducted in the U.S., the 2000 US census definition of race is often applied. This grouping recognizes five "races": black or African American, white (European American), Asian, native Hawaiian or other Pacific Islander, and American Indian or Alaska native. However, this definition is inconsistently applied across the range of studies that address race as a medical factor, making assessment of the utility of racial categorization in medicine more difficult.

From the perspective of genetics, human population structure is the result of patterns of mating. Francis Collins writes that increasing scientific evidence indicates that genetic variation can be used to make a reasonably accurate prediction of geographic origins of an individual, at least if that individual's grandparents all came from the same part of the world. [http://www.nature.com/ng/journal/v36/n11s/full/ng1436.html What we do and don't know about 'race', 'ethnicity', genetics and health at the dawn of the genome era] , Francis S Collins, Nature Genetics 36, S13 - S15 (2004)] Migration between countries in the last two centuries, with consequent racial admixture has caused some to question the significance of this notion of race to medicine.

In multiracial societies such as the United States, racial groups differ greatly in regard to social and cultural correlates such as economic status and access to healthcare. These factors are believed to explain most if not all of the differential health care outcomes among races. An open area of investigation is whether genetic differences still show evidence of presences after social and cultural correlates are taken into account.

Health

Health is measured through variable such as life expectancy, and incidence of diseases. The undeniable existence of health disparities indicate that there is a correlation between self-identified race or ethnicity and health or disease in some cases. But the relationship among these factors is complex and poorly understood. Some researchers suggest that to unravel the real causes of health disparities, research must move beyond weakly correlated variables, such as self-identified race or ethnicity, towards an understanding of the more proximate environmental and genetic factors.

Health disparities

Health disparities refer to gaps in the quality of health and health care across racial and ethnic groups. [U.S. Department of Health and Human Services (HHS), Healthy People 2010: National Health Promotion and Disease Prevention Objectives, conference ed. in two vols (Washington, D.C., January 2000).] The Health Resources and Services Administration defines health disparities as "population-specific differences in the presence of disease, health outcomes, or access to health care." [Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), page 3.]

In the United States, health disparities are well documented in minority populations such as African Americans, Native Americans, Asian Americans, and Latinos. [Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004).] When compared to European Americans, these minority groups have higher incidence of chronic diseases, higher mortality, and poorer health outcomes.Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), pages 4-5.] Among the disease-specific examples of racial and ethnic disparities in the United States is the cancer incidence rate among African Americans, which is 10 % higher than among European Americans.American Public Health Association (APHA), Eliminating Health Disparities: Toolkit (2004).] In addition, adult African Americans and Latinos have approximately twice the risk as European Americans of developing diabetes. Minorities also have higher rates of cardiovascular disease, HIV/AIDS, and infant mortality than whites.

In the United States

The twentieth century witnessed a great expansion of the upper bounds of the human life span. At the beginning of the century, average life expectancy in the United States was 47 years. By century's end, the average life expectancy had risen to over 70 years, and it was not unusual for Americans to exceed 80 years of age. However, although longevity in the U.S. population has increased substantially, race disparities in longevity have been persistent. African American life expectancy at birth is persistently five to seven years lower than European Americans. [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1360970 Racial Segregation and Longevity among African Americans: An Individual-Level Analysis] Thomas A LaVeist] Crime plays a significant role in this racial gap in life expectancy. A report from the U.S. Department of Justice states "In 2005, homicide victimization rates for blacks were 6 times higher than the rates for whites" and "94% of black victims were killed by blacks." [ [http://www.ojp.usdoj.gov/bjs/homicide/race.htm Homicide trends in the U.S.] , U.S. Department of Justice]

Princeton Survey Research Associates found that in 1999 most whites were unaware that race and ethnicity may affect the quality and ease of access to health care. ["Race, Ethnicity, and the Health Care System: Public Perceptions and Experiences" Medical Care Research and Review, Vol. 57, No. suppl 1, 218-235 (2000)] U.S. Latinos have higher rates of death from diabetes, liver disease, and infectious diseases than do non-Latinos (Vega and Amaro 1994). Native Americans suffer from higher rates of diabetes, tuberculosis, pneumonia, influenza, and alcoholism than does the rest of the U.S. population (Mahoney and Michalek 1998). European Americans die more often from heart disease and cancer than do Native Americans, Asian Americans, or Hispanics (Hummer "et al." 2004). In the United States, African Americans have higher rates of mortality than does any other racial or ethnic group for 8 of the top 10 causes of death (Hummer "et al." 2004).

