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• Research article
• Open access
• Published: 18 November 2020

Racial discrimination and health: a prospective study of ethnic minorities in the United Kingdom

• Ruth A. Hackett   ORCID: orcid.org/0000-0002-5428-2950 1 , 2 ,
• Amy Ronaldson 3 ,
• Kamaldeep Bhui 4 ,
• Andrew Steptoe 2 &
• Sarah E. Jackson 2  

BMC Public Health volume  20 , Article number:  1652 ( 2020 ) Cite this article

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Racism has been linked with poor health in studies in the United States. Little is known about prospective associations between racial discrimination and health outcomes in the United Kingdom (UK).

Data were from 4883 ethnic minority (i.e. non-white) participants in the UK Household Longitudinal Study. Perceived discrimination in the last 12 months on the basis of ethnicity or nationality was reported in 2009/10. Psychological distress, mental functioning, life satisfaction, self-rated health, physical functioning and reports of limiting longstanding illness were assessed in 2009/10 and 2011/12. Linear and logistic regression analyses adjusted for age, sex, income, education and ethnicity. Prospective analyses also adjusted for baseline status on the outcome being evaluated.

Racial discrimination was reported by 998 (20.4%) of the sample. Cross-sectionally, those who reported racial discrimination had a greater likelihood on average of limiting longstanding illness (odds ratio (OR) = 1.78, 95% confidence interval (CI) 1.49; 2.13) and fair/poor self-rated health (OR = 1.50; 95% CI 1.24; 1.82) than those who did not report racial discrimination. Racial discrimination was associated with greater psychological distress ( B  = 1.11, 95% CI 0.88; 1.34), poorer mental functioning ( B  = − 3.61; 95% CI -4.29; − 2.93), poorer physical functioning ( B  = − 0.86; 95% CI -1.50; − 0.27), and lower life satisfaction ( B  = − 0.40, 95% CI -0.52; − 0.27). Prospectively, those who reported racial discrimination had a greater likelihood on average of limiting longstanding illness (OR = 1.31, 95% CI 1.01; 1.69) and fair/poor self-rated health (OR = 1.30; 95% CI 1.00; 1.69), than those who did not report racial discrimination. Racial discrimination was associated increased psychological distress ( B  = 0.52, 95% CI 0.20; 0.85) and poorer mental functioning ( B  = − 1.77; 95% CI -2.70; − 0.83) over two-year follow-up, adjusting for baseline scores.

Conclusions

UK adults belonging to ethnic minority groups who perceive racial discrimination experience poorer mental and physical health than those who do not. These results highlight the need for effective interventions to combat racial discrimination in order to reduce inequalities in health.

Peer Review reports

Discrimination is defined as the differential treatment of an individual based on a socially ascribed characteristic [ 1 ]. In the United Kingdom (UK), the 1965 Race Relations Act [ 2 ] outlawed discrimination on the grounds of colour, nationality and ethnic or national origins. Race remains a protected characteristic under contemporary equality law [ 3 ]. Despite this legislative effort, ethnic inequalities in education, work, health and criminal justice remain [ 4 ].

Discrimination on the basis of ethnic origin is regarded as the most common type of prejudice in Europe, with 64% of adults perceiving racial discrimination to be widespread in a survey of 27,718 people [ 5 ]. In Britain in 2017, 26% of a representative sample described themselves as racially prejudiced [ 6 ], and race continues to be the most common motivator for hate crime incidents [ 7 , 8 ]. Against the backdrop of the vote to leave the European Union (Brexit), hostility towards migrants and the growth in right-wing nationalist movements [ 9 ], these figures reflect a rise in reported racial discrimination in both the UK and Europe [ 5 , 6 ].

A growing body of research has investigated discrimination as a determinant of mental health [ 10 , 11 , 12 ] and to a lesser extent physical health [ 11 ]. In an early meta-analysis of 110 studies, discrimination was linked with poor mental health, including psychological distress and decreased life satisfaction [ 11 ]. A sub-set of 36 studies in the review investigated associations with physical health. Significant associations were detected in a pooled analysis with various outcomes including hypertension and acute cardiovascular responses to laboratory discrimination protocols. A more recent meta-analysis of 328 studies focusing on discrimination and mental health outcomes alone, again observed that those who perceived discrimination had poorer mental health [ 12 ]. This finding was also detected in an independent analysis of 211 cross-sectional studies linking racial discrimination with poor mental health [ 12 ].

Racism is a recognised social determinant of health and a driver of ethnic inequities in health [ 13 ]. It can be understood as a complex, organised system embedded in socio-political and historical contexts, that involves classifying ethnic groups into social hierarchies. These groups are ideologically assigned differential value, which drives disparities in access to power, resources and opportunities [ 14 , 15 ]. It occurs at both structural and individual levels (self-reported experiences of racial discrimination) [ 14 , 15 ].

Several reviews and meta-analyses have focused solely on perceived racial discrimination and health outcomes [ 13 , 16 , 17 , 18 ]. The largest study to date meta-analysed the results from 293 studies and assessed both mental and physical health outcomes [ 16 ]. In this analysis, racial discrimination was associated with poorer overall mental health including greater psychological distress, poorer life satisfaction and poorer general mental functioning in independent analyses. Racism was also linked with poorer general health and poorer physical health overall, though few effects remained significant when looking at specific physical health outcomes in separate analyses.

Racial discrimination at the structural and individual level is theorised to impact health through several mechanisms [ 15 ]. At the structural level racial discrimination may operate through the unfair allocation of societal resources that are determinants of health (e.g. education, employment, housing) [ 14 , 15 ] and through differential access to healthcare, as well as perceived poorer quality of care [ 19 ]. Another mechanism linking racial discrimination and health could be through the dysregulation of stress-related biological processes [ 20 ]. Frequent exposure to racial discrimination is a chronic stressor and has been linked with dysregulated cardiovascular, neuroendocrine and inflammatory processes [ 21 , 22 ] which in turn impact both physical and mental health. Individual health risk (e.g. smoking, alcohol consumption) could link perceived racial discrimination and health, as means of coping with or avoiding discrimination [ 23 , 24 ].

Although a growing number of studies have investigated the link between racial discrimination and health, there are still areas where more research is required. In the 2015 racism meta-analysis of almost 300 studies, only 9% of the data included were prospective [ 16 ]. The authors aimed to compare the effect sizes of the cross-sectional and prospective studies included in their review but were unable to conduct this analysis for the physical outcomes data, emphasising the need for more prospective studies on physical health outcomes in particular.

Further, the literature is dominated by United States (US)-based studies drawn from convenience samples [ 12 , 16 ]. In the latest racism and health meta-analysis, over one third of the articles included were drawn from student samples and only nine (2.7%) of the included studies were UK-based [ 16 ]. This is important as the makeup of ethnic minority groups in the UK differs from that of the US, with those of South Asian backgrounds forming the largest minority group [ 25 ]. In addition, all of the UK studies were cross-sectional in nature and focused on mental health, with physical outcomes such as the number of physical illnesses [ 26 ] and self-rated health [ 27 ] included in only two of the studies.

To date, one UK study has assessed the relationship between racial discrimination and health prospectively. In an analysis of the UK Household Longitudinal Study (UKHLS), the authors found that those who reported racial discrimination had poorer mental functioning scores 4 years later [ 28 ]. They also reported a dose-response relationship between the experience of racial discrimination and mental health, with those who reported racial discrimination at more than one timepoint over a 3-year period experiencing a greater deterioration in mental functioning.

Overall, there is a dearth of prospective evidence on the link between racial discrimination and health in UK samples, particularly in relation to physical health outcomes.

To address these gaps in the literature, the present study set out to assess cross-sectional and prospective associations between racial discrimination and health in a large community-dwelling UK population cohort. Specifically, we were interested in psychological distress, mental functioning and life satisfaction, as indicators of mental health, as well as self-rated health and physical functioning as markers of physical health, along with limiting longstanding illness as an indicator of impairment. We hypothesised that those who perceived racial discrimination would have poorer health across all measures both cross-sectionally and prospectively.

Study population

The current study uses data from UKHLS [ 29 ]. The study began in 2009/10 (wave 1) with follow-ups yearly. This study uses data from waves 1 (2009/10) and 3 (2011/12) of the data collection. The UKHLS consists of a representative sample of the UK population, as well as an ethnic minority boost sample [ 25 , 30 ]. In this study we use data from ‘extra 5 minutes sample’ of over 8000 individuals who had an additional 5 min of questions on issues of importance to ethnicity research including discrimination. The majority of this sample are drawn from ethnic minority groups ( n  = 6722), in addition to a smaller comparison group of white participants ( n  = 1428) [ 25 ]. We restricted our analyses to those who provided information on racial discrimination at wave 1 ( n  = 5707) and self-reported being of non-white ethnicity ( n  = 4883). The participants included in our study were significantly older ( p  = 0.002) and were less likely to have an educational qualification ( p  < 0.001) than those who did not provide data for the study. They were also more likely to be male ( p  < 0.001) and of South Asian ethnicity ( p  < 0.001) The groups did not differ on income ( p  = 0.136). All participants provided fully informed written consent and the University of Essex Ethics Committee granted ethical approval for UKHLS.

Racial discrimination

To measure perceived discrimination, participants were asked whether in the past 12 months, they had (a) felt unsafe, (b) avoided going to or being in, (c) been insulted, called names, threatened or shouted at, or (d) been physically attacked in 7 different settings 1) At school/college/work, 2) On public transport, 3) At or around bus or train stations, 4) In a taxi, 5) Public buildings such as shopping centres or pubs, 6) Outside on the street, in parks or other public places, or 7) At home. If they answered yes to any one of these questions, a follow-up question asked them to choose an attribution for the discrimination from a list of categories including ethnicity, nationality, age, and sex among others. Participants could choose multiple settings and attributions for the perceived discrimination. Those who attributed any experience of discrimination to their ethnicity or nationality are treated as cases of perceived racial discrimination in our analyses. Those who did not perceive any form of discrimination serve as the comparison group in our analyses. Those who reported other (non-racial) forms of discrimination were not included in the analysis. This measure has been used in previous investigations to look at the link between perceived discrimination and health outcomes [ 28 , 31 , 32 ].

Mental health outcomes

We included 3 mental health measures at waves 1 (2009/10) and 3 (2011/12). Psychological distress was assessed using the General Health Questionnaire (GHQ)-12 [ 33 ], in line with previous studies [ 31 , 32 ]. This tool has been validated as a screening tool to detect psychological distress in community samples [ 34 ]. This measure involved ratings of 12 statements including whether the participant had “ Been able to enjoy your normal day to day activities ” or whether they “ Felt constantly under strain ” with binary response options (yes/no). After totalling, the overall score ranged from 0 (least distressed) to 12 (most distressed). The Cronbach’s alpha for the scale was 0.99.

The 12-item short-form health survey (SF-12) mental component summary score was used to measure limitations caused by emotional, mental health and social functioning issues [ 35 ], in keeping with previous studies [ 31 , 32 ]. This tool has been validated for use as a measure of mental functioning in community samples [ 35 , 36 ]. Items included ratings of feelings experienced over the past 4 weeks such as “ Have you felt downhearted or blue ?” or “Accomplished less than you would like” . A total score ranging from 0 (low functioning) to 100 (high functioning) was derived using standard methods [ 37 ]. The Cronbach’s alpha for this scale was 0.98.

One item was used to assess participants’ life satisfaction by asking them how satisfied they were with their “life overall”, on a scale from 1 (completely dissatisfied) to 7 (completely satisfied) [ 38 ]. Single item measures of life satisfaction are widely used in survey studies [ 39 ] This measure has been used in previous investigations to assess the link between discrimination and life satisfaction [ 31 , 32 ].

Impairment outcome

Self-reported limiting longstanding illness at waves 1 (2009/10) and 3 (2011/12) was used as measure of impairment. It was measured using one item “Do you have any long-standing physical or mental impairment, illness or disability?...mean [ing] anything that has … or is likely to trouble you over a period of at least 12 months” with response options of yes or no. Self-reported limiting longstanding illness has been investigated in relation to perceived discrimination in other studies [ 40 , 41 ].

Physical health outcomes

We included 2 measures of physical health that were assessed at waves 1 (2009/10) and 3 (2011/12). The SF-12 physical component summary score was used to measure limitations caused by deficits in physical functioning [ 35 ]. Participants were ask ed “Does your health now limit you a lot, limit you a little or not limit you at all?” in activities such “climbing stairs” or “moving a table, pushing a vacuum cleaner, bowling or playing golf”. Overall scores were derived using standard methods ranging from 0 (low functioning) to 100 (high functioning) [ 37 ]. The Cronbach’s alpha for the scale was 0.98. This tool has been validated for use as a measure of physical functioning in community samples [ 35 , 36 ].

A single item was used to assess self-rated health: “ Would you say your health is … poor/fair/good/very good/excellent?” In keeping with earlier work [ 31 , 32 , 42 ] self-rated health was dichotomised with 0 being “good/very good/excellent” and 1 being “poor/fair”. This single item measure has been shown to have good predictive validity for health outcomes [ 42 ].

Our analyses included covariates that are likely relevant to racial discrimination and physical and mental health. All covariates were assessed at wave 1. Age in years was included as a continuous variable. Self-reported sex was included and coded as male/female. Socioeconomic status is an important contributor to racial disparities in health [ 43 ]. Racial discrimination can compound these inequalities. Therefore, we included education as a 3-level variable, coded as 1 “university degree”, 2 “high school qualification” and 3 “no qualification”. Equivalised monthly household income was computed by dividing total household net income by the modified Organization for Economic Cooperation and Development (OECD) equivalence scale to account for the effects of household size and composition [ 44 ]. The UKHLS samples the 5 main ethnic minority groups in the UK [ 25 , 30 ]: Indian, Pakistani, Bangladeshi, Black African and Black Caribbean. Participants were asked “What is your ethnic group?” with response options standardised in line with the England and Wales 2011 Census [ 25 ]. Response options also accounted for those of “mixed backgrounds”. We included ethnicity as a 6-level variable with these 5 main UK minority groups and 1 additional category of non-white individuals from a range of other minority backgrounds including Chinese, Arab and mixed ethnic backgrounds among others. For our sensitivity analysis, we collapsed ethnicity into a 3-level variable with Indian, Pakistani and Bangladeshi participants coded as “South Asian” Black African and Black Caribbean participants coded as “Black” and other non-white participants coded as “Other”.

Statistical analyses

The characteristics of those who did and those who did not report racial discrimination at wave 1 were compared using Chi-squared tests for categorical variables and independent samples t-tests for continuous variables. Associations between racial discrimination and the mental and physical health measures were assessed using linear regression for continuous outcomes and binary logistic regression for categorical outcomes. For the mental health analyses, psychological distress, mental functioning and life satisfaction were the outcome variables. For the impairment analysis limiting longstanding illness was the outcome variable. For the physical health analyses, physical functioning and self-rated health were the outcome variables. Age, sex, household income, education and ethnicity at wave 1 were adjusted for in all analyses. Baseline (wave 1) score/status on the relevant outcome variable was included as an additional covariate in prospective analyses. Only those with complete case information at wave 1 ( n  = 4883) and wave 3 ( n  = 2833) were included in the analyses. We tested for interactions between racial discrimination and age, sex, income, education or ethnicity on the mental and physical health outcomes at both waves 1 and 3. No significant effects were detected. Thus, interaction terms were not included in our final reported models.

Results from linear regression analyses are presented as unstandardized B and 95% confidence intervals (95% CI). Results from binary logistic regression analyses are presented as odds ratios (ORs) and 95% CI. The level of significance was set at p  < 0.05. Unstandardized Bs and ORs rather than p values should be used to determine the strength of associations. All analyses were conducted using SPSS v.24.

Sensitivity analyses

To test the robustness of our findings, we conducted three sets of sensitivity analyses. In our first, we investigated whether a certain type of discriminatory experience (i.e. feeling unsafe, avoiding somewhere, being insulted or attacked) contributing to the measure of racial discrimination was driving the results. We tested this by removing each type of discriminatory experience from the exposure variable in turn, as has been done in previous investigations [ 31 , 32 , 40 ]. In the second sensitivity analysis, we assessed whether participants who were lost to follow-up differed from those who provided data at both waves, and tested whether this influenced the findings by conducting the cross-sectional analyses (wave 1) including only those who provided follow-up data at wave 3. In our final sensitivity analysis, we assessed whether the associations between racial discrimination and our health outcomes varied depending on ethnic group (South Asian, Black or Other), as there is currently limited evidence in this area outside of the US context [ 16 ].

A total of 4883 participants were included in our analysis and of these 998 (20.4%) reported ethnicity ( n  = 854) or nationality ( n  = 144) discrimination. The characteristics of the sample at wave 1 in relation to racial discrimination are displayed in Table  1 . Those who perceived racial discrimination were younger on average and were more likely to hold a university degree than those who did not perceive racial discrimination. There were no differences in sex or income, but reports of racial discrimination did vary by ethnic group. Those in the Indian (23.3%) and in the Other ethnic group (24%) were most likely to report experiences of racial discrimination. Further detail on the types of racial discrimination and the settings in which the racial discrimination occurred for the different ethnic groups can be found in Supplementary Table  1 .

Racial discrimination and mental health

The descriptive characteristics of the sample in relation to health outcomes are displayed in Table  2 . The mental health findings from the regression analyses are displayed in the upper panel of Table  3 . Cross-sectionally, those who reported racial discrimination had greater psychological distress ( B  = 1.11, 95% CI 0.88; 1.34, p  < 0.001), poorer mental functioning ( B  = − 3.61; 95% CI -4.29; − 2.93, p  < 0.001) and lower life satisfaction ( B  = − 0.40, 95% CI -0.52; − 0.27, p  < 0.001), than those who did not report racial discrimination, independent of covariates.

In prospective analyses, those who perceived racial discrimination had greater psychological distress 2 years later than those who did not perceive racial discrimination, independent of covariates and baseline psychological distress ( B  = 0.52, 95% CI 0.20; 0.85, p  = 0.002). We detected an association between racial discrimination and poorer mental functioning ( B  = − 1.77; 95% CI -2.70; − 0.83, p  < 0.001), independent of covariates and mental functioning at wave 1. In adjusted analyses, those who reported racial discrimination had slightly lower life satisfaction than those who did not report racial discrimination at follow-up (means = 4.77 vs 4.91), but this difference did not reach statistical significance ( p  = 0.102).

Racial discrimination, impairment and physical health

The impairment and physical health results are displayed in the lower panel of Table 3 . The cross-sectional findings suggest that independent of covariates, participants who perceived racial discrimination were significantly more likely on average to report having a limiting longstanding illness (OR = 1.78; 95% CI 1.49; 2.13, p  < 0.001), and were more likely on average to rate their health as fair/poor (OR = 1.50; 95% CI 1.24; 1.82, p  < 0.001) than those who did not perceive racial discrimination. Those who reported racial discrimination also had significantly poorer physical functioning ( B  = − 0.86; 95% CI -1.50; − 0.27, p  = 0.008) than those who did not report racial discrimination in adjusted analyses.

In prospective analyses, those who reported racial discrimination were significantly more likely on average to have a limiting longstanding illness 2 years later than those who did not report racial discrimination, independent of covariates and limiting longstanding illness at baseline (OR = 1.31; 95% CI 1.01; 1.69, p  = 0.039). A greater proportion of those who reported racial discrimination rated their health as fair/poor on average at follow-up than those who did not report racial discrimination (OR = 1.30; 95% CI 1.00; 1.69, p  = 0.048) in adjusted analyses. However, we failed to detect a prospective adjusted association between racial discrimination and physical functioning ( p  = 0.290).

In the first sensitivity analysis, removing each of the discriminatory experiences from the measure of racial discrimination in turn did not alter any of the cross-sectional results (Table  4 , upper panel). Prospectively, the association between racial discrimination and all the mental health measures and limiting longstanding illness remained the same regardless of the type of discriminatory experience removed from the measure (Table 4 , lower panel). For self-rated health, the association was fairly robust to the type of discriminatory experience, but was slightly attenuated when “feeling unsafe” was removed from the racial discrimination variable ( p  = 0.133). Again, for the most part, no significant prospective associations were detected for physical functioning except when “feeling unsafe” was removed from the racial discrimination variable ( p  = 0.027).

In the second sensitivity analysis (Supplementary Table  2 ), cross-sectional physical and impairment (lower panel) and mental health (upper panel) findings for those who provided complete data at wave 3 were similar to the full-sample at wave 1.

