II. DISPARITY IN AFRICAN-AMERICAN AND EUROPEAN-AMERICAN HEALTH STATUS
Negroes (or African-Americans) have been subject to victimization in the sense that a system of social relations operates in such a way as to deprive them of a chance to share in the more desirable material and nonmaterial products of a society which is dependent, in part, upon their labor and loyalty. They are ‘victimized’ also, because they do not have the same degree of access which others have to the attributes needed for rising in the general class system--money, education, contacts, know-how [and Health].
Full participation in a society requires money, education, contacts, know-how and health. Health is not only significant in itself, but it also affects availability of and decisions regarding choices throughout one's life. For example, lack of prenatal care leads to greater likelihood of infant death, neurological damage, or developmental impairment; childhood illnesses and unhealthy conditions can reduce learning potential; adolescent childbearing, substance abuse and injuries cause enormous personal, social and health effects; impaired health or chronic disability in adults contributes to low earning capacity and unemployment; chronic poor health among older adults can lead to premature retirement and loss of ability for self-care and independent living.
Thus, health status is an important ingredient in a person's “social position, . . . present and future well-being,” and a critical one for African-Americans. When one is born poor, with limited opportunity for quality education and with the burden of racism, one's “good” health becomes the only fungible asset. Understanding the nature of African-Americans health, is critical to appreciating the racist nature of health care institutions. Health is a complex concept that is difficult to measure. The difficulty in assessing one's health may result, in part, from a general inability to conceptualize good health. In addition, widespread professional disagreement over the meaning of health contributes to the difficulty in measuring it.
The World Health Organization defines health as “. . . a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” However, for African-Americans that definition has little validity. Given the fact that the pervasive nature of racism in American society affects African-Americans at all economic levels, there cannot be “complete . . . mental and social well-being” for African -Americans until the problem of racism in society is addressed and resolved.
Health is also defined as a “lifestyle in which an individual attempts to maintain balance and to remain free from physical incapacity while maximizing social capacity.” That definition currently has more validity for African-Americans because it recognizes that an individual's lifestyle impacts health and that lifestyle is influenced by social class. It recognizes that African-Americans, surrounded by racism, cannot strive for complete mental well-being, but can strive to maintain a balance. The definition recognizes that what the African-American must do to maintain balance and remain free from physical incapacity will be different from what is required of the European-American. For instance, recent discussions regarding hypertension among African-Americans hypothesize that the ongoing continued stress of living in a racist society may be a significant factor in the development of hypertension. If this is true, then a lifestyle of dieting and exercise (recommended preventive activity for hypertension) would not be sufficient to prevent hypertension in African-Americans although it might suffice for European-Americans.
Whatever the definition of health, generally speaking, “health” may mean the presence or absence of disease. Using that definition of health, there are several ways to determine health: by direct observations, records, and self-report. Each of these ways of measuring health presents its own measurement problems. First, inaccuracies can occur in direct observations because medical practices and diagnostic labeling may vary. That variation may be not only by geographic area but by physician and hospital. Second, interpretation errors can result if researchers misinterpret symptoms and results, or when researchers inappropriately generalize based on a condition of another time or a more general population group. Finally, failure to consider intra-ethnic diversity may lead to erroneous conclusions about African-American health.
Whatever the difficulty in measuring health status, understanding the full extent of differences in health between African-Americans and European-Americans is essential to fully appreciate the need for reform in the health care system and to understand inadequacies in current reform approaches that ignore, dismiss, or do not recognize these difference. To describe the health status of African-American, this paper presents research on the amount of dissatisfaction, discomfort, disability, disease, low-birth weight, and death that occurs in the African-American population as compared to the European-American population.
A. Health Status: African-Americans' Dissatisfaction
Dissatisfaction is the degree of discontentment a person has with his or her health. As a measure of health, it is assumed that a person who has poor health will be more dissatisfied overall than a person with good health. Because it relies on this self-evaluation, dissatisfaction is the most subjective of the health measurements. In fact, the reasons for dissatisfaction with health vary not only based on an individual's situation, but also on ethnicity, race, and culture. Consequently, it is subject to many potential interpretive errors.