The vast majority of studies focus on the black-white contrast, but a rapidly growing literature describes variations in health status among America's increasingly diverse racial populations. Where people live, combined with race and income, play a huge role in whether they may die young. [http://www.diverseeducation.com/artman/publish/article_6370.shtml Study: Race, Location Affects Longevity] ] A 2001 study found large racial differences exist in healthy life expectancy at lower levels of education. [" [http://cat.inist.fr/?aModele=afficheN&cpsidt=1050427 Trends in healthy life expectancy in the united states, 1970-1990 : gender, racial, and educational differences] "] A study by Jack M. Guralnik, Kenneth C. Land, Dan Blazer, Gerda G. Fillenbaum, and Laurence G. Branch found that education had a substantially stronger relation to total life expectancy and active life expectancy than did race. Still, sixty-five-year-old black men had a lower total life expectancy (11.4 years) and active life expectancy (10 years) than white men (total life expectancy, 12.6 years; active life expectancy, 11.2 years) The differences were reduced when the data were controlled for education. [ [http://content.nejm.org/cgi/content/abstract/329/2/110 Educational Status and Active Life Expectancy among Older Blacks and Whites] ]

History

Disparities in health and life span among blacks and whites in the US have existed since the period of slavery. David R. Williams and Chiquita Collins write that, although racial taxonomies are socially constructed and arbitrary, race is still one of the major bases of division in American life. Throughout US history racial disparities in health have been pervasive. [ [http://www.questia.com/PM.qst?a=o&se=gglsc&d=5000344680 US socioeconomic and racial differences in health: patterns and explanations.] ] Clayton and Byrd write that there have been two periods of health reform specifically addressing the correction of race-based health disparities. The first period (1865-1872) was linked to Freedmen's Bureau legislation and the second (1965-1975) was a part of the Black Civil Rights Movement. Both had dramatic and positive effects on black health status and outcome, but were discontinued. Although African-American health status and outcome is slowly improving, black health has generally stagnated or deteriorated compared to whites since 1980. [" [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12653396&dopt=Citation Race: a major health status and outcome variable 1980-1999.] "]

Demographic changes can have broad impacts on the health of ethnic groups. Cities in the United States have undergone major social transitions during the 1970s 1980s and 1990s. Notable factors in these shifts have been sustained rates of black poverty and intensified racial segregation, often as a result of redlining. [http://books.google.com/books?id=TWo8OFJpFtAC How East New York Became a Ghetto] by Walter Thabit. ISBN 0814782671. Page 42.] Indications of the effect of these social forces on black-white differentials in health status have begun to surface in the research literature. ["Segregation, Poverty, and Empowerment: Health Consequences for African Americans" The Milbank Quarterly, Vol. 71, No. 1 (1993), pp. 41-64] Race has played a decisive role race in shaping systems of medical care in the United States. The divided health system persists, in spite of federal efforts to end segregation, health care remains, at best widely segregated both exacerbating and distorting racial disparities. ["Health Care Divided: Race and Healing a Nation" By David Barton Smith. 1999 ISBN 047210991X]

Racism

Racial differences in health often persist even at "equivalent" socioeconomics levels. Individual and institutional discrimination, along with the stigma of inferiority, can adversely affect health. Racism can also directly affect health in multiple ways. Residence in poor neighborhoods, racial bias in medical care, the stress of experiences of discrimination and the acceptance of the societal stigma of inferiority can have deleterious consequences for health." [http://www.annalsonline.org/cgi/content/abstract/896/1/173 Race, Socioeconomic Status, and Health The Added Effects of Racism and Discrimination] "] Using The Schedule of Racist Events (SRE), an 18-item self-report inventory that assesses the frequency of racist discrimination. Hope Landrine and Elizabeth A. Klonoff found that racist discrimination is rampant in the lives of African Americans and is strongly related to psychiatric symptoms. ["The Schedule of Racist Events: A Measure of Racial Discrimination and a Study of Its Negative Physical and Mental Health Consequences" Journal of Black Psychology, Vol. 22, No. 2, 144-168 (1996)] A study on racist events in the lives of African American women found that lifetime racism was positively related to lifetime history of both physical disease and frequency of recent common colds. These relationships were largely unaccounted for by other variables. Demographic variables such as income and education were not related to experiences of racism. The results suggest that racism can be detrimental to African American's well being. [" [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&list_uids=12856911&dopt=Citation Experiences of racist events are associated with negative health consequences for African American women.] " Kwate NO, Valdimarsdottir HB, Guevarra JS, Bovbjerg DH.] The physiological stress caused by racism has been documented in studies by Claude Steele, Joshua Aronson, and Steven Spencer on what they term "stereotype threat." [African Americans and high blood pressure: the role of stereotype threat. Blascovich J, Spencer SJ, Quinn D and Steele C. Department of Psychology, University of California, Santa Barbara 93106, USA.] Kennedy et al found that both measures of collective disrespect were strongly correlated with black mortality (r = 0.53 to 0.56), as well as with white mortality (r = 0.48 to 0.54). A 1 percent increase in the prevalence of those who believed that blacks lacked innate ability was associated with an increase in age-adjusted black mortality rate of 359.8 per 100,000 (95% confidence interval: 187.5 to 532.1 deaths per 100,000). These data suggest that racism, measured as an ecologic characteristic, is associated with higher mortality in both blacks and whites. [Kennedy B, Kawachi I, Lochner K, Jones C, Prothrow-Stith D. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=9467703&dopt=Abstract (Dis)respect and black mortality] . Ethn Dis 1997; 7: 207-214 [Medline] .]

