Table of Contents
| 1 | Historical aspects of race/ethnicity and health | 1 |
| 2 | Conceptual issues in race/ethnicity and health | 15 |
| 3 | The demography of American racial/ethnic minorities | 30 |
| 4 | The epidemiological profile of racial/ethnic minorities | 53 |
| 5 | Mental health | 83 |
| 6 | Health care services among racial/ethnic groups | 108 |
| 7 | Theories of racial/ethnic differences in health | 133 |
| 8 | Socioeconomic status and racial/ethnic differences in health | 157 |
| 9 | Behavior and health | 180 |
| 10 | African American health issues | 205 |
| 11 | American Indian and Alaska Native health issues | 223 |
| 12 | Asian and Pacific Islander health issues | 242 |
| 13 | Hispanic/Latino health issues | 260 |
| 14 | Addressing disparities in health and health care | 283 |
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Minority Populations and Health
By Thomas A. LaVeist John Wiley & Sons
ISBN: 0-7879-6413-1
Chapter One
HISTORICAL ASPECTS OF RACE/ETHNICITY AND HEALTH
The history of the relationship between the U.S. government and racial/ethnic minorities plays an important role in understanding why health disparities exist and how they might be eliminated. In this introduction I will provide a brief overview of the history that has led to the contemporary state of health disparities. I will then discuss likely future trends and why the study of minority health is important. I will then end the chapter with a discussion of decisions made in deciding the terminology that will be used to refer to the various racial/ethnic groups to be discussed in this book.
Historical Background
Figure 1.1 summarizes the status of African Americans throughout the history of the United States. The exact date the first Africans arrived in the country is in dispute. Some historians place this as early as Columbus's first voyage, but the most commonly cited date is August 1619 (Quarles, 1987). From that point until President Lincoln issued the Emancipation Proclamation in 1863 (freeing the Africans who lived in the states that had seceded from the country, but not those in states that were not part of the confederacy), the country's African population was primarily slaves, although in every state there were some who were not slaves. The period of slavery lasted 244 years-63.4 percent of the time between 1619 and 2004.
The end of slavery throughout the country came when the Thirteenth Amendment to the U.S. Constitution was ratified in 1865. This also began the Reconstruction era and the "Jim Crow" period, in which the black codes relegated racial and ethnic minorities to second-class citizenship. These state laws limited or even prohibited racial minorities from exercising voting rights, reducing them to receiving substandard health care and education (Quarles, 1987; Smith, 1999).
In the early twentieth century, separate health care facilities for African Americans began to be developed, mainly by churches. Medical schools for Black doctors were created because most existing medical schools would not admit African Americans. These medical schools and Black hospitals were not as well funded as their segregated counterparts. When African Americans did have interactions with the White medical system (typically in segregated wards), the discourteous nature of the interpersonal communications during these medical encounters produced inequalities in medical treatment. These factors, along with other historical events such as the Tuskegee Syphilis Study, led to racial and ethnic disparities in the access to and utilization of health services and to distrust of the medical care system among racial and ethnic minorities.
In many ways the history of African Americans parallels the history of Native Americans. The arrival of the European settlers in the New World led to the introduction of diseases not native to the continent (such as measles and yellow fever). Disease outbreaks along with war led to the decimation of the Native American population. The importation of Africans to serve as free labor introduced a new group who, along with Native Americans, were barred from access to state-of-the-art health care, clean water, and good quality housing. In 1830, thirty-three years before the Emancipation Proclamation, the United States Congress passed the Indian Removal Act, which was signed into law by President Andrew Jackson. The act ushered in a period of forcible removal of the so-called five Civilized Tribes and their relocation (referred to as the Trail of Tears) to reservations in the Oklahoma territory. Treaties between the U.S. government and the various American Indian tribes typically promised education and health care. The responsibility for provision of health care was left to the U.S. Army, which was neither equipped nor provided the resources necessary to provide adequate care. Later the U.S. government established the Bureau of Indian Affairs (BIA), which assumed responsibility for providing health care to the American Indian population. The establishment of the Indian Health Service in 1955 led to the creation of a federal agency whose primary mission was the provision of health care to Native Americans. That same year, Rosa Parks's refusal to give up her seat on a Montgomery, Alabama, bus sparking the bus boycott that ignited the Civil Rights movement of the 1950s and 1960s (Morris, 1986).
