As seen by all our respondents, blocked opportunities and discrimination not only generate psychological pain and suffering, but also link to many different bodily conditions such as chest pains, stomach problems, headaches, and insomnia. Other research supports this observation. The economic status of African Americans has stagnated and even declined in regard to some indicators in recent years, and this decline in economic well-being is associated with worsening health status for African Americans. Some research has shown that the realization that negative treatment in the workplace is based on one's race or ethnicity causes more extreme stress than usual workplace problems that are not based on racial discrimination. Other research has found that not only are physical health problems associated with workplace discrimination but other health problems are also experienced by persons of under-represented groups.

The overall life expectancy of African Americans is lower than that of whites, and this gap increased between 1980 and 1991. African American infant mortality is twice the rate of that of whites. For African Americans under seventy years of age, fifty percent of excess deaths of males and sixty-three percent of female excess deaths can be accounted for by cardiovascular disease, cancers, and problems resulting in infant mortality. Despite popular conceptions, only nineteen percent of excess male deaths and six percent of female excess deaths can be accounted for by homicide. Additionally, excess deaths related to genetic problems make up a tiny percentage. For example, excess deaths from sickle cell anemia make up only three-tenths of one percent of all African American excess deaths. African Americans are disproportionately represented among people with coronary heart disease, myocardial infraction, strokes, and renal disease, and are more likely to have risk factors such as hypertension, high cholesterol, smoking, and diabetes. African Americans, regardless of socio-economic status, also have the highest age-adjusted rates of cancer incidence and mortality of any racial group in the United States. Not only do African Americans have higher rates of several illnesses, they also have poorer outcomes and survival rates for most illnesses, evidence that the health care they receive may not be adequate. For example, the cancer survival rate for African Americans is twelve percent lower than that of whites. In addition to the discrimination that increases the health problems of African Americans, racism in the health care system may cause African Americans to receive less adequate care than do whites.

African Americans tend to report more health complaints than do persons of other racial or ethnic groups. In a national study of two thousand African Americans, when asked if they have had any health complaints in the last month, only thirty-five percent of African Americans said that they had no health problems at all. The most common health complaints reported were high blood pressure (31.6%), arthritis (24%), and "nervous conditions" (21.9%). Twenty percent of the African Americans studied had never gone to see a doctor in an independent office setting, and twenty-one percent were uninsured. However, as in the case of psychological complaints, most (sixty-eight percent) of the respondents said that they have three or more people from whom they can seek informal health care.

As in the case of psychological health disparities, racial disparities in physical health can also not be totally accounted for by racial differences in socioeconomic status. In fact, some studies have found higher mortality rates for African Americans with higher socioeconomic status than whites with the same status. Neither can racial disparities in health be accounted for by oft-repeated notions of "genetics." In her research, Dr. Camara Jones, a Harvard epidemiologist, has found that African Americans have the most genetic diversity of any racially defined group. Nor do African Americans as a group have weaker immune systems than whites. In fact, African American transplant patients run the highest risk of complications because their immune systems are so strong that their bodies are more likely to reject donated organs. Moreover, excess hypertension cannot be attributed to genetics. Black blood pressure levels are similar to whites until adulthood, at which time they increase faster with age than those of whites. This suggests strongly that the racial differential is not a matter of genetics or lifestyle; it suggests that being a victim of racism has a detrimental effect on blood pressure. In a study of African American and white nurses, Jones found that the majority of African American nurses think about race at least daily, and many of them are constantly aware of their racial classification. This constant awareness contributes to undue stress.

Others have highlighted the need to take into account not only African Americans' personal context, but also the larger historical context when looking at racial disparities in health. For example, the civil rights movement seems to have had a positive effect on African American health. Other research has found that African American physical and mental well-being is highest when the discrimination reported by African Americans is lowest. Research suggests that racism can affect African American health in three major ways. First, racism can transform socioeconomic status such that its effects are not equal across race. For example, African Americans cannot expect the same returns on their educational investments, in terms of wages, as those of whites. Second, racism may restrict access of African Americans to health services and to recreational facilities that could benefit their health. Finally, racism causes psychological distress that may create severe health problems for African Americans.

