Race and health in the United States
Research shows many health disparities among different racial and ethnic groups in the United States.[1][2][3][4][5] Different outcomes in mental and physical health exist between all U.S. Census-recognized racial groups, but these differences stem from different historical and current factors, including genetics, socioeconomic factors, and racism.[5] Research has demonstrated that numerous health care professionals show implicit bias in the way that they treat patients.[6] Certain diseases have a higher prevalence among specific racial groups, and life expectancy also varies across groups.[2][3][4]
Health disparities are well documented in minority populations such as African Americans, Native Americans, and Latinos.[29] In the year 1985, a report, known as the Heckler Report, was released to address the state of concern regarding African American and minority populations.[30] This report sought to look at statistical data that showed its prevalence and the action towards bridging this health equity gap. The report identified six areas of health concern: cancer, cardiovascular disease and stroke, chemical dependency related to cirrhosis of the liver, diabetes, homicides and accidents, and infant mortality.[30] When compared to European Americans and Asian Americans, these minority groups have higher incidence of chronic diseases, higher mortality, and poorer health outcomes.[29] More importantly noted are the number of lives that could have been saved if healthcare were the same between both populations.[30] That is, African Americans and minority populations having access to healthcare that meets their needs and seek to address this much needed change.
Minorities often have higher rates of cardiovascular disease, HIV/AIDS, and infant mortality than whites.[29] U.S. ethnic groups can exhibit substantial average differences in disease incidence, disease severity, disease progression, and response to treatment.[31]
Latinos and Hispanics[edit]
History[edit]
While Latino and Hispanic populations are not considered a race category by the U.S. Census, this section of the article refers to Latinos or Hispanics as an ethnic group, as classified by the Census Bureau. Hispanic usually refers to the language and individuals whose ancestry comes from a Spanish-speaking country. Latino usually refers to geography, specifically to Latin America, including Mexico, the Caribbean, Central America and South America.[158] References to the Latino and Hispanic community in the United States are frequently linked to discussions about immigration. The geographic origins of Hispanic and Latino influxes of immigration have changed through the years. During the 2010s Latin American and Caribbean countries have accounted for the main source of immigrant populations migrating towards the United States.
The Hispanic Paradox is an important aspect of discussions around the history of the health of Latino and Hispanic populations in the United States. In 1986, Prof. Kyriakos Markides conceived the term "the Hispanic paradox" to refer to the epidemiological phenomenon that Hispanic individuals in the US live longer than their white non-Hispanic counterparts despite the general lower socioeconomic status of the population and their relative lack of access to healthcare. The US Centers for Disease Control and Prevention published a report on May 5, 2015, relating to the general status and causes of deaths of Hispanic population in the United States. The report utilized mortality indicators and national health surveillance of Hispanic populations compared to their White counterparts to explore the possibility of Markides' paradox. Primarily results indicated that Hispanic deaths from diabetes, liver disease, and homicide were substantially higher than in non-Hispanic white populations. Nevertheless, Hispanics generally had a 24% lower risk of all-cause mortality and lower risks of nine of the leading 15 causes of death in the USA (most notably, cancer and heart disease).
Tied to the health status of Latinos and Hispanic in the United States is an observed mistrust of doctors and the health system. This mistrust can stem from language barriers, threat of discrimination and historical events that dismissed the consent of patients like the sterilization of Latina women in California until 1979. According to a study conducted by the United States Census Bureau, Hispanics were the population that was most likely to have never visited a medical provider, with 42.3 percent reporting that they had never done so. The U.S healthcare system is largely geared toward serving English speakers which creates an issue for Latino and Hispanic individuals that don't speak English. Five(55%) of the nine studies examining access to acre found a significant adverse effect of language; three (33%) found mixed or weak evidence that language affected access. Six (86%) of the seven studies evaluating quality of care found a significant detrimental effect of language barriers.