Coming out of the civil rights movement were the Civil Rights Act of 1964 and the Voting Rights Act of 1965. These acts dismantled the most limiting components of the "Jim Crow" laws (black codes) and fulfilled the constitutional guarantees contained in the Fourteenth and Fifteenth Amendments. The Civil Rights movement shifted governmental policy away from support of racially discriminatory social norms such as racially segregated hospitals. As governmental policy shifted, the power of government shifted away from support of discrimination in favor of the enforcement of policies to dismantle discrimination in health care settings.
Today, health care facilities face the threat of government sanctions if they are found to be engaging in racially discriminatory practices. Minority health care providers can be found treating White patients, and it is not unusual to find White and non-White patients sharing hospital rooms. Yet although rigid segregation and overt discrimination are now illegal, the consequences are still with us. The health status disparities and health care disparities that have resulted are outlined in the chapters that follow.
Why Is It Important to Study Minority Health?
The last few decades of the twentieth century witnessed an explosion in the number of racial/ethnic minorities, particularly Hispanics/Latinos/Chicanos and Asians. This increase has occurred largely because of immigration, but that's not the only reason. Every major racial/ethnic group for which the U.S. government keeps records (African American-Black, Native American-American Indian-Alaska Native, Asian-Pacific Islander, and Hispanic-Latino-Chicano) has a higher fertility rate than White Americans. For this reason the U.S. Bureau of the Census projects that by the middle of the twenty-first century the United States will be a "majority-minority" country (see Figure 1.2). Whites will make up less than 50 percent of the U.S. population, and racial/ethnic groups that we now consider minorities will total more than 50 percent. As the country undergoes this transition, health statistics for the nation as a whole will become a reflection of the health status of racial minorities. What we now call minority health will become the nation's health. And, as we will learn in the chapters that follow, racial/ethnic minorities generally have a worse health status than Whites.
At the same time, the United States is undergoing another demographic transition. The baby boomers will soon be entering their senior years-the first wave of Boomers will celebrate their sixty-fifth birthdays in 2011. As this happens, the ranks of the elderly will expand tremendously, and this will continue for several decades. These two demographic trends-an aging society combined with increasing proportions of minorities-will place increasing demands on a health care system that seems ill-prepared to handle it. Thus it's important for minority health to be a central feature of training programs in public health, medicine, nursing, social work, pharmaceutical science, and other disciplines that relate to health, such as the biological and the social sciences. We must prepare the next generation of health professionals to work with and in minority populations.
A Note on Terminology and Placing Humans in Categories
Group identity is very important to humans. It goes to the core of who we are and where we see ourselves fitting into the world. There is nothing more human than to think in terms of in-groups. At a fundamental psychological level, we think of ourselves as belonging to this group and not belonging to that group. And we all belong to many groups.
We know how to identify others in our in-groups. Sometimes we can identify in-group members via a secret handshake. Other times we determine membership by more subtle means, such as physical appearance. The process of identifying in-group members is easiest when there is a secret handshake, password, or similar objective process. It is easier to tell who is in the group and who is not; either they know the handshake or they don't. But when it comes to racial or ethnic groups, there is no secret handshake. Instead, we try to identify groups by appearance, culture, nationality, and so on.
Variation in humans exists across many domains, such as skin color, hair texture, nationality, culture, shared history, language, or religion. These domains overlap. A person could be a Cuban American of African descent who has lived most of his or her life in a predominantly Chamorro community in the Marianas Islands and speaks mainly Chamoru on a daily basis. Which group does this person belong to?
An extreme example? Yes. But the point is that human variation does not conform to categories. However, categories are all we have to work with.
The United States' Office of Management and Budget (OMB) went through a multiyear process of determining how to create a set of categories that capture human variation within the United States. This process included countless hearings and studies and many hours of deliberation. It was a serious process undertaken by serious people. In the end those categories serve the purpose of being broad enough that nearly everyone can find their place in them. But the categories do not work for everyone. No set of categories can.
Often categories are too broad, combining people who really shouldn't be combined, thus obscuring the diversity of the group. For example, the Asian group includes many people from many different countries who speak very different languages. When you add Pacific Islanders (Asian/Pacific Islanders), the problem is exacerbated.
Which brings me to the question that defines my point: how do you write a book about the health of racial/ethnic minority groups in the United States while having to rely on statistics that combine individuals into categories that are less than ideal?