Nevertheless, 17% of African-Americans report their health as fair or poor compared to 9% of European-Americans. That is, 88.8% more African-Americans than European-Americans reported their health as fair or poor. Similarly, 50% more African- Americans than European-Americans report themselves as having some, little, or no satisfaction with their health and physical condition. Notwithstanding interpretive errors, these figures reflect a significant difference between African-Americans' and European-Americans' dissatisfaction with their health.
B. Health Status: African-Americans' Discomfort
Discomfort is the level of such feelings as aches and pains, tiredness, and sadness experienced by an individual. As for dissatisfaction, this information is obtained through self-reporting and is subject to considerable measurement error. Surveyors asked individuals to check fifteen symptoms that were (or were not) experienced in the last year. Some symptoms related to the various body systems representing both acute and chronic problems. Some symptoms were common experiences such as sore throat or runny nose. Other symptoms were infrequent and often associated with serious problems such as the loss of more than ten pounds in weight. The mean number of symptoms reported represents the score for a population group.
Measuring health status by the results of reported discomfort surveys presented some interesting results. One such result is the fact that African-Americans under 45 years of age actually reported fewer symptoms than European-Americans. There are several ways to interpret this result. The most obvious is that the African-American age group, in fact, has fewer and less severe symptoms. However, that interpretation would be at variance with results of studies based on more objective measurements, i.e., death rates. A second interpretation of this interesting result is that there is considerable under-reporting among African-Americans, particularly of the more serious symptoms. That interpretation is strengthened by a finding that once African-Americans with symptoms are in the health care system, they require more visits than their European-American counterparts. Thus, it is more likely that the under-reporting of symptoms contributes to an inaccurate reflection of health status.
C. Health Status: African-Americans' Disability
Health status based on disability can be defined as the inability to engage in gainful employment; or as the temporary or long-term reduction of a person's activities because of a health condition. Health researchers generally use three measurements of disabilities: restricted activity days, work loss days and bed disability days. This paper uses restricted activity days as a measure of health status since restricted activity days is a broader measurement than work loss days, and work loss days would not necessarily include unemployed individuals. It is also broader than bed disability days, since an individual could be sick enough to have many activities restricted without necessarily being confined to bed.
As in the other measurements, using restricted activity days to represent health status can lead to significant interpretive error. First, there are a number of reasons a person may lose workdays. Employees may take sick days to stay home with a sick child; children may miss school for physician appointments; and, people may falsely claim disability to collect insurance money. Second, instead of being a measure of disease, disability may be more a measure of morale and conformity. Despite the risk of interpretive error, restricted activity days are accepted as a general measure of health status.
Using the number of days of restricted activity per year, African-Americans under age five have no extraordinary disability. This outcome is entirely predictable since a child under five is involved in neither school nor work. What is not predictable is the 22.8% fewer restricted activity days for African-Americans in the age group 5-17. Given the higher death rate and disease rate of African-Americans to that of European-Americans in this age group, it is likely that this difference is either an interpretation or reporting error. This assessment of error would seem particularly true since African-Americans in the eighteen-and-over age group reported 37.5% more days of activity restriction per year than European-Americans.
D. Health Status: African-Americans' Disease Rate
Health status may also be based on the presence of which disease can be divided into acute conditions and chronic conditions. The most common method of determining the presence of disease in a population is by reviewing hospital medical records. When measuring African-American health based on reported acute conditions, it would appear that African-American health is better than that of European-Americans. For the age group under eighteen, 36.3% fewer African-Americans than European-Americans reported acute health conditions; for the 18-44 age group, 15.9% fewer African-Americans than European-Americans reported acute conditions; and, for ages 45 and above, 10.1% reported fewer conditions. Interestingly, despite the seemingly lower incidence of acute diseases among African-Americans, they have a higher mortality rate from acute conditions than European-Americans have.