Mental health[edit]
In many Hispanic and Latino communities, mental health problems are viewed as a sign of weakness and are not necessarily validated. Hispanics/Latino are often cited as a high-risk group for mental health issues, particularly for substance abuse, depression, and anxiety. A study conducted from 2008 to 2011, sampled more than 16,000 Hispanics/Latinos ages 18 to 74 in four diverse communities in the states of New York, Chicago, San Diego, and Miami. The findings demonstrated that 27 percent of Hispanics/Latinos in the study reported high levels of depressive symptoms.
U.S population is made up of 17.8% Hispanic and Latino individuals. Out of those individuals, 15% had a diagnosable mental illness. This means 8.9 million people who are Latino or Hispanic suffered from a mental illness. Immigrants in this community face inequalities in socioeconomic status, education, and access to health care services.[159] Hispanics are one of the lowest races/ethnicities to receive treatment based on research from 2013.
Research have signaled multiple sources of stress that could potentially impact mental health outcomes in Hispanic/Latino communities. For example, language influences the way patients are evaluated. Several studies have found that bilingual patients are evaluated differently when interviewed in English as opposed to Spanish and that Hispanics are more frequently under-treated. Furthermore, Hispanics/Latinos are more likely to report poor communication with their health provider. Income has also proven to be a significant factor that impacts the mental health of Latino communities, as low-income individuals may have limited access to mental health services. Nationally, 21.1% of Hispanics are uninsured compared to 7.5% non-Hispanic individuals. Low insurance coverage affects this group of people because ethnicity plays a role, immigration status, and citizenship status. Only 1 in 10 Hispanics with a mental disorder utilizes mental health services from a general health care provider. Moreover, only 1 in 20 Hispanic individuals receives such services from a mental health specialist.
Native Americans and Alaska Natives[edit]
History[edit]
American Indian and Alaska Native populations in the United States have experienced disproportionately negative health outcomes compared to non-Hispanic whites since colonists arrived at the continent in the 15th century, particularly due to epidemics introduced by colonial groups and violent encounters with colonists. A disparity in health outcomes between American Indians and Alaska Natives and the general U.S. population persists today, largely due to a lack of access to adequate medical care, language barriers, and decreased quality of medical services in regions with significant American Indian and Alaska Native populations. One of the elements of the inequality involves the lack of research that begins to look into access to medical care for Native Americans, and when research does exist, it tends to be broad and not focus on specific elements, including childhood.[160] As of October 2019, American Indian and Alaska Native people who are born today have a life expectancy of 73 years, compared to the 78.5 years for the general American population.[7]
The Indian Health Service (IHS) is a federal agency committed to serving the health needs of American Indian and Alaska Native populations. Two pieces of legislation, the Snyder Act of 1921 and Indian Health Care Improvement Act of 1976, obligated the United States government to provide healthcare to federally recognized Native American tribes.[161] This responsibility moved to the IHS, housed under the U.S. Department of Health and Human Services, in 1955.[162] The IHS currently serves over 2.3 million American Indians and Alaska Natives population from 573 different federally-recognized tribes.[163]
Since its implementation, IHS has been criticized for its treatment of patients. Most notably, throughout the 1960s and 1970s, IHS forcibly sterilized thousands of American Indian and Alaska Native women.[164] A study by the General Accounting Office of the United States government found that, between the years of 1973 and 1976, physicians at four IHS facilities – those in Albuquerque, Oklahoma City, Phoenix, and Aberdeen, South Dakota – sterilized a total of 3406 women, 3001 of which were of childbearing age at the time of sterilization.[164]
The federal government has also been criticized for the lack of funding granted to IHS. Expenditures per capita for IHS have been substantially lower than those for other federally funded healthcare programs.[162] Studies have found that physicians employed by IHS express a need for increased funding for the agency to adequately meet the healthcare needs of American Indians and Alaska Natives in the United States.[162]
Because IHS serves only federally-recognized tribes, not all people in the United States that identify with this racial group have access to IHS resources. The American Indian and Alaska Native population includes, but is not limited to, those who are affiliated with federally recognized tribes – there are also state-recognized tribes and unrecognized tribes, and individuals who do not live on tribal lands but identify as Native American.[163] Thus, while IHS plays a role in the health outcomes of American Indian and Alaska Native identifying people in the United States, it is not the sole determinant of health outcomes for this census group.
