Race and health in the United States

Research shows many health disparities among different racial and ethnic groups in the United States.^[1]^[2]^[3]^[4]^[5] Different outcomes in mental and physical health exist between all U.S. Census-recognized racial groups, but these differences stem from different historical and current factors, including genetics, socioeconomic factors, and racism.^[5] Research has demonstrated that numerous health care professionals show implicit bias in the way that they treat patients.^[6] Certain diseases have a higher prevalence among specific racial groups, and life expectancy also varies across groups.^[2]^[3]^[4]

Background

Health ratings by race in the United States

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.^[7] 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 United States continues to become more diverse, these Census categories have not changed for almost 20 years.^[8] 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 into two categories in its data, Hispanic or Latino and Not Hispanic or Latino. Hispanics may report as any race.^[9]

The 2010 U.S. Census 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.^[10]

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 it more difficult to assess racial categorization in medicine. 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.^[11] A 2023 scoping review of the literature found that in studies conducted in multiracial or multiethnic populations, the inclusion of race or ethnicity variables lacked thoughtful conceptualization and informative analysis regarding race or ethnicity as indicators of exposure to racialized social disadvantage.^[12] This highlights the need for the more thoughtful and theoretically sound rationale for the inclusion of race or ethnicity variables in health research, aligning with the understanding of race as a social construct and acknowledging its role as a marker of exposure to racialized social disadvantage.^[13]

There are significant disparities in health outcomes 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.^[14] There are also notable differences in access to healthcare and the quality of healthcare received by 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.^[15] 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^[14] and has been shown to contribute to health problems such as depression, anxiety, insomnia, heart disease, skin rashes, and gastrointestinal problems.^[16] As a scientifically studied topic in medicine, racism's Medical Subject Headings code for the United States National Library of Medicine's MEDLARS/MEDLINE, PubMed and PubMed Central bibliographic and open access medical journal databases is D063505.

Life expectancy

The twentieth century witnessed a great expansion of the upper bounds of the human life span. At the beginning of the century, average life expectancy in the United States was 47 years. By the century's end, the average life expectancy had risen to over 70 years, and it was not unusual for Americans to exceed 80 years of age. However, although longevity in the U.S. population has increased substantially, race disparities in longevity have been persistent. African American life expectancy at birth is persistently five to seven years lower than European Americans.^[17] By 2018 that difference had shrunk to 3.6 years.^[18]

As of 2020, Hispanics had a life expectancy at birth of 78.8 years, followed by non-Hispanic Whites at 77.6 years and non-Hispanic blacks at 71.8 Years.^[19] In 2021, life expectancy for Native Americans was 65 years. For black Americans, 71; for white Americans, 76; for Hispanic Americans, 78; and 84 for Asian Americans.^[20]

A study by Jack M. Guralnik, Kenneth C. Land, Dan Blazer, Gerda G. Fillenbaum, and Laurence G. Branch found that education had a substantially stronger relation to total life expectancy and active life expectancy than did race. While 65-year-old black men had a lower total life expectancy (11.4 years) and active life expectancy (10 years) than white men (total life expectancy, 12.6 years; active life expectancy, 11.2 years), those differences were reduced when controlling for education. The same was not true for females: at 65 years old, black and white women had similar life expectancies to white women. And at ages 75 and 85, both black men and black women had significantly longer life expectancies than their white peers, with the black advantage being even greater when matching for education.^[21]

During the 20th century, the difference in life expectancy between black and white men in the United States did not decline.^[22]