In our final sensitivity analysis (Supplementary Table  3 ), we assessed whether the associations between racial discrimination and our health outcomes varied depending on ethnic group (South Asian, Black, Other). For the cross-sectional analyses, the findings for psychological distress and mental functioning did not vary by ethnic group. However, for life satisfaction ( B  = − 0.23; 95% CI -0.47; 0.02, p  = 0.069), limiting longstanding illness (OR = 1.34; 95% CI 0.93; 1.92, p  = 0.113), physical functioning ( B  = 0.42; 95% CI -0.84; 1.68, p  = 0.511), and self-rated health (OR = 1.01; 95% CI 0.67; 1.53, p  = 0.955) the findings for the Black group were non-significant, with lower point estimates than when the ethnic groups were combined in the main analysis. For the prospective analyses, there was no group difference for the impairment and physical health outcomes. However, the findings for psychological distress ( B  = 0.32; 95% CI -0.18; 0.82, p  = 0.207), and mental functioning ( B  = − 1.37; 95% CI -2.83; 0.09, p  = 0.065), were not significant for the South Asian group, with lower point estimates than in the combined model. Interestingly, for life satisfaction, those in the Other ethnic group had significantly lower life satisfaction at wave 3 ( B  = − 0.39; 95% CI -0.69;-0.08, p  = 0.013), with greater point estimates than in the combined model. This finding remained non-significant for the South Asian and Black groups.

In this large UK-based prospective sample of ethnic minority participants, we detected associations between racial discrimination and poorer health. Cross-sectionally, those who reported racial discrimination had a greater likelihood on average of limiting longstanding illness and poor self-rated health, than those who did not report racial discrimination. Racial discrimination was associated greater psychological distress, lower life satisfaction, and poorer physical and mental functioning. In prospective analyses, those who reported racial discrimination had a greater likelihood on average of limiting longstanding illness and poor self-rated health than those who did not report racial discrimination. Racial discrimination was associated with greater psychological distress and poorer mental functioning over a two-year follow-up period, regardless of baseline health. No significant prospective associations with physical functioning or life satisfaction were detected.

To our knowledge, this is the first prospective UK-based study to investigate both mental and physical health outcomes in relation to racial discrimination. One earlier analysis of the UKHLS found that those who reported racial discrimination had poorer mental functioning over a 1–4 year follow-up period [ 28 ]. The current study also found a prospective association between racial discrimination and poor mental functioning. Our study builds upon previous findings by additionally showing that this association is independent of baseline mental functioning. We also observed a prospective association with psychological distress, another marker of mental health, with those reporting racial discrimination experiencing an increase in psychological distress over time. We did not detect a prospective association between racial discrimination and poorer life satisfaction. Mean scores trended in this direction but the association did not reach statistical significance. A 2015 longitudinal analysis of the US-based Health and Retirement Study with over 6000 participants also failed to detect a prospective association between racial discrimination and decreases in life satisfaction [ 45 ], and pooled analyses have been unable to investigate prospective associations with life satisfaction due lack of sufficient evidence [ 12 , 16 ]. A possible explanation for this null finding, consistent with earlier work, is that racial discrimination is more strongly associated with negative mental health outcomes such as psychological distress than with positive outcomes such as life satisfaction [ 12 , 16 ]. Another potential reason for these findings relates to duration of follow-up, as review evidence suggests that a recent experience of racial discrimination may be more strongly associated with poor mental health and more weakly related to life satisfaction measures [ 16 ]. Our follow-up period of 2 years was relatively short which may have contributed to these results.

Reviews in the field [ 16 , 17 ] have highlighted the need for more prospective evidence, particularly for physical health outcomes [ 16 ]. We found that participants who reported racial discrimination were more likely to report having a limiting longstanding illness and poorer self-rated health, independent of baseline status. Meta-analytic evidence has demonstrated an association between racism and poor general health and worse physical health outcomes [ 16 ]. We built upon this predominately US-based data (a considerable portion of which used convenience sampling) to demonstrate prospective associations between racial discrimination and physical health outcomes in a representative sample of UK adults from ethnic minority groups. We failed to observe a prospective association between perceived racial discrimination and physical functioning, although participants who reported racial discrimination had slightly lower physical functioning scores prospectively than those who did not report racial discrimination. This lack of association may indicate that ongoing experiences of racial discrimination had already made an impact on physical functioning at the time of wave 1 survey, limiting the scope for further significant decreases in this measure over time, particularly as we took baseline physical functioning into account in our analyses. Another possibility, is that the etiological period involved for a decline in physical functioning may differ from that of mental functioning [ 14 ]. These outcomes were measured using the same tool (SF-12) but only mental functioning was significantly associated with racial discrimination over the follow-up period.

Review evidence based on US data suggests that associations between racial discrimination and health may vary depending on ethnic group [ 16 ]. In our sensitivity analysis, the cross-sectional results for life satisfaction and impairment and physical health outcomes were non-significant for the Black group. Prospectively the findings for psychological distress and mental functioning were non-significant for the South Asian group. Whereas, life satisfaction was found to significantly decline for the Other group over the follow-up period. Taken together these results suggest associations with health outcomes are strongest for South Asian and Other groups cross-sectionally, while prospectively racial discrimination appears to most consistently impact mental health outcomes in Black and Other ethnic groups. These findings should be interpreted with caution due to the likelihood that some of our analyses were underpowered.

In our cross-sectional analyses, we found that those who perceived racial discrimination had poorer mental health, with greater psychological distress, poorer mental functioning and lower life satisfaction. Previous work in UKHLS has demonstrated a cross-sectional association with psychological distress using pooled data across three waves of data collection [ 46 ]. To our knowledge no prior UK-based work has reported on cross-sectional associations with poor mental functioning and low life satisfaction. These findings are consistent with earlier work in other countries [ 12 , 16 , 45 ].

We detected links between racial discrimination and poor physical health and impairment. Specifically, we found that those who reported racial discrimination had poorer self-rated health, poorer physical functioning scores and a greater likelihood of having a limiting longstanding illness than those who did not report racial discrimination. Earlier work using the 1993/1994 UK-based Fourth National Survey of Ethnic Minorities survey reported associations between perceived racial discrimination and poor self-rated health [ 27 , 47 ] and limiting longstanding illness [ 47 ]. Our more recent findings from 2009/2010 suggest that these deleterious associations remain an issue for minorities in the UK.

We detected stronger associations between racial discrimination and health for cross-sectional than for prospective comparisons, in keeping with earlier evidence [ 16 ]. However, cross-sectional work cannot determine whether reports of racial discrimination stimulate poor mental and physical health or whether perceptions of racial discrimination are a manifestation of feeling suboptimal mentally or physically. Our prospective findings therefore add to the field in establishing that racial discrimination predicts poor mental and physical outcomes prospectively, net of baseline associations, supporting the hypothesis that racial discrimination has adverse consequences for future health.

With regard to the pathways through which racial discrimination negatively impacts health, there are several possibilities that could help explain our results. One mechanism linking racial discrimination and health may be through the dysregulation of stress-related biological processes. In response to perceived chronic discrimination, stress processes may be frequently activated, which over time may result in disturbances across multiple biological systems, in line with the theory of allostatic load [ 20 ]. Review evidence indicates discrimination is associated with heightened cardiovascular responses to stress [ 11 , 21 ], though it is unclear whether this translates into an increased risk for clinical hypertension [ 48 ]. Another biological mechanism that may link discrimination and health is through activation of the hypothalamic-pituitary-adrenal (HPA) axis. Several reviews have linked racial discrimination [ 21 , 49 , 50 ] with changes in various cortisol parameters, which in turn have been linked with poorer mental and physical health [ 51 , 52 ]. Deleterious changes in other biological processes such as heightened inflammation [ 22 ] and alterations in DNA methylation of stress-related genes [ 53 ] have been linked with discrimination in recent studies. Alterations in these stress-related biological processes offer a plausible link to negative changes in physical [ 54 , 55 ] and, mental health outcomes [ 51 , 56 ]. Racial discrimination has also been associated with disturbances in neurobiological processes, with alterations observed in brain areas such as the anterior cingulate cortex, prefrontal cortex and amygdala which overlap with pathways associated with poor mental health [ 57 ].

Individual health risk (e.g. smoking, alcohol consumption etc.) could link perceived racial discrimination and poor mental and physical health, either as a method of coping with the negative psychological effect of perceiving racial discrimination (e.g. excessive alcohol consumption as a coping mechanism) or as a barrier to engaging in healthy behaviours (e.g. avoiding a health service perceived to be discriminatory). Racial discrimination has been associated with smoking [ 23 , 58 , 59 ], excessive alcohol consumption [ 23 , 60 ], as well as substance abuse [ 61 , 62 ]. Review evidence has linked discrimination with poor sleep [ 63 ] as well as weight gain in prospective studies [ 24 ]. This individual health risk offers a plausible indirect pathway linking racial discrimination with both poor mental [ 64 , 65 ], as well as physical health outcomes [ 66 ].

Another possibility at the broader structural level is that racial discrimination may impact health through differential access to societal resources such as education, employment, welfare and criminal justice [ 14 , 15 ]. In the UK, a 2016 report documented persistent ethnic disparities in educational attainment, employment, access to fair pay and adequate housing, as well the over-representation of ethnic minorities in the criminal justice system [ 4 ]. Further, data from this report highlight inequalities in access to healthcare among ethnic minority groups [ 4 ]. While meta-analytic evidence indicates that racial discrimination is associated with more negative patient experiences of health services, as well as delaying/not getting healthcare and lack of treatment uptake [ 19 ]. As these factors are social determinants of health in of themselves [ 13 , 14 , 15 ], they may act as a pathway through which perceptions of racial discrimination can act to negatively influence health.

The results of the current study need to be assessed in terms of strengths and limitations. There is a dearth of prospective evidence on the link between racial discrimination and health in UK samples, particularly in relation to physical health. Our large sample of ethnic minority participants allowed us to examine changes in mental and physical health over 2 years, and demonstrated both cross-sectional and prospective associations. We also adjusted statistically for factors that potentially confound associations, including age, sex, socioeconomic status and ethnicity. Although controlling for covariates does not tease out the complexity of the relationships between perceived racial discrimination and these sociodemographic characteristics [ 43 ]. For example, socioeconomic status contributes to racial inequalities in health [ 43 ], while racial discrimination can compound these disparities and can be conceptualised as an indicator of structural racism [ 13 ]; statistical adjusting for socioeconomic status does not capture these relationships.

The study of racism is a complex and contested area of research [ 67 , 68 ] and our study was not without limitations. Our measure of perceived discrimination was not specifically tailored for racial discrimination, as participants in the could attribute their experience to other forms of discrimination as well (e.g. sexism, ageism). There is evidence that the exposure instrument can influence associations between racism and physical and mental health outcomes [ 16 ] . Participants were able to attribute multiple reasons for their report of discrimination, which could have helped to avoid priming and this measure has been used to assess racial discrimination in previous work [ 28 ]. However, it is possible that measures such as the Schedule of Racist Events scale [ 69 ] and the Perceived Racism Scale [ 70 ] with more specific items on racist degradation and experiences of racism in personal and professional contexts could have garnered different results. Further, the self-report individual measure of racial discrimination employed in our study does not capture the structural conditions that shape the varied ways in which racial discrimination operates [ 14 ]. We only assessed perceived racial discrimination at baseline in this study and did not investigate whether racial discrimination experiences were persistent or changed over time.

Racial discrimination was assessed by self-reports of experiences in the past year and was therefore subject to recall bias. Our findings reflect the perception of racial discrimination rather than objective encounters with racial discrimination. It is possible that objective encounters with racism and perceiving one’s self as the target of racial discrimination might have different consequences for health. Experimental studies involving exposure to discriminatory scenarios have been used to investigate the health impact of objective exposures to racial discrimination. However, these studies may not represent a gold standard for the study of the relationship between discrimination and health, as meta-analytic evidence indicates that exposure to a single negative event in a laboratory setting does not negatively influence health [ 12 ].

In conclusion, this study adds to the field by demonstrating cross-sectional and prospective relationships between racial discrimination and both mental and physical health outcomes. With the rise in racial discrimination in the UK [ 6 ] in the aftermath of the Brexit vote [ 9 ] our findings highlight the need to reduce racial discrimination, not only to promote equity, but also to potentially benefit mental and physical health and reduce health inequalities.

Racial discrimination is a complex system that involves assigning ethnic groups differential value, which drives disparities in access to power, resources and opportunities [ 14 , 15 ]. Due to its multi-faceted nature, occurring at both the structural and individual level multiple interventions will be required to tackle this pervasive determinant of health. Historically, raising awareness of racial discrimination has been necessary to promote activism to bring about legislative and social change to improve the position of ethnic minority groups. In terms of public health, there are calls to integrate research about racial discrimination and health into medical teaching in an attempt to tackle structural racism and to highlight the impact racial discrimination has on health [ 71 , 72 ]. As well as strategies to reduce the pervasiveness of racial discrimination in institutional contexts, action through social media may have benefits for individual health too. The Black Lives Matter campaign is an example of a recent social media movement which has drawn attention to the issue of racial discrimination. There is some evidence that campaigns may provide a source of empowerment, particularly in a time where ethnic minority youth participation in traditional civic engagement activities are in decline [ 73 ]. Evidence suggests the Twitter conversation remained Black-led [ 73 ] and that the majority of the 40 million plus tweets were supportive of the movement [ 73 , 74 ]. However, whether social media campaigns positively [ 73 ] or negatively impact minority health [ 75 ] remains the subject of debate. Further, it should be acknowledged that interventions to educate and raise awareness do not tackle the structural macro-level forces that shape the position of ethnic minorities in society. Although, more challenging to address, work is required to identify socio-political processes that generate racial discrimination so attempts can be made to mitigate its effects. Research into the pathways underlying the link between racial discrimination and health are required to develop policy and to target interventions in this field.

Availability of data and materials

The UKHLS datasets analysed during the current study are freely available in the UK Data Service repository https://ukdataservice.ac.uk/

Abbreviations

Confidence Interval

General Health Questionnaire-12

Hypothalamic-pituitary-adrenal

Organization for Economic Cooperation and Development

Short-form Health Survey-12

United Kingdom

The United Kingdom Household Longitudinal Study

United States

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This research was funded by the Economic and Social Research Council ( https://esrc.ukri.org/ ), grant number ES/R005990/1. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Supplementary Table 1. Racial discrimination types and settings by ethnic group. Supplementary Table 2. Associations between racial discrimination and health outcomes (complete cases at wave 3). Supplementary Table 3. Cross-sectional and prospective associations between racial discrimination and health outcomes stratified by ethnic group

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Hackett, R.A., Ronaldson, A., Bhui, K. et al. Racial discrimination and health: a prospective study of ethnic minorities in the United Kingdom. BMC Public Health 20 , 1652 (2020). https://doi.org/10.1186/s12889-020-09792-1

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Inequality and Racial Backlash: Evidence from the Reconstruction Era and the Freedmen’s Bureau

How do majority groups respond to a narrowing of inequality in racially polarized environments? We study this question by examining the effects of the Freedmen’s Bureau, an agency created after the U.S. Civil War to provide aid to former slaves and launch institutional reform in the South. We use new historical records and an event study approach to estimate impacts of the Bureau on political economy in the South. In the decade immediately after the war, counties with Bureau field offices had reduced vote shares for Democrats, the major political party that previously championed slavery and opposed Black civil rights during Reconstruction. In the longer-run, we find evidence of backlash in the form of higher Democratic vote shares and increases in several forms of racial violence, including lynchings and attacks against Black schools. This backlash extends through the twentieth century, when we find that counties that once had a Bureau field office have higher rates of second-wave and third-wave Ku Klux Klan activity and lower rates of intergenerational economic mobility. Overall, our results suggest that the initial impacts of the Freedmen’s Bureau stimulated countervailing responses by White majorities who sought to offset social progress of Black Americans.

For helpful comments and discussions, we thank Bhash Mazumder and Patrick Testa. We also thank Katherine Cohen, Bethany Falcon, Cristine McCollum, and Vanessa Ntungwanayo for valuable research assistance. This project benefited from software developed by Joung Yeob Ha and Henry Mo. The views expressed in this paper are solely those of the authors and do not necessarily reflect the views of the Federal Reserve Bank of Philadelphia or the Federal Reserve System. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

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Psychological research has a racism problem, Stanford scholar says

Across five decades of psychological research, publications that highlight race are rare, and when race is discussed, it is authored mostly and edited almost entirely by white scholars, according to a new Stanford study.

Race plays a critical role in shaping how people experience the world around them, so one would expect a rich body of literature published in mainstream psychological journals to examine its effects on people’s thoughts, feelings and behavior.

Psychologist Steven Roberts led a recent examination of racial representation in psychological research that revealed a lack of diversity among authors and editors. (Image credit: L.A. Cicero)

However, race is almost absent from top psychological publications, according to a new study led by Steven O. Roberts , an assistant professor of psychology in the School of Humanities and Sciences . His research, published June 24 in Perspectives on Psychological Science , found that prominent psychological publications that highlight race are rare, and when race is discussed, it is authored mostly and edited almost entirely by white scholars.

“Psychologists are supposed to know about racial bias and how to prevent it from stratifying the world,” Roberts said, “but if we, the so-called experts, have a problem, then society really has a problem.”

To examine racial representation in psychological research, Roberts and his Stanford research team – Carmelle Bareket-Shavit, Forrest A. Dollins, Peter D. Goldie and Elizabeth Mortenson – looked at more than 26,000 empirical articles published between 1974 and 2018 in top-tier academic journals for three major areas of psychology: cognitive, developmental and social. The journals the researchers focused on were Cognition , Cognitive Psychology , Child Development , Developmental Psychology , The Journal of Personality and Social Psychology and Personality and Social Psychological Bulletin .

Who are the gatekeepers?

Unlike newspapers and magazines that the general public read, academic journals are intended for a scholarly audience. They are where scholars can debate and discuss their research findings with other experts in the field and also to inform themselves on how the discipline is evolving. Overseeing the entire publication process at an academic journal is an editor-in-chief. In addition to managing the journal’s editorial board and recruiting other scholars to assess submissions for a process known as peer review, the editor-in-chief makes the final decision on what research is fit to publish.

“The editor-in-chief is in a powerful position to shape the ideas of an entire community,” said Roberts. Given these gatekeeping responsibilities, Roberts wanted to know more about who edits research about race and whether an editor’s race can predict how much of that research is published.

To determine the race of the editors and the authors they publish, the researchers searched and categorized photos they found of them online, which were often from their faculty webpage. They then emailed the scholars to ask for their self-identified racial identity. This allowed the researchers to ensure that their own assessments were accurate, which they were.

Of the journals that Roberts and his team surveyed, they found that of the 60 editors-in-chief between 1974 and 2018, 83 percent were white, 5 percent were people of color (POC) and 12 percent were unidentifiable because the researchers were unable to code their race (for example, were deceased, retired or had no images online). Of the publications with research that highlighted race, 87 percent were edited by white editors.

Racial makeup among editors-in-chief also varied among different areas of psychology. For example, there has never been a POC editor in either of the journals about cognitive psychology, a subfield that studies mental processes such as perception, memory, thinking, attention and language.

The data also revealed that an editor-in-chief’s race predicted the publication of research that highlighted race. When editors were white, 4 percent of all publications highlighted race. When they were POC, the publication rate almost tripled to 11 percent.

Roberts’ data showed that from the 1970s to the 2010s, only 5 percent of publications in the top-tier psychological journals he examined highlighted race. Here too, differences emerged in different areas of the discipline – in cognitive psychology fewer than 0.01 percent of publications in that subfield looked at race, compared with 8 percent in developmental psychology and 5 percent in social psychology.

Roberts hypothesizes that cognitive psychologists may avoid race because of their pursuit to study race-neutral, universal phenomena.

“A handful of studies published in top-tier cognitive journals make clear that cognitive processes, such as auditory processing, categorization and memorization, do indeed vary as a function of racialized experiences,” Roberts explained. “To not acknowledge this, or to only study human thinking with white participants, is a disservice to science.”

Another explanation for the lack of racial diversity could be that white editors are subject to the same reluctance that white people in general have when it comes to discussing race. Previous research has shown that white people are more likely than persons of color to avoid conversations about race. Either they don’t feel qualified enough on the issue to discuss it or they want to project an image of color-blindness, said Roberts.

The writers

Roberts also wanted to know the racial composition of the academics who are publishing research on race in these journals. Among the publications that the researchers studied, they found that 63 percent of the paper’s first authors – the persons typically responsible for conducting the research and writing the manuscript – were white, 23 percent were POC and 14 percent were unidentifiable when it came to race.

The researchers next examined alternative explanations for why white authors might be overrepresented in top-tier psychology journals. For example, they explored whether the disparity might be explained by the quality of research. A measure academics use to assess quality is a scholar’s citation score; that is, how often they are referenced by other academics. Roberts found there was no difference between the citation counts of authors of color and white scholars.

