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Racial and Ethnic Disparities in Healthcare: A Background and History
Pages 455-527

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From page 455...
... For example, the health status of African Americans a racial-ethnic group already burdened with deep and persistent history-based health disparities has been recently characterized as stagnant or deteriorating (Byrd and Clayton, 2000, 2002; Collins, Hall, and Neuhaus, 1999; National Center for Health Statistics, 1998a; Sullivan, 2000; Williams, l999~. A body of nearly 600 scientific publications documenting racial and ethnic disparities in healthcare provides ample evidence of this problem (Geiger, 2000; Mayberry, Mill, and Ofili, 2000~.
From page 456...
... Moreover, the chronicle of African Americans, alongside Native Americans, epitomizes the depth, breadth, and intensity of the American racial and ethnic minority experience (Burns and Ades, 1995; Byrd and Clayton, 2000, 2001a, 2002; Feagin and Feagin, 1999; Outlaw, 1990; Smedley, 1999; Stuart, 1987~. Though viewed by many as recent occurrences, racial- and ethnicbased health disparities are centuries-old phenomena.
From page 457...
... A discussion built around appreciating the nation's health experience as an immigrant story, thus, provides a window on the present racial and ethnic health disparities. Following is an examination of the major U.S.
From page 458...
... colonists often took land from Native Americans (American Indians) by force or collusion.
From page 459...
... Women were not allowed suffrage until 1920, Native Americans until 1924, and most African Americans until 1965. First-generation Asian Americans could not become U.S.
From page 460...
... Likewise, the poor health status and outcomes of African American and other minority populations are inextricably linked to historical racial and ethnic discrimination (Byrd and Clayton, 2000, 2001b, 2002; Stuart, 1987; Williams, 1999~. If current demographic trends continue and people of color become the majority of the U.S.
From page 461...
... Until the 1850 census, African Americans were tabulated as either "Slave" or
From page 462...
... The first reliable statistics tabulated for Native Americans "are those for 1890, the year in which the Bureau of the Census and Bureau of Indian Affairs made a concerted effort to report accurately the Indian population and the occurrence of vital events" (Stuart, 1987, 96~. Census Bureau officials grouped mulattos with Negroes under "Colored" in 1880, but made finer distinctions in 1890, counting 6.3 million Negroes, 957,000 mulattos, 105,000 quadroons, and 70,000 octoroons.
From page 463...
... The 1997 standards have five racial groups: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, and White, all of which continue to offer possibilities for confusion and complexity. Respondents are able to select more than one of the five groups, which sometimes diminishes sample size, creates ambiguous results, and increases the likelihood of not meeting the standards for statistical reliability or confidentiality.
From page 464...
... Acknowledgment of the effects of racial and ethnic problems on health and disease, the health professions, and, finally, the health system is new and indicative of an ongoing contemporary cultural movement among liberal democratic governments worldwide. These social dimensions of health and healthcare delivery serve as markers of a growing awareness, critique, examination, and redirection that is finally committed to the notion of embracing all of the nation's diversity (Byrd and Clayton, 2000, 2001a, 2002; Glazer, 1997; The Healthcare Fairness Act of 1999, 1999; Section of House Committee Report to Accompany H.R.
From page 465...
... Not only does the Native American health experience serve as the opening chapter of the North American chronicle of racial and ethnic health, American Indian health and healthcare have been major factors shaping both their demography and their contact with Europeans. Prior to 1492, native people in the New World had few serious diseases compared with people of the Old World (Diamond, 1999; Pedraza and Rumbaut, 1996; Watts, 1997~.
From page 466...
... Dysfunc tional relationships with social and economic system result in persistent pov erty and isolation. Phase Two: Commercial Capitalism and the Slave Society: 1600-1865 English 1600s-1800s Mercantilism; land taken from Native Americans; English entrepreneurs and commercial capitalism emerges.
From page 467...
... Separate and unequal tiers of "health" and health system for blacks, the poor, Native Americans. "Slave health subsystem" established, and "slave health deficit" perpetuated, medical abuse and exploitation for blacks (246 years)
From page 468...