Inequalities in health care

There is a great deal of research into inequalities in health care. In some cases these inequalities are a result of income and a lack of health insurance a barrier to receiving services. Almost two-thirds (62 percent) of Hispanic adults aged 19 to 64 (15 million people) were uninsured at some point during the past year, a rate more than triple that of working-age white adults (20 percent). One-third of working-age black adults (more than 6 million people) were also uninsured or experienced a gap in coverage during the year. Blacks had the most problems with medical debt, with 61 percent of uninsured black adults reporting medical bill or debt problems, vs. 56 percent of whites and 35 percent of Hispanics. [http://www.hon.ch/News/HSN/534137.html] Compared with white women, black women are twice as likely and Hispanic women are nearly three times as likely to be uninsured. [ [http://www.ahrq.gov/research/minority.htm Health Care for Minority Women ] ]

In other cases inequalities in health care reflect a systemic bias in the way medical procedures and treatments are prescribed for different ethnic groups. Raj Bhopal writes that the history of racism in science and medicine shows that people and institutions behave according to the ethos of their times and warns of dangers to avoid in the future. [ [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1113412#B32 Spectre of racism in health and health care: lessons from history and the United States] ] Nancy Krieger contended that much modern research supported the assumptions needed to justify racism. Racism underlies unexplained inequities in health care, including treatment for heart disease, [Oberman A, Cutter G. Issues in the natural history and treatment of coronary heart disease in black populations: surgical treatment. Am Heart J. 1984;108:688–694.] renal failure, [Kjellstrand C. Age, sex , and race inequality in renal transplantation. Arch Intern Med. 1988;148:1305–1309.] bladder cancer, [Mayer W, McWhorter WP. Black/white differences in non-treatment of bladder cancer patients and implications for survival. Am J Public Health. 1989;79:772–774. ] and pneumonia. [Yergan J, Flood AB, LoGerfo JP, Diehr P. Relationship between patient race and the intensity of hospital services. Med Care. 1987;25:592–603.] Raj Bhopal writes that these inequalities have been documented in numerous studies. The consistent and repeated findings that black Americans receive less health care than white Americans—particularly where this involves expensive new technology—is an indictment of American health care. [ [http://www.pubmedcentral.nih.gov/redirect3.cgi?&&reftype=pubmed&artid=1113412&iid=118196&jid=3&FROM=Article|CitationRef&TO=Entrez|PubMed|Record&article-id=1113412&journal-id=3&rendering-type=normal&&http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Retrieve&list_uids=2182918 Council on ethical and judicial affairs. Black-white disparities in health care.] JAMA. 1990;263:2344–2346.]

The infant mortality rate for African Americans is approximately twice the rate for European Americans, but, in a study that looked at members of these two groups who belonged to the military and received care through the same medical system, their infant mortality rates were essentially equivalent (Rawlings and Weir 1992). Recent immigrants to the United States from Mexico have better indicators on some measures of health than do Mexican Americans who are more assimilated into American culture (Franzini "et al." 2001). Diabetes and obesity are more common among Native Americans living on U.S. reservations than among those living outside reservations (Cooper "et al." 1997).

A report from Wisconsin’s Department of Health and Family Services showed that while black women are more likely to die from breast cancer, white women are more likely to be diagnosed with breast cancer. Even after diagnosis, black women are less likely to get treatment compared to white women. [" [http://dhfs.wisconsin.gov/wcrs/pdf/cancerwi0004.pdf Wisconsin Cancer Incidence and Mortality, 2000-2004] " Wisconsin Department of Health and Family Services] University of Wisconsin African-American studies Professor Michael Thornton said the report’s results show racism still exists today. "There’s a lot of research that suggests that who gets taken seriously in hospitals and doctors’ offices is related to race and gender," Thornton said. "It’s related to the fact that many black women are less likely to be taken seriously compared to the white women when they go in for certain illnesses." [" [http://badgerherald.com/news/2007/10/24/breast_cancer_rates_.php Breast cancer rates differ in races] " by Amanda VillaWednesday, October 24, 2007. Badger Herald]

Krieger writes that given growing appreciation of how race is a social, not biological, construct, some epidemiologists are proposing that studies omit data on "race" and instead collect better socioeconomic data. Krieger writes that this suggestion ignores a growing body of evidence on how noneconomic as well as economic aspects of racial discrimination are embodied and harm health across the lifecourse. ["Refiguring "Race": Epidemiology, Racialized Biology, and Biological Expressions of Race Relations" International Journal of Health Services Volume 30, Number 1 / 2000] Gilbert C. Gee's study "A Multilevel Analysis of the Relationship Between Institutional and Individual Racial Discrimination and Health Status" found that individual (self-perceived) and institutional (segregation and redlining) racial discrimination is associated with poor health status among members of an ethnic group. ["A Multilevel Analysis of the Relationship Between Institutional and Individual Racial Discrimination and Health Status" Gilbert C. Gee April 2002, Vol 92, No. 4 | American Journal of Public Health 615-623]

