America's pervasive legacy of slavery, racism, and substandard, segregated health care for many of the nation's minorities has left a deep chasm between the health status of most minorities and whites. Despite the Civil Rights legislation of the 1960s and public health interventions of the last 30 years, African Americans still live an average of six to seven years less than whites. A black woman has a four times greater risk of dying from pregnancy complications than a white woman and twice the risk of a Hispanic woman. Even minority infants are at increased risk for death--black infants die at more than twice the rate of white and Hispanic infants. "Considering where we came from and what we're up against, there hasn't been much time to receive equal care," says Brian Gibbs, who heads the School's Program to Eliminate Health Disparities. "It's only been 36 years since the passage of the Voting Rights Act for African Americans; a system that employed and advanced slavery and is ingrained in our social culture doesn't turn around that fast."

In An American Health Dilemma, A Medical History of African Americans and the Problem of Race, Beginnings to 1900, authors W. Michael Byrd, M.P.H.'92, and Linda A. Clayton, M.P.H.'92, both gynecologists and adjunct faculty at the Harvard School of Public Health's Division of Public Health Practice, meticulously catalog the brutal impact of the institution of slavery and the "grim continuum of poor outcomes" that has dogged African Americans ever since. They examine the collusion of white doctors and the legal system in degrading the status of blacks and other minorities to "sub-human" through pseudoscientific theories of racial inferiority that were used to justify America's economic dependence on slaves. Eventually about eight million Native Americans would die as a result of white domination; when genocidal mortality rates among native people led early American farmers to seek African slaves, about 50 million died in the process.

According to Clayton and Byrd, white physicians developed an ethical "blind spot" regarding the high rates of death, disease, and disability from this "chattel" system where slaves were "due no more legal consideration than hogs, sheep, or cattle." Rather than acknowledge the impact of severe deprivation and harsh punishment on the health status of blacks, the white medical establishment used racist science to establish poor black health as a "natural" and acceptable difference between whites and blacks. This belief was incorporated into a system of separate and unequal medical care that remained entrenched for more than 300 years--and continues to resonate in current health practices. According to Clayton and Byrd, "it is doubtful that the expectation and acceptance of poor Black health status and outcome--exacerbated by the pattern of nihilism and inattention to high medical or ethical standards regarding the system's race and class problems exhibited by organized medicine today--would be problematic without the slavery experience."

GENETIC DIFFERENCES?
While a majority of scientists finally refuted racial inferiority in reaction to Nazi-era Aryan supremacy theories, strands of research into the late 20th century continued to focus on genetic differences to account for black/white gaps in health and longevity. "There is a long history of looking at racial and ethnic health disparities in the U.S. as proof of the so-called inferiority of people of color and of attributing the differences by and large to innate factors--now understood as genetics," says Nancy Krieger, an associate professor in the School's Department of Health and Social Behavior. "The net effect of such views has been an overemphasis in epidemiologic research on allegedly genetic explanations of racial/ethnic inequalities in health and a disregard for how racism, rather than ‘race,' drives these disparities." She analyzes the links between discrimination and health in a chapter of the groundbreaking book, Social Epidemiology, the first textbook to focus on major social factors that influence health outcomes.

Norman Anderson, professor of health and social behavior at the School, has done extensive research on the processes underlying disparities in health. He illustrates how facile genetic explanations may lead to faulty conclusions with the example of higher levels of hypertension, considered a genetic vulnerability in African Americans. "Studies have found hypertension to be nearly non-existent in rural African communities," he explains, "while in African urban areas, hypertension matches the rates of white Americans--but not the higher rates of African Americans. Similarly, in the Caribbean, black populations have a much lower incidence of hypertension." Based on these population studies, Anderson concludes that hypertension seems to be more related to the stresses of urban life than to genetic inheritance. In discounting genetic racial differences, he notes researchers have found more genetic variation within racial groups, than between American blacks and whites, for example. Nancy Krieger summarizes, "The dominant view among contemporary population geneticists, other biologists, anthropologists, and social scientists is that racial categories reflect social and ideological conventions, not meaningful natural distinctions."