Life expectancy by race in each state in 2018
State	All Races^[18]	White^[18]	Hispanic^[18]	Black^[18]	Asian^[18]	American Indian and Alaska Native^[18]
United States	78.7	78.6	82.0	75.0	86.3	77.4
Alabama	75.4	76.0	79.1	72.9	80.2	78.7
Alaska	78.8	80.0	80.9	79.0	87.1	70.5
Arizona	79.9	80.0	81.0	76.8	87.0	71.8
Arkansas	75.9	76.0	79.2	72.8	80.6	78.4
California	81.6	80.7	83.6	76.0	87.6	75.7
Colorado	80.5	80.6	81.0	77.2	87.9	74.2
Connecticut	80.9	80.6	82.9	78.0	87.2	83.6
Delaware	78.4	78.5	81.3	75.2	85.7	83.1
District of Columbia	78.6	87.5	87.8	72.6	89.5	98.5
Florida	80.0	79.9	82.1	76.1	86.1	81.6
Georgia	77.8	78.0	81.3	75.5	85.2	80.8
Hawaii	82.3	81.3	87.9	80.9	83.7	81.9
Idaho	79.3	79.1	83.1	81.3	84.9	74.6
Illinois	79.3	79.1	82.9	73.9	85.3	83.0
Indiana	77.0	76.8	82.0	73.2	85.1	81.2
Iowa	79.4	79.3	81.8	74.8	86.6	80.1
Kansas	78.5	78.2	81.5	73.8	84.2	79.1
Kentucky	75.4	75.5	79.6	72.9	80.2	78.9
Louisiana	76.1	77.1	80.9	73.1	81.1	80.5
Maine	78.7	78.6	82.1	80.9	85.9	83.8
Maryland	79.1	80.0	81.9	75.3	87.3	83.7
Massachusetts	80.5	80.2	82.1	78.8	86.1	84.1
Michigan	78.0	78.0	80.9	73.5	86.0	79.8
Minnesota	80.9	81.0	83.4	79.3	86.8	69.9
Mississippi	74.9	76.0	79.3	72.6	80.8	79.2
Missouri	77.3	77.5	81.9	73.6	84.6	81.0
Montana	78.8	79.3	82.1	81.9	86.1	69.5
Nebraska	79.6	79.6	82.1	73.9	86.3	71.1
Nevada	78.5	76.8	80.7	76.3	84.1	74.9
New Hampshire	79.5	79.3	83.5	80.8	87.6	84.4
New Jersey	80.4	80.2	82.7	74.8	87.2	84.1
New Mexico	78.1	78.7	78.6	74.8	81.8	73.9
New York	81.3	81.0	82.4	78.0	87.4	83.7
North Carolina	78.0	78.5	81.8	75.0	84.3	76.8
North Dakota	79.9	80.1	85.1	82.1	88.3	69.7
Ohio	76.9	77.1	81.1	73.0	85.9	80.6
Oklahoma	76.0	76.1	80.9	72.9	81.0	73.6
Oregon	79.8	79.5	84.0	77.5	86.4	76.9
Pennsylvania	78.3	78.3	82.2	73.2	86.9	82.2
Rhode Island	79.9	79.7	83.9	73.6	86.4	84.0
South Carolina	77.0	78.0	81.4	73.6	83.1	80.9
South Dakota	79.1	80.0	82.7	81.2	85.2	67.8
Tennessee	76.0	76.1	80.7	72.7	82.6	80.4
Texas	79.1	78.5	81.3	74.2	85.1	81.8
Utah	79.9	79.6	81.9	80.2	84.3	74.3
Vermont	79.7	79.6	83.1	81.1	87.2	85.0
Virginia	79.5	79.7	84.7	74.5	86.0	82.3
Washington	80.4	80.1	81.7	78.0	84.3	74.0
West Virginia	74.8	74.8	79.7	72.2	79.8	79.0
Wisconsin	79.4	79.4	83.3	73.4	85.8	71.7
Wyoming	79.0	79.0	81.8	80.2	85.2	72.9

Socioeconomic factors

While socioeconomic status (SES) is a contributing factor in race health disparities, it does not account for all the variation.^[23] Even when controlling for socioeconomic status, racial divides in health persist. For example, Black Americans with college degrees have worse health outcomes than White and Hispanic Americans who have high school diplomas.^[24] Studies on heart disease mortality have found that gaps between Black and White Americans exist at every education level. A longitudinal study over more than twenty years found that Black physicians had higher prevalence of cardiovascular disease, earlier onset of disease, twice the incidence of hypertension, and higher prevalence of diabetes compared to White physicians.^[23] For maternal mortality, Black women who are college graduates have pregnancy-related mortality ratios (number of pregnancy-related deaths for every 100,000 live births) that are 1.6 times greater than White women who had not finished high school.^[25] Black women have higher maternity mortalilty rates than white women regardless of socioeconomic status and pre-existing health conditions.^[26]