Cardiovascular disease

In a summary of recent studies Jules P. Harrell, Sadiki Hall, and James Taliaferro describe how a growing body of research has explored the impact of encounters with racism or discrimination on physiological activity. Several of the studies suggest that higher blood pressure levels are associated with the tendency not to recall or report occurrences identified as racist and discriminatory. In other words, suppression of awareness of instances of racism has a direct impact on the blood pressure of the person experiencing the racist event. Investigators have reported that physiological arousal is associated with laboratory analogs of ethnic discrimination and mistreatment. [ [http://www.ajph.org/cgi/content/abstract/93/2/243 Physiological Responses to Racism and Discrimination: An Assessment of the Evidence] ] Racism may lead to a higher incidence of cardiovascular disease in African Americans in three ways:

# Institutional racism leads to limited opportunities for socioeconomic mobility, differential access to goods and resources, and poor living conditions.
# Perceived racism acts as a stressor and can induce psychophysiological reactions that negatively affect cardiovascular health.
# Negative self-evaluations and accepting negative cultural stereotypes as true (internalized racism) can have deleterious effects on cardiovascular health. [ [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=12811228 Racism and cardiovascular disease in African Americans.] ]

Fear of racism

While actual racism continues to have adverse impacts on health, fear of racism, due to historical precedents, can also cause some minority populations to avoid seeking medical help. For example, a 2003 study showed that a large percentage of respondents perceived discrimination targeted at African American women in the area of reproductive health. ["Birth Control Conspiracy Beliefs, Perceived Discrimination, and Contraception among African Americans: An Exploratory Study" Sheryl Thorburn Bird Journal of Health Psychology, Vol. 8, No. 2, 263-276 (2003)] Likewise beliefs such as "The government is trying to limit the Black population by encouraging the use of condoms" have also been studied as possible explanations for the different attitudes of whites and blacks towards efforts to prevent the spread of HIV/AIDS. ["Conspiracy Beliefs About HIV/AIDS and Birth Control Among African Americans: Implications for the Prevention of HIV, Other STIs, and Unintended Pregnancy" Journal of Social Issues 61 (1), 109–126.]

Infamous examples of real racism in the past, such as the Tuskegee Syphilis Study (1932-1972), have injured the level of trust in the Black community towards public health efforts. The Tuskegee study deliberately left Black men diagnosed with syphilis untreated for 40 years. It was the longest nontherapeutic experiment on human beings in medical history. The AIDS epidemic has exposed the Tuskegee study as a historical marker for the legitimate discontent of Blacks with the public health system. The false belief that AIDS is a form of genocide is rooted in recent experiences of real racism. These theories range from the belief that the government promotes drug abuse in Black communities to the belief that HIV is a manmade weapon of racial warfare. Researchers in public health hope that open and honest conversations about racism in the past can help rebuild trust and improve the health of people in these communities. ["The Tuskegee Syphilis Study, 1932 to 1972: implications for HIV education and AIDS risk education programs in the black community." Am J Public Health. 1991 November; 81(11): 1498–1505.]

egregation

Some researchers suggest that racial segregation may lead to disparities in health and mortality. Thomas LaVeis (1989; 1993) tested the hypothesis that segregation would aid in explaining race differences in infant mortality rates across cities. Analyzing 176 large and midsized cities, LaVeist found support for the hypothesis. Since LaVeist's studies, segregation has received increased attention as a determinant of race disparities in mortality...] Studies have shown that mortality rates for male and female African Americans are lower in areas with lower levels of residential segregation. Mortality for male and female European Americans was not associated in either direction with residential segregation. ["Metropolitan governance, residential segregation, and mortality among African Americans." K D Hart, S J Kunitz, R R Sell, and D B Mukamel. Am J Public Health. 1998 March; 88(3): 434–438.]

In a study by Sharon A. Jackson, Roger T. Anderson, Norman J. Johnson and Paul D. Sorlie the researchers found that, after adjustment for family income, mortality risk increased with increasing minority residential segregation among Blacks aged 25 to 44 years and non-Blacks aged 45 to 64 years. In most age/race/gender groups, the highest and lowest mortality risks occurred in the highest and lowest categories of residential segregation, respectively. These results suggest that minority residential segregation may influence mortality risk and underscore the traditional emphasis on the social underpinnings of disease and death. ["The relation of residential segregation to all-cause mortality: a study in black and white." Jackson SA, Anderson RT, Johnson NJ, Sorlie PD.] Rates of heart disease among African Americans are associated with the segregation patterns in the neighborhoods where they live (Fang "et al." 1998). Stephanie A. Bond Huie writes that neighborhoods affect health and mortality outcomes primarily in an indirect fashion through environmental factors such as smoking, diet, exercise, stress, and access to health insurance and medical providers. [" [http://taylorandfrancis.metapress.com/(4mofmj45dowzx445b21cbw55)/app/home/contribution.asp?referrer=parent&backto=issue,8,15;journal,30,40;linkingpublicationresults,1:102491,1 THE CONCEPT OF NEIGHBORHOOD IN HEALTH AND MORTALITY RESEARCH] "] Moreover, segregation strongly influences premature mortality in the US. [" [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1497360 Relationship between premature mortality and socioeconomic factors in black and white populations of US metropolitan areas.] "]