The researchers also wondered if the disparity could be explained by the quantity of the researchers. If there are simply more white authors, then white authors should be overrepresented across all journals. However, Roberts found that in lower-tier specialty journals, white authors were actually underrepresented.

“The overrepresentation of white authors in top-tier psychology journals is not explained by the quality of the research or by the quantity of the researchers. But it is explained by structural racism,” said Roberts. “These journals are dominated by white psychologists, which has implications for what and who is excluded from the scientific record.”

What to do next, and what can be done right now

Roberts’ paper includes a set of recommendations to help journals and authors make psychological science more equitable.

“Our discipline is supposed to know how racism works. If we are to eradicate racism from our society we need to eradicate it from our science,” Roberts said. “We need to put anti-racist systems in place.”

The first thing journals can do is communicate a top-down commitment to diversity, said Roberts. This means explicitly stating whether the journal publishes research that is sensitive to diversity and whether it values the editing, writing and participation of diverse scientists.

Other recommendations are to include diverse individuals across all levels of the publication process, evaluate the diversity of research participants in the review process, release public diversity reports annually and establish a diversity task force.

Authors can make a change as well. Roberts recommends that, for instance, authors detail and justify the racial demographics of their research participants. Doing so is uncommon in mainstream psychology journals, says Roberts.

Roberts hopes that this work will give recognition to generations of psychologists who have worked tirelessly in the field and largely been ignored in the publication process of the most esteemed journals.

“I see this paper is a tribute to all the great psychologists of color who have for decades navigated an unfair system,” Roberts said. “Hopefully this paper will inspire the change needed for everyone to get their perspectives shared.”

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We explore the diverse views and experiences of Black people in America with in-depth surveys and other research. Our work focuses on three themes: Black identity, the economic and social mobility of Black people in America, and Black representation in American political and social life. This work is part of our wider  race and ethnicity  research portfolio.

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New and timely research

Facts about the u.s. black population.

An estimated 47.9 million people in the U.S. identified as Black in 2022. The Black population has grown by more than 10 million since 2000, when 36.2 million of the U.S. population identified as Black, marking a 32% increase over roughly two decades.

• Overview: Key facts about the nation's 47.9 million Black Americans

Key facts about Black eligible voters in 2024

Wealth surged in the pandemic, but debt endures for poorer black and hispanic families, black americans’ experiences with news, sign up for our race & ethnicity newsletter.

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Black americans support gender equality but are split on transgender and nonbinary issues   .

Nearly six-in-ten want organizations working for Black progress to address the distinct challenges facing Black LGBTQ people.

Black Americans Have a Clear Vision for Reducing Racism but Little Hope It Will Happen

Black Americans support significant reforms to or complete overhauls of several U.S. institutions to ensure fair treatment.

Race Is Central to Identity for Black Americans and Affects How They Connect With Each Other

Many Black Americans say they learn about their ancestors and U.S. Black history from family.

One-in-Ten Black People Living in the U.S. Are Immigrants

Immigrants – particularly those from African nations – are a growing share of the U.S. Black population.

All Black Americans Publications

A look at black-owned businesses in the u.s..

While Black-owned businesses have grown significantly in the U.S. in recent years, they still make up a small share of overall firms and revenue.

8 facts about Black Americans and the news

76% of Black adults say they at least sometimes get news on TV, compared with 62% of both White and Hispanic adults and 52% of Asian adults.

Black Americans’ Views on Success in the U.S.

While Black adults define personal and financial success in different ways, most see these measures of success as major sources of pressure in their lives.

Among Black adults, those with higher incomes are most likely to say they are happy

Black adults in upper-income families are about twice as likely as those in lower-income families to say they are extremely or very happy.

Fewer than half of Black Americans say the news often covers the issues that are important to them

40% of Black Americans say that the issues and events most important to them are often covered, and similar shares of Asian (38%) and Hispanic (37%) adults say the same.

Key facts about the nation’s 47.9 million Black Americans

The number of Black people living in the United States reached a new high of 47.9 million in 2022, up about a third (32%) since 2000.

Key statistics and data about the demographic, geographic and economic characteristics of the U.S. Black population.

The number of Black eligible voters in the United States is projected to reach 34.4 million in November 2024 after several years of modest growth.

Black Americans are more likely than others to say they see problematic news coverage of Black people

About four-in-ten Black Americans (39%) say they extremely or fairly often see or hear news coverage about Black people that is racist or racially insensitive.

5 facts about Black Americans and health care 

More Black Americans say health outcomes for Black people in the United States have improved over the past 20 years than say outcomes have worsened.

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About Pew Research Center Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of The Pew Charitable Trusts .

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• 04 Mar 2024
• Research & Ideas

Want to Make Diversity Stick? Break the Cycle of Sameness

Whether on judicial benches or in corporate boardrooms, white men are more likely to step into roles that other white men vacate, says research by Edward Chang. But when people from historically marginalized groups land those positions, workforce diversification tends to last. Chang offers three pieces of advice for leaders striving for diversity.

• 02 Jan 2024
• Cold Call Podcast

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Cold Call: Building a More Equitable Culture at Delta Air Lines

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• 31 Oct 2023

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• 16 Oct 2023

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Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care; Smedley BD, Stith AY, Nelson AR, editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington (DC): National Academies Press (US); 2003.

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.

• Hardcopy Version at National Academies Press

UNDERSTANDING AND ELIMINATING RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE BACKGROUND PAPER RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE: A BACKGROUND AND HISTORY

W. Michael Byrd, M.D., M.P.H.

Linda A. Clayton, M.D., M.P.H.

Division of Public Health Practice

Harvard School of Public Health

CONSULTANTS: Joe Feagin, Ph.D; Augustus A. White III, M.D., Ph.D; Ricardo Guthrie, M.A.

• Introduction

Despite steady improvement in the overall health of the United States' population, the health of America's racial and ethnic minorities varies from the mainstream. For example, the health status of African Americans'–a racial-ethnic group already burdened with deep and persistent history-based health disparities–have been recently characterized as stagnant or deteriorating (Byrd and Clayton, 2000, 2002; Collins, Hall, and Neuhaus, 1999; National Center for Health Statistics, 1998; Sullivan, 2000; Williams, 1999). A body of nearly 600 scientific publications documenting racial and ethnic disparities in health care provide ample evidence of this problem (Geiger, 2000; Mayberry, Mili, and Ofili, 2000). Though it is well known that these disparities reflect socioeconomic differences and inadequate access to quality health care, contemporary evidence suggests that racial, ethnic, class, and gender bias along with direct and indirect discrimination are also important factors (Geiger, 2000; Mayberry, Mili, and Ofili, 2000; U.S. Commission on Civil Rights, 1999a, 1999b; Williams, 1999).

Following the lead of the legislation and committee reports, this Institute of Medicine (IOM) study is one part of a multifaceted effort by the United States Congress to understand and eliminate racial and ethnic disparities in health care. Factors mentioned in these documents and linked to the racial and ethnic health and health care disparities such as American racial, ethnic, and immigrant relations; “racism”; “historic racial discrimination” and bias; biased clinical decision-making; a health system structured on the basis of race, ethnicity, and class; and access barriers caused by shortages of racial and ethnic minority providers are explored, described in detail, analyzed, and incorporated into suggestions for corrective actions (Byrd and Clayton, 2000, 2002; The Health Care Fairness Act of 1999 , 1999; Section of House Committee Report to Accompany H.R. 3064, 2000; Sullivan, 2000).

Differences in population characteristics such as race, ethnicity, class, culture, and gender are at the root of many present health and health system problems in the United States. From racial and ethnic relations perspectives such differences have generated group identities and self-awareness, racial mythology, group interaction, stereotyping, competition, conflict, a corpus of critical theory, accommodation, and in some instances assimilation and integration. A number of academic disciplines and formidable bodies of scientific literature have grown around each of these subjects. African Americans serve as surrogates for racial and ethnic minority groups in the United States in many instances. This is not by design, but based on the fact the overwhelming majority of the research, published literature, and data on racial and ethnic disparities before 1985 was focused on that group. Moreover, their chronicle, alongside Native Americans, epitomizes the depth, breadth, and intensity of the American racial and ethnic minority experience (Burns, 1995; Byrd and Clayton, 2000, 2002; Feagin and Feagin, 1999; Outlaw, 1990; Smedley, 1999; Stuart, 1987).

Though viewed by many as recent occurrences, racial- and ethnic-based health disparities are centuries-old phenomena. They are outcomes reflecting medical-social values and policies in Western and later U.S. medicine and health care, which paralleled the values and policies in the larger societies. Have these racial and ethnic differences, and the biases and discrimination they both generated and reflected, always dictated, even distorted, how the U.S. health system functions? If so, what are the characteristics and profile of this dysfunction? Indeed, what are the origins, bases, and evolution of the biases and inequities that are focal points of and, at the very least, major contributors to what are arguably the most important sets of the nation's pressing health and health system problems–persistent racial and ethnic health and health care disparities? Their persistence represents a major challenge to and an affront to the genius of the American health system, while serving as the driving force behind this IOM study. Acquisition of the requisite knowledge to begin answering these questions will lead to understanding the nature of the problems, the performance of objective analyses, and, eventually, to crafting fact-based, logical, interventions and solutions for the problems (Byrd and Clayton, 2000, 2002; Feagin and Feagin, 1999; Section of House Committee Report to Accompany H.R. 3064, 2000; Smedley, 1999; The Health Care Fairness Act of 1999 , 1999; U.S. Department of Health and Human Services, 1985a).

It is clear that health and health care in the United States are multi-racial, multi-ethnic, immigrant stories. A brief examination of racial and ethnic relations in this country from its colonial past to the present provides the context for the larger examination of health and health care as social processes and problems. In addition, since virtually all modern health policy decisions are based on the collection of accurate demographic, health, and health-related data, a background on data collection with regard to America's various racial and ethnic groups is essential. An examination of the intricacies of the process, its standardization, and its evolutionary phases is both a prerequisite and a necessity, especially as it has related to health and health care. A factual chronology about data and its collection is provided in order to appreciate and learn from the past experiences, dispel common sense assumptions and mythologies, and as a preparation for future fact-based policy-making.

America is a nation of immigrants. 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 disparity situation. Following is an examination of the major racial and ethnic groups, both European and people of color, focusing on their health and the variables that impact it. This lends a broader and much needed health policy perspective on where we have been and where we need to go. Recurrent themes resonate throughout the inquiry. For example, as racial and ethnic minorities become larger percentages of our total population the health and health care of minority Americans in both relative and absolute terms become national public policy issues of the first rank. Another theme is that health care is presently being conceptualized as a human right.

Obtaining a background regarding the roles race, ethnicity, gender, culture, and class play in U.S. society and health care are requisite to deciphering the message inherent in the racial and ethnic health and health care disparities. In order to obtain a deeper understanding of the present racial and ethnic health and health care disparities one must gain an understanding of the origins, evolution, and perpetuation of racial and ethnic bias, inequities, and disparities in health and health care in the United States and, earlier, Western predecessor cultures. Because of the variation in opinions and usage of certain terms emanating from a wide range of disciplines, a glossary has been included which contains accepted definitions of terms the IOM Committee thought would be useful to the readers (Byrd and Clayton, 2000, 2002; Feagin and Feagin, 1999; Fee, 1997; Fluss, 1997; The Health Care Fairness Act of 1999 , 1999; Section of House Committee Report to Accompany H.R. 3064, 2000).

• American Racial and Ethnic Relations: The Context

Racial and ethnic diversity is a basic tenet in the evolution of this society. Neither health nor health care is an exception. “The development of social and economic inequalities based on race and ethnicity has been a central theme–and a central dilemma–of the history of the United States [and the Western World], shaped over many generations by the European conquest of indigenous peoples and by massive waves of both coerced and uncoerced immigration from all over the world” (Pedraza and Rumbaut, 1996, xvi). Moreover, racial and ethnic relations have always been tumultuous in the United States. The use of terms such as dominant group and subordinate group in the study of American racial and ethnic relations suggest, and has often been linked to, racial and ethnic hierarchy, stratification and substantial inequality among groups. Disparate outcomes between European Americans and racial- and ethnic- minority Americans in many spheres of social life–health and health care as social processes–as a result of this state of affairs are not new nor should they be unexpected (Byrd and Clayton, 2000, 2002; Feagin and Feagin, 1999; Jaco, 1979; Kosa and Zola, 1975; Pedraza and Rumbaut, 1996; Smedley, 1999).

Founded more than 200 years ago after a revolution that cut colonial ties with Europe, the creation of the United States was based on Enlightenment principles of freedom and equality. A vigorous nation of great racial and ethnic diversity emerged. However, racial and ethnic prejudices, biases, oppression and conflict were embedded in the colonial antecedents, the founding period, and central documents of the new republic (Brinkley, 1993; Feagin, 2000; Omi and Winant, 1994). Further, as Rumbaut notes, “[I]mmigration and conquest–by hook or by crook–have been the originating processes by which American ethnic groups have been formed and through which, over time, the United States itself has been transformed into arguably the world's most ethnically diverse society” (Pedraza and Rumbaut, 1996, xvi). The European, predominantly English, colonists often took land from Native Americans (American Indians) by force or chicanery and by the late-17th century had established an economy strongly based in African American chattel slavery in the South and on the slave trade in the North. Moreover, throughout succeeding centuries a tradition of oppressing non-English (e.g., Irish and Italians) and non-European (e.g., Chinese, Japanese, and Mexican Americans) immigrants was also established (Brinkley, 1993; Burns, 1995; Feagin, 2000; Feagin and Feagin, 1999; Stuart, 1987).

At first liberty and justice were for males of British descent only, and inequality in life chances along racial, gender and ethnic lines became a fundamental fact of the new nation's institutions. As Flexner observed, “Whatever their social station, under English common law, which became increasingly predominant in the colonies...women had many duties, but few rights” (1975, 7). Conflict between Anglo-Protestant Americans and Indians varied from outright warfare to separate coexistence. Though the promotion of non-English immigration had coincided with English mercantile and colonial aims and intensified in the nineteenth century, new White immigrants, “foreigners,” often met hostility and found themselves less than equal socially or under law. Women struggled continuously for their rights (Flexner, 1975). Racial tension and conflict was a constant between Anglo-Protestant Americans and African Americans under 246 years of brutal and exploitive chattel slavery, followed by 100 years of social segregation, physical oppression, political subjugation, and economic exploitation. As English domination was modified over the next two centuries by the challenges and occasional ascendency of other northern Europeans, southern and eastern Europeans, and other non-European groups trying to move up socially, economically and politically, the United States became an unprecedented and uneasy mix of diverse peoples (Brinkley, 1993; Burns, 1995; Feagin, 2000; Feagin and Feagin, 1999; Omi and Winant, 1994; Shipler, 1997; Stuart, 1987).

Basic documents of the new republic reflect its patterns of racial subordination, ethnic discrimination, and gender difference. Neither the Articles of Confederation, the Declaration of Independence, nor the Naturalization Law of 1790 extended the doctrines of freedom and equality to African Americans (Brinkley, 1993; Feagin and Feagin, 1999; Omi and Winant, 1999). One provision of the Naturalization Law of 1790 was that only “White” persons could become citizens (Takaki, 1993, 273). After a failed campaign by southern slaveholders to count Black slaves for apportioning states' legislative representation though not for direct taxation (Brinkley, 1993, 150), enslaved Americans were counted as three-fifths of a person in the U.S. Constitution. 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. citizens until 1952 (Brinkley, 1993, 576-577, 816; Feagin and Feagin, 1999, 209, 391; Office of Research on Women's Health, 1998, 17). Slavery was not only legal with Blacks designated as chattel, the slave trade was allowed to continue until 1808 and a fugitive slave provision was incorporated in the U.S. Constitution, one that required the return of runaways to their owners. Neither the Declaration of Independence's famous statement that “all men are created equal” nor the Constitution's Bill of Rights applied to African Americans (Higginbotham, 1978, 1996). The Alien, Sedition, and Naturalization Acts compromised the rights and citizenship status of immigrants as early as the late 1700s and early 1800s. The Page Act of 1875 restricted the immigration of Chinese women while prohibition of the group as a whole was accomplished with the Chinese Exclusion Act of 1882 (Brinkley, 1993; Feagin, 2000; Feagin and Feagin, 1999; Takaki, 1993).

By adopting the English language and accommodating to English-oriented institutions, White non-British immigrant groups have gained substantial power and status in the United States. However, voluntary and involuntary immigrants from Africa, Asia, and Latin America, as well as Native Americans, have remained subordinate to White Americans in political, cultural, and in most instances economic terms. For example, despite their arrival as agricultural laborers recruited in the 1880s, Japanese Americans could not become naturalized citizens until the passage of the McCarran-Walter Act of 1952 (Omi and Winant, 1994, 81). Though racial and ethnic diversity, inequality, and oppression were and continue to be part of the foundation of U.S. society, Americans of color continue to challenge their subordinate status (Feagin and Feagin, 1999; Omi and Winant, 1994). In many ways the continuing story of the United States' racial, ethnic, class, and gender biases and conflicts are evidence of the system's dynamism–the promises and sorrows of the American Dream. America's troubled past has profoundly affected its health system. 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, 2002; Stuart, 1987; Williams, 1999). If current demographic trends continue and people of color become the majority of the U.S. population by the middle of the twenty-first century, dramatic institutional changes will be necessary–including in the nation's health system (Brinkley, 1993; Byrd and Clayton, 2000, 2002; Collins, Hall, and Neuhaus, 1999; Feagin, 2000; Feagin and Feagin, 1999).

• Racial and Ethnic Data Collection and Definitions

Racial and ethnic minority groups are among the more difficult demographic categories with which to deal because there is no simple scheme for defining these groups or classifying the categories' subgroups (U.S. Department of Health and Human Services, 1985). As will be discussed later, attempts at categorization are further complicated by the complex histories and chronological layers of definitions and classifications related to racial and ethnic concepts in Western culture (Byrd and Clayton, 2000, 2002; Smedley, 1999). Imprecise and changing definitions of race and ethnicity emanating from the federal government, anthropologists and other social scientists further complicate the issue of definitive categories or classifications (American Anthropological Association, 1997; Thernstrom, Orlov, and Handlin 1980; Zenner, 1996). Nevertheless, in order to assess the health status, outcomes, and services utilization of various racial and ethnic groups in the United States, data must be collected with some type of category system. Though current data collection systems are both imprecise and do not adequately collect data for all the important U.S. racial or ethnic minority groups, the federal government attempts to perform this task in a systematic manner (U.S. Office of Management and Budget, 1997).

The U.S. government provides a standard classification system for record keeping, collection, and presentation of data on race and ethnicity in federal program administrative reporting and statistical activities. The five defined racial and ethnic categories are American Indian or Alaskan Native, Asian or Pacific Islander, Black, Hispanic, and White [See Box 1-1 ] and originate from a 1977 Office of Management report (Haynes and Smedley, 2000). Depending on the data source, these racial or ethnic classifications are based on self-classification or on observa tion by an interviewer or other person filling out the questionnaire (National Center for Health Statistics, 2000).

Before 1980 the National Vital Statistics System for newborn infants and fetal deaths tabulated the race of the fetus or newborn according to the race of both parents. If the parents were of different races and one parent was White, the child was classified according to the race of the other parent. When neither parent was White, the child was classified according to the father's race, with one exception: if either parent was Hawaiian, the child was classified as Hawaiian. Starting in 1989 newborn infants and fetal deaths are tabulated according to the race of the mother (National Center for Health Statistics, 1998). In spite of these efforts, most existing sources of health data, with the exception of those derived from the census and from the vital registration system (birth and death certificates), permit examination of only the three largest racial and ethnic categories: non-Hispanic White persons, non-Hispanic Black persons, and persons of Hispanic or Mexican origin (National Center for Health Statistics, 2000).

The gathering of racial data by the U.S. Census Bureau is emblematic of its centrality in the nation's culture (Omi and Winant, 1994). As the U.S. health system developed, these data sets profoundly affected health policy and health services delivery. Race has been such an important characteristic in this country that census takers have tallied the racial composition of the population since the first U.S. Census taken in 1790: “[T]he U.S. Census has always included a question about race. Whites were normally distinguished from nonwhites” (Thernstrom, Orlov, and Handlin, 1980, 869). However, “[t]he racial categories used in census enumeration have varied widely from decade to decade” (Omi and Winant, 1994, 3). Until the 1850 census African Americans were tabulated as either “Slave” or “Free Colored,” and the latter sometimes included detribalized Native Americans. Though the 1850 and 1860 censuses collected data for free persons in “White,” “Black,” or “Mulatto” categories, the main tables continued to designate the overall population as “White,” “Slave,” and “Free Colored.” The 1860 census also counted “Civilized Indians” (who were required to pay taxes because they did not live on reservations) and Chinese. In 1870 Japanese were added, and the “Civilized Indian” category was divided into “Pure Indians” and “Half-breeds” designations. 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 octaroons. Finally admitting these divisions were valueless for analytical purposes, they grouped them all together with the Chinese, Japanese, and Indians under the general heading “Colored” (Thernstrom, Orlov, and Handlin 1980).

