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Black–White Differences in Health and Mortality: A Review and Conceptual Model
Hummer, Robert A., 1996 The Sociological Quarterly, 37(1):105–125. †
This paper focuses on differences in health and mortality between African Americans and
non–Hispanic US whites. It does not present the results of a new study, rather it documents some of the
current health and mortality differences, reviews and critiques the most common explanations and presents an
alternative conceptual framework for the future study of these differentials. In particular, the author
considers multiple forms of racism as crucial sociological determinants of health and mortality
differentials.
Earlier research has reported on black–white differences in health and mortality,
including life expectancy, birth weight, infant mortality, women's reproductive health status and
hypertension. A host of health and mortality measures mark the severe disadvantages experienced by the
African American population in comparison to non–Hispanic whites. They have higher age–adjusted
mortality rates for most leading causes of death. Even black children aged 1–14 have nearly twice the
rate of mortality as white children. This is probably a consequence of higher rates of childhood illnesses
due to fewer black children being immunized against infectious diseases. While many measures of health and
mortality have improved for both whites and blacks over the past fifty years, the black–white gap
remains wide, and blacks are not expected to achieve health equality with whites anytime in the near future.
The three most common explanations for black–white health and mortality
differentials are racial genetic, cultural/behavioral and socioeconomic.
A genetic component is often suggested as most studies report poorer health and higher
mortality among African Americans even controlling for some socioeconomic, behavioral and health care
variables. However, there is little evidence that the racial population distribution of genes accounts for
the numerous health and mortality differences exhibited between blacks and whites. Many studies ignore the
social stratification of race in US society. The author suggests that the historically unfavorable positions
held by minority groups should be emphasized over genetic factors.
The cultural/behavioral approach suggests that group variations in values, beliefs,
attitudes, traditions and lifestyles are instrumental in maintaining health and mortality differentials.
Controlling for these factors has been shown to reduce black–white differences and they are important.
However, they fail to close the gap. These variables need to be placed in a context that emphasizes their
partial dependence on social, economic and historical circumstances. A focus on the root causes rather than
the symptoms (as the current approach does) may facilitate more wide ranging and long term solutions.
The socioeconomic approach posits that blacks are disproportionately concentrated within
the lower socioeconomic strata of society and are therefore faced with higher risks associated with poor
education, poverty and unemployment. These factors do play key roles, but they do not fully explain the
differences and are often controlled for without being properly understood. The author states that African
Americans do not just happen to be over–represented in the lower strata, rather it is a reflection of
what it means to be black in US society. The black–white social distinction is the cause of both
socioeconomic–and health–based inequality. While education, income and/or occupation are often
used as measures, wealth, purchasing power, the quality of education, insurance coverage and occupational
stability are often ignored. Blacks generally have far fewer resources with which to achieve economic
security to cope with economic and health adversities throughout their lives.
In the alternative conceptual framework, the author proposes that race is an important
social determinant of health and mortality, operating through three primary pathways and five intervening
sets of factors to affect health and mortality.
The three primary pathways are institutional forms of racism, racial socioeconomic
stratification and individual–level forms of racism. The author discusses the significance of the
African slave trade and the degree of racism that still exists despite developments through the civil rights
movement and legislation. He highlights the problems associated with residential segregation, racial
isolation and political under–representation. He also mentions individual level discrimination, where
the accumulation over time is often more than the sum of the individual instances and can be potentially
damaging. This leads to the suggestion of using a skin color by age interaction term in analyses.
The five intervening factors are health care, physical environment, health and coping
behaviors, stress and social roles and social support. These factors may operate additively, interactively or
even counter one another. They are the mechanisms by which the primary pathways can affect health.
The author presents this conceptual framework as a model that organizes the factors that
could be incorporated in future research work. He acknowledges that no single study is likely to encompass
all factors, but considers it to provide a useful foundation. The fundamental ideas behind the framework are
the sociological significance of race, an organized order of causality, a multidisciplinary approach and
flexibility in the dependent variable. The general process can be extended to other race/ethnic groups,
although the specific variables and disease etiologies will vary by group.
This article makes three conclusions. Firstly, current black–white differences in
health and mortality are wide and show few signs of imminent convergence. Secondly, current theoretical
approaches to understanding black–white differences are inadequate. Finally, the author suggests that
more thorough understanding of such differences, as well as effective solutions for eliminating them, must
consider not only socioeconomic and behavioral differences between groups but also the effects of both
institutional and individual–level racism. This implies that it is critical to identify the principal
intervening variables through which both racial socioeconomic stratification and multiple forms of racism
operate to lead to poorer health and higher mortality among African Americans.
† This paper is based on US experience.