According to the American Journal of Preventive Medicine, a data analysis was performed using The Behavioral Risk Factor System survey to examining the perceptions of racial privilege in healthcare among different races.^[27] These results showed that whites with a higher income and an educational background had an increase perception in receiving medical treatment and a decrease in discrimination. Oppose to blacks the perceptions were the complete opposite compared to whites.^[27] Several studies suggest that race is a positive association with socioeconomic (SES) and education when providing health services.^[28] Currently, there are future research being conducted to understand the concept behind racial privileges in the healthcare.^{[citation needed]}

Specific diseases

Health disparities are well documented in minority populations such as African Americans, Native Americans, and Latinos.^[29] In the year 1985, a report, known as the Heckler Report, was released to address the state of concern regarding African American and minority populations.^[30] This report sought to look at statistical data that showed its prevalence and the action towards bridging this health equity gap. The report identified six areas of health concern: cancer, cardiovascular disease and stroke, chemical dependency related to cirrhosis of the liver, diabetes, homicides and accidents, and infant mortality.^[30] When compared to European Americans and Asian Americans, these minority groups have higher incidence of chronic diseases, higher mortality, and poorer health outcomes.^[29] More importantly noted are the number of lives that could have been saved if healthcare were the same between both populations.^[30] That is, African Americans and minority populations having access to healthcare that meets their needs and seek to address this much needed change.

Minorities often have higher rates of cardiovascular disease, HIV/AIDS, and infant mortality than whites.^[29] U.S. ethnic groups can exhibit substantial average differences in disease incidence, disease severity, disease progression, and response to treatment.^[31]

African Americans have higher rates of mortality than does any other racial or ethnic group for 8 of the top 10 causes of death.^[32] The cancer incidence rate among African Americans is 10% higher than among European Americans^[33] and the mortality rate from asthma is twice the rate of European Americans.^[34]
African Americans are found to have some of the highest rates of chronic Hepatitis C and Hepatitis C-related deaths in comparison to other populations.^[35]
U.S. Latinos have higher rates of death from diabetes, liver disease, asthma, and infectious diseases than do non-Latinos.^[36]^[34]
In 2015, nearly 2.2 million Hispanics/Latinos nationwide reported having asthma, with Puerto Rican Americans possessing almost tripled the asthma rate of the overall Hispanic population. A part of this disparity can be said to be due to the higher rates of pollution found in communities of people of color.^[35]
Adult African Americans and Latinos have approximately twice the risk as European Americans of developing diabetes.^[33]
Asian Americans are 60% more likely to being at risk of developing diabetes in comparison to European Americans and are more likely to develop the disease at lower BMIs and lower body weights. South Asians are especially more likely to developing diabetes as it is estimated South Asians are four times more likely to developing the disease in comparison to European Americans.^[37]^[38]^[39]^[40]
Native Americans suffer from higher rates of diabetes, tuberculosis, pneumonia, influenza, and alcoholism than does the rest of the U.S. population.^[41] Disparities in diabetes and cardiovascular disease have been hypothesized to be linked to higher rates of suboptimal sleep in this population.^[42]^[43]
European Americans die more often from heart disease and cancer than do Native Americans, Asian Americans, or Hispanics.^[32]
White Americans have far higher incident rates of melanoma of the skin or skin cancer than any other race/ethnicity in the US. In 2007 incident rates among white American males were approximately 25/100,000 people, whereas the next highest group (Hispanics and natives) has an incidence rate of approximately 5/100,000 people.^[44]
Asian Americans are at higher risk for hepatitis B, liver cancer, tuberculosis, and lung cancer.^[45] The subgroup of Filipino Americans suffer health risks similar to that of African Americans and European Americans combined.^[46]
According to the NIH, African Americans are more likely to develop diabetes. Usually, type 2 diabetes is more prominent in middle-aged adults. Being obese or having a family history can also affect this. Over the past 30 years in the US, "black adults are nearly twice as likely as white adults to develop type 2 diabetes."^[47] Besides this difference just being between black and white adults, we see the greatest margin of comparison between black and white women.
In 2015, 87 percent of all TB cases in the United States occurred in those that are identified as racial and ethnic minorities, especially Hispanics, Asians, and African Americans.^[35] Even more recently, African Americans are considered the group with the highest rate of infection, totaling more than 1,000 cases in 2019. Socioeconomic factors are the related cause, alongside it presenting barriers to treatment in the disease.^[30]
Sickle cell disease is more susceptible to be found in those of descent from places such as those in the Mediterranean, Italy, Turkey, and Greece, as well as Africa and regions of South and Central America.^[48] The disease affects how oxygen is delivered to the red blood cells and is often diagnosed at a young age, discovered through a diagnosis of anemia.
In a 2019 study on racial discrimination and dental health in the U.S. the authors found that the "emotional impact of racial discrimination" results in fewer visits to a dentist.^[49]
According to the National Health and Nutrition Examination Survey data, childhood obesity is more common among Hispanic (25.8%) and Black children (22.0%) compared to white children (14.1%).^[50] In other studies the same results are seen in adults from the same race and ethnicity.
A 2021 systematic review on hearing loss in adults found an absence of racial and ethnic diversity in studies that did not represent the diversity of the US population.^[51]