... UNEQUAL TREATMENT Selected Indigenous and Immigrant Groups: An Overview of Race, Ethnicity, and Immigration in Relationship to Health and Health Care in North America Indigenous and Immigrant Group Time of Entry 1880s-1910s Economic Conditions in North America Industrial capitalism utilized their skilled and unskilled labor; small entrepreneurs re-established themselves; much antiSemitic discrimination. Governm and Actic Eastern European Jews Japanese 1880s-1900s Recruited as agricultural laborers for Hawaii; later migrated to West Coast as laborers; served in domestic work; created small businesses and farms.
From page 469...
... Initially assigned to lower tiers of health system (public hospitals, dispensaries, charity care) as immigrants; Early poor health status and outcomes.
From page 470...
... Since the nineteenth century, Native American health and healthcare have been poor. Today the health of Native Americans is characterized as being isolated from the mainstream health system; administered by a government that is often culturally insensitive; inadequately funded and understaffed; paternalistic; disparate from health status and outcomes perspectives; and has been allowed to spread communicable diseases such as smallpox and tuberculosis (Frost, 1990; Garrett, 2000; Stuart, 1987; Trennert, 1998~.
From page 471...
... Black health plummeted due to Civil War collapse of the slave health subsystem. Deleterious effects were compounded by the preexisting slave health deficit, abandonment of African Americans by the mainstream health system, and continuation of racially discriminatory health policies and treatment.
From page 472...
... Instead, it is more likely that improvements in public health measures such as sanitation, water and milk supplies augmented by improvements in diet, housing, and personal hygiene are responsible for the decline in mortality (Leavitt and Numbers, 1985; Ewbank, 1987~. Nevertheless, groups on the margins of, or sometimes excluded from, social progress or the health system such as African Americans, Native Americans, Asian Americans, Mexican Americans, other ethnic and religious minority groups, and large blocs of the poor, were not full beneficiaries of these positive results.
From page 473...
... Commission on Civil Rights, 1999a, l999b; Williams, 1999~. An Uneasy Mix of Diverse Peoples: The Dynamics of the United States' Racial and Ethnic Group Interaction Other than Native Americans, all Americans are immigrants who arrived on the North American continent within the last 500 years (see Figure 1 for distribution of ancestry groups)
From page 474...
... and Australian Aboriginal (sometimes referred to as Malay) types (Omi and Winant, 1994; Stringer and McKie, 1997; Thernstrom, Orlov, and Handlin 1980; Van den Berghe, 1967~.
From page 475...
... Few deny that African Americans, Native Americans, and Hispanics disproportionately occupy the lowest strata of the class system and have been traditionally restrained within these strata by political, ideological, legal and economic mechanisms. Traditionally, groups under Anglo-Protestant political or economic dominance, especially when compounded by racial worldview-caste considerations and stereotyping Native Americans, Hispanics, African Americans, or Asians, or immigrants who arrived as indentured servants or laborers have moved into and circulated within the lower rungs of the social hierarchy.
From page 476...
... Commission on Civil Rights, l999a,23~. For a plethora of reasons, African Americans have experienced the worst health status, suffered the worst health outcomes, and been forced to utilize the worst health services of any racial or ethnic group.
From page 477...
... Native Projected by the U.S. Census Bureau in 2001 to number 2,448,000, or 0.9 percent of the U.S.
From page 478...
... Under Title VIII of the 1975 Native American Programs Act, Pacific Islanders who are not all immigrants to the United States as are many other Asians along with American Indians, Alaska Natives (Eskimos and Aleutians) , Native Hawaiians, and Samoans, are defined as "Native Americans." Representing only 5 percent of the total Asian American and Pacific Islander (AAPI)
From page 479...
... While college graduation rates were the highest in the country for Asian and Pacific Islander Americans (42%) and the median income for Asian and Pacific Islander households as of 1998 was over $46,000 the highest of all major racial and ethnic groups some 14 percent of AAPIs have incomes below the poverty level, almost twice the rates of non-Hispanic whites (7.7%~.
From page 480...
... High AAPI college graduation rates vary from the very high rate for Asian Indians of 58 percent to Tongan, Cambodian, Laotian, and Hmong rates of 6 percent or less. As in other groups, educational levels are strongly correlated with health status and outcomes (Office of Research on Women's Health, 1998; U.S.
From page 481...
