The Significance of Race and Ethnicity for Health

The health consequences of race/ethnic classification are born out in data from multiple countries with heterogeneous populations. As Krieger (2000) states,

Throughout our Ufe course we Likewise embody these social realities - whether oppression or privilege, depending on our ascribed and internalized race/ethnic identity - and in doing so manifest what can be called 'biological expression of race relations.' (p. 212)

Data from the USA, UK, Canada, Australia, Brazil, and South Africa consistently show that most non-white groups in each of these countries experience more health problems, rate their health lower, and have lower overall life expectancies and higher all-cause mortality than whites.

For example, for the 15 leading causes of death in the USA, blacks have higher death rates than whites for nine causes including heart disease, stroke, flu/pneumonia, septicemia, homicide, cancer, diabetes, kidney diseases, and hypertension (National Center for Health Statistics, 2009). Moreover, the white-black gap in life expectancy in the USA has widened over the past 25 years due to slower improvements in black health status compared to the overall population (Mensah et al, 2005). American Indians also have markedly poorer health than whites for a number of outcomes including infant mortality, diabetes and injury related mortality, activity limitation, and self-assessed fair/poor health (National Center for Health Statistics, 2009). Although the health of US Hispanic and Asian immigrants, as reflected in overall mortality rates, tends to be comparable or better than that of whites, research suggests that their health advantage declines with longer length of US residency, number of generations in the USA, and US nativity (Frisbie et al, 2001; Fujimoto et al, 2000; Koya and Egede, 2007; Lutsey et al, 2008; Sundquist and Winkleby, 1999). This pattern has been well documented for cardiovascular disease and related biomedical and behavioral risk factors, but exists for a broad range of outcomes.

Although US race/ethnic disparities in health are compelling, the data are not without problems. Studies show that 10-25% of Hispanics, American Indians, and Asian/Pacific Islanders are misclassified on death certificates, with the problem being greatest for American Indians (Williams, 2005). This numerator undercount leads to an underestimate of mortality and suggests that mortality rates for these groups are higher than the officially reported ones. Demographic analyses conducted by the U.S. Census Bureau have long indicated that the census fails to count over 10% of middle-aged black males. Denominator undercounts inflate reported rates. Some evidence from post-enumeration surveys of the US Census indicates that there may also be an undercount problem for American Indians and Hispanics (Williams, 2005).

In the UK, Pakistani, Bangladeshi, and black Caribbean people report the poorest health of all population groups and the absolute percentages of people reporting poor health increases dramatically with age for these ethnic groups compared to whites (Nazroo and Williams, 2006). Additionally, Bangladeshi and Pakistani men are 50% more likely to have a heart attack or angina and Caribbean men are 50% more likely to die of stroke despite lower levels of coronary artery disease than the general population (Parliamentary Office of Science and Technology, 2007). Results from the Health Survey of England indicate that hypertension and diabetes prevalence rates are also higher among Caribbeans than whites (Nazroo, Jackson, Karlsen, and Torres, 2007).

Similarly, studies from Brazil confirm significantly higher hypertension rates among blacks than whites. Interestingly, they also show striking color gradients in age-adjusted cerebrovascular disease mortality where rates increase with darker skin color (Lotufo et al, 2007; Sichieri et al, 2001). Data from the Pan-American Health Organization (PAHO) (2007a) indicate that indigenous and black Brazilian populations have a higher incidence of mortality from vaccine preventable diseases than whites. Additionally, the PAHO (2007a) data show that blacks have a greater risk of death than whites from endocrine diseases and complications of pregnancy/child birth and greater prevalence rates for hypertension and diabetes. Persons of mixed descent also have a higher risk of death from pregnancy/child birth than whites, but lower death rates associated with neoplasms, circulatory, respiratory, and digestive diseases. Data for the "mixed" racial group may be unreliable; however, due to the relatively high rate of race misclassification for this group (Pan-American Health Organization, 2007a).

In contrast, data from the Canadian National Population Health Survey indicate that black Canadians, Southeast Asians, and South Asians experience high levels of functional and self-rated health that are comparable to levels for white Canadians (Wu and Schimmele, 2005). Indigenous, Arabic, and mixed raced groups experience health outcomes that are poorer than the Canadian sample average (Wu and Schimmele, 2005). PAHO (2007b) data show that the indigenous population, known as the Canadian First Nation, has a disproportionately high prevalence of chronic disease. These conditions including hypertension, heart disease, tuberculosis, HIV infection, fetal alcohol syndrome, and diabetes which are five times higher than the Canadian national average. The data also indicate that death rates due to injury and poisoning for the First Nation group are four times higher than for the overall Canadian population. Additionally, babies born to First Nation mothers are more likely to be born preterm and infant mortality is twice the rate for other Canadian populations. Moreover, life expectancy among First Nation men and women is between 5 and 7 years shorter than the Canadian national average (PAHO, 2007b).

In South Africa, results from several studies provide evidence of health disparities among race groups resulting, in part, from the differential impact of the epidemiologic transition in the country. Results show that among older adults, Africans are at greatest risk of death from infectious diseases such as tuberculosis and diarrhea. Additionally, the prevalence rate for HIV among Africans over 2 years of age is 13.3% (Human Sciences Research Council, 2009). This is nearly seven times greater than the HIV infection rate for colored and Indian groups (1.9 and 1.6%, respectively) and nearly 22 times greater than the rate for whites (0.6%) (Human Sciences Research Council, 2009). Results from the South African Stress and Health Study also indicate that black groups report higher levels of self-rated ill health and higher levels of psychological distress than whites (Williams et al, 2008). Moreover, Africans and other non-whites are approximately two times more likely to die at younger ages of adulthood (45-59 years of age) than whites which may reflect differences in underlying causes of mortality associated with the epidemiologic transition.

In contrast, white adults are at greatest risk of death from chronic diseases such cardiovascular disease (CVD) and cancer, but have greater longevity, on average, than non-whites. Results from the South Africa Adult Demographic and Health Survey indicate that age-adjusted hypertension rates and stroke deaths are higher among whites, Asians, and coloreds compared to Africans (Bradshaw et al, 2004). Additionally, these groups are also significantly more likely to smoke heavily (Bradshaw et al, 2004).

Health disparities exist in Australia as well. For example, the infant mortality rate for aborigines persists at greater than two times the Australian national average (Australian Bureau of Statistics, 2007). Additionally, life expectancy is nearly 20 years shorter for aboriginal people than the general population. This largely reflects the higher prevalence rates of heart disease, stroke, diabetes, alcohol consumption, and smoking among members of this group (Australian Bureau of Statistics, 2008; 2007).

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