African Americans

History

Disparities in health and life span among blacks and whites in the US have long existed before today. Many African Americans and minorities weren't subjects of outreach, nor attended to for communicable or non-communicable conditions. Several incidents throughout early history show maltreatment, neglect, and being denied healthcare in comparison to the white population. Foregoing early treatment progresses infection, leads to disability, or ultimately death, dependent upon the disease. One of those namely events in history is the flu epidemic of 1918. The virus infected more than 675,000 people, with a total of 500 million worldwide.^[52] Black communities were either refused care, received subpar attention, or, where available, expected and pursued aid from black nurses. Although current information reflects that minorities in the United States have lower life expectancies and encounter a larger number of health conditions than their white counterparts, the health of black people has not always been documented.^[53] Accurate numbers showing the number of African Americans infected, disabled, or died—or succumbed to it—aren't available; records remain scarce, since so few of those victims were able to get to institutional healthcare providers or agencies.^[52] David R. Williams and Chiquita Collins write that, although racial taxonomies are socially constructed and arbitrary, race is still one of the major bases of division in American life. Throughout US history racial disparities in health have been pervasive.^[54] In a 2001 paper, Williams and Collins also argued that, although it is no longer being legally enforced, racial segregation is still one of the primary causes of racial disparities in health because it determines socioeconomic status by limiting access to education and employment opportunities.^[55] Clayton and Byrd write that there have been two periods of health reform specifically addressing the correction of race-based health disparities. The first period (1865–1872) was linked to Freedmen's Bureau legislation and the second (1965–1975) was a part of the Civil Rights Movement. Both had dramatic and positive effects on black health status and outcome, but were discontinued. Even though African-American health status and outcome is slowly improving, black health has generally stagnated or deteriorated compared to whites since 1980.^[56]

The Tuskegee study was another prime example of health disparities among African Americans.^[57] The study showed lack of medical treatment and discrimination among blacks.^[57] African Americans find it difficult to participant in clinical trials due to lack of understanding and knowledge received by researchers.^[58]

In 1932, the Tuskegee study was involved with 600 black men, 399 with syphilis and 201 with no disease.^[59] Researchers explained to the men they were being treated for "bad blood," a term used in the study to describe several ailments, including syphilis, anemia, and fatigue.^[59] The men were told by researchers and health professionals that they would be participating in a study to cure their current illnesses.^[59] The men in the study later found they were not being treated for the purpose they agreed upon. This study resulted in a class action lawsuit due to lack of evidence, no consent, misleading information, and medical neglect.^[59] As a result, by July 1972 when the study ended, over 100 participants had died, 40 spouses had been diagnosed, and disease had been passed to 19 children at birth.^[60]

