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January 14, 2013 11:43 AM Race and Population Level Health Statistics

By Aaron Carroll

Whenever I write about population level health statistics, inevitably some people feel a need to email, post, tweet, or message me about their belief that it all comes down to race. The US looks bad with respect to life expectancy? It’s race. We look bad with respect to birth outcomes? It’s race. We are obese, or have high levels of drug abuse or sexually transmitted diseases? It’s race.

And then they get angry when I don’t respond.

Let me be clear: I have no problem, per se, with the question itself. It’s somewhat natural for individuals to question whether race or ethnicity has some impact. What bothers me is the fact that so many people act as if they’re the first to ask about it, as if no one else has thought of this before. What bothers me more is when some of these same people ignore what we know from existing research about disparities, or the fact that other Western democracies are increasingly becoming more diverse, but without such disparities.

Most frustrating is when it’s not questions, but assertions, often made with no evidence whatsoever. No links, no studies, no data. Just a belief – they just know – that some races are going to die earlier, be more obese, have more teen sex, or something. They almost always believe that’s it’s minorities that are bringing down our statistics. From comments on a recent piece:

What other industrial countries have a comparable racial demographic to the U.S.? I realize the religious Left refuses to use “nuance”, science, and reams of data on race to join the reality-based community, but can you commit a sin here for your readers and tell us how white Americans compare to “peer” white Europeans, for example?

I don’t even want to respond to this notion that if only we could look at “whites”, then the US would do well. It completely ignores the fact that there’s no reason to believe that “whites” do the best. It ignores the fact that Japan has one of the highest life expectancies around. It ignores the Hispanic paradox. With a growing Hispanic population, you’d expect our numbers in the US to be going up.

It also ignores the fact that some of these studies have been done, in particular this one on 55-65 year olds (page 261):

Comparisons with England have already demonstrated that the U.S. health disadvantage appears to persist across racial and ethnic groups in the United States and among college-educated and upper income populations (Banks et al., 2006; Martinson et al., 2011a, 2011b)

Here, from later in the report (page 268, emphasis mine):

What specific factors explain the unfavorable birth outcomes (e.g., high infant mortality rates) experienced in the United States, which exist even after adjusting for race, ethnicity, and maternal education?

I’l be the first to say that I wished the evidence base here was deeper. The number of studies that focus on this exact question is small. But those that do exist point to the fact that even “advantaged” Americans do worse than their counterparts in other countries (page 269):

Four studies have now reported this pattern (Avendano et al., 2009, 2010; Banks et al., 2006; Martinson et al., 2011a), but some of them looked only at education and not other variables (Avendano et al., 2010), or are restricted to comparisons of a narrow age group in only two countries (Banks et al., 2006). Replication with more focused criteria would help confirm the finding.

We need more than these, but let’s acknowledge that the data that we do have favor the hypothesis that it’s not something inherent in race, or our demographics, that causes us to do so poorly. Let’s stop assuming the opposite is true.

But that’s not even the worst of it. So many of the things presented in the report show that it’s not death at old age that’s bringing us down. It’s death at a young age, when racial biological characteristics and genetics aren’t a factor. It’s accidents, it’s violence, and it’s infant mortality. Still – people scream “race!” Yes, race is a factor. The report is explicit about that. Just not in the way many think (pages 167-8):

In many countries, a variety of health outcomes vary markedly by race and ethnicity (Agency for Healthcare Research and Quality, 2011; Commission on Social Determinants of Health, 2008). These health disparities often mirror large differences in income, wealth, education, occupation, and neighborhood conditions among people of different races and ethnicities, differences that reflect a historical legacy of discrimination (Acevedo-Garcia et al., 2008; Bleich et al., 2012; Cullen et al., 2012; Williams, 1999; Williams and Collins, 1995, 2001).7 For example, in the United States, blacks with the same level of education as whites have lower incomes, as well as markedly lower levels of accumulated wealth even at the same level of income (Braveman et al., 2005; Kawachi et al., 2005). Living in a society with a high degree of racial inequality may harm the health of society at large—not only of those who experience disadvantage—in the same ways that some researchers have argued that relative economic inequality may be detrimental to society at large, for example, by undermining social cohesion and trust (Wilkinson and Pickett, 2009) or by affecting individuals’ sense of their relative social standing (Marmot, 2006). Unfortunately, as noted below, data are lacking to compare degrees of racial inequality across high income countries.
In the United States, racial and ethnic groups that have historically experienced discrimination,8 including blacks, Native Americans, and Hispanics, may suffer ill health effects from these experiences. The health effects may result both from material deprivation and other conditions that directly damage health and from physiologic mechanisms involved in reactions to stress (see below). Such stress, which has been linked with smoking (Purnell et al., 2012) and hypertension (Sims et al., 2012), can result not only from overtly discriminatory experiences but also from a pervasive vigilance about whether harmful incidents will occur to themselves or their families (Krieger et al., 2011; Nuru-Jeter et al., 2009). A relative difference in social standing or a sense of social exclusion for any reason may induce stress and influence one’s sense of self-worth or control, which may in turn influence subsequent economic success, health-related behaviors, and health outcomes (Dunn, 2010; Umberson et al., 2008).

Racial disparities, old and new, are absolutely, positively impacting minorities’ health negatively. But that’s not because those minorities are somehow deficient in some way, it’s because the US health care system (and society at large) treats them differently. The disturbingly bad outcomes for minorities aren’t bringing down the standing of the United States. In many ways, it’s just the opposite.

Almost all the findings you can point to that show minorities fare worse here are an indictment of the United States, not an excuse for it.

[Cross-posted at The Incidental Economist]

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Aaron Carroll ,MD, is an associate professor of Pediatrics and the associate director of Children’s Health Services Research at Indiana University School of Medicine.
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