The percentage calculated for limitations in activity due to chronic diseases is higher in African-Americans than in European-Americans for all age groups. For instance, for the under-18 age group, 20% more African-Americans than European-Americans reported limitations in activity because of chronic disease; for the 18-44 age, group 22.5% more African-Americans than European-Americans reported limitations; in the 45-64 age group, 34.8% more African-Americans than European-Americans reported limitations; and in the 65-69 age group, 31.6% more African-Americans reported limitations than European-Americans. Finally, in the seventy-and-over age group, 23.8% more African-Americans than European-Americans reported limitations. Therefore, while African-Americans report fewer acute conditions, they tend to report more limitations based on chronic conditions.
E. Health Status: African-Americans' Low Birth Weight Rate
Low birth weight is a common measurement of the health of infants. Low birth weight is defined as weight of less than 2500 grams. Prior to the 1960's, low birth weight infants had a very low chance of survival. As survival rates improved, low birth weight babies were often found to suffer extensive handicaps, including severe and moderate mental retardation, cerebral palsy, seizure disorder, blindness, hearing defects, and behavioral, learning, and language disorders. Therefore, low birth weight can be an objective measurement of future health status.
In 1980, European-Americans had a low birth weight rate of 5.7%, while African-Americans had a low-birth-weight rate of 12.5%. The evidence indicates that while low birth weight is holding steady at 5.7% for European-Americans, it has actually risen over the last 12 years to 12.7% for African-Americans. Therefore, African-American infants are 222.81% more likely to suffer from low birth weight and its accompanying handicaps.
F. Health Status: African-Americans' Death Rate
The most objective measure of health is the death rate. Despite some subjective self-reporting (dissatisfaction, discomfort and acute disease), which might suggest equal, if not better well-being among the African-American population, the objective statistics based on death show just the opposite.
Wounded, [racism] retreated to more subtle expressions from its most deeply entrenched bunker . . . [F]orms of sophisticated racism attached to economic opportunities unfortunately can still be found today.
. . . NOWHERE IS THAT BETTER EXEMPLIFIED THAN IN THE RATE OF EXCESS DEATH AMONG BLACK AMERICANS. (emphasis added). “Excess death” is the number of deaths actually observed prior to the age of 70 years, minus the number of deaths that would be predicted when age- and sex-specific death rates of the U.S. European-American population are applied to the African-American population. African-American women have 53.12% excess deaths and African-American men have 52.67% excess deaths. In fact, African-Americans experience 60,000 excess deaths a year compared to mortality rates of European-Americans. When death rate statistics are broken down by causes of death, the data are striking. For instance, African-American women had 324.1% more deaths due to homicides, 163% more deaths due to diabetes, 77.6% more deaths due to cerebrovascular disorders, 78.4% more deaths due to cirrhosis of the liver, and 78.4% more deaths due to heart disease than European-American women. Furthermore, African American women have a 178.43% excess maternal rate. African-American men had 598.7% more deaths due to homicides, 100% more deaths due to diabetes, 92.6% more deaths due to cerebral vascular disorders, 88.4% more deaths from cirrhosis of the liver, and 81.8% more deaths due to pulmonary infectious disease than European-American men.
Deaths in the first year of life have consistently been used as an objective determination of health of a population. Therefore, it is significant that in the first year of life, 108.14% more African-American infants die than do European-American infants. Finally, not only is infant mortality used as an objective determination of the health of a population, but it is also used as a measure of the health of a nation. Generally, the United States infant mortality rate is reported as one general rate: 8.6 which places the United States twenty-second among nations. However, as indicated, that rate is misleading. When compared to the infant mortality of other nations, African-Americans rank thirty-second among countries compared to European-Americans' twelfth-place ranking.
The picture that is clearly painted by these health measurements is one of significant disparity between two races. While there are some age group variations in the more subjective health measurements (e.g., dissatisfaction), the most objective health measurement (death) clearly indicates that African-Americans are sicker than European-Americans.
If African-Americans are sicker as a result of disparate treatment in the health care system, then they are victims of unequal access to health care. Without decent health, it becomes nearly impossible for African-Americans to gain the other attributes (money, education, contacts, know-how) necessary to gain access to the American economic system. Therefore, when African-Americans are sick and poor, they are just as enslaved as if the law made them so.