... Projected by the U.S. Census Bureau to number at least 32,832,000 by November 1, 2000, Hispanics were reportedly tied with African Americans numerically as of March 2001 as constituting between 11.9 and 12.8 percent of the U.S.
From page 482...
... After generations of intermingling between the dominant groups (Spaniards and Portuguese, Native Americans, black African slaves) and a complex series of political events and territorial wars, various Latino groups were either colonized (e.g., Cuba and Puerto Rico)
From page 483...
... Census Bureau, 2001a)
From page 484...
... These phenomena, along with a strong and influential nineteenth century transatlantic biomedical and scientific exchange with Germany and Austria, led to a strong German influence on the health system and facilitated German acculturation and blending into the mass of white American health, medicine, and healthcare just as they blended into larger white America (Lyons and Petrucelli, 1978; Pedraza and Rumbaut, 1996; Rosenberg, 1987; Shryock, 1974; Viner, 1998~.
From page 485...
... Moreover, the Catholic group made significant contributions defining urban, ethnic politics, and forcing religious tolerance through their allegiance to the Roman Catholic church (Feagin and Feagin, 1999; O'Connor, 1995; Pedraza and Rumbaut, 1996; U.S. Census Bureau, 2001a)
From page 486...
... Italian Americans are now one of the major groups in the American tapestry of blending and ethnic pluralism (Feagin and Feagin, 1999; Pedraza and Rumbaut, 1996; Rosenberg, 1974; U.S. Census Bureau, 2001a)
From page 487...
... Their health system experiences were similar to other immigrants modulated by what regions of the country they settled in, their religious affiliation, whether they were urban or rural, and if they migrated to the suburbs after World War II (Feagin and Feagin, 1999; Pedraza and Rumbaut, 1996; Starr, 1982; Steinberg, 1989; Stevens, 1999~. Racial and Ethnic Health and Healthcare Disparities and Their Documentation in the United States The black experience of poor health status, poor health outcomes, and limited access to the worst health services for the 366 years before 1985well-known to African Americans, a small group of government officials, and a tiny cadre of academics was not appreciated by the general public until relatively recently.
From page 488...
... Even though some health data on African Americans had been collected over time, it is only recently that specific efforts are underway to collect adequate health data for Native Americans, Hispanics, and Asian Pacific Island Americans. However, shortfalls in these areas remain (U.S.
From page 489...
... , the Civil Rights era in healthcare from 1965-1980 (American Cancer Society, 1988; Baquet et al., 1986; Clayton and Byrd, 1993a; Davis and Schoen, 1978; Davis et al., 1989; Haynes, 1975; Henschke et al., 1973; Leffall Jr., 1974, 1979; National Center for Health Statistics, 1991, 1992; Rene, 1987; Stuart, 1987; U.S. Department of Health and Human Services, 1985b, 1986)
From page 490...
... " (Van den Berghe, 1967, 9~. Some modern zoologists refer to subspecies or varieties as synonymous with a race a partially isolated breeding population with some differences in gene frequencies from other related populations.
From page 491...
... Such a paradigm shift has undermined the scientific standing of race as a purely biological or physical concept. Van den Berghe offers a precise and simple sociological definition of race referring "to a group that is socially defined but on the basis of physical criteria" (Van den Berghe, 1967, 9~.
From page 492...
... Race and racism are closely related and interdependent. As Van den Berghe points out: The existence of races in a given society presupposes the presence of racism, for without racism physical characteristics are devoid of social significance.
From page 493...
... America's racial health problem should be at the leading edge of all our efforts to ameliorate racial and ethnic health disparities through cultural competence, multicultural medicine, anti-bias, and diversity training efforts. There are several archetypes we have found useful in understanding how race operates.
From page 494...
... . It is the racism of differential taxation schemes wherein unequal, inner-city, public schools are produced; the racism wherein African Americans who have more kidney and heart disease than any other population subgroup receive fewer transplants and other highly desired invasive therapeutic procedures; discrimination and selection for education and jobs based on white culture-based "aptitude" and "achievement tests"; the racism of
From page 495...
... Aside from the difficulties in defining ethnicity, the term has been the focus of a long-standing academic controversy between scholars who choose to define the term narrowly and another group who want to use it broadly, subsuming previous racial, cultural, religious, national-origin, or linguistic categories (Feagin and Feagin, 1999; Soilers, 1989; Sowell, 1981; Steinberg, 1989, 1995; Van den Berghe,1967~. As Takaki noted "Race .