UGLY SOCIAL FACTS
Despite these changes in definition, "race continues to be the most defining social issue in our country," says Harold Freeman, president of the Ralph Lauren Cancer Center at North General Hospital in New York City. Freeman spoke at a February 8, 2001 School panel presentation on reducing social disparities in health, hosted by Dean Barry Bloom. In a stirring commentary to the packed audience, he asserts that "four hundred years of enslavement have led to an America where both blacks and whites see each other through the lens of race instead of the individual persons they are." Through studies on racial profiling and disparate health outcomes, researchers have begun to document that discrimination is an active force in American culture, says Freeman, with a deadly impact on health.

In a recent study on racial discrimination and blood pressure, Nancy Krieger found 80 percent of the African American participants reported having experienced racial discrimination in one or more settings, including getting a job, at work, at school, getting housing, getting medical care, from the police or in the courts, and on the street or in a public setting. To put these results into context, she refers to the results of a 1990 General Social Survey that found fully 75 percent of white Americans agreed that "black and Hispanic people are more likely than whites to prefer living on welfare" and that a majority concurred that "black and Hispanic people are more likely than whites to be lazy, violence-prone, less intelligent, and less patriotic." These findings are bolstered by hundreds of similar studies and daily media revelations of blatant racism in virtually all aspects of American life--from thousands of accounts of racial profiling in traffic stops to a recent study by the Fair Housing Center of Greater Boston (We Don't Want Your Kind Living Here, April 24, 2001) that found almost all of the African Americans and Section Eight "test" renters inquiring about an apartment faced discrimination--from additional application fees to units that suddenly became "unavailable." Krieger calls these "ugly social facts, with profound implications for not only our body politic but also the very bodies in which we live, love, rejoice, suffer, and die."

LIVING IN POVERTY
How does discrimination translate into poor health? Krieger considers the study of the health consequences of discrimination "at heart, the investigation of intimate connections between our social and biological existence." Like many social scientists, she begins by pointing to America's astounding differences in socioeconomic position based on race. The following is an abstract of her table on selected racial/ethnic inequalities in socioeconomic position, taken from Census and Indian Health Service reports from the mid-1980s to mid-1990s.

When one considers that more than half of African American and American Indian families and about 60 percent of Hispanic families, compared to 23 percent of white families, live at or below 200 percent of the poverty level ($27,300 for a family of three in 1998), America's economic inequities are even more apparent. Consequently, people of color face the health sapping consequences of being poor in disproportionate numbers, says Krieger, with both economic and non-economic aspects of racial discrimination.

Studies document that poor people have greater exposure to environmental toxins, from lead paint to proximity to chemical plants and waste incinerators that are consistently built in poorer neighborhoods. The high fat, high salt, and low vegetable/fruit diets found in disadvantaged populations are often less the result of bad choices than the unfortunate consequence of the shrinking number of good, affordable supermarkets in inner-city neighborhoods, the explosion of fast food restaurants in urban areas, and food traditions originating in deprivation. Similarly, Harold Freeman notes that higher rates of smoking and alcohol use related to higher levels of chronic disease in African American communities are more a response to the pressures of poverty and lack of employment opportunities than "lifestyle choice." Numerous studies have shown that as income levels rise, the rates of smoking and drinking levels fall--in all ethnic and racial groups. In a succinct analysis, Freeman states, "Poverty acts through the prism of culture."