In one study, researchers found medical professionals perceive black patients to be less susceptible to pain than their white patients. White patients are given better treatment and access than black patients. As a result, black patients are more vulnerable to disease than white counterparts.^[61]

Demographic changes can have broad effects on the health of ethnic groups. Cities in the United States have undergone major social transitions during the 1970s, 1980s, and 1990s. Notable factors in these shifts have been sustained rates of black poverty and intensified racial segregation, often as a result of redlining.^[62] Indications of the effect of these social forces on black-white differentials in health status have begun to surface in the research literature.^[63]

Race has played a decisive role in shaping systems of medical care in the United States. The divided health system persists, in spite of federal efforts to end segregation, health care remains, at best widely segregated both exacerbating and distorting racial disparities.^[64] Furthermore, the risks for many diseases are elevated for socially, economically, and politically disadvantaged groups in the United States, suggesting to some that environmental factors and not genetics are the causes of most of the differences.^[65]^[66]^[67]

Racism

Racial differences in health often persist even at equivalent socioeconomic levels. Individual and institutional discrimination, along with the stigma of inferiority, can adversely affect health. Racism can also directly affect health in multiple ways.^[68] Residence in poor neighborhoods, racial bias in medical care, the stress of experiences of discrimination and the acceptance of the societal stigma of inferiority can have deleterious consequences for health.^[69]^[70] Racism is a key determinant of socioeconomic status (SES) in the United States, and SES, in turn, is a fundamental cause of racial inequities in health.^[71] Using The Schedule of Racist Events (SRE), an 18-item self-report inventory that assesses the frequency of racist discrimination. Hope Landrine and Elizabeth A. Klonoff found that racist discrimination was frequent in the lives of African Americans and is strongly correlated to psychiatric symptoms.^[72]

A study on racist events in the lives of African American women found that lifetime racism was positively correlated to lifetime history of both physical disease and frequency of recent common colds. These relationships were largely unaccounted for by other variables. Demographic variables such as income and education were not related to experiences of racism. The results suggest that racism can be detrimental to African Americans' well-being.^[73] The physiological stress caused by racism has been documented in studies by Claude Steele, Joshua Aronson, and Steven Spencer on what they term "stereotype threat."^[74]

Kennedy et al. found that both measures of collective disrespect were strongly correlated with black mortality (r = 0.53 to 0.56), as well as with white mortality (r = 0.48 to 0.54). A 1 percent increase in the prevalence of those who believed that blacks lacked innate ability was associated with an increase in age-adjusted black mortality rate of 359.8 per 100,000 (95% confidence interval: 187.5 to 532.1 deaths per 100,000). These data suggest that racism, measured as an ecologic characteristic, is associated with higher mortality in both blacks and whites.^[75]

Two local governments in the US have issued declarations stating that racism constitutes a public health emergency: the Milwaukee County, Wisconsin executive in May 2019, and the Cleveland City Council, in June 2020.^[76]^[77]

Princeton Survey Research Associates found that in 1999 most whites were unaware that race and ethnicity may affect the quality and ease of access to health care.^[78]

Inequalities in health care

There is a great deal of research into inequalities in health care. In 2003, the Institute of Medicine released a report showing that race and ethnicity were significantly associated with the quality of healthcare received, even after controlling for socioeconomic factors such as access to care.^[79] In some cases these inequalities are a result of income and a lack of health insurance, a barrier to receiving services. Almost two-thirds (62 percent) of Hispanic adults aged 19 to 64 (15 million people) were uninsured at some point during the past year, a rate more than triple that of working-age white adults (20 percent). One-third of working-age black adults (more than 6 million people) were also uninsured or experienced a gap in coverage during the year. Blacks had the most problems with medical debt, with 31 percent of black adults aged 18 to 64 reporting Past-Due Medical Debt, vs. 23 percent of whites and 24 percent of Hispanics.^[80]