From page 496...
... culture (Feagin, 2000; Feagin and Feagin, 1999; Feagin and Vera, 1995; Smedley, 1999~. The stark differences in health status, services, and outcomes evidenced by African Americans, especially, and other racially identifiable non-white groups certainly seem to suggest the soundness of these principles.
From page 497...
... Racism is embedded in the Chain of Being; the idea was used to rank the various races into "higher" and "lower." Of course, the white Europeans who devised it were at the top (Milner, 1990, 201~. These biased and inequitable tendencies were exacerbated by traditions of fee-for-service medical practice and the incorporation of the Hippocratic Oath, along with what many medical ethicists consider its self-serving medical ethical tradition and weak social covenant.
From page 498...
... Fueled by the wars of the reconquest on the Iberian peninsula between the white Christians and African Moors, increases in anti-black prejudices and biases and the exclusive relegation to slave status for people of color in Moslem and Christian societies resulted. Racial, class, and ethnic bias contained in the preserved Platonic-Aristotelian, Hippocratic, Galenic medical corpus combined with the inequities contained in patriarchal slave-based Moslem societies to promote a growing deprecatory view and treatment of blacks in both Moslem and European cultures and to undergird the receipt of less
From page 499...
... More destructive were the residual biases, practices, and hatreds generated by the Moslem-African versus Christian-European wars in Spain, a nascent Atlantic slave trade, and the travelers' tales (which at the time had a veneer of science) depicting African and other nonwhite people as inferior to Europeans.
From page 500...
... The Atlantic slave trade and New World slavery were not only dominant world events, they were also deficit-producing situations healthwise for the expropriated Africans and the Native Americans forced into slavery. Both situations produced new epidemiologic exposures, crowd diseases, marginal nutrition, poor sanitation, disciplinary brutality, and high mortality rates.
From page 501...
... Americans dominated the field until they were supplanted by Darwin's theory of evolution after 1859 (Byrd and Clayton, 2000, 2001b; Gould, 1981; Hailer, 1971; Reed, 1989; Stanton, 1960~. The Civil War With the exception of the material circumstances of Southerners and their slaves, whose health status and outcomes were adversely affected by major shortages in providers and medical resources, there were no discernable changes in the hierarchical and layered delivery of healthcare for non-military populations on the basis of race, gender, moral judgments, and class during the Civil War.
From page 502...
... Meanwhile all African Americans, whether slave, free, or contraband, suffered health crises related to the war and abetted by collapse of the slave health subsystem. Disappearance of the bedrock of traditional slave providers and slavery's institutional justifications for the delivery of some healthcare, along with continued anomie and discriminatory wartime acts and policies toward the few trained black physicians, exacerbated an already critical situation (Byrd and Clayton, 2000; Cobb, 1952a, 1952b, 1981; Duffy, 1990; Mohr, 1986; Morals, 1967; Shryock, 1966~.
From page 503...
... The growth of a "Negro medical ghetto" a group of black health professionals and institutions serving the black community and the acceptance of separate but unequal health, healthcare, and tiers of the health system based on race and class as the norm characterized the Gilded Age and Progressive eras of the U.S. health system.
From page 504...
... As a result of these occurrences, white health improved dramatically. In contrast, the health of African Americans improved very little, remaining the worst of any racial or ethnic group as they continued to receive little or deficient healthcare, especially in rural areas.
From page 505...
... By World War II, this forced more government involvement in healthcare and some restructuring of the system, especially as related to healthcare financing. Nevertheless, patterns of bias and inequities in health and healthcare continued as black and white health inequities and gaps continued at the policy, systems, professional, health status, outcomes, and services levels.
From page 506...
... A Civil Rights Era in Healthcare Between 1965 and 1980 some of the most momentous progress in healthcare history for African Americans and other disadvantaged groups occurred. For blacks, the period between 1965-1975 represented a "Second Reconstruction in health and healthcare" as: there were dramatic improvements in black health status and outcomes; access, and quality of care improved dramatically as hospitals desegregated, affirmative action began increasing minority representation and access to health professions, and a community health center (CHC)
From page 507...