Mental health[edit]
American Indian and Alaska Native identifying people are more likely to have unmet mental health needs and to experience major depressive episodes than the non-Hispanic white population. Compared to only 5.4% of the non-Hispanic white population, 6.7% of American Indian and Alaska Native adults reported having needs for mental health services that had been unmet in the last twelve months. Furthermore, 8.3% of American Indian and Alaska Native adults reported experiencing a major depressive episode in the past twelve months, whereas only 7.4% non-Hispanic white adults did so.[165] American Indian and Alaska Native adolescents are also more likely to have experienced a major depressive episode in their lifetime, with 16.7% of adolescents reporting such an episode compared to 14.4 of non-Hispanic white adolescents.[165] The 2014 White House Report on Native Youth noted that Native Americans between the ages of 15 and 24 years were 2.5 times more likely to commit suicide than the national average.[166] Rates of post-traumatic stress disorder (PTSD) are also higher for American Indians and Alaska Natives than the general United States population.[167]
Historical trauma is also an issue faced by Native Americans. Dr. Maria Yellow Horse Brave Heart first described historical trauma for Native Americans in the 1980s as, "cumulative emotional and psychological wounding", which in turn affects both physical and mental health.[168] The traumatic events she references include imprisonment and genocide, among other causes.[168] She outlines the six steps of the historical trauma as follows: 1) First Contact (including the grieving period and following colonization period), 2) Economic Competition, 3) Invasion (causing more death and grieving), 4) Reservation Period, 5) Boarding School Period (focusing on the destruction of cultural aspects, including family structure and language), and 6) Forced Relocation.[168]
Some critics of current mental health practices have argued that mental health professionals working with American Indian and Alaska Native communities should adjust their practices to patients' cultures, particularly by increasing attention to spirituality.[165] There have also been efforts to increase understanding of how the symptoms of DSM-recognized disorders may differ in indigenous communities as a result of different cultural practices.[165]
American Indian and Alaska Native youth are slightly less likely than non-Hispanic white youth to receive specialty mental health services, they are significantly more likely to receive non-specialty mental health services such as counseling from social workers, school counselors, and pediatricians.[165]
Alcoholism in American Indian and Alaska Native populations has often been studied, although the rates found depend on both the statistics used and how the statistics are divided. One study from 1995 found that 26.5% of deaths for American Indian and Alaska Native men were alcohol-related, while about 13.2% were for women.[169] Another study from 1996 found that in 1993, 34% of adolescents (grades 7–12) reported they had ever been drunk.[169] Historically, the perceived rates of alcoholism in Native Americans led to the stereotype that they are genetically more prone to alcoholism.[169] This stereotype has been called into question, with modern researchers instead focusing on how historical trauma[168] and PTSD are correlated with alcoholism.[169]
Vaccination[edit]
In 2020, Moderna slowed enrollment in its COVID-19 vaccine testing for the purpose of increasing representation of minorities. In Phase 1a, vaccination eligibility was extended solely to public health workers and residents of long-term care facilities.[197] 60% of public health workers were white. 75% of long-term care facility residents were white.[198] Prior to the September 2020 announcement, 20% of enrollees were Hispanic/Latino and 7% were black. At Pfizer, 25% of enrollees were Hispanic or nonwhite, including 8% who were black.[199][200] A government representative cited "historical abuse", "present racial injustices and health care disparities", and "recent social unrest (and) the faltering economy" as factors impeding recruitment of blacks.[201]
Health care workers[edit]
Minority representation in medicine[edit]
It is estimated that minority populations will represent about half the U.S. population by 2050 which means that there will be a crucial need for more representation in medicine. Studies have shown that having a diverse physician workforce is essential for the future of health care because minority students are more likely to provide health services to underserved communities. A 2012 study done in California found that physicians from minority backgrounds were more likely to practice in underserved or areas of health shortages than their white counterparts, no matter what their specialty. When looking more into the study, it was discovered that doctors from minority backgrounds were more likely to work in underserved areas because many of them grew up in those same underserved communities and saw many of the health disparities that existed. As a result, they looked at working in underserved communities to give back.[206]