Under the growing influence of anthropological notions of race, in 1900 census officers determined to assess the U.S. population in terms of the then-presumed four great races: The Caucasian or White, Negro or Black, Mongolian or Yellow, and Indian or Red. Chinese and Japanese were designated subdivisions of Mongolian, and it was finally decided to use the term Negro and abandon the ambiguous term “Colored.” * By 1910 census officials reverted to “Black” and “Mulatto” but avoided the term “Colored.” The main divisions were “White,” “Negro,” “Indian,” “Chinese,” “Japanese,” and “All Other” (including subdivisions for Hawaiians, part-Hawaiians, and other races). The Indian population was treated separately in a special census recording both the “civilized” and those residing on reservations, and provided details on tribes, languages and geographic areas. This set many precedents for modern censuses. Mexicans were put in the “Other Races” category in 1930 but were later counted as Whites. Other Asian and Pacific Islander subgroups were tabulated, but only appeared in general tables. Enumerators in 1960 were instructed to consider how the person or family identified itself, and in 1970 self-identification was introduced into racial and ethnic tabulations (Thernstrom, Orlov, and Handlin 1980).

Ethnicity is a much more recent concept. As a response to the general movement toward self-identification and the modern notions of a pluralistic democratic society, the ethnic-origin category was introduced in the Current Population Survey in 1969 and included in the U.S. Census in 1980. Difficulties with this mode of distinguishing races and ethnic origin remain: in the area of sampling variation, changes in respondent fashion, and the difficulties of handling racial and ethnic mixtures are yet to be resolved (Haynes and Smedley, 1999; National Center for Health Statistics, 2000; Thernstrom, Orlov, and Handlin 1980). The 1997 standards with five racial groups: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, and White 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. All federal data systems are required to be compliant with this system by 2003 (National Center for Health Statistics, 2000). Whether or not one is of Hispanic origin reflects another dimension as the U.S. Census Bureau reiterates, “Hispanics are classified as an ethnicity, not as a race. People of Hispanic origin, therefore, may be of any race” (U.S. Census Bureau, 2001a). Therefore, the Office of Management and Budget outlines a more complex “combined format” whose minimum acceptable categories are: American Indian or Alaskan [sic] Native; Asian or Pacific Islander; Black, not of Hispanic origin; Hispanic; or White, not of Hispanic origin (Haynes and Smedley, 1999).

Distinguishing racial and ethnic groups from one another is useful in medical, health services, and epidemiologic research provided that researchers are clear on the nature and source of human variation (e.g., cultural and behavioral patterns, environmental influences) and their relationship to health outcomes. Race and ethnicity affect factors as varied as disease rates; health behaviors; conceptions of well-being and attitudes toward health maintenance and home treatment; illness behavior; utilizations patterns; concepts of disease and illness; interactions with mainstream health professionals and organizations; and ethnic interest groups and medical delivery (Harwood, 1981). Using such information applicable to distinct groups could direct appropriate and efficient biomedical and health services research, focus health promotion disease prevention efforts, objectively redirect health services and restructure components of the health system, and guide diversity and cultural competence programs. However, if the “boundaries” of ethnic identity remain unclear, continue to be perceived as more flexible rather than rigid, become agents to de-focus and fragment the nation's health policy and political mechanisms, all compounded by increased numbers of mixed ethnicity families in this country (where individuals claim two or more ethnicities), the challenge of pluralistic ethnic-oriented data collection, analysis, research, and program creation remains daunting. As we develop the methodology and science of tracking racial and ethnic health and health care outcomes, urgent efforts should be directed toward eliminating racial and ethnic bias in the care-givers and re-educating both care-givers and the patients to eliminate stereotyping, conscious, and unconscious biases. In the interim there can be no delay in making recommendations leading to: patient and provider education to understand the existence and dynamics of racial and ethnic bias in the health care arena; programs at all levels teaching the dynamics of the stereotyping and the bias-producing processes and how they affect health care; and the development of measures to teach patients and providers the specific cultural competence, diversity and cross-cultural skills to maximize the benefits of the doctor-patient relationship (Haynes and Smedley, 1999; White, Rutledge, and Brown, 2000; Zenner, 1996).

• Immigration, Racial and Ethnic Groups, Health and Health Care

Racial and ethnic groups are viewed today as by-products of social processes such as immigration, group interaction and conflict, group hierarchies and dominance, acculturation, and assimilation (Feagin and Feagin, 1999; Pedraza and Rumbaut, 1996). Acknowledgment of the effects racial and ethnic problems had and are having on health and disease, the health professions, and, finally, the health system is new and emblematic of an ongoing contemporary cultural movement among liberal democratic governments worldwide. These social dimensions of health and health care delivery serve as markers of a growing awareness, critique, examination, and redirection–finally committed to the notion of embracing all of the nation's diversity (Byrd and Clayton, 2000, 2002; Glazer, 1997; The Health Care Fairness Act of 1999 , 1999; Section of House Committee Report to Accompany H.R. 3064; Taylor et al., 1994).

The World Health Organization has defined health as “...a complete state of physical, mental, and social well-being and not merely the absence of disease or infirmity” (Sutchfield and Keck, 1997, 3 ), and has proclaimed that “health [without qualification] is a human right” (Fluss, 1997, 377). These declarations, evidence of the fact that health is viewed as a universal human need–a “primary good,” along with income, education, religious freedom, freedom of conscience, speech, press, and association, due process, the right to vote, and the right to hold office–are givens (Taylor et al., 1994, 4). Another corollary of this ongoing reassessment is that American health and health care are increasingly being viewed as immigrant, multicultural, racial and ethnic minority stories with biomedical, medical historical, sociocultural and political, public health, health policy, and medical-social dimensions (See Table 1 ). These developments highlight why a brief overview of North American health and health care from racial, ethnic, and immigration perspectives is germane to this discussion (Byrd and Clayton, 2000, 2002; Fluss, 1997; Garrett, 2000; Malone and Johnson, 1986; U.S. Commission on Civil Rights, 1999a, 1999b).

Native Americans, North America's original racial/ethnic group, are the indigenous people of the land now occupied by the United States. Scholarship concerning their 15th through 21st century interface with European explorers and invaders, the backdrop for America's racial and ethnic immigrant saga, is growing exponentially. What is becoming clear is that health factors such as disease transmission, epidemics, and exposures of non-immune populations to new diseases had as much to do with early group interaction and eventual European dominance of New World, pre-Columbian (North, Central, and South American) people as political and military activity (Burns and Ades, 1995; Byrd and Clayton, 2000, 2002; Diamond, 1999; Stannard, 1992; Watts, 1997).

As we set the stage for this inquiry, we discover that the 105 years between Columbus's landfall in the Caribbean and English colonization in 1607 had profound health effects in North America. Sixteenth century Spanish colonies spreading from the Caribbean, South America, Mesoamerica (central and southern Mexico and adjacent areas of Central America), Mexico, and St. Augustine, Florida, bolstered by expeditions deep into North America itself, facilitated the spread of Old World diseases that greatly reduced American Indian populations. The resulting depopulation may have contributed to the myth of an “empty” American continent ripe for European settlement (Byrd and Clayton, 2000; Diamond, 1999; Stannard, 1992; Watts, 1997).

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 health care 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 to people of the Old World (Diamond, 1999; Pedraza and Rumbaut, 1996; Watts, 1997, 87). Isolated from the Old World's domesticated animals * and diseases such as smallpox, influenza, measles, typhus, malaria, leprosy, cholera, bubonic plague, gonorrhea, and chancroid–even New World exposure to virulent forms of tuberculosis or syphilis is questionable–95 percent of the 8 to 12 million Native Americans inhabiting the North American continent at that time succumbed to European conquests, politics, and diseases (Diamond, 1999; Pedraza and Rumbaut, 1996; Stannard, 1992; Watts, 1997). By 1900 about 250,000 Native Americans remained in the United States (Pedraza and Rumbaut, 1996). Though much of this toll was directly related to health-related causes such as smallpox epidemics (some intentionally caused [Diamond, 1999, 199; Stannard, 1992, 241]), other causes included warfare with Europeans and Americans, mortality related to the Amerindian slave trade, and massive forced population relocations (Pedraza and Rumbaut, 1996; Stannard, 1992). Native American health and health care since the nineteenth century has been poor and has been characterized as: isolated from the mainstream health system; paternalistic, often culturally insensitive, government administered health care; disparate, from health status and outcomes perspectives; inadequately funded; understaffed; and allowing the spread of communicable diseases such as smallpox and tuberculosis (Frost, 1990; Garrett, 2000; Stuart, 1987; Trennert, 1998).

In contrast to relatively well organized Iberian-run health systems (Risse, 1987), early North American colonial health systems were rudimentary. The environment, poisoned by ongoing conflict with Native Americans, was dangerous. Moreover, as Leavitt and Numbers noted, “Early settlers in America often suffered from malnutrition, which increased their vulnerability to infectious diseases....The gravest threats to life and health were malaria and dysentery in summer and respiratory ailments, like influenza and pneumonia, in winter” (1985, 3). Thus, for the early English and Dutch settlers these endemic , meaning they were always present, and epidemic , appearing from time to time with great intensity, threats–most of which were infectious and transmitted from one person to another–brought basic human survival into question. By the eighteenth century, English commitment to a plantation economy and Black chattel slavery had combined with Protestant and Puritan elements of the culture to implement legal racial slavery and a race- and class-based health system. Poorhouses and almshouses, based on English models, served as the first hospitals in the colonies. There was a dearth of scientifically trained physicians, and a separate and unequal slave health subsystem serviced African Americans. A slave health deficit whose origins can be traced back to the African continental and Atlantic slave trade was institutionalized (Blanton, 1930, 1931; Byrd and Clayton, 1992, 2000; Ewbank, 1987; Higginbotham, 1978; Leavitt and Numbers, 1985; Numbers, 1987; Trennert, 1998).

Territorial growth fueled by Native American elimination or displacement, economic success spurred by commercial plantation agriculture and Black chattel slavery, and the political freedom spawned by a successful Revolutionary War liberating the colonies from England all served to foster the institutionalization (founding of medical schools, private hospitals, and a formally trained branch of the medical profession), segregation, and complexity of the health system. Home care or self-care were the health delivery norms for all but poor or marginal populations (Byrd and Clayton, 2000; Feagin, 2000; Vogel,1980, 1985).

Late 18th and early 19th century Anglo-Protestant affluence and sophistication only added to the race- and class-based stratification and segregation of the health system. Adding to the squaller and crowding in America's rapidly growing 18th and 19th century cities and “dual” health system were waves of poor immigrants, many of whom arrived “half starved, half sick, and often barely alive” (Dowling, 1982, 9). By the Jacksonian and Antebellum periods, White immigrants (e.g., Germans, Scottish, Irish, Scandinavians) were assigned to the lower tiers of the mainstream system (public hospitals, dispensaries, and health charities) extant in the East, the slave health subsystem burgeoned, while all Americans in frontier areas in the West, both slave and free, suffered deficient and primitive health conditions and services. The South, where most African Americans resided as slaves, was the most backward region with regard to public health policies and institutions. As a result, there were mid-19th century increases in mortality affecting urban ethnic immigrants, Black slaves, and free Blacks (Breeden, 1989; Byrd and Clayton, 2000; Duffy, 1990; Leavitt and Numbers, 1985; Rosenberg, 1974, 1987, 1989; Savitt, 1978, 1985; Vogel, 1980, 1985). Between ten (10) and fifteen (15) percent of American doctors had medical degrees, while the rest were either apprentice-trained or pretenders (Barzun, 2000, 405; Garrett, 2000, 285; Trennert, 1998, 11). Native Americans in the throes of displacement or elimination had little contact with the European health system until the latter half of the nineteenth century (Trennert, 1998).

The Civil War, in addition to being a turning point in the nation's political and economic affairs, was a watershed in American health. It highlighted the weakness in U.S. public health, medical education, and health delivery systems. However, it convinced average European Americans of the importance of biomedicine and public health and paved the way for major medical educational and professional, sanitary, and health reforms–simultaneously spurring a national hospital movement (Byrd and Clayton, 2000; Duffy, 1990; Rosenberg, 1987, 1989). 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, poor nutrition and sanitation, and continuation of racially discriminatory health policies and treatment. In lieu of emancipation, the war and its aftermath represented a health catastrophe for African Americans as their health status fluctuated wildly until 1910. This led influential biostatisticians, such as Frederick Hoffmann, and many in the medical profession to confidently predict Black extinction by year 2000 (Byrd and Clayton, 1992, 2000; Duffy, 1990; Jones, 1993; Morais, 1967; Tucker, 1994).

On one level the late nineteenth century represented an era of reconciliation and progress for White European American ethnic groups–both North and South–as the United States emerged as a world power. However, traditional patterns of racial and ethnic oppression and conflict between dominant White, Anglo-Saxon, Protestant groups and non-European, early-, as well as more recent-immigrant groups (e.g., Italians and Jews) continued (Feagin and Feagin, 1999). Improvements in biomedical education and science, medical practice, and a burgeoning hospital movement were evident. However, based on the evidence they do not explain the decline in infectious diseases and mortality and the increase in general (Blacks did not share in this benefit) life expectancy (Byrd and Clayton, 2000, 2002; Duffy, 1990; Leavit and Numbers, 1985). During this period, public health measures such as sanitation, improved water and milk supplies, augmented by improvements in diet, housing, and personal hygiene are more likely explanations for the decline (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 in these positive results. Members of these groups, along with women, were professionally segregated and isolated from the mainstream health system and systematically excluded from health professions training (Byrd and Clayton, 2000, 2002; Leavitt and Numbers, 1985; Trennert, 1998; Walsh, 1977)

After World War I, the Great Depression, and World War II it became clear to all the nation's racial and ethnic groups that medicine and medical care could make a difference in reducing infectious disease morbidity and mortality, increasing life-spans, and improving health outcomes and quality-of-life in America (Byrd and Clayton, 1992, 2000, 2002; Fee, 1997, 1997a; Leavitt and Numbers, 1985). As the efficacy of health interventions, therapies, and technologies increases, the equitable distribution of medical care and health services becomes even more important. As Byrd observed, “American medicine is now devastatingly effective, corrective, preventive, and selective. Doing without health care these days spells doom or defectiveness” (Byrd, 1986, 1026). For a plethora of reasons * race-, class-, and ethnic-based health status, outcome, and services disparities between America's racial and ethnic minorities and the European American majority narrowed over the first three-fourths of the twentieth century. Though overall U.S. health status and outcomes continue to slowly improve, for racial and ethnic minorities these history-based disparities have either stagnated or worsened during the past two decades (Byrd and Clayton, 2000, 2002; Clayton and Byrd, 2001; Collins, Hall, and Neuhaus, 1999; Garrett, 2000; Haynes, 1975; Malone, 1986; Mayberry, 2000; U.S. Commission on Civil Rights, 1999a, 1999b; Williams, 1999).

Understanding the character, causation, mediators, and mechanisms of the racial and ethnic disparities could eventually lead to recommendations and interventions toward significantly reducing or eliminating them.

• An Uneasy Mix of Diverse Peoples: United States' Racial and Ethnic Groups

Other than Native Americans, all Americans are immigrants arriving on the North American continent within the last 500 years. Of varying races and ethnicities, some of these people entered English North America (later the United States) voluntarily, some were recruited, and others were brought in involuntarily. American immigration took place in waves during various socioeconomic and political periods of our nation's history, with various groups dominating particular periods. Comprehending this immigrant cavalcade from a racial-ethnic relations perspective (including group characteristics, group interactions, power relationships and experiences juxtaposed to a changing capitalistic economy and expanding political and governmental framework), (See Table 1 ) provides a backdrop which clarifies their health status and outcomes and evolving relationships with and within the health system (Byrd and Clayton, 2000, 2002; Diamond, 1999; Feagin, 2000; Feagin and Feagin, 1999; Garrett, 2000).

Shared culture and national origin are prime characteristics of both indigenous- and immigrant-Americans, thus, all can be considered members of ethnic groups (Feagin and Feagin, 1999). Scientists who study race now consider it a socially determined category based on shared physical characteristics (most often skin color and appearance). Most popular classification schemes, still based on traditional cosmological ordering systems that divides the world's people into what were thought to be biologically discrete and exclusive groups, divide the human family into between three and five major “racial” groups. Arbitrary and no longer considered legitimate biological or genetic entities, these socially defined racial types are Asian (sometimes referred to as Mongoloid or Yellow), White (sometimes referred to as Caucasoid or Indo-European), and Black (sometimes referred to as Negroid) with some authorities adding American Indian (sometimes referred to as Red) and Australian Aboriginal (sometimes referred to as Malay) types (Omi and Winant, 1994; Smedley, 1999; Stringer and McKie, 1997; Thernstrom, Orlov, and Handlin 1980; Van den Berghe, 1967). Of the range varying from 2 to more than 60 arbitrary “racial” types that popular ideology and science have created over the centuries, the U.S. government has adopted the first four, with Hispanic reserved as an ethnic category (Cavalli-Sforza, 2000; Cavalli-Sforza, Menozzi and Piazza, 1994; Haynes and Smedley, 1999; National Center for Health Statistics, 2000). Virtually none of the scientific authorities still believe in “pure” races, and all serious scholars concede there are many groups that overlap the various socio-racial classification systems and that there are a few groups that cannot be classified at all.

The United States is still highly stratified on the basis of race, ethnicity, and class, and growing income inequality over the past decades may be accentuating these trends (Feagin and Feagin, 1999; U.S. Census Bureau, 2001f; Wolff, 1995). Though they are analytically separable, race, socioeconomic status (SES), ethnicity, and class phenomena are closely interrelated in the United States. They are also health and health care variables. From the nation's 17th century beginnings English Americans have had much greater power and resources than other groups, and such power and resource inequality has tended to persist from one generation to the next. Other factors facilitating White, European American groups becoming members of the mainstream have been identificational assimilation and their progressive acceptance as “White Americans” between the mid-nineteenth century and World War II (Feagin and Feagin, 1999, 114, 156; Jacobson, 1998; Lipsitz, 1998; Steinberg, 1989). Historically some groups are confined to lower-class positions because of lack of access to both power and economic means that are built into the status system by formal and informal, structural, and to some extent, legal norms. That individual class system mobility is also limited and that experiences differ markedly for certain groups is also based on understanding the two very different patterns of ethnic incorporation– discrimination versus exclusion .

Among those who suffered from discrimination were the Irish, Italians, Greeks, Jews, and Poles–the European immigrants, mostly from southern and eastern Europe, that came to American voluntarily in the mid-nineteenth to early twentieth centuries. Among those who suffered from social exclusion were Blacks, Native Americans, Mexican Americans, and Puerto Ricans–those whose history began as the product of involuntary conquest, annexation, and colonialism, as a result of which they were not allowed to become integrated into the major institutions of the society (Pedraza and Rumbaut, 1996, 16).

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 world view-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. However, in the ensuing racial and ethnic acculturation and assimilation , competition, and struggles which evolved over time, individuals and groups, even of the less-favored races and ethnicities, have later moved into positions of power (e.g., African American and Italian Supreme Court justices; Mexican, African American, Jewish, and Italian mayors). The various groups' distinctive health and health care profiles largely reflect these factors along with their demographics, sociocultural, and racial and ethnic experiences (Feagin, 2000; Feagin and Feagin, 1999; Harwood, 1981; Smedley, 1999; Takaki, 1993; Terry, 1992; Williams, 1999).

• Black or African American [Black, not of Hispanic origin]

Presently America's oldest, largest, non-indigenous racial group, * the Black population was projected by the U.S. Census Bureau to number 35,470,000 as of January 2, 2001, 12.8 percent of the U.S. population (Bohannan and Curtin, 1995, 13; U.S. Census Bureau, 2001b). Erroneously considered an homogenous population, the categories “Black” or “African American” include the descendants of the original seventeenth- through nineteenth-century slave population, immigrants from Jamaica, Haiti, Trinidad, Barbados, and other Caribbean nations along with more recent immigrants from Ghana, Nigeria, Egypt, Ethiopia, Somalia, Sudan, the Cape Verde Islands, Liberia and other African countries. Viewing this group monolithically, though making it easier to perform tasks related to health policy and health status indicators, masks dramatic linguistic and cultural diversity issues, varied illness behavior, and preferences among these individuals and groups (Office of Research on Women's Health, 1998; U.S. Commission on Civil Rights, 1999a).