... There was continuing evidence of bias and inequities in American medicine, health, and healthcare during the Reagan-Bush era from 19801992. In fact, new areas cropped up and several established areas intensified and included increasing race- and class-based inequities and gaps in health status and outcomes; drastic cuts in public healthcare sector funding such as Medicare, Medicaid, and tax-supported institutional funding cuts; retrenchment on Civil Rights laws; maintenance of structural inequities and segregation of the health system; and continued under-representation of blacks and other disadvantaged minorities in the health system and health professions (Andrulis and Carrier, 1999; Byrd and Clayton, 2001, 2001b, 2002; Clayton and Byrd, 2001; Smith, 1999~.
From page 508...
... The adverse health experience of Native Americans and African Americans are the oldest, with the former being
From page 509...
... For African Americans there have been two periods of health reform to address black health inequities and disparities. The First Reconstruction in Black Health occurred between 1865 and 1872 and the Second Reconstruction in Black Health occurred between 1965 and 1975.
From page 510...
... This background information has been provided to lend some of Me historical, sociocultural, and medical-social facts and contexts necessary to understand and eliminate Me heals system flaws and biases related to our complex racial and ethnic health experience (Bonnyman, 2000; Byrd and Clayton, 2000, 2002; Garrett, 2000; Johnson and Broder, 1996; Skocpol, 1997~. REFERENCES Ackerknecht EH.
From page 511...
... Volume 1. A Medical History of African Americans and the Problem of Race: Beginnings to 1900.
From page 512...
... 1993b. Report prepared for hearings and submitted into the Congressional Record on "Health Care Reform: What Does It Mean to African Americans," held for the Congressional Black Caucus Health Braintrust, 103rd Congress, Congressman Louis Stokes, D-Ohio, Presiding, Rayburn House Office Building, Room 2175, Washington, DC.
From page 513...
... J Natl Med Assoc 81:885. Ewbank DC.
From page 514...
... 1975. The gap in health status between black and white Americans.
From page 515...
... 1996. "The Health Status of Indigenous Women of the U.S.: American Indian, Alaska Native, and Native Hawaiians." Background paper for the Canada-USA Forum on Women's Health, Ottwa, Canada, August 8-10, 1996.
From page 516...
... 9-14. From: the Proceedings of the American Cancer Society National Conference on Meeting the Challenge of Cancer Among Black Americans.
From page 517...
... 1991. Health Status of the Disadvantaged Chartbook/1990.
From page 518...
... 1985. Black Health on the Plantation: Masters, Slaves, and Physicians.
From page 519...
... J Natl Med Assoc 3:33-39.
From page 520...
... 2001e. Young African Americans boost high-school completion rate, Census Bureau reports.
From page 521...
... Wing KR, Rose MG.1980. Health facilities and the enforcement of civil rights.
From page 522...
... ARCHAIC MEDICAL SYSTEM Though possessing religion and magic as distinct features, archaic medical systems were distinguished by empiricism, systemization, practical organization, recording its experiences and cases for future utilization, and incorporating some public health measures into its corpus of knowledge and practice. ASIAN OR PACIFIC ISLANDER A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands.
From page 523...
... . ETHNIC AMERICAN Historically, groups that have been designated with a hyphenated name: "African Americans," "Asian-Americans," "Native-Americans," "Hispanic-Americans." The hyphenation implies that a second person would not recognize these individuals as Americans unless designated as such.
From page 524...
... RACE 1. As many physical anthropologists abandon racial taxonomies altogether, race can be more objectively considered a sociocultural concept wherein groups of people sharing certain physical characteristics are treated differently based on stereotypical ~inking, discriminatory
From page 525...
... SLAVE HEALTH DEFICIT The dramatic and deliterious Black/White differentials in health status and outcome presumed to be the consequence of slavery and subordinate racial status. SLAVE HEALTH SUBSYSTEM The inconstant, inferior, alternate health system made up of traditional healers, root doctors, granny midwives and nurses, overseers, and planters' wives, sometimes backed up by formally trained physicians, provided African Americans during slavery.
From page 526...
... Volume 1. A Medical History of African Americans and the Problem of Race: Beginnings to 1900.
From page 527...
... RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE 527 Van den Berghe PL.


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