Compared with white women, black women are twice as likely and Hispanic women are nearly three times as likely to be uninsured.^[81] However, a survey conducted in 2009, which examined whether patient race influences physician's prescribing, found that racial differences in outpatient prescribing patterns for hypertension, hypercholesterolemia, and diabetes are likely attributable to factors other than prescribing decisions based on patient race. Medications were recommended at comparable rates for hypercholesterolemia, hypertension and diabetes between Whites and African Americans.^[82]

It has been argued that other cases of inequalities in health care reflect a systemic bias in the way medical procedures and treatments are prescribed for different ethnic groups. Raj Bhopal writes that the history of racism in science and medicine shows that people and institutions behave according to the ethos of their times and warns of dangers to avoid in the future.^[83] Nancy Krieger contended that much modern research supported the assumptions needed to justify racism. Racism contributes to unexplained inequities in health care, including treatment for heart disease,^[84] renal failure,^[85] bladder cancer,^[86] and pneumonia.^[87] Raj Bhopal writes that these inequalities have been documented in numerous studies. The consistent and repeated findings that black Americans receive less health care than white Americans—particularly where this involves expensive new technology—is an indictment of American health care.^[88]

The infant mortality rate for African Americans is approximately twice the rate for European Americans, but, in a study that looked at members of these two groups who belonged to the military and received care through the same medical system, their infant mortality rates were essentially equivalent.^[89] Recently a study was conducted by the KFF, the Henry J Kaiser Family Foundation, in order to learn more about the infant mortality rate throughout the United States. All fifty states were surveyed. Different distributions of racial categories used in the study includes, "Non-Hispanic White, Non-Hispanic Black, American Indian or Alaska Native, Asian or Pacific Islander, or Hispanic".^[90] The infant mortality rate was compiled by the number of infant deaths per one thousand live births. In 2015, on an average nationwide, the United States reported that for Non-Hispanic white had an infant mortality rate of NSD meaning there as not enough sufficient data, Non-Hispanic black's rate was 11.3, Indian or Alaska Native's was 8.3, Pacific Islander was 4.2, and the infant mortality rate on average for Hispanic was 5.0.^[90]

Recent immigrants to the United States from Mexico have better indicators on some measures of health than do Mexican Americans who are more assimilated into American culture.^[91] Diabetes and obesity are more common among Native Americans living on U.S. reservations than among those living outside reservations.^[92] The number of Native Americans diagnosed increased by 29% just between the years of 1990 and 1997. The prevalence of this among women and men shows that women more often have diabetes than men, especially in communities of Native American people.^[93]

A report from Wisconsin's Department of Health and Family Services showed that while black women are more likely to die from breast cancer, white women are more likely to be diagnosed with breast cancer. Even after diagnosis, black women are less likely to get treatment compared to white women.^[94] University of Wisconsin African-American studies Professor Michael Thornton said the report's results show racism still exists today. "There's a lot of research that suggests that who gets taken seriously in hospitals and doctors' offices is related to race and gender," Thornton said. "It's related to the fact that many black women are less likely to be taken seriously compared to the white women when they go in for certain illnesses."^[95]

Krieger writes that given growing appreciation of how race is a social, not biological, construct, some epidemiologists are proposing that studies omit data on "race" and instead collect better socioeconomic data. Krieger writes that this suggestion ignores a growing body of evidence on how noneconomic as well as economic aspects of racial discrimination are embodied and harm health across the lifecourse.^[96] Gilbert C. Gee's study A Multilevel Analysis of the Relationship Between Institutional and Individual Racial Discrimination and Health Status found that individual (self-perceived) and institutional (segregation and redlining) racial discrimination is associated with poor health status among members of an ethnic group.^[97]

In the 2020 covid pandemic, a disproportionate rate in the amount of covid deaths in the African American communities compared to other racial groups has been demonstrated in some part of the United States. Many cases such as covid and AIDs has led more African Americans to lose trust in healthcare intuitions and the government that is supposed to protect their rights. Milwaukee County is just one of many examples of such communities that were hit hard by covid. African American represented three fourths of covid deaths. This has been a common factor for many parts of the countries major populated cities that have has high percentage of African Americans.^[98]