Demographically the Black population remains younger (median age 30.4 years) than the general (median age 35.9 years) and White non-Hispanic population (median age 38.6 years), has less affluence and higher poverty levels (23.6% in poverty) than the general (9.8% in poverty) or White (7.7% in poverty) populations, suffers higher unemployment rates than the general or White populations, and exhibits lower educational levels (Blacks 13% college graduates) than the White (25% college graduates) population. Eighty-seven percent of African Americans live in cities and they reside in all 50 states. However, over half live in 13 Southern states–Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, South Carolina, Tennessee, Texas, and Virginia. Though subpopulations vary, people are usually assigned to the Black or African American category based on appearance–characteristics such as skin color, hair texture, and facial features (e.g., Negroid features such as wide nose, and thick lips compared to Whites). Generally African Americans experience higher unemployment rates and employment in lower paying jobs, which helps explain their high rates of lack of health insurance in a largely employment-based health system (Byrd and Clayton, 2000, 2002; Office of Research on Women's Health, 1998; U.S. Census Bureau, 2001c, 2001d, 2001e).

Mired in corrosive sociocultural, health and biomedical system legacies of 2000 years of being portrayed as being biologically and intellectually inferior; 246 years of chattel slavery, including a slave health deficit and a slave health subsystem; 100 years of legal segregation and discrimination and a “Negro medical ghetto”; and contemporary social, political, and economic isolation, oppression, exploitation, and a “dual” and unequal health system (Byrd and Clayton, 2000, 2002) , “African Americans experience health care differently from [W]hites and other populations within the nation” (U.S. Commission on Civil Rights, 1999a, 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. Based on the latest available data as the new millennium began, African Americans are faced with persistent, or worsening, wide and deep, race-based health disparities compared to the White or general population (Byrd and Clayton, 2000, 2002; Clayton and Byrd, 2001; Collins, Hall, and Neuhaus, 1999; Mayberry, 2000; Williams, 1999).

• American Indian or Alaskan [sic] Native

Projected by the U.S. Census Bureau in 2001 to number 2,448,000, or 0.9 percent of the U.S. population, American Indians, Eskimos, and Aleuts * are the smallest of the major racial and ethnic groups discussed in this report. However, their numbers are growing three times more rapidly than the White population. Comprised of culturally diverse, complex, and distinctive groups of people speaking more than 300 languages, the American Indian or Alaskan Native population is made up of 535 federally recognized (plus 100 which are not officially recognized) tribes in seven nations (e.g., Navajo, Iroquois) on nearly 300 reservations in the lower 48 states, and approximately 500 government units in Alaska (Office of Research on Women's Health, 1998; U.S. Census Bureau, 2001b).

The commonality of their poor health experience while obscuring their diversity, mirrors their shared sociocultural experience which includes, but is not limited to:

• the rapid and forced change from a cooperative, clan-based society to a capitalistic and nuclear family-based system;
• the outlawing of language and spiritual practices (reminiscent of the Black slavery experience);
• the death of generations of elders to infectious diseases or war; and
• the loss of the ability to use the land walked by their ancestors for thousands of years (Office of Research on Women's Health, 1998, 2).

For much of the 20th century the observations of the 1928 Meriam Report that the health of the Indian population was characterized by “a high birth rate and high death rate with excessively high infant mortality and a large proportion of deaths from tuberculosis” (Stuart, 1987, 96), held true. Health-seeking behavior and responses to health care services such as being strongly autonomous, being non-linear thinkers (especially regarding time), using indirect communication and styles, and having a historical suspicion of authority reflect these experiences (Kingfisher, 1996). Moreover, “Health care for the Amerindian population had been poorly provided by the Bureaux of Indian Affairs since 1849" (Porter, 1999, 288). Their health and demographic profile–including poverty, lower education levels, and disease profiles often compounded by substance abuse problems–reflects the residue of this legacy. Due to treaty obligations they largely receive their health services via the federal government, and “[T]he Indian Health Service (IHS)–since 1955 a part of the United States Public Health Service–provides health care through its clinic and hospitals to all American Indian/Alaska Natives who belong to federally recognized tribes and live on or near the reservations in its 12 service areas” (Office of Research on Women's Health, 1998, 2). Though “[t]he health status of American Indians has improved dramatically during the twentieth century, particularly after the transfer of Indian health to the Public Health Service in 1955" (Stuart, 1987, 95), their diversity–compounded by their many small population groups scattered throughout the country–have made it difficult to provide consistent, quality, readily accessible health care; their health status and outcomes are reflections of these circumstances (Burns and Ades, 1995; Office of Research on Women's Health, 1998; Trennert, 1998; U.S. Commission on Civil Rights, 1999a).

• Asian American [Asian American or Pacific Islander]

Numbering less than one million until the Supreme Court ruled against immigration quotas in 1965, Asians and Pacific Islanders are the fastest growing minority group in the United States–representing 3 percent of the total population and around 13 percent of all people of color. Asian American immigrants to the United States have come from more than 20 countries. Having immigrated from countries such as China, Japan, India, the Philippines, Korea, Laos, Cambodia, Vietnam, and Thailand, representing more than 60 different ethnic groups, they speak more than 100 different languages. Though the largest subpopulations that are detailed here– Filipino, Chinese, Japanese, Asian Indian, Korean and Southeast Asian–that in no way lessens the importance of smaller groups such as the Laotians, Belauans, Micronesians from Nauru, Thai, Melanesians on Fiji, Cambodians, Tongans, or Hmong (Feagin and Feagin, 1999; Office of Research on Women's Health, 1998). 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) category, they present bipolar health and social profiles of artificially aggregated groups, their health outcomes being akin to those of American Indians/Alaska natives rather than to other Asian subpopulations. Disaggregating their health status and outcomes from other Asian subpopulations whenever possible would seem to lend clarity to any health assessments or analyses of such arbitrarily combined groups (Feagin and Feagin, 1999; Office of Research on Women's Health, 1998; U.S. Commission on Civil Rights, 1999a).U.S. Census Bureau projections of the Asian American and Pacific Islander population at 11,279,000, or 4.1 percent of the population, by November 1, 2000 reflect their 37 percent rate of population growth between 1990 and 1998, the highest in the nation. The AAPI population is young, with a median age of 32.1 years–3.8 years younger than the general population and 6.5 years younger than non-Hispanic Whites. Fifty-six percent of Asian and Pacific Islanders live in the Western United States with the highest concentrations residing in Hawaii (63% of the total population), California (12%), Washington (6%), and New York and New Jersey (5% each). Asian and Pacific Islander Americans are more likely to reside in metropolitan areas (95% compared to 75% overall). In the late-1990s 24 percent of the nation's foreign-born residents were Asian Americans and Pacific Islanders, and 6 of 10 AAPIs in the United States were foreign-born. Only Mexico produced more foreign-born residents than the Philippines or China (including Hong Kong) (U.S. Census Bureau, 2001b; U.S. Commission on Civil Rights, 1999a).

Despite projections as a privileged and prosperous minority–now a part of their “model minority” image–many subgroups of Asian Americans are economically disadvantaged. 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 non-Hispanic White rates (7.7%). Vietnamese Americans, for example, have an average family income that is about half that of AAPI populations as a whole. Moreover, AAPI families being larger (3.15 persons compared to 2.23 persons in metropolitan White households), translates into a lowered estimated income per member. There are more than 365,000 Pacific Islander Americans residing in more than 22 islands–either Polynesian (Hawaii, Samoa, and Tonga), Micronesian (Guam, Belau, and the Carolines, Marianas, Marshalls, and Gilberts), and Melanesian (e.g., Fiji). Their health profiles are distinct from other Asian groups. Half the Pacific Islander Americans live in Hawaii, 30 percent live in California, 4 percent in Washington, and 2 percent each in Texas and Utah. Not only do some of these islands represent autonomous governments with varied political relationships with the United States, they have varying levels of health and health care. The health system in Guam is relatively advanced, the Commonwealth of the Northern Marianas offers a lesser level of care to its residents, while the Republic of Belau and the Federated States of Micronesia have old hospitals and provide a generally poorer level of care. Though the health problems of the Native Hawaiians and other Pacific Islander groups today largely reflect their poor socioeconomic and educational status, whether in island or urban settings, barriers to health and health care such as linguistic isolation, cultural differences (e.g., obesity is acceptable in Polynesian culture and large body size is equated with power and respect) and traditions, and health beliefs and practices remain problematic (Office of Research on Women's Health, 1998; U.S. Census Bureau, 2001c, 2001e, 2001g; U.S. Commission on Civil Rights, 1999a).

Educational attainment differs among Asian and Pacific Islander Americans, ranging from 31 percent high school graduation rates among the Hmongs, 64 percent for Tongans, 80 percent for Hawaiians, to 88 percent for Japanese. 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. Commission on Civil Rights, 1999a).

Based on the economic and educational progress some AAPI groups had made by the late-1960s, the “model minority” image replaced many of the negative stereotypes applied to Chinese and other Asian Americans. Some viewed this as an attempt, after several years of civil unrest and urban riots, to prove that the U.S. social system does work for minorities. “However, Asians often are pitted against other minority groups and are made scapegoats by low-income [W]hites and other minorities who indirectly blame Asians for their failure to succeed and claim that Asians take away their educational and job opportunities” (Office of Research on Women's Health, 1998, 18). Moreover, the highly stereotypical “model minority” image tends to trivialize the health problems of Asians and suggests that they can take care of the problems themselves, while overlooking the diversity among Asian populations and the health and health system problems faced by the newest AAPI refugees ( Office of Research on Women's Health, 1998; Steinberg, 1989; U.S. Commission on Civil Rights, 1999a).

• Hispanic (Latino)

Hispanic has been a term widely used, and later designated by the government, to identify persons of Mexican, Puerto Rican, Dominican, Cuban, and Central and South American ancestry and heritage. Hispanic is an English-language word derived from Hispania , the Roman name for Spain emphasizing the Spanish heritage of these groups while ignoring the other (e.g., Native American, Mestizo, and African) geographical and cultural components. Origins from predominantly Native American (Indian) people, but with significant infusions of Blacks, Whites, or Asians explain why Hispanics can be of any race. An alternative Spanish-language word and collective designation, Latino , recognizes the Latin American origins of these groups and is, therefore, more acceptable to many Spanish-speaking Americans (Feagin and Feagin, 1999, 291; Office of Research on Women's Health, 1998).

Projected by the U.S. Census Bureau to number at least 32,832,000 by November 1, 2000, they were reported to be tied with African Americans numerically as of March, 2001 constituting between 11.9 and 12.8 percent of the U.S. population (Canedy, 2001; U.S. Census Bureau, 2001b). The major subgroups are Mexican Americans (64%), Central and South Americans (14%), Puerto Ricans (10%), “other Hispanics” (7%), and Cuban Americans (4%).

More than one-third of Hispanic Americans are foreign-born, and around one-half the women giving birth to Hispanic infants were born outside the 50 states and Washington, D.C. Ninety (90) percent of the nation's Hispanic population is urban and 70 percent reside in six of the most populous states (California, Texas, New York, Florida, New Jersey, and Illinois). The largest concentrations are in four cities (New York City, Los Angeles, Chicago, and San Antonio) and the South and West (three-fourths of all Hispanics) regions of the nation (Office of Research on Women's Health, 1998; U.S. Census Bureau, 2001b)

The diversity of the Hispanic population is remarkable. Comprised of all races, that group diversity also embraces 75% of all United States farmworkers–laborers in this nation with a life expectancy of 49 years (for Hispanic farm workers), infant mortality rates 25% higher than the United States average, and higher cancer rates. Occupations and living conditions range from university professors and executives to people living in colonias, unincorporated areas lacking septic tanks, sewers, and running water. The median age of the Hispanic population is much younger (26.6 years) than the general (35.9 years) or White (37.0 years) population; educational levels are lower; and they suffer higher poverty rates (22.8%) compared to the White non-Hispanic population (7.7%). Though subpopulations vary, generally Hispanics experience higher unemployment rates, and are employed in lower paying jobs, which helps explain their high rates of lack of health insurance in an employer based health system (Office of Research on Women's Health, 1998; U.S. Census Bureau, 2001b, 2001c, 2001e).

Hispanic subpopulations, especially Mexican Americans, appear to enjoy better health than would be predicted given their low socioeconomic status and their low utilization rates for health care services. Some groups such as Mexican American women, despite their greater pov erty, have lower rates of hypertension than Cuban, White, or African American women. Another example is the fact that Puerto Rican and Cuban Americans use health facilities at rates comparable to Whites while overall group utilization rates are lower. Moreover, prevalence rates for certain diseases like cancer and low birth-weight infants favor new-immigrant, less-acculturated Hispanics. For poorly understood reasons, as these immigrants become more “American,” their risks for these health problems climb. The unfortunate tendency to use such data to lessen Latino health problems must be acknowledged and ameliorated. Clearly, there is so much variation in the health of Hispanic American subgroups, looking at aggregated measures can obscure meaningful intragroup differences; this compels the collection of more focused and analyzed health data and statistics for these groups along with more research to understand the patterns, forge health policy, and improve outcomes (Office of Research on Women's Health, 1998; U.S. Commission on Civil Rights, 1999a)

Among the original occupants of the New World from Cape Horn to Alaska and the Caribbean, to California, the Southwestern United States, and Texas, the ancestors of Latinos were militarily and politically dominated by Spaniards and Portuguese in the 1500s. 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) or annexed (large parts of Mexico) by European minorities, which sometimes grew into majorities–while Latinos became second-class citizens in the process (Feagin and Feagin, 1999; Numbers, 1987; Takaki, 1993). Heavily recruited by the United States for agricultural and low-wage labor in the 20th century, as these groups have acculturated and grown numerically they have struggled against racism, prejudice and stereotypes, discrimination, poverty, being politically marginalized, and the legacies of being considered purveyors of a “foreign” language and culture. Their health experience reflects their social, economic, and political realities which is a distinct theme of health care disparities in the United States (Canedy, 2001; Feagin and Feagin, 1999; Office of Research on Women's Health, 1998; U.S. Commission on Civil Rights, 1999a).

• White Non-Hispanic Ethnic Groups

White Non-Hispanic people, who number 196,929,000 or 71.3 percent of the population, constitute the largest bloc of the United States' population. This combination of White ethnic groups are dominant players in American society controlling the mainstream (or what is understood as “the” mainstream) culturally, socially, economically, politically, and institutionally. This also applies to the health system: its professions, its politics, its policies, and its institutions (Byrd and Clayton, 2000, 2002; Feagin, 2000; Feagin and Feagin, 1999; Starr, 1982; U.S. Census Bureau, 2001b). Often thought of in monolithic terms, brief descriptions of some of these European ethnic groups from ethnic and health care perspectives reveal that they are quite variegated. These “White American” ethnic groups are the major determinants at both the production phase and receiving ends of what constitutes “normal” health and health care in the United States. Other specific White ethnic groups not mentioned here–such as the French, Dutch, Scottish, Scotch-Irish, Swedish, Norwegian, or Slovak–in no way lessens their importance in the health system or contribution to American society (Feagin and Feagin, 1999; Pedraza and Rumbaut, 1996; Starr, 1982; Stevens, 1971, 1999; U.S. Census Bureau, 2001a).

• A English Americans and Anglo-Protestant Culture

Having led in the domination and settling of English North America, the Anglo-Protestant (sometimes referred to as White Anglo-Saxon Protestant [WASP]) transported the core “American” values of achievement, conscience, industry, antisensuality, and civic-mindedness to the new culture. However, they also brought, at times, caste-like exclusivity, bigotry, and their hierarchical views on matters of culture and race. As much a high status-power group as an ethnic group, until recently they dominated the presidency, cabinet, governmental, judicial, financial, educational, and corporate positions, established the nation's institutional infrastructure and administered and managed its institutions. At 33 million claiming partial or total English ancestry, they rank numerically among the three largest White groups (Germans and Irish) and though currently being challenged culturally and politically remain the most powerful group in America [PIE CHART FOR ALL THE GROUPS]. Most significantly, “of America's many groups...the English immigrants and their descendants require attention, for they possessed inordinate power to define American culture and make public policy” (Takaki, 1993, 7) , they have been the determiners and the purveyors of the “overall American culture which serves as a reference point for immigrants and their children” (Feagin and Feagin, 1999, 76). In short, they set the tone for American political, business, and cultural life. The health system is a byproduct of these forces (Byrd and Clayton, 2000, 2002; Domhoff, 1983; Feagin and Feagin, 1999; Jordan, 1968; Pedraza and Rumbaut, 1996; Schlesinger, 1998; Smedley, 1999).

The presence of the English Americans and their culture is so pervasive, both are taken for granted and few references are made to their existence. Many allege they have lost much of their authority and power in the past five decades, especially after the 1960s when the Anglo Protestant establishment was brought into question. Nevertheless, they are the leading edge of medical and health establishments and are a strong determinant of the “norms” for health and health care in America (Byrd and Clayton, 2000, 2002; Dowling, 1982; Starr, 1982; Stevens, 1971).

• German Americans (1840s forward)

German Americans, the largest American ancestry group at 58 million, have blended into the White majority so well that they are sometimes portrayed as a “model White minority.” Their early health experience was shaped by the typical European immigrant health experience. The largest immigrant group of the mid-19th century and unusually concentrated in urban areas of the Eastern seaboard, most early German immigrants were poor and dependent upon the indigent public, dispensary, and charity care upon which other poor populations depended. Squaller and overcrowding seemingly bred rampant disease rates. However, outstanding academic and practicing immigrant physicians eventually made a mark on American academic medicine (Lyons and Petrucelli, 1978; Pedraza and Rumbaut, 1996; Shryock, 1974; Viner, 1998).

For example, the heavy infant and childhood toll extracted by New York tenement living on German immigrants spurred immigrant physicians Abraham Jacobi and Maximillian Herzog to establish the German Dispensary and the Department for the Diseases of Children in the 1850s, the first of its type in America. From there they conducted research, studied, published scientific articles, and trained practitioners not only influencing the New York medical community but establishing the scientific basis of pediatric pathology, physiology, and therapeutic practice. Physician Emil Noeggerath made significant scientific contributions to pathology, obstetrics, and gynecology while headquartered at the German Dispensary. Such efforts not only led to medical school faculty appointments at the New York Medical College but “served to build a reputation for the Germans in the wider American profession, and to encourage the introduction of German science to American audiences” (Viner, 1998, 453). Moreover, institutions such as Philadelphia's German Hospital (founded 1860-1861) and New York City's German (now Lenox Hill) Hospital (founded 1869) appealed to ethnic and language-centered identity. 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 health care just as they blended into larger White America (Lyons and Petrucelli, 1978; Pedraza and Rumbaut, 1996; Rosenberg, 1987; Shryock, 1974; Viner, 1998).

• Irish Americans

Separate branches of the same nationality, Irish Catholic and Scotch-Irish Americans total around 11 percent of the population. They represent the second (39 million) and twelfth (6 million) largest ancestral groups respectively. The earlier Protestant Irish groups which settled disproportionately in the South and frontier areas acculturated and blended into White America by the nineteenth century while the much more numerous Catholic faction suffered significant amounts of racial stereotyping, discrimination, and religious bigotry until recently. “Targets of nativist hatred toward them as outsiders, or foreigners, they sought to become insiders, or Americans, by claiming their membership as whites. A powerful way to transform their own identity from ‘Irish' to ‘American' was to attack blacks. Thus, blacks as the ‘other' served to facilitate the assimilation of Irish foreigners” (Takaki, 1993. 151). 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).

Their early health experience was a stormy immigrant one. As Paul Starr observed, “...the Massachusetts General Hospital initially refused to admit Irish patients on the grounds that their presence would deter other people from entering the hospital” (1982, 173). Such discrimination struck fear in ethnic and religious minority members already disadvantaged in the health system by their immigrant, cultural and SES circumstance. “Discrimination was a principal reason for the formation of separate religious and ethnic hospitals” (Starr, 1982, 173). As signs of ethnic progress, New York's Catholics founded St. Vincent's Hospital in 1849 and St. Francis Hospital in 1865. “By 1885, the Catholic community had opened 154 hospitals throughout the United States, more than had existed in the United States in toto in the late 1860s” (Rosenberg, 1987, 111). Not only did this assuage Catholic religious concerns (e.g., being assured last rites), but it offered professional training and staff opportunities for Irish and other Catholic health professionals who would otherwise have been passed over. Recent indicators are that Irish Americans now rank at or above the national average for all Whites on the educational, occupational distribution, and income levels (Feagin and Feagin, 1999; O'Connor, 1995; Pedraza and Rumbaut, 1996; Rosenberg, 1987; Starr, 1982; U.S. Census Bureau, 2001a).