Particularly destructive aspects of poverty in the African American community are the chronically higher levels of unemployment embedded in it. As Clayton and Byrd note in their book, each 1 percent rise in the unemployment rate is accompanied by a 2 percent increase in the mortality rate, a 5-6 percent increase in homicides, a 5 percent increase in imprisonment, a 3-4 percent increase in first admissions to mental hospitals, and nearly 5 percent increase in infant mortality rates. Loss of insurance is at least partially to blame for this harrowing list of social ills--a loss that affects minorities at significantly higher rates. Almost 23 percent of black Americans, 37 percent of Hispanics, 24 percent of Native Americans, and 22 percent of Asians lack any kind of insurance--compared to 14 percent of whites, according to a Henry J. Kaiser Family Foundation report. These numbers include millions of full-time workers in low-wage jobs that don't offer insurance benefits and those who lost Medicaid benefits through the 1996 welfare reforms. In a market-driven health care system that links insurance coverage to high paying jobs "poor health outcome for Black and other disadvantaged groups is preordained," write Byrd and Clayton.

The Kaiser report confirms their prognosis. Nearly 40 percent of the uninsured compared to 8 percent of those with insurance postponed necessary care due to costs, and 30 percent of the uninsured Americans compared to 11 percent of the insured didn't fill their prescriptions. Without access to early treatment and regular care, the uninsured are at least twice as likely to be hospitalized for avoidable complications of manageable conditions like diabetes and hypertension. Over 40 percent are more likely to be diagnosed with late stage breast and prostate cancer--and uninsured women with breast cancer are 40-50 percent more likely to die from the disease.

In his 34 years as head of the surgery department at the Harlem Hospital Center in New York, Harold Freeman personally experienced the anguish of caring for poor black patients with tragically advanced cases of breast and colon cancer that could have been treated successfully at earlier stages. "Poor people have to concentrate on day-to-day survival and often feel too hopeless and powerless to seek help until it's too late," he explains. In a 1990 Harlem study of excess mortality rates from all causes, including cancer, Freeman and a colleague found such high rates of death (twice that of whites and 50 percent higher than that of blacks in general) that the authors concluded these rates "justify special consideration analogous to that given to natural-disaster areas." (New England Journal of Medicine, January 18, 1990)

ACCUMULATED INSULTS
Yet Freeman is adamant that "giving everyone an insurance card won't solve health disparities." Even with Medicaid or access to subsidized health services, poorer Americans are often forced to seek care in overburdened, underfunded clinics, sometimes hours from their homes, where long waits and insensitive, confusing bureaucracies are common. With minority patients, these indignities may be exacerbated by racist encounters. In a phone survey of about 3,900 King County residents in the state of Washington, public health researchers found one in six African American respondents reported experiencing discrimination in health care settings (Report on Racial and Ethnic Discrimination in Health Care Settings, January 24, 2001). In follow-up interviews with 51 African Americans who were generally better educated and insured than average black county residents, most expressed shock or surprise at the level of discrimination they encountered in nearly 30 different health care facilities (an average of 1.5 "relatively severe" discrimination incidents were reported per interviewee); they expressed anger at being treated "rudely" and "belittled"--from insulting accusations of illegal drug use to reluctant distribution of pain medications based on assumptions that a history of slavery increased pain tolerance. Subsequently, some delayed treatment or refused to return to the offending facility.

For many older African Americans, unpleasant health care experiences intensify a deep distrust of the medical profession that has historically been part of black oppression--from unethical government studies like Tuskegee to nearly one hundred years of segregated health care. Brian Gibbs explains that the legacy of betrayal and poor care from America's two-tiered health system has "sent a message across generations. People of color don't want to be cut open. You didn't see success stories frequently enough--just tragic endings." In a vicious Catch 22, many continue to avoid seeking medical treatment until symptoms are too severe to ignore--perpetuating the belief that seeking medical care is the last step before death.