Race-Based Diagnoses

Racial groups, especially minority groups, are frequently exposed to different types of barriers when in need of medical treatment. The World Health Organization identifies some of these barriers, including unequal access to health services, lack of cultural sensitivity, differing quality of services, timeliness of access to such services, and general discrimination in healthcare systems.^[99] Certain racial groups can receive different courses of treatment, diagnoses, and prescription medications than those that self-identify as other races.^[100] These differences can be commonly linked to correction factors in medical calculators, algorithms that are unable to account for variables rooted in social disparities, and drugs designed for specific racial populations. BiDil is a drug used to treat congestive heart failure in black people.^[101] The Food and Drug Administration initially rejected applications of the medication since their clinical trials did not demonstrate any efficacy for a general racial population within the United States, except for African Americans.^[102] BiDil's manufacturer, NitroMed, then completed a clinical trial that solely enrolled African Americans. They found a decrease in mortality for this exclusive group and in 2005, the FDA approved the drug's usage exclusively for black patients.^[102] It is currently still in use with the same stipulation.

BiDil has been considered to be a "race drug"^[103] by some in the medical community. Backlash stems from a debate on whether race can be a reliable factor in making diagnoses and prescriptions. Those that oppose its usage believe its prescription process to be unscientific. With respect to BiDil's racialization, Sheldon Krimsky wrote, "'self-identified race' is a subjective term, influenced by cultural factors, and not even grounded in the ancestral genomics."^[103]

Ziad Obermeyer M.D., et al. found that a specific algorithm, which determines what patients need further care, favors additional medical attention towards white people over black people.^[104] This analysis was based on data concerning average health costs that are incurred by these specific races. The same article puts forward the claim, "Bias occurs because the algorithm uses health costs as a proxy for health needs," as African Americans have been found to face disproportionate poverty levels in the United States and are forced to spend less on healthcare than white patients.^[105] This bias caused the algorithm to find that black patients are generally healthier than white patients and a conclusion was created by the algorithm that black patients do not need extra care in such instances.

Estimated glomerular filtration rate (eGFR) is a scored measurement of a patient's kidney function. Once measured, healthcare providers can utilize the test score to determine the quality of kidneys' filtering ability in a given patient. According to a study by Dr. Darshali Vyas, et al., the equation for eGFR reports a higher score for black patients by a factor of 1.210,^[106] which the study's authors doubt the validity of. The algorithm's developers backed the results, citing that black people have higher creatinine levels, which can be a lurking variable in eGFR calculations. Vyas makes a rebuttal to this idea, stating, "Explanations that have been given for this finding include the notion that black people release more creatinine into their blood at baseline, in part because they are reportedly more muscular." In reality, this generalization may not be the case and can be harmful to minorities that encounter such correction factors.

Similarly, the vaginal birth after Caesarean section (VBAC) medical calculator is used to estimate the probability that a patient will successfully complete a vaginal birth if they have already had a birth via Caesarean section. There are correction factors based on race that have been commonly used in this calculator; self-reported African American patients' results are multiplied by a factor of 0.671.^[106] The VBAC calculator is in the process of being altered by the Maternal-Fetal Medicine Units Network, as of December 2021, to omit race and ethnicity in the interest of ignoring such "socially constructed variables"^[107] that may be inaccurate.

Mental health

Stress can be derived from many individualistic factors or experiences, has multiple effects on health. Stress is also associated with chronic diseases. Stress that is derived from racism has specific contextual factors, which adds a daily burden to African-Americans and other demographic groups that are discriminated against. These demographic groups do not often realize that these stressors may be contributing to the state of their mental health.^[108] Groups of people are also affected in ways that may not be outward acts of racism by another person, but through education, economics, the justice system, and largely through law enforcement. It is also possible that people who hold racist ideals have mental health problems as well, such as self-centeredness, inability to empathize, and paranoia over groups of people they are discriminating against. Individuals can develop complexes about ethnic groups and races, automatically displaying emotions without learning about the people themselves, and will cut off all friendliness to them.^[109]