Other research has also shown that representation of minorities in the healthcare workforce has many positive influences such as healthcare access for underserved demographics, better cultural effectiveness between healthcare providers, and new medical research that includes all individuals of the population[207]
Trends in admission[edit]
An area of where this representation needs to happen really begins in the admissions offices of professional schools such as nursing, medicine, dentistry, and pharmacy. According to Cheney (2019), the number of students from underrepresented backgrounds applying to professional medical schools has increased, but this increase has not been enough to keep up with the rapidly increasing minority population. Overall, the numbers of underrepresented minority medical school students such as African Americans, Hispanics, and American Indians, or Alaska Natives enrollees increased slightly. However, the only group that showed a statistically significant increase in representation was Hispanic females. The article faults a lack of early educational opportunities for minority groups which is contributing to the low numbers of minorities pursuing careers in the health care field[207]
Flores and Combs (2013) detail the barriers at the organizational level when it comes to recruiting minority applicants. Organizations, such as nursing schools, tend to operate on "normative actions." As a result, societal stereotypes became so instilled within the culture of organizations that it becomes difficult to change the climate of the organization. For long as history has existed, stereotypes of minorities have placed their roots into society and many still that hold true today. Because of this, many organizations tend to still display varying levels of both intentional and unintentional biases toward minorities[208] (Flores & Combs, 2013). For example, it explores the field of nursing. Nursing is one of the many healthcare careers where acceptance into school is very competitive. In the year 2006, minority applicants had an only 40% chance of being accepted into nursing school compared to over 85% of white applicants. Acceptance rates for minority applications have improved only slightly since 2006.[208]
Data from the American Medical Association indicates that the combined percentage of minority groups entering medical school such as African Americans, Native Americans, Latino backgrounds make up 31%. However, out this 31% about 15% are current medical school applicants, 12% become medical school graduates, while only 6% become practicing physicians, and it unclear what happened to the other 6%.[206]
Increasing minority representation in medicine[edit]
Students interested in pursuing a career in medicine need to be reminded that a career in medicine takes time and a substantial financial investment where the revenue will be returned later down the line. More early exposure programs targeted to underrepresented groups in high school would help, since early exposure has been linked to an increase of applications to medical school. In these programs, students build their resumes while also establishing professional connections. Finally, admissions policies should be revised to create more diverse medical school classes rather than relying exclusively on academic achievements. As a result of this, helps to increase cultural competence within healthcare where providers have the opportunity to learn from colleagues of different ethnic and cultural backgrounds in order to care for patients from different backgrounds.[206]
Criticisms[edit]
Some scholars have argued for a genetic understanding of racial health disparities in the United States, suggesting that certain genes predispose individuals to specific diseases.[209] However, the U.S. Census Bureau's recognition of race as a social and not biological category necessitates a social understanding of the causes of health disparities. Additionally, the restricted options for "race" and "ethnicity" in Census Bureau data complicates the results of their findings.
This issue is illustrated with the example of those who identify themselves as Hispanic/Latino, typically a mix of White, American Indian and African ancestry. Although some studies include this as a "race", many such as the U.S. Census do not, forcing members of this group to choose between identifying themselves as one of the listed racial categories, even if they do not personally identify with it. Additionally, individuals who identify as biracial or multiracial must choose one category to identify with, limiting the ability of many Americans to select a census category that they actually identify with. The inability of many individuals to fully identify with one census category indicates the necessity of cultural, historical, and socio-economic explanations of health disparities rather than a biological one.[210]
Census groupings have also been criticized for their broadness. "Race" and "ethnicity" are used in many different ways in the United States, and the lack of subgroups in Census categories fails to account for the diversity of people identifying with each group. Every group on the Census includes people who identify with a number of unrepresented racial and ethnic sub-categories, but the Hispanic/Latino ethnicity group and Asian racial group have been particularly criticized for this lack of specificity.[211]