ocioeconomic factors

A study by Christopher Murray contends the differences are so stark it is "as if there are eight separate Americas instead of one." Leading the nation in longevity are Asian-American women who live in Bergen County, N.J., and typically reach their 91st birthdays, concluded Murray’s county-by-county analysis. On the opposite extreme are American Indian men in swaths of South Dakota, who die around 58.

* Asian-Americans, average per capita income of $21,566, have a life expectancy of 84.9 years.
* Northland low-income rural Whites, $17,758, 79 years.
* Middle America (mostly White), $24,640, 77.9 years.
* Low-income Whites in Appalachia, Mississippi Valley, $16,390, 75 years.
* Western American Indians, $10,029, 72.7 years.
* Black Middle America, $15,412, 72.9 years.
* Southern low-income rural Blacks, $10,463, 71.2 years.
* High-risk urban Blacks, $14,800, 71.1 years...]

The risks for many diseases are elevated for socially, economically, and politically disadvantaged groups in the United States, suggesting that socioeconomic inequities are the root causes of most of the differences (Cooper "et al." 2003; Cooper 2004).

Trends

Based on data for 1945 to 1999, forecasts for relative black:white age-adjusted, all-cause mortality and white:black life expectancy at birth showed trends toward increasing disparities. From 1980 to 1998, average numbers of excess deaths per day among American blacks relative to whites increased by 20%. [" [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1497364 Black-white inequalities in mortality and life expectancy, 1933-1999: implications for healthy people 2010.] "] David Williams writes that higher disease rates for blacks (or African Americans) compared to whites are pervasive and persistent over time, with the racial gap in mortality widening in recent years for multiple causes of death.

Environmental racism

Environmental racism is a form of racial discrimination where race-based differential enforcement of environmental rules and regulations; the intentional or unintentional targeting of minority communities for the siting of polluting industries such as toxic waste disposal; and the exclusion of people of color or lack thereof from public and private boards, commissions, and regulatory bodies results in greater exposure to pollution. RD Bullard writes that a growing body of evidence reveals that people of color and low-income persons have borne greater environmental and health risks than the society at large in their neighbourhoods, workplaces and playgrounds. [ [http://md1.csa.com/partners/viewrecord.php?requester=gs&collection=ENV&recid=4501580&q=racism+health&uid=790216955&setcookie=yes Dismantling Environmental Racism in the USA] ]

Policies related to redlining and urban decay can also acts as a form of environmental racism, and in turn have an impact on public health. Urban minority communities may face environmental racism in the form of parks that are smaller, less accessible and of poorer quality than those in more affluent or white areas in some cities." [http://www.berkeleydaily.org/text/article.cfm?issue=11-13-07&storyID=28458 Minority Communities Need More Parks, Report Says] " by Angela Rowen The Berkeley Daily Planet] This may have an indirect impact on health since young people have fewer places to play and adults have fewer opportunities for exercise." [http://www.berkeleydaily.org/text/article.cfm?issue=11-13-07&storyID=28458 Minority Communities Need More Parks, Report Says] " by By Angela Rowen The Berkeley Daily Planet]

Robert Wallace writes that the pattern of the AIDS outbreak during the 80s was affected by the outcomes of a program of 'planned shrinkage' directed in African-American and Hispanic communities, and implemented through systematic denial of municipal services, particularly fire extinguishment resources, essential for maintaining urban levels of population density and ensuring community stability. ["Urban desertification, public health and public order: 'planned shrinkage', violent death, substance abuse and AIDS in the Bronx." Wallace R. Soc Sci Med, 1990 - ncbi.nlm.nih.gov] Institutionalized racism affects general health care as well as the quality of AIDS health intervention and services in minority communities. The overrepresentation of minorities in various disease categories, including AIDS, is partially related to environmental racism. The national response to the AIDS epidemic in minority communities was slow during the 80s and 90s showing an insensitivity to ethnic diversity in prevention efforts and AIDS health services. ["AIDS and racism in America." Hutchinson J., Journal of the National Medical Association, 1992 Feb;]

Race and genetic biomedical research

The role of race in biomedicine is actively debated among biomedical researchers. The primary impetus for considering race in biomedical research is the possibility of improving the prevention and treatment of diseases. Many previous studies have observed that disease susceptibility and environmental responses vary by race. Thus, some researchers believe that race may be an informative category for biomedical research. Other researchers believe that racial categories have no valid biomedical applications, and may be socially harmful (Jackson, 2004).

The role of race in biomedicine is actively debated among biomedical researchers.

