85 Health in the United States

Health by Race and Ethnicity

When looking at the social epidemiology of the United States, it is hard to miss the disparities among races. The discrepancy between black and white Americans shows the gap clearly; in 2008, the average life expectancy for white males was approximately five years longer than for black males: 75.9 compared to 70.9. An even stronger disparity was found in 2007: the infant mortality, which is the number of deaths in a given time or place, rate for blacks was nearly twice that of whites at 13.2 compared to 5.6 per 1,000 live births (U.S. Census Bureau 2011). According to a report from the Henry J. Kaiser Foundation (2007), African Americans also have higher incidence of several other diseases and causes of mortality, from cancer to heart disease to diabetes. In a similar vein, it is important to note that ethnic minorities, including Mexican Americans and Native Americans, also have higher rates of these diseases and causes of mortality than whites.

Lisa Berkman (2009) notes that this gap started to narrow during the Civil Rights movement in the 1960s, but it began widening again in the early 1980s. What accounts for these perpetual disparities in health among different ethnic groups? Much of the answer lies in the level of healthcare that these groups receive. The National Healthcare Disparities Report (2010) shows that even after adjusting for insurance differences, racial and ethnic minority groups receive poorer quality of care and less access to care than dominant groups. The Report identified these racial inequalities in care:

1. Black Americans, American Indians, and Alaskan Natives received inferior care than White Americans for about 40 percent of measures.
2. Asian ethnicities received inferior care for about 20 percent of measures.
3. Among whites, Hispanic whites received 60 percent inferior care of measures compared to non-Hispanic whites (Agency for Health Research and Quality 2010). When considering access to care, the figures were comparable.

Health by Socioeconomic Status

Discussions of health by race and ethnicity often overlap with discussions of health by socioeconomic status, since the two concepts are intertwined in the United States. As the Agency for Health Research and Quality (2010) notes, “racial and ethnic minorities are more likely than non-Hispanic whites to be poor or near poor,” so many of the data pertaining to subordinate groups is also likely to be pertinent to low socioeconomic groups. Marilyn Winkleby and her research associates (1992) state that “one of the strongest and most consistent predictors of a person’s morbidity and mortality experience is that person’s socioeconomic status (SES). This finding persists across all diseases with few exceptions, continues throughout the entire lifespan, and extends across numerous risk factors for disease.” Morbidity is the incidence of disease.

It is important to remember that economics are only part of the SES picture; research suggests that education also plays an important role. Phelan and Link (2003) note that many behavior-influenced diseases like lung cancer (from smoking), coronary artery disease (from poor eating and exercise habits), and AIDS initially were widespread across SES groups. However, once information linking habits to disease was disseminated, these diseases decreased in high SES groups and increased in low SES groups. This illustrates the important role of education initiatives regarding a given disease, as well as possible inequalities in how those initiatives effectively reach different SES groups.

Health by Gender

Women are affected adversely both by unequal access to and institutionalized sexism in the healthcare industry. According a recent report from the Kaiser Family Foundation, women experienced a decline in their ability to see needed specialists between 2001 and 2008. In 2008, one quarter of females questioned the quality of her healthcare (Ranji and Salganico 2011). In this report, we also see the explanatory value of intersection theory. Feminist sociologist Patricia Hill Collins developed this theory, which suggests we cannot separate the effects of race, class, gender, sexual orientation, and other attributes. Further examination of the lack of confidence in the healthcare system by women, as identified in the Kaiser study, found, for example, women categorized as low income were more likely (32 percent compared to 23 percent) to express concerns about healthcare quality, illustrating the multiple layers of disadvantage caused by race and sex.

We can see an example of institutionalized sexism in the way that women are more likely than men to be diagnosed with certain kinds of mental disorders. Psychologist Dana Becker notes that 75 percent of all diagnoses of Borderline Personality Disorder (BPD) are for women according to the Diagnostic Statistical Manual of Mental Disorders. This diagnosis is characterized by instability of identity, of mood, and of behavior, and Becker argues that it has been used as a catch-all diagnosis for too many women. She further decries the pejorative connotation of the diagnosis, saying that it predisposes many people, both within and outside of the profession of psychotherapy, against women who have been so diagnosed (Becker).

Many critics also point to the medicalization of women’s issues as an example of institutionalized sexism. Medicalization refers to the process by which previously normal aspects of life are redefined as deviant and needing medical attention to remedy. Historically and contemporaneously, many aspects of women’s lives have been medicalized, including menstruation, pre-menstrual syndrome, pregnancy, childbirth, and menopause. The medicalization of pregnancy and childbirth has been particularly contentious in recent decades, with many women opting against the medical process and choosing a more natural childbirth. Fox and Worts (1999) find that all women experience pain and anxiety during the birth process, but that social support relieves both as effectively as medical support. In other words, medical interventions are no more effective than social ones at helping with the difficulties of pain and childbirth. Fox and Worts further found that women with supportive partners ended up with less medical intervention and fewer cases of postpartum depression. Of course, access to quality birth care outside the standard medical models may not be readily available to women of all social classes.

Mental Health and Disability

The treatment received by those defined as mentally ill or disabled varies greatly from country to country. In the post-millennial United States, those of us who have never experienced such a disadvantage take for granted the rights our society guarantees for each citizen. We do not think about the relatively recent nature of the protections, unless, of course, we know someone constantly inconvenienced by the lack of accommodations or misfortune of suddenly experiencing a temporary disability.

Another fairly commonly diagnosed mental disorder is Attention-Deficit/Hyperactivity Disorder (ADHD), which statistics suggest affects 9 percent of children and 8 percent of adults on a lifetime basis (National Institute of Mental Health 2005). ADHD is one of the most common childhood disorders, and it is marked by difficulty paying attention, difficulty controlling behavior, and hyperactivity. According to the American Psychological Association (APA), ADHD responds positively to stimulant drugs like Ritalin, which helps people stay focused. However, there is some social debate over whether such drugs are being overprescribed (American Psychological Association). In fact, some critics question whether this disorder is really as widespread as it seems, or if it is a case of over diagnosis. According to the Centers for Disease Control and Prevention, only 5 percent of children have ADHD. However approximately 11 percent of children ages four through seventeen have been diagnosed with ADHD as of 2011.

Autism Spectrum Disorders (ASD) have gained a lot of attention in recent years. The term ASD encompasses a group of developmental brain disorders that are characterized by “deficits in social interaction, verbal and nonverbal communication, and engagement in repetitive behaviors or interests” (National Institute of Mental Health). As with the personality disorders described above, the Diagnostic and Statistical Manual on Mental Disorders’ description of these is in the process of being revised.

The National Institute of Mental Health (NIMH) distinguishes between serious mental illness and other disorders. The key feature of serious mental illness is that it results in “serious functional impairment, which substantially interferes with or limits one or more major life activities” (National Institute of Mental Health). Thus, the characterization of “serious” refers to the effect of the illness (functional impairment), not the illness itself.