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Intro (Updated)

Research on race and health in the United States shows many health disparities between the different racial/ethnic groups. The possible causes, such as genetics, socioeconomic factors, and racism, continue to be debated. Different outcomes in mental and physical health exist between all census-recognized racial groups, but these differences stem from different historical and current factors. Research has demonstrated that numerous health care professionals show "implicit bias" in the way that they treat patients.[1] Certain diseases have higher prevalence among specific racial groups, and life expectancy also varies across groups. This article is directed towards some of historical and societal factors that impact the health of various minorities groups in the United States. Race and health in the United States is a topic that has been researched many times, but the causes of disparate outcomes remain something that can be further explored.

Background (Updated)

The U.S. Census definition of race is often applied in biomedical research in the United States. According to the Census Bureau in 2018, race refers to one's self-identification with a certain racial group. The Bureau also specifies that its use of "race" is as a social concept, not a biological or anthropological one. The Census Bureau recognizes five races: Black or African American, White (European American), Asian, Native Hawaiian or other Pacific Islander, and American Indian or Alaska Native. Despite the fact that the Journal of Behavioral Medicine reports that the United States continues to become more diverse, these Census categories have not changed for almost 20 years. The Census Bureau also recognizes differences in ethnicity among the population, and it defines ethnicity as whether a person is of Hispanic origin or not. For this reason, ethnicity is broken out in two categories in its data, Hispanic or Latino and Not Hispanic or Latino. Hispanics may report as any race.

The 2010 U.S. Censu s further specifies the number of Americans who identified with each racial and ethnic group; in 2010, 38.9 million identified as African American, 14.6 million as Asian American, 2.9 million as American Indian or Alaskan Native and 50.4 million as Hispanic or Latino.

Because race is a social construct and not a biological trait, measures of the relationship between race and medicine are imperfect and inconsistent. The 2000 U.S. Census definition is inconsistently applied across the range of studies that address race as a medical factor, making assessment of the utility of racial categorization in medicine more difficult. Additionally, the socially constructed nature of race makes it so that the different health outcomes experienced by different racial groups can be connected to social factors rather than inherent biological ones.

Significant disparities in health outcomes exist between the five racial groups recognized by the U.S. Census. These health disparities are in part caused by different levels of income across the five groups recognized by the U.S. census. There are also notable differences in access to healthcare and the quality of healthcare received those who identify with different racial categories.

Bias and racism also contribute to disparities in health outcomes. Non-white racial groups may experience bias and racism within the medical system, impacting these groups' access to and quality of care. Additionally, the racism experienced in daily life affects health outcomes. The stress associated with racism can negatively impact a person’s physical and mental health and has been shown to contribute to health problems such as depression, anxiety, insomnia, heart disease, skin rashes, and gastrointestinal problems.

Criticism (Updated)

Some scholars have argued for a genetic understanding of racial health disparities in the United States, suggesting that certain genes predispose individuals to specific diseases.92 However, the U.S. Census Bureau's recognition of race as a social and not biological category necessitates a social understanding of the causes of health disparities. Additionally, the restricted options for "race" and "ethnicity" in Census Bureau data complicates the results of their findings.

This issue is illustrated with the example of those who identify themselves as Hispanic/Latino, typically a mix of Caucasian, Native American and African ancestry.[92] Although some studies include this as a "race", many such as the U.S. Census do not, forcing members of this group to choose between identifying themselves as one of the listed racial categories, even if they do not personally identify with it. Additionally, individuals who identify as biracial or multiracial must choose one category to identify with, limiting the ability of many Americans to select a census category that they actually identify with. The inability of many individuals to fully identify with one census category indicates the necessity of cultural, historical, and socio-economic explanations of health disparities rather than a biological one.[94]

Census groupings have also been criticized for their broadness. "Race" and "ethnicity" are used in many different ways in the United States, and the lack of subgroups in Census categories fails to account for the diversity of people identifying with each group. Every group on the Census includes people who identify with a number of unrepresented racial and ethnic categories, but the Hispanic/Latino ethnicity group and Asian racial group have been particularly criticized for this.