• Italian Americans

Making up 6 percent of the U.S. population, the fifth largest ancestry group, Italian Americans have been less rapidly assimilated, and slower to yield their distinctive ethnic identity. Having endured poverty, difficult working conditions, anti-Catholic prejudice, and intense nativist attacks along with the poor health status and outcomes associated with those conditions, they finally shrugged off the “inferior race” imagery and have made rapid progress up the political, social, and economic ladder, especially after World War II. Victims of a deprived European American immigrant health experience during their early years, they were also integral parts in the establishment and maintenance of the Catholic hospital system. 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).

• Jewish Americans

Jews are often regarded as the most widely persecuted ethnic group in world history. They now constitute some 6 million persons or 2.5 percent of the population. Present in the Atlantic Coast colonies since at least 1654, Jewish Americans face and have endured the most severe and persistent levels of discrimination and anti-Semitism of all “White American” ethnic groups. Establishing unique niches in U.S. society, they have utilized educational and cultural means to become an economically prosperous group. The medical profession and health care have been major vehicles for Jewish advance. Early victims of hospital discrimination, “Jews feared they would have to eat nonkosher food and face ridicule for their appearance and rituals” (Starr, 1982, 173). Despite this and their hard-scrabble immigrant experience in the health system, the name change of Jews Hospital in New York City to Mt. Sinai was to signify that it served the community at large. Participation in the health system at the institutional and professional levels offered immigrant Jews another stepping stone into mainstream America. Through their struggles against nativist stereotyping and discrimination they have also led the way in creating an environment of religious tolerance and diversity in America, simultaneously spreading their values of justice, tolerance, and fairness throughout the culture (Feagin and Feagin, 1999; Pedraza and Rumbaut, 1996; Rosenberg, 1974; Starr, 1982; Steinberg, 1989; Viner, 1998).

• Polish Americans

Polish Americans as an ancestral group make up approximately 4 percent of the U.S. population. Other than their being Eastern European and being subjected to a more intense nativist reaction in the early-20th century than some other “White American” ethnic groups, their racial and ethnic experience could be viewed as typical. Even the more privileged Northern European immigrant groups such as the French, Dutch, Scottish, Swedish, and Norwegians experienced acculturation trauma and sometimes discriminatory barriers to their entry into American society and the health system. In the 1960s President John F. Kennedy appointed the first Polish American cabinet officer. “By the third generation, Polish Americans were entering universities in large numbers and joining the professional middle class” (Pedraza and Rumbaut, 1996, 204). 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 Health Care Disparities and Their Documentation in the United States

The Black experience of poor health status, poor health outcomes, and being limited to access to the worst health services for the 366 years before 1985–well-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. The shock waves that reverberated throughout the health system caused by the release of Margaret Heckler's, then Secretary of Health and Human Services, 1985-1986 report on minority health and its acknowledgment that “ there was a continuing disparity in the burden of death and illness experienced by Blacks and other minority Americans as compared with our nation's population as a whole [Heckler's emphasis]” (U.S. Department of Health and Human Services, 1985a, ix) was emblematic of the high unawareness levels regarding disparate health and health care for the nation's racial and ethnic minorities. The broadened focus on all of the nation's racial and ethnic minority groups marked a new era in racial and ethnic health and health care in the United States. The Report of the Secretary's Task Force on Black and Minority Health (also known as the Malone-Heckler report) noted the health disparity had existed “ever since accurate federal record keeping began” and that it “was the first time...a common effort [has been attempted] to carry out a comprehensive and coordinated study to investigate the longstanding disparity in the health status of Blacks, Hispanics, Asian/Pacific Islanders, and Native Americans compared to the nonminority population” (U.S. Department of Health and Human Services, 1985a, ix, 2). Despite Malone-Heckler Report findings that “Although tremendous strides have been made in improving the health and longevity of the American people, statistical trends show a persistent, distressing disparity in key health indicators among certain subgroups in the population” (U.S. Department of Health and Human Services, 1985a, 2), and “[t]hese disparities in health status persist...15 years later” (U.S. Commission on Civil Rights, 1999a, 16). Major impediments to understanding and eliminating racial and ethnic health and health care disparities have been in areas related to inadequate data collection and analysis (Byrd and Clayton, 2000, 2002; Clayton and Byrd, 2001; Collins, Hall, and Neuhaus, 1999; U.S. Commission on Civil Rights, 1999a; U.S. Department of Health and Human Services, 1985a).

Before 1985 requisite record-keeping on Black and minority health and health care was totally inadequate to the task of correcting the history-based disparities and sharing the beneficence of the health system and medical progress equitably across America's increasingly diverse racial and ethnic population. Even though some health data on African Americans had been collected over time, only recently have specific efforts begun to collect adequate health data for Native Americans, Hispanics, and Asian Pacific Island Americans. Shortfalls in these areas remain (U.S. Commission on Civil Rights, 1999a; U.S. Department of Health and Human Services, 1985a). Emblematic of the difficulties inherent in racial and ethnic data collection that reflected the health status and outcomes of various population groups, “The first survey and tabulation of deaths by disease and race was taken by the U.S. Census Bureau in 1850" (Byrd and Clayton, 2000, 284). Moreover, before the implementation of a nationalized system of registering deaths in 1933, when all states registered as least 90 percent of their deaths and, thus, were qualified for inclusion in the Death Registration Area (DRA) * system, it was difficult to describe mortality trends for any U.S. group before 1940 (Byrd and Clayton, 2002; U.S. Commission on Civil Rights, 1999a; U.S. Department of Health and Human Services, 1985a).

Some of the earliest records documenting racial and ethnic health disparities germane to the North American colonies and, later, the United States were embedded in slave trade data, race-based census data, Annual Reports from the Commissioner of Indian Affairs, insurance company data, and isolated instances of record-keeping of racially comparative mortality rates, infant death rates, and epidemic disease record keeping by the mercantile slave traders, plantations, government agencies, insurance companies, cities and towns, and some states. A representative survey of available data sources from major historical periods are contained in Byrd and Clayton's data base at the Harvard School of Public Health and their book An American Health Dilemma . **

Virtually all of the data suggest that from the United States' beginnings–even before the Revolutionary War–Black, poor, Native American, and immigrant populations suffered the worst health status, outcomes, and health care–reflecting an evolving health system rigidly structured on the basis of race, ethnicity, class, gender, moralistic judgements, and indentured servitude-racial slavery. As the modern U.S. health system evolved during the 20th century it has made impressive medical and scientific progress. Despite changes in politics, health policy and administration; reforms in health professions education and research; restructuring of old, along with the addition of new delivery systems; and major health care and health system financing changes, it has had great difficulties in shedding its racial-, ethnic-, class-, and gender-based tiering, hierarchies, and medical-social culture (Byrd and Clayton, 2000, 2002; Farley, 1970; Farley and Allen, 1989; Garrett, 2000; Morais, 1967; Smith, 1999; Stuart, 1987; U.S. Commission on Civil Rights, 1999a).

• CHANGING CONCEPTS OF RACE AND ETHNICITY

On Racial Groups and Hierarchies

In contrast to ethnicity , race is a concept with roots stretching back to antiquity. The Feagins's observation that, “This singling out of people within the human species in terms of a biologized ‘race' hierarchy is a distinctively European and Euro-American idea” (1999, 6), highlights the Western origins of today's pervasive racial worldview . The origins of the word race are disputed and may derive from Arabic, Latin, Spanish, or German sources, and predate the 16th and 17th century beginnings of modern Western science. Initial English use of the word may have been in a 1508 poem by William Dunbar in which he referred to "bakbyttaris of sindry racis" (backbiters of sundry races) (Banton and Harwood, 1975, 13). The word race appeared in the formal English literature in 1580 according to Webster's Dictionary and other sources. The Webster's Dictionary definitions of race are so broad and variegated they seem somewhat nebulous. Webster's first definition of race is "a breeding stock of animals" alluding to current biological definitions. Since the 18th century “race” has served as a biological term, a descriptive term for people sharing certain physical characteristics, and a culturally determined hierarchical human ranking system embodied in the Western worldview . Webster also defines race as "a family, tribe, people, or nation belonging to the same stock," and further describes race as "a class or kind of people unified by community of interests." Moreover, the destructive potential embodied in race–the Western cultural concept strongly grounded in human inequality with its bias producing capabilities that Jordan began documenting several decades ago (Jordan, 1968)– began surfacing long before its 16th century English language usage (Banton and Harwood, 1975; Byrd and Clayton, 2000; Smedley, 1999).

As recently as the early part of the 20th century laymen and some scientists used the word race to describe human groups that shared particular cultural characteristics such as religion or language (e.g., the "Jewish race" or the "French race"). Earlier, "[p]hysical anthropologists have called races the various sub-species of Homo sapiens characterized by certain phenotypical and genotypical traits (e.g., the ‘Mongoloid race' or the ‘Negroid race')" (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.

Recent conceptualizations of race have reinforced movement away from the biological to the sociological sphere. Audrey Smedley noted “of fifty-eight introductory textbooks in physical anthropology published between 1932 and 1979 there has been a progressive elimination of the term and concept of race from textbooks...in the United States....when either the term was no longer mentioned in the texts or the authors argued that races do not exist or are not ‘real'” (Smedley, 1999, 2). 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). Since there are virtually no biologically significant or inherent differences within the species Homo sapiens , what happens to people after the social selection process takes place is paramount to understanding what's important about race (Byrd and Clayton, 2000, 2002; Smedley, 1999; Mayr, 1982; Van den Berghe, 1967).

The ancient founders of medicine and science's precursors began a hierarchical, discriminatory, and bias producing cycle as they started using race and ethnicity as means of classifying mankind. Driven since ancient times by folk beliefs, religious teachings, and social customs based on differences in physical appearances of various geographic populations, by the 18th century race became the subject of formal theoretical speculation and scientific investigation (Byrd and Clayton, 2000; Levi-Strauss, 1951; Smedley, 1999). As an extension of Western culture's intellectual preoccupation with human inequality, race became a focus of empirical and scientific inquiry for the next three centuries codifying a color-coded, racial hierarchy of man–White, Yellow, Red, and Black in descending order–in the process (Banton, 1986; Byrd and Clayton, 2000; Smedley, 1999). By the middle third of the 20th century traditional biology- and anthropology-based ideas of race and “races of man” which had become dominant during the 19th century rise of science began breaking down as more objective anthropological, genetic, paleontological, archeological, linguistics, biogeographical, and DNA and other molecular biological studies proved the unity of the human species, common African origins of all racial groups, and the biological insignificance of the old parameters of racial classification such as skin and eye color, hair texture, physical features, and skull size and shape (Banton, 1986; Banton and Harwood, 1975; Cavalli-Sforza, Menozzi and Piazza, 1994; Cavalli-Sforza, 2000; Smedley, 1999). Yielding to a deluge of scientific evidence, race has come to be more objectively considered a sociocultural concept wherein groups of people sharing certain physical characteristics are treated differently–often on the basis of stereotypical thinking, discriminatory institutions and social structures, a shared worldview and social myths (Byrd and Clayton, 2000, 2002; Diamond, 1999; Feagin, 2000; Feagin and Feagin, 1999; Smedley, 1999).

After briefly surveying the broad range of ideas about race, racism –the nefarious byproduct that produces negative results and outcomes for the persecuted race–requires definition.

Racism is any set of beliefs that organic, genetically transmitted differences (whether real of imagined) between human groups are intrinsically associated with the presence or the absence of certain socially relevant abilities or characteristics, hence that such differences are a legitimate basis of invidious distinctions between groups socially defined as races (Van den Berghe, 1967, 11). 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. It is not the presence of objective physical differences between groups that creates races, but the social recognition of such differences as socially significant or relevant (Van den Berghe, 1967, 11).

Racism translates into actions that are both overt and covert. “It takes two, closely related forms: individual whites acting against individual blacks, and acts by the total white community against the black community. We call these individual racism and institutional racism . The first consists of overt acts by individuals, which cause death, injury or the violent destruction of property....the second type...originates in the operation of established and respected forces in the society, and thus receives far less public condemnation than the first type” (Carmichael and Hamilton, 1967, 4). Understanding how racism–which usually has strong class overtones–works (the mechanisms) and creates its outcomes (through mediators) in health and the health system is critical. Such an approach utilizing race should also be useful in understanding other bias-producing mechanisms such as ethnicity, class, culture, gender, disability, sexual preference, and age and their impact on health and health care for several reasons. We now know that:

The racial experience has been, and remains, the most intense in discriminatory levels and differential outcomes, especially with regard to health and health care;

Being one of the oldest bias-producing concepts which simultaneously produced high interest levels, more is known about race and racism;

As critical theory, psychology, and the sociological study of racism have revealed, it is an excellent surrogate and is often a fellow-traveler with most other major types of bias, prejudice, and discrimination;

Race and racism embody virtually all of the moral, egalitarian, medical ethical, and American creed issues that burden our society and health system as we enter the 21st century;

Understanding the basic human psychological mechanisms, regardless of who the perpetrators or victims may be, that produce racism, bias, stereotyping, discrimination, and group hatreds that might affect clinical decision-making is critical to crafting strategies and interventions for solving the problems;

Finally, if the racial bias and discriminatory aspects of the U.S. health system are solved, America will have gone a long way toward achieving justice and equity in health and health care for all its citizens (Byrd and Clayton, 2000, 2002).

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 cross-cultural skills and diversity training efforts. There are several archetypes we have found useful for understanding how race operates–genesis points of principles applicable to the health system and comprehending how some other types of bias operate (Byrd and Clayton, 2000, 2002; Smedley, 1999; Van den Berghe, 1967).

Racial Models as Tools for Analysis and Understanding

Van den Berghe summarized some of the differences between the old-fashioned form of racism associated with slavery, paternalistic racism , and the more modern variety, competitive racism . In the former type Blacks were viewed as immature, irresponsible, improvident, fun loving, child-adults–inferior, but lovable as long as they did not deviate from clearly defined roles. This paternalistic racism allowed for extreme intimacy because it maintained social distance. The prejudiced White superior loved and was committed to the dependent Black who was loyal and loved the master in return. Resistance or rebellion by the slave triggered extreme brutality. With the abolition of slavery, poor and working class Whites, who were the majority (and demanded control) no longer accepted the slaveowner's paternalistic image of Blacks as good children or pets. To them Blacks were seen as clannish, uppity, insolent, aggressive, dishonest competitors for scarce resources. Therefore, competitive racism became the dominant racist mechanism of modern U.S. society (Van den Berghe, 1967).

Robert W. Terry's investigations on racism have evolved over the past three decades. His most recent efforts have crystallized on the concepts of societal and individual racism. Bias also operates at these levels. Incorporating many of his original theories, Terry also focuses on social and institutional mediators of racism defined through power relationships. These mediators include: (1) Power , the unfair distribution or disproportionate capacity by the dominant White/Anglo group to make and enforce decisions; (2) differentially controlling Resources such as money, education, information, and political influence by the dominant racial group; (3) establishing societal Standards according to dominant White/Anglo definitions, automatically marginalizing other group norms, and; (4) incorrectly defining Problems by the dominant White/Anglo group such that perceptions and solutions are distorted, inappropriate, manipulable, and dysfunctional. These four points are major contributors to what Feagin and others describe as White privilege. Terry's work also could be viewed as predecessor or groundwork suggesting the application of some of these principles and concepts to public health as embodied in the work of Camara Phyllis Jones. Presenting a theory based on 3 levels of racism– institutionalized racism , personally mediated racism , and internalized racism –as explanatory and analytic tools for understanding race-associated differences in health outcomes, Jones posits a new paradigm that can be used for crafting interventions to mitigate the impacts of racism on health and health care, and expand the national conversation on racism (Jones, 2000). In the health arena, all of these principles can be applied in both historical and contemporary configurations, and also lend themselves to understanding the European American dominance of the health system (Carmichael and Hamilton, 1967; Feagin, 2000; Feagin and Feagin, 1999; Feagin and Vera, 1995; Jones, 2000; Terry, 1992).

Psychiatrist Joel Kovel devised a psychological archetype of racism focusing on European Americans as the source of the race problem. His dominative racism was based on direct physical oppression and sexual obsession, while his more modern aversive racism is characterized by avoidance of the dominant group (Whites) based on isolation of the subordinate group (Blacks). Grounded in complex and infantile psychological mechanisms it explains the White flight to the suburbs and the creation of inner-city Black ghettos with all the attendant problems of segregation, isolation, and inequality. The most subtle, modern, and malignant form of racism is Kovel's metaracism . It pervasively represents pure racism because it is systematic and independent of individual factors representing the last stage of racism that remains when racial passions have been washed away. Metaracism is "....the racism of technocracy, i.e., one without psychological mediation as such, in which racist oppression is carried out directly through economic and technocratic means" (Kovel, 1984, xi ). 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 police profiling wherein African Americans are automatically criminal suspects; the racism of "reverse discrimination" wherein White males are "protected" by Civil Rights laws that were designed to help Blacks who were previously denied participation in American society; and the racism of computerized arrest record files for job screening in neighborhoods where most of the Black adolescent males experience police encounters (whether convicted of crimes or not). Because it incorporates the most advanced forms of domination, mutates into multiple chame leon-like configurations (whatever forms are necessary to carry out its racist mission), and is the most detached from the older, hate-filled, odious forms of racism leading to discrimination and overt and covert violence, metaracism is the dominant mode of racism in postmodern, * late capitalist, U.S. society. Applying and building upon what has been learned in these areas to other aspects of bias and discrimination in the health system represents the future of cultural competence, diversity, and multicultural medicine (Byrd and Clayton, 2000, 2002; Feagin and Sikes, 1994; Kovel, 1984; Kozol, 1991; Lemann, 1999; Massey and Denton, 1993; Meyer, 2000).

On Ethnic Groups

In contrast to race as a group designation, ethnic group –a group socially distuinguished or set apart, by others or by itself, primarily on the basis of cultural or national-origin characteristics–is a much more recent concept and has been considered a more indefinite category (Feagin and Feagin, 1999; Thernstrom, Orlov, and Handlin 1980). The preeminent paradigm in an attempt to subsume race since the end of World War 2, deficiencies inherent in applying a model based on White ethnic history to non-White groups and its failures to explain or illuminate America's lived racial realities have repeatedly undercut the concept's utility (Feagin, 2000; Feagin and Feagin, 1999; Omi and Winant, 1994).

Besides the difficulties in defining ethnicity , the term has been the focus of a longstanding 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 linguistics categories (Feagin and Feagin, 1999; Sollers, 1989; Sowell, 1981; Steinberg, 1989, 1995; Van den Berghe, 1967). As Takaki noted “Race...has been a social construction that has historically set apart racial minorities from European immigrant groups. Contrary to the notions of scholars like Nathan Glazer and Thomas Sowell, race in America has not been the same as ethnicity” (1993, 10). Furthermore, many race relations authorities argue that such a strategy ignores the day-to-day realities of American bias, racism, and discrimination (Cose, 1993, 1997; Feagin, 2000; Feagin and Sikes, 1994; Feagin and Vera, 1995; Omi and Winant, 1994; Van Ausdale and Feagin, 2001; West, 1994); the country's racial history (Feagin, 2000); its systematic inequalities (Feagin, 2000; Feagin and Sikes, 1994; Feagin and Vera, 1995; Hacker, 1995; Steinberg, 1989, 1995); and the ideological racism encompassed in the worldview on race which is an integral part of Western, and U.S., 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. Whether the nation's racial and ethnic minorities are to be allowed adequate health status and outcome to fulfill their human capital and social potential–necessary prerequisites to be competitive in the 21st century– is the issue with which our system, ultimately, must grapple (Byrd and Clayton, 2000, 2002; Mayberry, 2000; U.S. Commission on Civil Rights, 1999a; Williams, 1999). Failure of our health system to successfully cope with increasing health care costs, increasing race- and ethnic-based health inequities and disparities, and increasing disability, cuts our nation's competitive edge, compromises overall quality-of-life, and poses a threat to the national good from a public health standpoint (Byrd and Clayton, 2000, 2002; Garrett, 2000; Haynes and Broder, 1996; Skocpol, 1997).