Although some cultural beliefs and lower socioeconomic position account for some of the black/white gap in health, Norm Anderson emphasizes that "blacks tend to have worse health status at every age and economic level." He refers to a CDC study (published in JAMA, 1990, by Otten et al.) that concludes that at least one-third of the factors contributing to mortality differences were "unexplained"--Anderson calls these factors the "social impact of racism." Nancy Krieger elaborates that the "accumulated insults arising from everyday and at times violent experiences of being treated as a second-class citizen, at each and every economic level" are a constant source of stress, with a devastating impact on health. Hundreds of studies have found a relationship between high stress and increased rates of heart disease, stroke, and cancer. In an analysis of 20 studies that actually measured the impact of self-reported discrimination, Krieger found that higher levels of discrimination were linked to psychological stress, depression, and hypertension.

Arnold M. Epstein, who chairs the School's Department of Health Policy and Management, notes "many studies have shown that black Americans are less likely than whites to receive a wide range of medical services, including potentially life-saving surgical procedures" in a New England Journal of Medicine editorial on racial disparities in medical care (May 10, 2001). His own work analyzing access to kidney transplantation found that twice as many whites as blacks were rated as appropriate candidates for the procedure; of those patients designated "appropriate," blacks were less likely to be referred for transplant evaluation, placed on a waiting list, or to actually receive the transplant. Differences in treatment preferences based on race, Epstein explains, were too small to account for these variations. In a similar vein, Harold Freeman points to research that indicates physicians recommend life-prolonging coronary-artery bypass surgery and cardiac catheterization less often for black patients, and blacks are less likely to receive surgery for early-stage lung, colon, or breast cancer--leading to lower survival rates. "The common thread in these findings is a subtle form of racial bias on the part of medical care providers," Freeman concludes in another NEJM editorial (April 6, 2000). In a surprising footnote to these studies, racial difference in care did not vary with the race of the patient's attending physician; researchers found that both minority and white physicians may have an unconscious bias against minority patients, especially if they're less educated and poor.

A NATIONAL PRIORITY
Although scientists have been quantifying the corrosive impact of racism on health status since the mid-1800s, it was only in 1998 that former President Clinton made eliminating health disparities a national priority as part of his Initiative on Race. In 2000 he designated more than $150 million to establish the National Center on Minority Health and Health Disparities. Norman Anderson, who was the associate director of the National Institutes of Health for Behavioral and Social Sciences Research for five years until coming to Harvard last year, is enthusiastic about these efforts and took the lead in promoting the health disparity agenda at NIH during his years there. "Every NIH institute and center is now developing a strategic plan for addressing health disparities, especially in the areas of heart disease, cancer, HIV/AIDS, and diabetes," he reports. "Funding from NIH will help provide some answers--but it'll take targeted public health intervention programs and policy initiatives to have an impact."

This is just the approach that Brian Gibbs is taking in directing the School's Program to Eliminate Health Disparities, in place since 1999. A strong advocate for community coalitions, Gibbs is working with Cherishing Our Hearts and Souls (COHS), a group of local agencies and leaders in the Roxbury section of Boston to reduce high rates of heart disease and hypertension through a CDC-funded project, Racial and Ethnic Approaches to Community Health (REACH). In an effort he calls "social transformation," COHS is planning an anti-racism after-school curriculum to help elementary school children build self-esteem and manage both their individual and group behaviors more responsibly, while they also learn about good diet and exercise. Along with these early steps to prevent heart disease, COHS is holding community-wide workshops in local churches on the impact of stress and racism and how to reduce the risk of heart disease; additional workshops for health care professionals focus on strategies to encourage heart healthy behaviors in patients and reduce any possible care biases. "You can't compartmentalize people's lives," says Gibbs. "We have to bring everybody together--those living in the community and experts from many disciplines--to bring systems into balance again so that communities of color won't have to pay such a heavy health toll."

Community programs like REACH are just the beginning. To address the pernicious pattern of unequal care and higher mortality rates among African Americans and other minorities requires widespread interventions. "We know something terrible is happening," cautions Harold Freeman. "We have the research, the aggregates of numbers. We need to continue to develop policies, not just put the studies on the shelf with the tears wiped away."

Gabrielle Amersbach