Latino/Hispanic Populations (New Section- Claudia)

History

While Latinos and Hispanic populations are not considered a race category by the U.S. Census, this section of the article refers to Latinos or Hispanics as an ethnic group, as classified by the Census Bureau. References to the Latino and Hispanic community in the United States are frequently linked to discussions about immigration. The geographic origins of Hispanic and Latino influxes of immigration have changed through the years. During the 2010s Latin American and Caribbean countries have accounted for the main source of immigrant populations migrating towards the United States.

The Hispanic Paradox is an important aspect of discussions around the history of the health of Latino and Hispanic populations in the United States. In 1986, Prof. Kyriakos Markides conceived the term “the Hispanic paradox” to refer to the epidemiological phenomenon that Hispanic individuals in the US live longer than their white non-Hispanic counterparts despite the general lower socioeconomic status of the population and their relative lack of access to healthcare. The US Centers for Disease Control and Prevention published a report on May 5th 2015, relating to the general status and causes of deaths of Hispanic population in the United States. The report utilized mortality indicators and national health surveillance of Hispanic populations compared to their White counterparts to explore the possibility of Markides' paradox. Primarily results indicated that Hispanic deaths from diabetes, liver disease, and homicide were substantially higher than in non-Hispanic white populations. Nevertheless, Hispanics generally had a 24% lower risk of all-cause mortality and lower risks of nine of the leading 15 causes of death in the USA (most notably, cancer and heart disease).

Tied to the health status of Latinos and Hispanic in the United States is an observed mistrust of doctors and the health system. This mistrust can stem from language barriers, threat of discrimination and historical events that dismissed the consent of patients like the sterilization of Latina women in California until 1979. According to a study conducted by the United States Census Bureau Hispanics were the population that was most likely to have never visited a medical provider (42.3 percent).

Mental Health

In many Hispanic and Latino communities, mental health problems are viewed as a sign of weakness and are not necessarily validated. Hispanics are often cited as a high-risk group for mental health issues, particularly for substance abuse, depression, and anxiety. A study conducted from 2008 to 2011, sampled more than 16,000 Hispanics/Latinos ages 18 to 74 in four diverse communities in the states of New York, Chicago, San Diego, and Miami. The findings demonstrated that 27 percent of Hispanics/Latinos in the study reported high levels of depressive symptoms.

Research have signaled multiple sources of stress that could potentially impact mental health outcomes in Latino communities. For example, language influences the way patients are evaluated. Several studies have found that bilingual patients are evaluated differently when interviewed in English as opposed to Spanish and that Hispanics are more frequently undertreated. Furthermore, Hispanics are more likely to report poor communication with their health provider. Income has also proven to be a significant factor that impacts the mental health of Latino communities. Sometimes individuals have to cope with low paying jobs and terrible housing which limits access to health services. Only 1 in 10 Hispanics with a mental disorder actually utilize mental health services from a general health care provider. Moreover, only 1 in 20 Hispanic individuals actually receive such services from a mental health specialist.

Maternal and Child Health

According to the Census Bureau, while the number of non-Hispanic white women of childbearing age (15-44 years) is projected to decrease from 36.5 million in 2010 to 35.2 million in 2020, the number of Hispanic women of childbearing age is projected to increase from 11.8 million in 2010 to more than 13.8 million Hispanic women. The increase in the Hispanic population in the United States is driven in part by high fertility rates. During 2012, the fertility rate for Hispanic identifying women was 74.4 births per 1,000 women of ages 15-44. In 2012, Hispanic women accounted for 23 percent or 907,677 of all of the 3,952,841 live births in the United States. When we divide up the sub-groups with the Hispanic population the majority of the births occurred among those of Mexican descent (61.2%), followed by Central/South American (14.5%), Puerto Rican (7.4%), and Cuban (1.9%).