Our respondents noted the impact of racism on their health. One focus group participant, a dental assistant, made the connection between the discrimination and physical ailments eloquently:

I don't think a lot of [people] realize that, when you're talking about ailments, you're talking about more colds, higher blood pressure, things like that. People don't relate that to your job. Like when you come down with more colds, a lot of times, it's [racial] stress on your job . . . . [I was] in another job, and it seemed like the more stress I was under, it would make me feel worse. I would be sick, I would have more colds, I would want to sleep more, and basically it was related to my job, the pressure on my job. But I didn't put it that way, you know, a lot of times I would think if I was under stress, I wouldn't relate it to a cold.

Similarly, a nurse in a southeastern state noted that the bottling up of stress from discrimination leads to a variety of health problems, as well as to excessive smoking and drinking:

But you stuff that stuff inside, and it comes out in these kinds of ways. And we can sit down and talk to each other, and that pain . . . they said that it can cause fibroids in women, that's why black women have a lot of fibroids. Because all of that pain gets stuffed inside. . . . That's why black men . . . die so early. You know, if you take out the factors of drinking, and smoking, and why is it that black men die from heart disease or from-it's that stuffing inside of those subtle things that we, that we just, that we can't say anything . . . .

From this perspective, it seems discrimination has many consequences, ranging from fibroids to heart disease. To ease their pain stemming from racial harassment, some African Americans smoke and use alcohol excessively. Benjamin suggests that racial barriers are likely to be associated with stress patterns, alcohol abuse and other health problems. Gibbs similarly contends that anger created in black men by racial discrimination is likely to manifest itself in chronic fatigue, depression, anxiety, and psychosomatic complaints such as headaches.

A. Headaches

A number of male and female respondents spoke of severe headaches that they attributed to workplace stress, such as a nurse in the Midwest: "I would have this headache and it would be for eight hours until I walked out the door and then it was like . . . a weight was lifted off." A social services coordinator described headaches and other consequences in a discussion of discriminatory work conditions:

I was having severe headaches and chest pains. . . . It would be times when I would almost be in the office hyperventilating. And . . . it was just a lot of physical things happening to me. I would pull hair more, because, just the stress, you know? You just, you're trying to do so much, and collect your thoughts and do what needs to be done. And my hair had fallen out in the back of, the back of my hair, it just had fallen out! . . . And the headaches were just, just terrible, just unbearable. And it's also a psychological kind of ill, in that, well you know if [white] people are constantly watching you. . . . But it, it's just amazing the psychological ill that it does to you. And even though you know you're competent? People can do that so much to you . . . they can get in meetings and try to show you up and make you look like you just don't know anything. And it is so many of them, you are outnumbered! Sometimes, you come out, and lash out, and you almost validate what they're trying to say about you, because you feel outnumbered! . . . So, you, you begin to doubt yourself, you begin to psychologically feel somewhat incompetent. . . . So, it, it can take a toll on you, and I think it takes more of a psychological toll on us than we even care to admit.

Headaches are only one part of an often complex set of consequences that come from coping with hostile or unsupportive whites in a workplace with fewAfrican Americans. Chest pains, hyperventilating, and serious psychological doubts also accompany headaches that stem from whites questioning African Americans' competence and abilities.

B. High Blood Pressure

Recent research reports have indicated that high blood pressure is a serious problem among black Americans. A few studies have shown that stressful life events, such as racial inequalities, are linked to high blood pressure. For African Americans, socioeconomic status has been shown to be associated with blood pressure and hypertension; as socioeconomic status decreases, blood pressure increases. A recent research study of 1784 African Americans found that this relationship may be in part due to poorer nutrition of those with lower socioeconomic status. Yet, racism also has an effect. Research by Krieger and Sidney examined stress and blood pressure in over 2000 African Americans. Those who gave accounts of facing discrimination on three or more of seven situational questions tended to have higher blood pressure than those who reported facing discrimination on one or two questions. In a previous study, Krieger found that black Americans who usually keep quiet about or accept unfair treatment are more likely to report hypertension problems than those who talk to others and take action against unfair treatment. Another study, which controlled for age and weight, found that higher levels of discrimination were positively related to higher blood pressure for African Americans. Still other studies have found that for hypertension, as well as for certain forms of cancer, socioeconomic status alone did not account for differences in illness rates between whites and African Americans.