Several questions are considered:

* can the concept of "race" be considered valid?
* When should race be taken into account when studying humans?
* What definition of race is appropriate for biomedical research?
* Do the biological differences between races justify the use of racial categories in research?
* Can genetic assignment to population groups be used in lieu of self-identified race?
* What are the ethical implications of using race in research?

The primary impetus for considering race in biomedical research is the possibility of improving the prevention and treatment of diseases. Many previous studies have observed that disease susceptibility and environmental responses vary by race. Thus, some researchers believe that race may be an informative category for biomedical research. Other researchers believe that racial categories have no valid biomedical applications, and may be socially harmful (Jackson, 2004).

Genetic differences among races

The biomedical relevance of genetic differences among races is a matter of debate. These issues can be illustrated by looking at an example, sickle-cell disease. This disease has a clear relation to geographic origin since the associated gene also provides protection to a common tropical disease, Malaria. Thus, it is much more common in people of African descent than people of European descent. In an emergency room, this may help a doctor doing an initial diagnosis if a patient presents with symptoms compatible with this disease. However, this is still unreliable evidence. Testing the genotype by examining the blood of the patient gives the definitive evidence, not the race. Also, the disease does not follow absolute racial lines, it is most common in African American and Hispanics of Caribbean ancestry, but the trait has also been found in those with Middle Eastern, Indian, Latin American, Native American, and Mediterranean heritage, making it difficult to exclude patients who present with compatible symptoms simply based on race. [ [http://uuhsc.utah.edu/uuhsc/healthierU/articles/sicklecell.html Health Tools- University Health Care ] ] Most diseases argued to have some correlation to race have much weaker correlation to geographic origin than sickle-cell disease, meaning that the value of knowing the race and not the exact genotype is even weaker.

Disease association studies

Michael Bamshad writes that inference about an individual’s ancestry trough self-identified race can make it easier to predict how likely an individual is to have a some disease-causing variants. HbSallele in sub-Saharan Africans and Southern Europeans or the C282Y-HFEand ∆508-CFTRalleles, which cause haemochromatosis and cystic fibrosis, respectively,in Northern Europeans are well known examples,but many others have been discovered. [ [http://www.fiu.edu/~biology/pcb5665/RACEgen.pdf DECONSTRUCTING THE RELATIONSHIP BETWEEN GENETICS AND RACE] ]

The common disease-common variant (often abbreviated CD-CV) hypothesis predicts common disease causing alleles will be found in all populations. An often cited example is an allele of apolipoprotein E, "APOE" ε4, which is associated in a dose-dependent manner with susceptibility to Alzheimer's disease. This allele is found in Africans, Asians and Europeans. However, many disease causing alleles are found to have different (technically called epistatic) effects in different populations. For example, the increased risk of Alzheimer's disease that is associated with the "APOE" ε4 allele is 5-fold higher in individuals with Asian rather than African ancestry.Fact|date=March 2007

Polymorphisms in the regulatory region of the "CCR5" gene affect the rate of progression to AIDS and death in HIV infected patients. While some CCR5 haplotypes are beneficial in multiple populations, other haplotypes have population-specific effects. For example, the HHE haplotype of CCR5 is associated with delayed disease progression in European-Americans, but accelerated disease progression in African-Americans. Similarly, alleles of the "CARD15" (also called "NOD2") gene are associated with Crohn's disease, an inflammatory bowel disorder, in European-Americans. However, none of these or any other alleles of CARD15 have been associated with Crohn's disease in African-Americans or Asians.Fact|date=March 2007

The effects of racial and ethnic identities on health

Although, considerable evidence indicates that the racial and ethnic health disparities observed in the United States arise mostly through the effects of discrimination, differences in treatment, poverty, lack of access to health care, health-related behaviors, racism, stress, and other socially mediated forces, differences in allele frequencies certainly contribute to group differences in the incidence of some monogenic diseases, and they may contribute to differences in the incidence of some common diseases (Risch "et al." 2002; Burchard "et al." 2003; Tate and Goldstein 2004). For the monogenic diseases, the frequency of causative alleles usually correlates best with ancestry, whether familial (for example, Ellis-van Creveld syndrome among the Pennsylvania Amish), ethnic (Tay-Sachs disease among Ashkenazi Jewish populations), or geographical (hemoglobinopathies among people with ancestors who lived in malarial regions). To the extent that ancestry corresponds with racial or ethnic groups or subgroups, the incidence of monogenic diseases can differ between groups categorized by race or ethnicity, and health-care professionals typically take these patterns into account in making diagnoses.Fact|date=March 2007

Even with common diseases involving numerous genetic variants and environmental factors, investigators point to evidence suggesting the involvement of differentially distributed alleles with small to moderate effects. Frequently cited examples include hypertension (Douglas "et al." 1996), diabetes (Gower "et al." 2003), obesity (Fernandez "et al." 2003), and prostate cancer (Platz "et al." 2000). However, in none of these cases has allelic variation in a susceptibility gene been shown to account for a significant fraction of the difference in disease prevalence among groups, and the role of genetic factors in generating these differences remains uncertain (Mountain and Risch 2004).