When we examine the data from 2010, the infant mortality rate (death during the first year of life) among Hispanic women was 5.3 per 1,000 live births. This rate accounted for more than 20 percent of all infant deaths in the United States during the year 2010. According to the National Center for Health Statistics, “when specific causes of infant mortality are examined the leading cause of infant deaths in 2010 among Hispanics was birth defects (136.5 per 100,000 live births), followed by prematurity/low birth-weight (85.0 per 100,000 live births), maternal complications of pregnancy (32.3 per 100,000 live births), and Sudden Infant Death Syndrome (31.4 per 100,000 live births)”. (National Center for Health Statistics, natality data.).

Native Americans and Alaska Natives (New Section - Sela)

History

American Indian and Alaska Native populations in the United States have experienced disproportionately negative health outcomes compared to non-Hispanic whites since colonists arrived at the continent in the 15th century, particularly due to epidemics introduced by colonial groups and violent encounters with colonists. A disparity in health outcomes between American Indians and Alaska Natives and the general U.S. population persists today, largely due to a lack of access to adequate medical care, language barriers, and decreased quality of medical services in regions with significant American Indian and Alaska Native populations.

The Indian Health Service (IHS) is a federal agency committed to serving the health needs of American Indian and Alaska Native populations. Two pieces of legislation, the Snyder Act of 1921 and Indian Health Care Improvement Act of 1976, created the federal obligation to provide healthcare to federally recognized Native American tribes. This responsibility moved to the IHS, housed under the U.S. Department of Health and Human Services, in 1955. The IHS currently serves over 2.3 million American Indians and Alaska Natives population from 573 different federally-recognized tribes.

Since its implementation, IHS has been criticized for its treatment of patients. Most notably, throughout the 1960s and 1970s, IHS forcibly sterilized thousands of American Indian and Alaska Native women. A study by the General Accounting Office of the United States government found that, between the years of 1973 and 1976, physicians at four IHS facilities – those in Albequerque, Oklahoma City, Phoenix, and Aberdeen, South Dakota – sterilized a total of 3406 women, 3001 of which were of childbearing age at the time of sterilization.

The federal government has also been criticized for the lack of funding granted to IHS. Expenditures per capita for IHS have been substantially lower than those for other federally funded healthcare programs. Studies have found that physicians employed by IHS express a need for increased funding for the agency to adequately meet the healthcare needs of American Indians and Alaska Natives in the United States.

Because IHS serves only federally-recognized tribes, not all people in the United States that identify with this racial group have access to IHS resources. The American Indian and Alaska Native population includes, but is not limited to, those who are affiliated with federally recognized tribes – there are also state recognized tribes and unrecognized tribes, and individuals who do not live on tribal lands but identify as Native American. Thus, while IHS plays a role in the health outcomes of American Indian and Alaska Native identifying people in the United States, it is not the sole determinant of health outcomes for this census group.

Mental Health

American Indian and Alaska Native identifying people are more likely to have unmet mental health needs and to experience major depressive episodes than the NHW population. Compared to only 5.4% of the NHW population, 6.7% of American Indian and Alaska Native adults reported having needs for mental health services that had been unmet in the last twelve months. Furthermore, 8.3% of American Indian and Alaska Native adults reported experiencing a major depressive episode in the past twelve months, whereas only 7.4% NHW adults did so. American Indian and Alaska Native adolescents are also more likely to have experienced a major depressive episode in their lifetime, with 16.7% of adolescents reporting such an episode compared to 14.4 of non-Hispanic white adolescents. Rates of post-traumatic stress disorder (PTSD) are also higher for American Indians and Alaska Natives than the general United States population.

Some critics of current mental health practices have argued that mental health professionals working with American Indian and Alaska Native communities should adjust their practices to patients' cultures, particularly by increasing attention to spirituality. There have also been efforts to increase understanding of how the symptoms of DSM-recognized disorders may differ in indigenous communities as a result of different cultural practices.

American Indian and Alaska Native youth are slightly less likely than NHW youth to receive specialty mental health services, they are significantly more likely to receive non-specialty mental health services such as counseling from social workers, school counselors, and pediatricians.