• ORIGINS AND EVOLUTION OF INEQUITIES AND BIAS, IN WESTERN AND U.S. HEALTH CARE AND HEALTH SYSTEMS

Introduction to a Historical Perspective on Inequities and Bias

Examining the origins, bases and evolution of health and health care inequities, inequalities, and biased thinking in Western life sciences , whether they are framed in racial, ethnic, class, gender, or cultural terms is a necessary foundation for understanding and eliminating racial and ethnic health disparities. Such an unprecedented examination will also be instructive. For many readers examining racial and ethnic bias and discrimination from health professions, medical-social, and health systems perspectives requires a different mode of thinking: sociocultural, historical, constructionist , and structural, instead of reductionist , purely disease-oriented paradigms framed in public health, medical model, or quantitative terms. Such an exercise has certain drawbacks. Some are: focusing on race and class biases, inequities, and inequalities, for example, may overlook the effects of other problems such as gender or ethnicity, longstanding foci of bias, inequity, and inequality; only brief allusions to the broader historical or social contexts are possible; our examination will be limited to Western and, later, American medicine, health, and health care; and class dimensions will automatically creep in. With these caveats in mind we will proceed.

Ancient Origins

The Classical period of Western scientific dominance beginning around 500 BC was pivotal, for the Greeks brought the gifts of objectivity, empiricism, and logic to the world and began separating the natural world from the religious one. However, along with their ethnocentrism and hierarchical cultural antecedents, their early efforts at taxonomy, a developmental stage of the scientific method, seemed to be preoccupied with human inequality (Byrd and Clayton, 2000; Drake, 1987, 1990; Finley, 1983; Goldberg, 1990). Greek philosophers including Plato and Aristotle, often considered the fathers of modern science and medicine, began arbitrarily assigning slaves to lower categories within the human family, along with Blacks and Asians (Harris, 1972, 13-28; Jordan, 1968, 11-12, 60;Wasserman, 1974, 13-20). For example, Plato's Great Chain of Being and Aristotle's modification, the Scala natura, “one of the half-dozen most potent and persistent presuppositions in Western thought” according to Lovejoy (1964), ranked everything:

Peasants at the bottom, then servants to the gentry, then various grades of nobility and the monarch at top. 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).

Such biased and inequitable principles were readily incorporated into scientific taxonomy schemes, and their medical-social effects were exacerbated by traditions of fee-for-service medical practice and the widespread adoption of the Hippocratic Oath along with what many medical ethicists consider its self-serving medical ethical tradition and weak social covenant. As Veatch points out regarding the Hippocratic tradition, “It is consequentialistic; it is paternalistic; it is individualistic...[and] It permits physicians with bizarre and confused notions of benefit and harm to wreak havoc on unsuspecting patients” (1981, 147, 150). Further, “The Hippocratic tradition...does not have in its history even a token of a principle of justice or equality that could prick the conscience of the physician” (Veatch, 1981, 65). Its leanings toward individualistic contracts between independent agents; vows to hide “trade secrets,” even incompetence; and pledges to channel the educational process to advantage each others' children have been downplayed as factors normalizing the “walling off” of the poor and disadvantaged from medical care and “normalizing” the medical profession as a socially distant upper-class activity (Byrd and Clayton, 2000; Goldberg, 1990; Veatch, 1981).

By the 3rd century BC in Alexandria the overutilization or the poor, defenseless, and disenfranchised for medical experimentation and demonstration purposes was established as “Herophilos and Erasistratos...laid open men whilst alive–criminals received out of prison from the kings–and whilst these were still breathing, observed parts which beforehand nature had concealed” (Majno, 1975, 354). Moreover, an academic physician-scientist and medical demi-god who dominated Western medicine from AD 200 to AD 1700 (or 45 generations), Galen, inserted his overtly racist and biased views into the formal medical corpus “documenting” Black inferiority at physiologic, clinical, and intellectual levels (Davis, 1984; Devisse, 1979; Drake, 1987, 1990; Lewis, 1990) Bias, inequities and inequalities were, thus, operationalized in the Greco-Roman world not only at the social but at ideological, so-called scientific, and health delivery levels as slaves, non-Whites, the disadvantaged, and non-citizens received lesser, often very different, health services (Byrd and Clayton, 2000; Drake, 1987, 1990; Finley, 1983; Porter, 1999).

Precursor archaic medical systems in Mesopotamia and Egypt starting around 4000 BC were plagued with serious social, process, and structural biases and inequities based on slavery and class, but there seemed to be little concern with race. Moreover, the Egyptian health system embraced some communitarian, public health, and egalitarian principals that were much ahead of their time (Byrd and Clayton, 2000; Lyons and Petrucelli, 1978; Porter, 1999; Thorwald, 1962).

The Middle Ages

Christian monks and Arab scholars recorded and perpetuated Western medical and health care traditions throughout the Middle Ages. As clerical suzerainty over medicine and health waned in the Early Middle Ages, Arab Moslem culture became dominant between the 8th and 12th centuries. 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 and lower quality health care for slaves and non-White people (Byrd and Clayton, 2000; Finley, 1983; Lewis, 1990; Sanders, 1978).

The Renaissance

The Galenic-Greek medical corpus remained dominant in the West during the Renaissance. Some influential physician-scientists such as Paracelsus hypothesized that Blacks were inferior to Whites (Stannard, 1992, 209). The receipt of patronage from royalty, clerics, and the aristocracy for health-related enterprises such as medical schools and hospitals influenced the medical profession's acceptance into the European Medieval universities as a prestigious pedagogy and profession, but the mantle of elitism distanced the profession socially from the populations they served. The health system itself remained inequitable and strongly structured along class lines (Bullough, 1966; Sirasi, 1990; Wear, 1992). By the end of the drought between European and African contact between the 14th and 16th centuries largely based on the Mediterranean and Atlantic slave trades, iconographic and documentary evidence suggests rising bias, prejudice, and discrimination levels against Blacks in Europe ( Devisse, 1979; Devisse and Mollat, 1979; Pieterse, 1992). 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) depiction of African and other non-White people as inferior to Europeans. These developments set the stage for the inequitable and unequal hierarchical health arrangements, political ideology, and later scientific justifications made during the Age of Discovery for the slave trade and overseas conquests (Byrd and Clayton, 2000; Davidson, 1961, 1984; Jordan, 1968; Klein, 1978; Lewin, 1988; Sanders, 1978; Stannard, 1992).

The Age of Science and Enlightenment

Inequities already established in health and health care in Western Europe and America continued and increased during the Age of Science and Enlightenment between 1600 and 1800. Huge gaps existed in access to and the quality of health care delivered to the peasant masses and European aristocracy, and many aspects of these systems were exported worldwide to the colonies (Ackerknecht, 1982; Lyons and Petrucelli, 1978; Numbers, 1987; Rosen, 1993; Wear, 1992). French physician Francois Bernier wrote the first scientific article on racial classification in the Paris Journal des Scavans in 1684, and Carl Linnaeus's, a Swedish physician-scientist and the “Father of Biological Classification,” seminal work establishing binomial nomenclature as the standard in biological classification, Systema Naturae , appeared in several editions after 1735. Both used skin color as major classification criteria and both marginalized Blacks, the former as a different species (Davis, 1966, 454; Marshall and Williams, 1982, 242-243) and the latter adding degrading psychological and behavioral characteristics (Byrd and Clayton, 2000, 94-95, 214; Jordan, 1968, 218-222; Marshall and Williams, 1982, 245). Other dominant physicians and natural scientists of the era such as George-Louis Leclerc Buffon, Johann Fredreich Blumenbach, Petrus Camper, and Georges Cuvier all added to the bias-producing myth of White male superiority and non-White inferiority in their teachings, scientific discourse, and published works. The growing influence of science manifested in that much of this hierarchical material was being utilized to justify social inequities and inequalities such as slavery, colonization and exploitation, and social segregation and stratification (Boorstin, 1989; Byrd and Clayton, 2000; Gossett, 1965; Gould, 1981; Haller, 1971; Haller and Haller, 1977; Jordon, 1968).

Enterprises contributing substantially to biases, inequities, and inequalities in health and health care during the period from 1600 to 1800 were the Atlantic slave trade and the worldwide establishment of European colonies (Byrd and Clayton, 2000; Kiple, 1981; Savitt, 1978; Sheridan, 1985). The Atlantic slave trade and New World slavery were not only dominant world events, they were deficit-producing situations health-wise for the expropriated African 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. More important may have been the deleterious effects these events had on the health system subculture (Byrd and Clayton, 2000; Kiple, 1981; Savitt, 1978; Sheridan, 1985; Stannard, 1992; Watts, 1997). In the North American English colonies the aforementioned slave health deficit was perpetuated, a slave health subsystem institutionalized, and Black slaves joined the poor and disenfranchised by being overutilized for surgical, demonstration, and dissection purposes. Meanwhile, the health system and the delivery of health services were founded and structured on the basis of race, class, and puritan-oriented moral judgements–inherently biased and inequitable ideological, structural, and process arrangements. In English North America oversight of the health and health care enterprise was under the stewardship of a tiny cadre of White, often European-trained, physicians and boards of elite and wealthy Christian philanthropists (Blakely and Harrington, 1997; Byrd and Clayton, 1991, 1992, 2000; Dowling, 1982; Kiple, 1981; Rosenberg, 1987; Savitt, 1978; Schultz, 1992; Sheridan, 1985).

The Colonial, Republican, Jacksonian, and Antebellum Periods

In the rapidly evolving medical and scientific communities during the American Colonial, Republican, Jacksonian, and Antebellum periods between 1619 and 1861 scientific racism burgeoned. As Reed pointed out, before the 20th century “Scientific racism was not ‘pseudo-science' but an integral part of the intellectual world-view that nurtured the rise of modern biology and anthropology” (1989, 1358). During the early 19th century the scientific study of race not only became more hierarchical with Blacks, other non-Whites, and women being relegated to the lower echelons of humanity, it continued to be dominated by European males. Influential studies by prominent academic European physicians such as Charles White ( Account of the Regular Gradation in Man , 1799), James Cowles Prichard ( Researches into the Physical History of Man , 1813-1847), Charles Hamilton Smith ( The Natural History of the Human Species , 1848), and Robert Knox ( The Races of Men , 1850 and 1862) (Banton, 1986; Byrd and Clayton, 2000) supplemented those by the three most dominant natural scientists of the 19th century, Georges Cuvier, Charles Darwin, and Sir Charles Lyell, all of whom held Blacks in low esteem (Gould, 1981, 35-36). However, between the 1830s and the Civil War the first seriously considered American scientific movement emerged, the “American school” of anthropology. Building upon the work of Louis Agassiz, a physician and chief biologist at Harvard, and Samuel George Morton ( Crania Americana , 1839, Crania Aegyptiaca , 1844), a prominent University of Pennsylvania academic physician, the first extensive body of quantitative data in support of “polygenism”–the theory that human races were separate biological species, descendants of different Adams–took the scientific lead in the reification of race and its relation to racial hierarchies and biological determinism. Americans dominated the field until supplanted by Darwin's theory of evolution after 1859 (Byrd and Clayton, 2000, 2002a; Gould, 1981; Haller, 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 health care for non-military populations on the basis of race, gender, moral judgements, and class during the Civil War. Black Union Army soldiers received inferior health care at all levels, from the Medical Bureau in Washington, to the field hospitals and combat units, individual professional providers, to the field soldiers on the battlefields. In lieu of the generalized improvements in medicine, public health, and health services as a result of the Civil War, higher African American mortality rates and poorer health outcomes reflected another set of realities–Black social and economic collapse; health segregation, discrimination, and exploitation at all levels throughout the Civil War, Reconstruction, Gilded Age, and Progressive eras; collapse of the slave health subsystem; refusal by the mainstream health system to incorporate Freedmen (Barbeau and Henri, 1974; Byrd and Clayton, 2000; Cobb, 1952; Cornish, 1966; Duffy, 1990; Rabinowitz, 1978). Meanwhile all African Americans, slave, free, and contraband, suffered health crises related to the war 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 health care along with continued anomic and discriminatory wartime acts and policies toward the few trained Black physicians, exacerbated an already critical situation (Byrd and Clayton, 2000; Cobb, 1952, 1952a, 1981; Duffy, 1990; Mohr, 1986; Morais, 1967; Shryock, 1966). Black Civil War soldiers were utilized as subjects of the United States Sanitary Commission Anthropometric Study–the largest “scientific” comparison of the races ever undertaken–an enterprise utilized to “document” Black inferiority and White superiority for the next half century (Byrd and Clayton, 2000; Haller, 1971).

The Reconstruction, Gilded Age, and “Progressive” Eras

The Reconstruction period threatened the disappearance of the entire Black population due to social conditions exacerbated by health or health-related causes. Epidemics, homelessness, breakdowns in housing and sanitation, and abandonment of the Freedmen by the mainstream health system were all factors. Emergency measures and Freedmen's Bureau legislation led to a “First Reconstruction in Black health” which led to the opening of African American-accessible hospitals, clinics, and medical schools which reversed some of the results of bias and inequities in the health system and may have saved the Black population from extinction (Byrd and Clayton, 2000; Morais, 1967). Physicians, politicians, and other opinion leaders throughout the late 19th century utilized biased analyses of the Ninth, Tenth, and Eleventh censuses of 1870, 1880, and 1890, corroborated by insurance company data such as the Prudential's to confidently predict such an outcome (Byrd and Clayton, 2000, 411; Numbers, 1978, 16-19; Tucker, 1994, 33). Perhaps as important was the establishment of an entrepreneurial precedent and separate, albeit limited in some respects, Black health, health delivery, and health professions training traditions and institutions (Byrd and Clayton, 1992, 2000; Cobb, 1981; Morais, 1967). The nadir of Black health during and immediately after the end of Reconstruction in 1877 were related to social chaos and dislocation affecting the Freedmen, barriers to Black entry into the mainstream health system, the termination of most of the Freedmen's Bureau health activities by 1872, the lack of health facilities and personnel willing to serve African Americans, all exacerbated by rampant scientific racism sweeping over the society and the health system. The growth of a “Negro medical ghetto,” a group of Black health professionals serving the Black community, and the acceptance of separate but unequal health, health care, and tiers of the health system based on race and class as the norm characterized the Gilded Age and Progressive eras U.S. health system. Persistent bias and inequities in the health system were also manifest by the split of the medical profession into White, the American Medical Association, and Black, the National Medical Association, factions, the former becoming a monolithic supporter of social conservatism and the status quo while the latter crusaded for health justice and equity and established the tradition of promoting egalitarian approaches to health and health care (Byrd and Clayton, 1992, 2000, 2002; Cobb, 1981; Duffy, 1990; Morais, 1967; Tucker, 1994).

The Early 20th Century

Early 19th century scientific racist movements such as anthropometry, phrenology, and craniometry were displaced by movements such as social Darwinism , eugenics, and psychomet ric testing later in the century. The medical and other scientific establishments provided elaborate classifications for and predicted the imminent extinction of inferior “races” such as Blacks, criminals, Jews, southern Europeans, the Irish, the poor, and the insane. Much of the research and deprecation, especially with the rise of IQ testing, was directed at newly arrived White (e.g., Irish, Eastern European Jews) and non-White (e.g., Chinese, Mexicans, and Japanese) immigrant groups. Good breeding and sterilization of the “unfit” were posited as solutions to all social and many medical problems. Thus, medical and scientific developments continued to provide an underpinning for ongoing biases, inequities, and inequalities in health and health care as they related to race, ethnicity, gender, class, social status, and moral criteria (Byrd and Clayton, 2000, 2002; Chase, 1980; Haller, 1963; Kevles, 1985; McClintock, 1995; Reilly, 1991; Tucker, 1994; Weisbord, 1975).

As the United States emerged as a world power in the early-20th century the U.S. health system remained locked in patterns of bias, inequity, and inequality. Seemingly unable to shed its racial, class, gender, and moralistic shibboleths, the Progressive era worsened many racial, class, and ethnic biases, prejudices, and inequities in the health system, often shifting issues such as poverty, insanity, imbecility, and congenital malformations, in attempts to divorce them from areas of social concern, into the domain of health care under the aegis of so-called scientific dispensation. So-called scientific data such as family trees and IQ tests were used to justify sterilization, incarceration, and immigration restriction. Biometric testing which had classified most of the U.S. World War I soldiers as mentally limited or deficient reached its zenith during the 1920s and was later adapted for educational selection and tracking. Between the late-19th and the first quarter of the 20th century educational reform swept through the health professions training and research infrastructure. The medical schools and medical research laboratories became the darlings of the elite foundation and corporate benefactors–Black institutions were relegated to a caste status remaining on the margins (Allen, 1995; Brown, 1979; Byrd and Clayton, 2000, 2002; Chase, 1980; Epps, 1989; Guthrie, 1998; Hunt, 1993; Jonas, 1989; Lemann, 1999; Summerville, 1983)

The health system at all levels remained racially segregated and highly discriminatory along race, class, ethnic, and gender lines. This reflected a continuum of nationally adopted health traditions and policies extent since the Colonial era, and a burgeoning, deficient, public, largely tax-supported subsystem for the poor, immigrants, or incapacitated was erected. Reform of the growing medical education and research system conformed to previous race-, gender-, and class-biases and inequities (Byrd and Clayton, 2000, 2002; Dowling, 1982; Flexner, 1910; Hunt, 1993), and the medical profession became more elite, homogenous, and distant from the general public they served. The cultural fabric of the society changed with an unquestioning acceptance of biologically, statistically, and psychologically determined principles of scientific racism– growing eugenics and social Darwinism movements shaped and influenced the health system with regard to immigrants, Blacks, the impoverished, or the mentally challenged–while an increasingly dominant private health system for the well-to-do and middle class blossomed with new medical advance and technology (Byrd and Clayton, 2000, 2002; Chase, 1980; Haller, 1963; Kevles, 1985; Reilly, 1991; Tucker, 1994).

As a result of these occurrences: White health improved dramatically; in contrast, African Americans' health improved very little remaining the worst of any racial or ethnic group as they continued to receive little or deficient health care, especially in rural areas; immigrant health was poor as they were either excluded or marginalized by the mainstream health system, being confined, in many instances, to the system's deficient public or charity-supported lower tiers; eugenics and social Darwinism movements flourished shaping and influencing the health system with regard to the care and disposition of immigrants, Blacks, the impoverished, or the mentally challenged; the Negro medical ghetto continued to grow in size and complexity (Cobb, 1947, 1948, 1981; Gamble, 1995; Wesley, 1998); scientific exploitation of Blacks and the poor continued (Byrd and Clayton, 2000, 2002; Chase, 1980; Kenney, 1941; Townsend, 1911); and underrepresented African American physicians came of age with their own agenda (Byrd and Clayton, 1992, 2000, 2002; Bullough and Bullough, 1972; Chase, 1980; Cobb, 1947, 1948, 1981; Dowling, 1982; Farley, 1970; Farley and Allen, 1989; Leavitt and Numbers, 1985; Rosenberg, 1987; Starr, 1982).

The Great Depression and World War II

The Great Depression disrupted, almost destroying in the process, a health system with contours one could recognize today. By World War II this forced more government involvement in health care and some restructuring of the system, especially along health care financing lines. Nevertheless, patterns of bias and inequities in health and health care continued as: Black/White health inequities and gaps continued at the policy, systems, professional, health status, outcomes, and services levels; White health progress slowed; the medical profession remained segregated by race with the White profession becoming a power center, a leader in the fight against progressive health reform (other opponents included insurance companies, a conservative series of Congresses, some members of the pharmaceutical industry, and White health professions organizations), and nidus of reaction while the Black profession continued to be victims of discrimination; the Negro medical ghetto continued; and repeated efforts to reform the health system along unitary, egalitarian and more communitarian lines failed (Beardsley, 1987; Byrd and Clayton, 1992, 2001, 2002; Campion, 1984; Cray, 1970; Hirshfield, 1970; Morais, 1967; Starr, 1982; Stevens, 1971, 1999; Wesley, 1998).

Groundwork for Civil Rights in Health Care

From a bias and equity perspective the two decades after World War II, 1945-1965, laid the groundwork for Civil Rights Movements in both the health care system and society at large. Nevertheless, the same health and health care patterns of bias and inequities detailed above continued until 1964 when the courts outlawed government-sponsored hospital segregation and 1965 when Congress passed the Medicare and Medicaid legislation (Title 18/19). This took place despite vigorous opposition from the AMA and the health care and medical establishments. A successful civil rights struggle often led by Black physicians, especially W. Montague Cobb, and organizations such as the NAACP culminated in a national civil rights campaign for justice and equity in health and health care, a series of desegregation lawsuits won against segregated medical schools, and a series of Imhotep Hospital Integration conferences that took place between 1957 and 1964 culminating in desegregated hospitals (Beardsley, 1987; Byrd and Clayton, 1992, 2000, 2002; Cobb, 1981; Cray, 1970; Morais, 1967; Smith, 1999).