Human Genome Diversity Project

The Human Genome Diversity Project (HGDP) has attempted to map the DNA that varies between humans. In the future, HGDP could possibly reveal new data in disease surveillance, human development and anthropology. HGDP could unlock secrets behind and create new strategies for managing the vulnerability of ethnic groups to certain diseases. It could also show how human populations have adapted to these vulnerabilities.Fact|date=March 2007 To date, HGDP research has collected samples from 52 distinct ethnic groups, this methodology has been criticised by some on the basis that ethnic groups are considered socio-cultural constructs and not biological populations. Anthropologist Jonathan Marks has stated that: "As any anthropologist knows, ethnic groups are categories of human invention, not given by nature. Their boundaries are porous, their existence historically ephemeral. There are the French, but no more Franks; there are the English, but no Saxons; and Navajos, but no Anasazi...we cannot really know the nature of the actual relationship of the modern group to the ancient one...The worst mistake you can make in human biology is to confuse constructed categories with natural ones. And to overload a big project with cultural categories as the overall sampling strategy would be a serious problem. First it would make those labels appear to be genetic units; indeed, it would "make" them genetic units, which they had not been previously. Second, it would emphasise the genetic distinctions among these groups; it would force them to "be" genetically distinct by being labeled at the outset."Marks, J. (2002) "What it means to be 98% chimpanzee" (paperback ed.) pp.202-207. Berkley. University of California Press.] Many indigenous peoples have refused to take part in the HGDP due to concerns about misuse of the data: "In December [1993] , a World Council of Indigenous Peoples in Guatemala repudiated the HGDP."The project has raised ethical questions. Some worry that the results will be misued by racists. [ [http://www.stanford.edu/dept/news/pr/93/930608Arc3222.html Human Genome Diversity Project raises serious ethical issues ] ] However, members of this project have been described as "liberals who argue that the project will help to reduce racism by showing that the concept of race is scientifically unsustainable" by Human Genetics Alert (HGA) [" [http://www.hgalert.org/topics/personalInfo/hgdp.htm The Human Genome Diversity project] " GenEthics News issue 10]

ee also

* Health and intelligence
* Race and height
* List of countries by life expectancy
* Health disparities
* Center for Minority Health
* Black Report
* Pharmacogenomics
* Medical genetics
* Ethnic bioweapon
* Social determinants of health