Maternal and Child Health

Maternal mortality rates are 4.5 times higher for American Indian and Alaska Native women than they are for non-Hispanic white women in the United States. Between 2008 and 2012, 5.3% of American Indian and Alaska Native women giving birth were diagnosed with gestational diabetes compared to just 3.7% of NHW women.

American Indian and Alaska Native women also are less likely to receive prenatal care than non-Hispanic white women in the United States. Only 60.4% of American Indian and Alaska Native women receive prenatal care in their first trimester, compared to 81.6% of non-Hispanic white women. Additionally, American Indian and Alaska Native women are significantly more likely to not begin receiving prenatal care until their third trimester – 9.3% of American Indian and Alaska Native women compared to 2.9% of non-Hispanic white women. Whereas only 0.8% of non-Hispanic white women do not receive any prenatal care throughout their pregnancy, 2.3% of American Indian and Alaska Native women go entirely without prenatal care.

The infant mortality rate for American Indian and Alaska Native populations also exceeds that of non-Hispanic white identifying people in the United States. American Indians and Alaska Natives experience an infant mortality rate of 8.4 per 1000 live births, compared to 4.1 per 1000 non-Hispanic white live births. Additionally, 15.2% of infants born to American Indian and Alaska Native women are born prematurely compared to just 10.7% of infants born to non-Hispanic white women.

Asian Americans - New Section by Raghav

History

Asian Americans have been a prominent group in the United States for the past 200 years. According to the U.S. Census Bureau, there were estimated to be more than 22 million Asian Americans in the United States as of 2018. The five most prominent subgroups amongst Asian Americans are: Chinese Americans, Indian Americans, Filipino Americans, Vietnamese Americans and Korean Americans.

Asian immigration in large numbers began in the 19th century with significant populations of Chinese Americans, Korean Americans and Japanese Americans entering the United States. However, in the 20th centuries, other groups such as Indian Americans began to immigrate in larger numbers due to more specialized jobs available in the United States.

Asian Americans have often been subject to racism like other minority groups within the United States. This can be seen in events like the Japanese Internment camps like Camp Manzanar that were built during World War II for Japanese Americans to live in and were subject to inhumane treatment.

As Asian Americans have not been coming to America in the numbers of Hispanic immigrants and African-Americans, there have been less instances in which they have been used in medical trials and unfairly compensated. In addition, as the wave of migration of Asians to the United States has happened more recently, the history of this group in the United States is relatively young. As a result, there have not been governmental efforts to address health disparities between Asian Americans and the general populations like there have been with other groups like Hispanic Americans, African Americans, and Native Americans.

Maternal and Child Health

In 2002, it was reported that Asian American births comprised of 5.2% of the total number of births in the United States. One study that compared births among Indian Americans and non-Hispanic white Americans revealed that Indian Americans had significantly lower birth weights than did non-Hispanic white Americans. It was revealed that Indian American mothers and non-Hispanic white American mothers had similar rates of adequate prenatal care. In addition, when the infant mortality rates were compared between the groups, Asian Americans (excluding Pacific Islanders) had a lower rate than did non-Hispanic white Americans. However, Pacific Islanders had an infant mortality rate that was much higher than did the Asian Americans and the non-Hispanic white Americans. Similarly, Asian Americans had a maternal mortality rate that was lower than that of non-Hispanic whites as well as the national average in the United States.

Mental Health

There are not many studies concerning mental health in Asian Americans. Mental health in this subset of the population is reported to be relatively better than that of other groups. The Chinese American Psychiatric Epidemiological Study (CAPES) was commissioned to determine the incidence of mental health problems in the DSM III in Chinese American populations. The results of the study showed that roughly 4.9% of the population of Chinese Americans experienced depression this compares to 17.1% of White Americans were classified as clinically depressed. However, this may not be entirely indicative of the true trends with respect to mental health in the population of Asian Americans. According to the NGO Mental Health in America, 5.4% of Americans identify as Asian American, and 13% of this population reported having a diagnosable mental illness in the past year. This proportion of Asian Americans experiencing depression is lower than that of non-Hispanic white Americans. This may be a result of underreporting or lack of diagnoses in the Asian American community due to cultural stigmas surrounding mental health.