The second issue that one must consider is terminology. What do you call the groups?
Black or African American?
Hispanic or Latino or Chicano or persons of Spanish descent?
Native American or American Indian?
The problem is a serious one because, as I have found, those who have an opinion on this issue tend to hold that opinion very strongly. That would be OK if the opinions were consistent, but they are not. I talked with many people about this issue-scholars, activists, students, cafeteria workers-even my mother. I sent out emails to people I know would have thought about these issues. I read everything I could find on the subject. I must say, nearly every one of them made a compelling argument for his or her point of view. Unfortunately, I found starkly conflicting opinions. Here is a sample of quotes from people I talked with or exchanged emails with.
"I think I like Hispanic; Latino is for Mexicans, not us."
"Latino is the only proper name, because Hispanic is a name created by the U.S. government."
"We use the term American Indian-period."
"American Indian denotes affiliation with the oppressor; you should use 'indigenous people.'"
"Nobody uses African American in normal conversation; that's more for formal writing."
"African American excludes native Africans living in the United States."
I could go on, but I think you see my point. No matter what terms I use, I will be making some set of readers unhappy. So as not to insult anyone, I even considered using all of the names separated by a hyphen (that is, African American-Black, Native American-American Indian-Alaska Native, Asian-Pacific Islander, and Hispanic-Latino-Chicano). Obviously that won't work for an entire book.
Census Terminology Study
In 1996 the U.S. Bureau of the Census conducted a survey to determine preferences for terms to designate racial/ethnic groups. People who identified themselves as Hispanic, White, Black, American Indian, Eskimo, Aleut, or multiracial were given a list of terms describing their respective racial or ethnic group and were asked to choose which term they preferred, or to indicate whether they preferred some other term or had no preference. Table 1.1 gives the percentage from each group preferring a particular term. These results have been collapsed across the panels.
The majority of Hispanic respondents chose Hispanic as the term they preferred, and about 10 percent of the Hispanics chose each of the other terms. A majority of Whites chose White. A large plurality of Blacks preferred the term Black, but almost as many chose African American or Afro-American. More than half of those identifying as American Indian or one of the classes of Alaska Native preferred either American Indian or Alaska Native, but over a third chose the more generic Native American. Almost 30 percent of those identifying as multiracial preferred the term multiracial, but about as many had no preference.
There is no consensus term that will satisfy everyone in all cases. In spite of the fact that I will be using terminology that is not favored by some set of readers, I had to make decisions that I hope will minimize the number of readers that are put off. If you are one who does not like the choices I made, I apologize. I hope you will be sympathetic to my plight and use this chapter as an opportunity to address the issue in the classroom. Ask students how they would have handled the problem. I think this will lead to a worthwhile class discussion.
I applied the following usage rules to address the various populations:
The term race/ethnicity refers to the set of categories used to group individuals.
The term minority refers to all of the groups generically.
Black and African American are used interchangeably to refer to people of African descent (including African Americans, native Africans, and persons from the Caribbean and South America).
When referring to a specific subgroup such as native Africans, I use the generic term African or the specific country or tribal affiliation.
Hispanic/Latino is used in combination to refer to persons from Central and South America (including Mexico), the Spanish-speaking Caribbean (Puerto Rico, Cuba, and the Dominican Republic), and Brazil.
American Indian refers to all indigenous Americans from what is now the continental United States.
Alaska Natives refers to indigenous populations of Alaska.
The generic terms American Indian/Alaska Native and Native American are used interchangeably.
Asian/Pacific Islander refers to persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa.
If the data are for Asians only, I refer to the category as Asian without Pacific Islander.
When data on Native Hawaiians are available, I use those data. Otherwise, Native Hawaiians are combined with Pacific Islanders.
In each case I use the lowest level of categorization available. For example, if the data allow me to talk about a specific Native American tribe, I use the tribal name. If the data are categorized only as American Indian (and specifically not Alaska Native), I use American Indian. If it is not possible to specify tribal affiliation or whether the data are for Alaska Natives or American Indians, I use the generic terms Native American or American Indian/Alaska Native.
Finally, when referring to a specific report, study, book, or other document, I use whichever term was used in that document, even if it does not conform to the above usage rules. (See Appendix B for additional readings.)
(Continues...)
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