References

Further reading

* Bohannon, A.D. (1999), ‘Osteoporosis and African American women’, J. Women's Health Gend. Based Med. Vol. 8, pp. 609-615.
* Boni, R., Schuster, C., Nehrhoff, B. and Burg, G. (2002), ‘Epidemiology of skin cancer’, Neuroendocrinol. Lett. Vol. 23 (Suppl. 2), pp. 48-51.
* Douglas, J.G., Thibonnier, M. and Wright, Jr., J.T. (1996), ‘Essential hypertension: Racial/ethnic differences in pathophysiology’, J. Assoc. Acad. Minor. Phys. Vol. 7, pp. 16-21.
* Dvornyk, V. "et al." Differentiation of Caucasians and Chinese at Bone Mass Candidate Genes: Implication for Ethnic Difference of Bone Mass. "Ann. Hum. Genet." 67, 216 - 227 (2003)
* Editorial. Genes, drugs and race. "Nature Genetics" 29, 239 - 240 (2001).
* Farrer, L. A. "et al." Effects of age, sex, and ethnicity on the association between apolipoprotein E genotype and Alzheimer disease. A meta-analysis. APOE and Alzheimer Disease Meta Analysis Consortium. "JAMA" 278, 1349-1356 (1997).
* Ferguson, R. and Morrissey, E. (1993), ‘Risk factors for end-stage renal disease among minorities’, Transplant. Proc. Vol. 25, pp. 2415-2420.
* Fernandez, J. R. "et al." Association of African genetic admixture with resting metabolic rate and obesity among women. "Obes. Res." 11, 904-911 (2003).
* Gaines, K. and Burke, G. (1995), ‘Ethnic differences in stroke: Black-white differences in the United States population. SECORDS Investigators. Southeastern Consortium on Racial Differences in Stroke’, Neuroepidemiology Vol. 14, pp. 209-239.
* Gonzalez, E. "et al." Race-specific HIV-1 disease-modifying effects associated with CCR5 haplotypes. "Proc. Natl Acad. Sci. USA." 96, 12004-12009 (1999).
* Gower, B. A. "et al." Using genetic admixture to explain racial differences in insulin-related phenotypes. "Diabetes" 52, 1047-1051 (2003).
* Halder I, Shriver MD. (2003). Measuring and using admixture to study the genetics of complex diseases. Hum Genomics 1, 52-62.
* Hardy, J., Singleton, A. & Gwinn-Hardy, K. Ethnic differences and disease phenotypes. "Science" 300, 739-740 (2003).
* Hargrave, R., Stoeklin, M., Haan, M. and Reed, B. (2000), ‘Clinical aspects of dementia in African-American, Hispanic, and white patients’, J. Nat. Med. Assoc. Vol. 92, pp. 15-21.
* Hodge, A.M. and Zimmet, P.Z. (1994), ‘The epidemiology of obesity’, Baillieres Clin. Endocrinol. Metab. Vol. 8, pp. 577-599.
* Hoffman, R.M., Gilliland, F.D., Eley, J.W. "et al." (2001), ‘Racial and ethnic differences in advanced-stage prostate cancer: The Prostate Cancer Outcomes Study’, J. Nat. Cancer Inst. Vol. 93, pp. 388-395.
* Holden, C. Race and medicine. "Science" 302, 594-596 (2003).
* Hugot, J. P. "et al." Association of NOD2 leucine-rich repeat variants with susceptibility to Crohn's disease. "Nature" 411, 599-603 (2001).
* Inoue, N. Lack of common NOD2 variants in Japanese patients with Crohn's disease. "Gastroenterology" 123, 86-91 (2002).
* Jackson, F. L. C. (2004). Book chapter: " [http://cshd.tamu.edu/pdfFiles/jackson.pdf Human genetic variation and health: new assessment approaches based on ethnogenetic layering] " British Medical Bulletin 2004; 69: 215–235 DOI: 10.1093/bmb/ldh012. Retrieved 29 December 2006.
* Martin, M. P. "et al." Genetic acceleration of AIDS progression by a promoter variant of CCR5. "Science" 282, 1907-1911 (1998).
* Martinez, N.C. (1993), ‘Diabetes and minority populations. Focus on Mexican Americans’, Nurs. Clin. North Am. Vol. 28, pp. 87-95.
* Martinson, J. J., Chapman, N. H., Rees, D. C., Liu, Y. T. & Clegg, J. B. Global distribution of the CCR5 gene 32-basepair deletion. "Nature Genet." 16, 100-103 (1997).
* McKeigue, P.M., Miller, G.J. and Marmot, M.G. (1989), ‘Coronary heart disease in south Asians overseas: A review’, J. Clin. Epidemiol. Vol. 42, pp. 597-609.
* McKeigue, P.M., Shah, B. and Marmot, M.G. (1991), ‘Relation of central obesity and insulin resistance with high diabetes prevalence and cardiovascular risk in South Asians’, Lancet Vol. 337, pp. 382-386.
* Molokhia, M. and McKeigue, P.M. (2000), ‘Risk for rheumatic disease in relation to ethnicity and admixture’, Arthritis Res. Vol. 2, pp. 115-125.
* Ogura, Y. "et al." A frameshift mutation in NOD2 associated with susceptibility to Crohn's disease. "Nature" 411, 603-606 (2001).
* Risch, N.; Burchard, E.; Ziv, E. & Tang, H. (2002). Categorization of humans in biomedical research: genes, race and disease. "Genome Biol." 3, comment2007. [http://dx.doi.org/10.1186%2Fgb-2002-3-7-comment2007]
* Rosati, G. (2001), ‘The prevalence of multiple sclerosis in the world: An update’, Neurol. Sci. Vol. 22, pp. 117-139.
* Schwartz, A.G. and Swanson, G.M. (1997), ‘Lung carcinoma in African Americans and whites. A population-based study in metropolitan Detroit, Michigan’, Cancer Vol. 79, pp. 45-52.
* Shimizu, H., Wu, A.H., Koo, L.C. "et al." (1985), ‘Lung cancer in women living in the Pacific Basin area’, Nat. Cancer Inst. Monogr. Vol. 69, pp. 197-201.
* Songer, T.J. and Zimmet, P.Z. (1995), ‘Epidemiology of type II diabetes: An international perspective’, Pharmacoeconomics Vol. 8 (Suppl. 1), pp. 1-11.
* Wiencke, J. K. Impact of race/ethnicity on molecular pathways in human cancer. "Nature Rev. Cancer" 4, 79-84 (2003).
* Yancy, C. D. Does race matter in heart failure. "Am. Heart J." 146, 203-206 (2003).
* Zoratti, R. (1998), ‘A review on ethnic differences in plasma triglycerides and high-density-lipoprotein cholesterol: Is the lipid pattern the key factor for the low coronary heart disease rate in people of African origin?’, Eur. J. Epidemiol. Vol. 14, pp. 9-21.

External links

* [http://videos.med.wisc.edu/event.php?eventid=2 Cultural Diversity in Healthcare Speaker Series] University of Wisconsin School of Medicine and Public Health
* [http://videos.med.wisc.edu/event.php?eventid=30 Cultural Diversity in Healthcare Research Symposium] University of Wisconsin School of Medicine and Public Health
* [http://www.news-medical.net/?id=7317 News-Medical.net]
* [http://www.unnaturalcauses.org/video_clips.php Unnatural causes, videos on how racial inequalities influence health]
* [http://www.pbs.org/race RACE: The Power of an Illusion companion site]


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