Recent research has associated a cultural pattern known as "John Henryism" with higher blood pressure. "John Henryism" refers to the attempts made by African Americans to control their environment through hard work. These attempts amount to long-term, intensive contending with the psychosocial stressors associated with dealing with racism. Sherman James and his colleagues have found that African Americans with higher "John Henryism" are more likely to have high blood pressure. Several focus group participants gave details on how hypertension is linked to racial stress, including that encountered at work. One nurse in the Midwest commented on her reactions as she enters the driveway of the place where she is employed:

That's when I got high blood pressure. And my doctor . . . I told him what my reaction, my body's reaction would be when I would go to this place of employment . . . . which was a nursing home. When I turned into the driveway I got a major headache. I had this headache eight hours until I walked out that door leaving there. . . . I went to the doctor because the headaches had been so continuously. And he said, "[Her name], you need to find a job because you do not like where you work." And within myself I knew that was true. But also within myself I knew I had to have a job because I had children to take care of. But going through what I was going through wasn't really worth it because I was breaking my own self down. . . . It was constant intimidation. Constant racism, but in a subtle way. You know, but enough whereas you were never comfortable. . . . And then I finally ended up on high blood pressure pills because for the longest, I tried to keep low. I tried not to make waves. It didn't work. I hurt me.

Again the workplace is filled with the headaches and other pains of "constant racism."

In one focus group, a secretary working in the South believed that being repeatedly passed over for promotions caused her hypertension:

And to me, it hurt me deeply. . . . So I had, you know, I had stood in prayer lines for prayer, to help me ease my mind and everything. To help me say the right thing, or go to the right, appropriate department, to get, you know, get it started. And it was just hard, because I was real hurt, and sometimes I would just down and cry about it. . . . So, well, to make the story short, I had applied for a promotion, and I had applied for this promotion twice. . . . I was tired, I was getting stressed out, and everything, and plus this-so I was in a lot of pain, so I think I built up my blood pressure, really.

Later, this woman required a doctor's care for her high blood pressure:

I had to see several doctors, because of the discrimination, and I went through a lot of stress. And then, my blood pressure, I had never had high blood pressure, and all of the sudden, it just went on the rise, and I couldn't control it. And . . . [her supervisor] wanted me to perform the duties, you know, totally by myself, which it took like three, two or three people to do.

This account underscores the levels of pain and the loss of energy involved in contending with mistreatment seen as racially motivated. Using religion for solace, as well as speaking out, are strategies for the daily struggle. Although this woman noted in the interview that she finally received the help needed at work, the damage to her health had already been done.

As we have noted previously, in the focus groups, the suffering of other African Americans was sometimes cited as a cause of personal stress for the commentator. In one focus group an engineer explained how he empathized with a fellow employee who developed hypertension:

I have a prime example of this, this has actually happened in our job. A particular [black] person in our, in the branch. . . . was being discriminated against. The supervisor knew of it, and-what was happening, all our branch chiefs, they knew of it. And knew that the [white] supervisor was discriminating against this young lady. And, matter of fact, it drove this young lady to where now she's on high blood pressure medicine, and it really affected her. She wasn't getting promoted and all that. And the branch chief knew what was going on. . . . But the thing is, is that this person went through all that, and now the person is on high blood [pressure medicine]-it affected her mentally and physically.

Being hired is only the first hurdle for black employees. For recurring promotion problems are also reported by African American employees in a variety of businesses. Not surprisingly, they create great stress. In late 1996, some unexpected evidence of this problem surfaced on an audiotape made of top Texaco executives discussing a lawsuit brought by black employees, some of whom asserted they had been passed over for promotions because they were black. In the taped meeting the white executives did not take the reports of the black employees about the pain and frustrations of a "hostile racial environment" seriously.