Simultaneously, unethical experimentation on Blacks, incarcerated populations, military populations, infirm elderly, and other disadvantaged groups increased in volume and intensity. The silences surrounding the atomic bomb experiments on U.S. soldiers, widespread institutional research abuse, government radiation and nuclear experiments on individuals, and the Tuskegee experiment would not break until later (Beecher, 1966; Byrd and Clayton, 2002; Hornblum, 1998; Jones, 1993; Washington, 1994, 1994a; Welsome, 1999).

A Civil Rights Era in Health Care

Between 1965 and 1980 some of the most momentous progress in health care history for African Americans and other disadvantaged groups occurred. For Blacks 1965-1975 represented a “Second Reconstruction in health and health care” 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)/neighborhood health center (NHC) movement burgeoned (Byrd and Clayton, 1992, 2000, 2002; Davis and Schoen, 1978; Sardell, 1988). These events occurred despite lax enforcement of the civil rights laws applicable to health and health care (Smith, 1999; U.S. Commission on Civil Rights, 1999a, 1999b; Wing and Rose, 1980). Nevertheless, mainstream resistance to reform of the system occurred, as: many White doctors refused to participate in Medicaid/Medicare programs; dual track health and public policy, public health, and health system strategic planning relative to Blacks and the disadvantaged poor remained in place; covert racial segregation was often maintained and institutional racism went unaddressed; Black, ethnic minorities, and the poor were still largely confined to the public health care sector (e.g, public hospitals, NHCs, CHCs, teaching hospital clinics, and health departments); mainstream medicine and its establishment continued to fight against progressive health reform and policies; and increasing inequities for Black doctors continued to be incorporated into professional training, principally as underrepresentation, and intensified in the peer review processes (Byrd and Clayton, 1992, 2000, 2002; Campion, 1984; Cobb, 1981; Ehrenreich and Ehrenreich, 1970; Morais, 1967; Sidel and Sidel, 1984; Smith, 1999; Wesley, 1998).

A Retrenchment Era in Health Care

After the legislative defeat of the AMA and the mainstream system in 1965 with the passage of Medicare and Medicaid and a short period of being held at bay, mainstream resistance to reform of the system continued unabated. Retrenchment after 1975 consisted of: unaddressed health system structural segregation, discrimination, and institutional racism; continued ethnic, class, gender, cultural segregation and discrimination in health and the health system; stagnation or deterioration of health status and outcomes for Blacks and the poor; steep cuts in public funding for health care; complicity in non-enforcement of civil rights laws and regulations (Byrd and Clayton, 1992, 2000, 2001a, 2002; Campion, 1984; Cobb, 1981; Morais, 1967; Smith, 1999).

There was continuing evidence of bias and inequities in American medicine, health, and health care during the Reagan-Bush era from 1980-1992–in fact, new areas cropped up and several established areas intensified. Some were: increasing race- and class-based inequities and gaps in health status and outcomes; drastic cuts in public health care sector funding such as Medicare, Medicaid, tax-supported institutional funding cuts; retrenchment on Civil Rights laws; maintenance of structural inequities and segregation of the health system; and continued underrepresentation of Blacks and other disadvantaged minorities in the health system and health professions (Andrulis and Carrier, 1999; Byrd and Clayton, 2001, 2001a, 2002; Clayton and Byrd, 2001; Smith, 1999) Black doctors suffered increasing professional inequities centered around the managed care peer review process as: Black doctors continued to be reviewed without benefit of representation in the process; providers for poorer and sicker patients, the typical Black/minority provider profile, received systematically harsher treatment; the increased prevalence of patient and practice profiling; economic credentialing became widespread; and practice norms and profiles continued to be determined by the White, less ill, majority (Andrulis and Carrier, 1999; Byrd and Clayton, 2002; O'Bannion, 1995). Other systemic bias and inequity problems surfaced as: the Malone-Heckler report (1985-1986) reminded the nation of continuing racial and ethnic health disparities in lieu of the Second Reconstruction in health care; increasing uninsured rates disproportionately affected minorities, children, and the working poor; a “Mainstream health crisis” (runaway cost inflation, 14% of GDP consumed by health, huge health budget, growing numbers of uninsured) emerged; and the little acknowledged and constitutionally different “African American and disadvantaged patient health crisis” (segregated health/health policy/health system, structure-based race/class inequities and inequalities, origins almost 4 centuries old, health insurance crisis) formed what was in reality a “dual health crisis in Black and White” (Byrd and Clayton, 2000, 2002; Clayton and Byrd, 1993a; U.S. Department of Health and Human Services,1985a; Woolhandler and Himmelstein, 1992, 1998). Nevertheless, after revelations surrounding the Tuskegee experiment; documentation of scores of thousands of unethical sterilizations and surgical abuse; widespread experimental abuse of prison and military populations; and instances of experimental exploitation and abuse of frail elderly populations and disabled children, some improvements occurred in these areas regarding Blacks, the disadvantaged, and other vulnerable groups (Byrd and Clayton, 2002; Chase, 1980; Hornblum, 1998; Jones, 1993; National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1979; Reilly, 1991; Washington, 1994, 1994a; Welsome, 1999).

Failed Reform and Corporate Takeover

The 1993-1994 period was dominated by the failed Clinton health reform (Johnson and Broder, 1996; Skocpol, 1997). Between 1995 and 2001 what some view as a corporate takeover of medicine, health, and health care, as predicted by Starr, by an insurance company-dominated managed care infrastructure has occurred. However, bias, inequity, and inequality in health and health care are still problems as: “patchy destabilization” of the health system is occurring with increasing regularity; de-funding, contraction, and neglect of the public health care sector continues; managed care organizations selectively lock out Black and poor patients and the providers that care for them; inequitable managed care peer review continues for Black and disadvantaged minority doctors; biased clinical decision-making, a tradition more than 380 years old in America, continues; and increasing race-, ethnic-, and class-based inequities, inequalities, and disparities continue (Andrulis and Carrier, 1999; Byrd and Clayton, 2002; Clayton and Byrd, 2001; Collins, Hall, and Neuhaus, 1999; Garrett, 2000; Gray, 1991; Knox, 1999; Mayberry, 2000; Navarro, 1993; Schulman, et al, 1999; Starr, 1982).

A Health System Shedding Some Negative Aspects of its Past?

The Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Health Disparities represents an important early step at solving a major set of problems in the United States' health system. The roots of American racial and ethnic health and health care disparities are more than 2,000 years old. The adverse health experience of Native Americans and African Americans are the oldest. The former being 5 centuries old and the latter nearly 4 centuries old. Both groups health experiences parallel their citizenship and social status in many respects. 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; the Second Reconstruction in Black Health occurred between 1965 and 1975. Both were underfunded and stopped too soon to have permanent positive effects on Black health. For other ethnic minorities, especially non-Europeans, disparate health is a persistent norm. As we enter the new millennium these racial and ethnic disparities in health care remain to plague the system (Byrd and Clayton, 2000, 2002; Collins, Hall, and Neuhaus, 1999; Mayberry, 2000; U.S. Department of Health and Human Services, 1985a; Williams, 1999).

Many actions need to be taken if amelioration of the nation's history-, health system-, and medical-social culture-based racial and ethnic health and health care disparities is to occur. Specific recommendations are in other realms of this report, but changes will have to occur in these general areas:

At ideological and philosophical levels;

Educational levels–diversity, cultural competence, anti-bias;

Health policy level;

Structure and processes levels of health system;

Functional component levels of the health system;

Race, class, and ethnically relevant research levels;

Specific interventions levels required;

Community advocacy, adoption, and involvement levels (Byrd and Clayton, 2001, 2002)

This study represents the nation's potential to ameliorate a set problems that are over 394 years-old for the Native American community, * over 382 years-old for the African American community, is a growing problem in various Hispanic communities, and is becoming more of a problem in various Asian/Pacific Islander communities (Byrd and Clayton, 2000, 2002; Garrett, 2000; Malone and Johnson, 1986; Mayberry, 2000; Sullivan, 2000; U.S. Commission on Civil Rights, 1999a, 1999b; Williams, 1999). As Laurie Garrett observed:

American....health leaders....struggle with questions of race, genetics, ethnicity, and economic class, unable to define the relative impacts those had on individual and population health. And that debate, coupled with social exclusions from the health system...form a critical, lasting, and shameful theme of U.S....health (Garrett, 2000, 306).

The issues have again been placed on the agenda, and the health system, public health, the political process, and American public are at another crossroads. The future health of America's health system, indeed its population, may hinge on attaining a satisfactory resolution of its racial, class, and ethnic disparities–one of the major sets of 21st century health system problems, lingering from the nation's health past, in an antigovernment age with an impending majority minority population. This background information has been provided to lend some of the historical, sociocultural, and medical-social facts and contexts necessary to understand and eliminate the health 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).

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The modification of the culture of a group or an individual, a process encompassing infancy onward, as a result of contact with a different culture. This cultural assimilation, which can take two to three generations, moves toward the dominant Anglo-Protestant culture.

A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliations or community recognition.

A more accurate term for those often referred to as White Anglo-Saxon Protestant Americans.

a term that originally referred to Germanic tribes, the Angles and the Saxons, that came to the area now called England in the fifth and sixth centuries A.D.; it was later applied to the inhabitants of England and to those English who came to North America.

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.

A person 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.

An incoming group's adoption of the cultural traits and identity of the host group or integration into the primary networks and secondary organizations of the host group.

A preference or an inclination, especially one that inhibits impartial judgement; 2. An unfair act or policy stemming from prejudice.

A person having origins in any of the black racial groups of Africa.

A social stratum whose members share certain economic, social, or cultural characteristics.

Refers to the social formed dimensions of an inquiry. Such and inquiry includes elements such as the history, social dimensions, and culture shaping a subject.

The accumulated store of shared values, ideas (attitudes, beliefs, values, and norms), understandings, symbols, material products, and practices of a group of people. Culture has both material and non-material aspects.

The study of the characteristics of human populations, such as size, growth, density, distribution, and vital statistics.

Actions carried out by members of dominant groups, or their representatives, that have a differential and harmful impact on members of subordinate racial or ethnic groups.

A racial or ethnic group with the greatest power and resources in a society (also called a majority group).

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.

A group socially distinguished or set apart, by others or by itself, primarily on the basis of cultural or national-origin characteristics.

Ethnicity is a concept referring to a shared culture and way of life, especially as reflected in language, folkways, religious and other institutional forms, material culture such as clothing and food, and cultural products such as music, literature, and art. The collection of people who share an ethnicity is often called an ethnic group.

Denotes individuals usually called “white” which need no designation (such as ethnic or hyphenated Americans) because they are recognized and presumed to be Americans.

A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. [WHO definition]

Those services provided to individuals or communities by agents of the health services or professions, for the purpose of promoting, maintaining, monitoring, or restoring health. Health care is broader than, and not limited to medical care, which implies therapeutic action by or under the supervision of a physician.

A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.

A term involving giving up one's ethnic identity for that of the dominant Anglo-Protestant culture, or an incoming group's development of a sense of identity linked to that of a host group.

An ideology that considers a group's unchangeable physical characteristics to be linked in a direct, causal way to psychological or intellectual characteristics and that, on this basis, distinguishes between superior and inferior racial groups.

Overt acts by individual Whites against individual Blacks which cause death, injury, or violent destruction of property. The act may occur without the presence of conscious bigotry and may be masked intentionally or innocently.

Acts of the total White community against the Black community originating in the operation of established and respected forces in the society. This often manifests as differential access to the goods, services, and opportunities of society by race. Institutionalized racism is normative, sometimes legalized, and often manifests as inherited disadvantage. It is structural, having been codified in our institutions of custom, practice, and law, so there need not be an identifiable perpetrator. It is often evident as inaction in the face of need and may occur without the presence of conscious bigotry and may be masked intentionally or innocently.

Acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth. It is characterized by their not believing in others who look like them, and not believing in themselves. It involves accepting limitations to one's own full humanity, including one's spectrum of dreams, one's right to self-determination, and one's range of allowable self-determination, and one's range of allowable self-expression. It manifests as an embracing of “whiteness” (use of hair straighteners and bleaching creams, stratification by skin tone within communities of color, and “the white man's ice is colder” syndrome); self devaluation (racial slurs as nicknames, rejection of ancestral culture, and fratricide); and resignation, helplessness, and hopelessness (dropping out of school, failing to vote, and engaging in risky health practices.

An inclusive term designating all branches of science (e.g., biology, medicine, anthropology, epidemiology, or sociology) that deal with living organisms and life processes.

A term that is often used to describe the “general market,” usually refers to a broad population that is primarily White and middle class.

The science and art dealing with the prevention, cure, or alleviation of disease ...the Western Greek model sites of activity are: the bedside, library, hospital, community, and the laboratory.

a group that is singled out because of physical or cultural characteristics whose members become objects of discrimination; it typically has less power and resources than the dominant group (also called a subordinate group).

The non-Asian stereotype that views certain Asian American groups as uniquely exemplary in socioeconomic and moral characteristics compared to other people of color.

Prejudice and discrimination, where prejudice means differential assumptions about abilities, motives, and intentions of others according to their race, and discrimination means differential actions toward others according to their race.

An antipathy, felt or expressed, based upon a faulty generalization and directed toward a group as a whole or toward individual members of a group.

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 thinking, discriminatory institutions and social structures, a shared worldview, and social myths; 2. A term developed in the 1700s by European analysts to refer to what is also called a racial group (see racial group).

A social group that persons inside or outside the group have decided is important to single out as inferior or superior, typically on the basis of real or alleged physical characteristics subjectively selected.

The belief, very prevalently used in science, that the whole of reality consists of a minimal number of entities or substances. The major methodological reductive triumph of recent years is the demonstration that the classical unit of heredity, the gene, is a macromolecule–deoxyribonucleic acid, or DNA.

The creation and employment of a body of legitimately scientific, or patently pseudoscientific, data as rationales for the preservation of poverty, inequality of opportunity for upward mobility, and related regressive social arrangement. Usually creating a myth of two distinct races of mankind–one consisting of a small, healthy, wealthy, educable elite, while the second race is a far larger population of poor or nonwealthy, vulnerable, and allegedly uneducable by virtue of hereditarily inferior brains–scientific racism has often also instituutionalized and lent scientific respectability to racist dogma and practices that were all far, far older than science itself.

The dramatic and deliterious Black/White differentials in health status and outcome presumed to be the consequence of slavery and subordinate racial status.

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. Some plantation infirmaries and hospitals and slave dispensaries and hospitals served as institutional sites.

A rigid, oversimplified, often exaggerated belief or image that is applied to both an entire category of people of a racial or ethnic outgroup and to each individual within it, usually negative, that is false or that greatly distorts the real characteristics of the outgroup.

A subculture pertains only to those standards that are operative when a person is acting in a particular social capacity or group. For example, occupations and ethnic groups develop their own subcultures–standards for what exists, what goals are to be valued, how one should behave–which are relevant when one is acting either on the job or as a member of the ethnic group but which are largely irrelevant outside those contexts. The medical profession and health system are excellent examples of subcultures (see culture).

A group that is singled out because of physical or cultural characteristics for differential and unequal treatment and whose members become objects of discrimination; it typically has less power and fewer resources than the dominant group.

A culturally structured, systematic way of looking at, perceiving, and interpreting various world realities. The Western racial worldview holds that racial groups are by nature unequal and can be ranked along a gradient of superiority–inferiority.

A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

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• Van den Berghe PL. 1967. Race and Racism: A Comparative Perspective . New York: John Wiley and Sons, Inc.
• Webster's Collegiate Dictionary , 5th Edition, s.v. “medicine.”.

While the 1890 Census had used the term “Colored” to mean all nonwhite persons, in the West Indies it meant part-European, part-Negro, and in the earlier censuses, in some southern states, and in some other countries it meant anyone with a Negro ancestor.

Though it is not fully understood, the origins of the germs (bacteria, viruses, etc.) causing many human diseases can be traced to many animals domesticated in the Old World such as pigs, cows, horses, sheep, and goats. SOURCES: Diamond J. Guns, Germs, and Steel: The Fates of Human Societies . Paperback Edition. New York: W.W. Norton and Company, Inc, 1999; Pedraza S, Rumbaut RG. Origins and Destinies: Immigration, Race, and Ethnicity in America . Belmont, California: Wadsworth Publishing Company, 1996.

Reasons for overall health improvement and convergence of health and health care for all Americans can be attributed to scientific (e.g., vaccinations, antibiotics), social (e.g., improved nutrition, housing, and sanitation), political (e.g. movement toward egalitarianism and the welfare state), economic, medical-social (e.g., acceptance of public health goals), and health policy (e.g., policies promoting a healthy population and good health) factors– realms detailed in the references.

Release of 2001 census data indicated Hispanics were tied with Blacks as America's largest racial/ethnic minority group. SOURCE: Canedy D. Troubling label for Hispanics: ‘Girls most likely to drop out.' New York Times, Sunday, March 25, 2001, p. 1.

A Native American people inhabiting the Aleutian Islands and coastal areas of southwest Alaska.

Death Registration Ares is a geographic area for which mortality data are published. SOURCE: Last JA, ed. A Dictionary of Epidemiology. Second Edition. New York: Oxford University Press, 1988, 35.

They include the African continental and Atlantic slave trade period (Curtin, 1969; Davidson, 1961; Kiple, 1981; Klein, 1978; Lewis, 1942; Ransford, 1983; Savitt, 1978; Sheridan, 1985), the North American colonial era (Blanton, 1930, 1931; Klein, 1978; Savitt, 1978, 1985; Sheridan, 1985), the Republican era (Boles, 1984; David, et al, 1976; Ewbank, 1987; Fogel, 1989; Owens, 1976; Reuter, 1970; Steckel, 1979), the Jacksonian and Antebellum periods (Curry, 1981; Ewbank, 1987; Farley and Allen, 1989; Lewis, 1942; Savitt, 1978, 1985), the Civil War era (Barbaeu and Henri, 1974; Bremner, 1980; Cobb, 1952; Mohr, 1986; Shryock, 1966), the Reconstruction era (Blassingame, 1973; Farley and Allen, 1989; Morais, 1967; White, 1970), the Gilded Age and Progressive eras (Du Bois, 1967; Manning, 1983; Rabinowitz, 1978; Stuart, 1987; Summerville, 1983), the Early 20th century from 1901-1929 (Du Bois, 1896, 1906; Ewbank, 1987; Farley, 1970; Farley and Allen, 1989; Stuart, 1987), the Great Depression and World War II eras from 1930-1945 (Ewbank, 1987; Farley and Allen, 1989; Hart, 1991; Lewis, 1942; Morais, 1967; Myrdal, 1944; Reuter, 1970; Stuart, 1987), the post-war and Civil Rights eras from 1945-1965 (Beardsley, 1987; Ewbank, 1987; Farley, 1970; Farley and Allen, 1989; Jaynes and Williams, 1989; Morais, 1967; Pettigrew, 1964; Rosenbaum, Layton, and Liu, 1991; Smith, 1999; Stuart, 1987; U.S. Bureau of the Census, 1975), the Civil Rights era in health care from 1965-1980 (American Cancer Society, 1988; Baquet, et al, 1986; Clayton and Byrd, 1993; Davis and Schoen, 1978; Davis, et al, 1989; Haynes, 1975; Henschke, 1973; Leffall Jr., 1974, 1979; National Center for Health Statistics, 1991, 1992; René, 1987; Stuart, 1987; U.S. Department of Health and Human Services, 1985, 1986), and the era of the Black Health Crisis of the 1980s and 1990s (American Cancer Society, 1997, 1998; Braithwaite and Taylor, 1992; Clayton and Byrd, 1993, 2001; Collins, Hall, and Neuhaus, 1999; Jaynes and Williams, 1989; Livingston, 1994; National Center for Health Statistics, 1992, 1992a, 1996, 1997, 1998, 1998a, 2000; René, 1987; Singh and Yu, 1995; U.S. Department of Health and Human Services, 1985a, 1986, 1986a).

Postmodern is a family resemblance term (often relating to art, architecture, or literature) that reacts against earlier modernist principles, as by reintroducing traditional or classical elements of style or by carrying modernist styles or practices to extremes.

This applies to the Native American health experience in the North American English colonies. If Christopher Columbus's land fall is taken as the starting point, 105 years are added making a grand total of 499 years.

This population is currently referred to as “Alaska Native.”

• Cite this Page Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care; Smedley BD, Stith AY, Nelson AR, editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington (DC): National Academies Press (US); 2003. UNDERSTANDING AND ELIMINATING RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE, BACKGROUND PAPER RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE: A BACKGROUND AND HISTORY.
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