C. Stomach Problems and Emotional Distress

According to several of the focus group participants, stress in the workplace creates or contributes significantly to stomach and other intestinal problems. A telephone technician explained the intertwined nature of psychological and physical problems resulting from overt racial animosity:

Well, psychologically, the psychological part and the physical part kind of go hand and hand. . . . And I have never been a sickly type person, and I had never had any problems with my stomach, but I actually did have to go to the doctor, and the doctor said I was having-they ran a test and he diagnosed it as gastrointestinal problems. And . . . depending on the amount of stress work would be in, I would actually have serious attacks, where I would really get, really feverish, high fever, and I would just get real, real sick. And they prescribed Tagamet . . . for me to take, but after taking that a couple of times, it made me really sick, and so, when I would have these gastrointestinal, these attacks, I would just kind of really have to go through it. And a lot of times my job would just be so stressful, because I work for people that . . . they were overt . . . not covert . . . they'd just flat out let you know that they just didn't like black folks . . . . I worked with those kind of people. And even though I kind of enjoyed my work, I didn't enjoy those people, because they could make the situation really hard for me. . . . And they would actually try to find . . . something wrong with [your work] . . . and that would just bug me, because, you know, I know that I meticulously try to do it, but even in that they could come right behind me and try to pinpoint little, little small things, and find something wrong with it.

Then she added how she copes in advance: "It was very, very stressful, because every day you're constantly mentally trying to prepare yourself when you get out of the car in the morning and you go in, go into work, you're trying to prepare yourself, 'Well what do I have to face today?"' One factor in the personal cost of discrimination is that which comes from having to be constantly prepared. One strategy used by African Americans to counter mistreatment from whites is to put on a defensive "shield," the term used in a conversation with a retired teacher recorded by Feagin and Sikes. In that account an older black woman contrasted her life with that of a white woman, who, like her, bathes and dresses before leaving the house. Unlike the white woman, however, she must put on her "shield" just before she leaves. She noted that for six decades, she has had to prepare herself in advance for the often unpredictable racist actions in the white worlds she often traverses.

Another woman, a supervisor in the Southeast, reported stomach problems that she believed stemmed from actions of a fellow white employee:

But I was just so frustrated because she was . . . prejudiced, and she let it be known. And even though I confronted her on it, and any time she would say something to me, and I would tell her, I said "Look, if you can't deal with me on a professional level, then don't deal with me at all." And she was the type that, she would just do little things. And that just would annoy me . . . and I never knew it then, and then I was reading a book one day, and it said don't let things bother you, because, you know, physical breakdown. . . . I can't really say it's an ulcer, but I had stomach problems. I'm gonna tell you what, what I did come to find out about her, though, was that sometimes when people are like that . . . she was raised in [names a southern state], this is backwoods. So she was brought up that black people-you know to treat us like that. And I told her, I said, "Well, you can't treat-everybody's not the same, what if I treat all white people bad? You know, call you all kind of names and everything like that? That's not fair!" I said, "Because I could miss out on a good friend, or a good person." And it took some convincing, but what I did, I didn't step to her level. Because she would [say] little things-I would never get upset with her, but I always remained myself, because I didn't want her to think that she was getting next to me, because once they figure that out, then they really start to pour it on. . . . . But see, sometimes people do you like that, it was a girl at work . . . she called me and another girl . . . a "nigger" one day. And the other girl got mad, was very, was ready to fight.

Physical ailments are only one aspect of such complex situations. Again one sees the energy lost in making and implementing one's decision about interpersonal confrontations over racial matters. This black woman shows much understanding and even forgiveness for a white employee. In a later account, not quoted here, she relates how the woman became sick and how the respondent was the one who accompanied the woman to the hospital and stayed with her. In the end, the white woman eventually told the respondent that "all black people aren't bad." This black woman was able to treat the prejudiced white woman with compassion despite how the white woman had treated her.