There are many barriers that exist in the relationship for African Americans accessing mental health services. These barriers can range from family dynamics, institutional racism, socioeconomic status, and a host of other reasons. This is particularly true for African Americans in need of mental health services who could benefit from effective treatment. "Effective treatment exists for many mental disorders, an indicator of need for mental health services (MHS), receive any treatment. This underutilization is more pronounced among African Americans than Non Hispanic whites (Villatoro & Aneshensel, 2014).^[110] There is something to be said about the lack of utilization of mental health services amongst African Americans. There are several possible explanations for the state of mental health use in African American communities. While many African Americans do not receive mental health services, those who do receive services are negatively impacted by the institutional bias that exists between them and non-black counselors. In a study of 47 clinicians and 129 African Americans who sought therapy, researchers found that African Americans tend to have a healthy cultural paranoia about their non-black therapists. Interviews with them found Black patients simultaneously engaged in and scanned the encounter for feelings of comfort; safety in disclosing personal information; being trustful of the provider; and being listened to, understood, and respected by the provider. For some patients, judgments about the initial encounter seem to have less to do with clinical expertise or experience of the provider and more with perceptions of empathy and the quality of the interpersonal connection between the two individuals (Earl, Alegría, Mendieta, & Diaz Linhart, 2011^[111]). In order to improve the outcomes of therapy for African Americans, it is imperative that non-black therapists are culturally competent. Increasing cultural competence of mental health clinicians will help foster an empathetic relationship between clinicians and their clients.

In addition, the social environment in which African Americans live in plays a role in their mental health. As it relates to African Americans, it is not enough to deal with them independent of the world they exist in. Mental health clinicians must strive to see their African American clients within the context of the environments they move through. How these social factors impact the African American client must be examined and thoroughly processed by both the clinician and the client. The examination of how social factors influence individual thought and behavior is particularly critical for African Americans. Social environment constructs, psychosocial mediators, and sociodemographic are factors that have to be considered when it comes to African Americans and mental health. Ecological approaches that aim to systematically modify how the world interacts with blackness, life experiences that African Americans perceive as stressful, depression, and perceived racial discrimination, may have the greatest impact on mental health in African Americans and may lead to additional improvements in the holistic well-being of African Americans (Mama, Li, Basen-Enquist, Lee, Thompson, Wetter, Nguyen, Reitzel, & McNeill, 2015).^[112] For example, there must be institutional efforts at a national and grassroots level that address the numerous social issues impacting African American communities. Particularly, programs that enhance their life outcomes. In other words, there must be advocacy for African American clients who are engaging in therapy, and that advocacy must extend to the world they live in outside of their therapy sessions.

African American millennial's mental health has also raised concerns due to the lack of being able to find employment. African American males between the age of twenty and twenty-four were studied and were found to experience unemployment at almost double the rate of their white peers. Mental issues are presented in the form of addictions such alcohol and smoking. Conditions of depression have reported as well. Societal pressure of gender norm is one factor that leads to mental health issues for African American males.^[113]

Maternal and child health

Tamara speaks about feeling "ignored" as a Black mother in the United States in 2019.

African American women are three to four times more likely to die in childbirth than white women, while their babies are twice as likely to die than white babies, even when controlled for many factors such as education, income, and health. Danyelle Solomon argues that "White racism" is the highest cause of unrest in communities, pushing them further apart, and causing more black women and infants to die because of it.^[114] Racism affects several components of a black woman's life in regards to being able to give birth or currently carrying. Racism found in the delivery of health care and social service means black women often receive substandard care in comparison to white women.^[115] As well, denial of care to black women that seek help when enduring pain, or that health care and social service providers fail to treat them with dignity and respect when it comes to their wellbeing.^[115] African American women face greater chances than white women to have chronic stress which can stem from living in impoverished neighborhoods or encountering discrimination. These embedded stressors as a result of societal inequities and prejudice could largely explain the underlying health disparities in negative birth outcomes. Although studies examining the effects of prenatal stress are limited, for a few reasons, evidence does support the consequences of high levels of stress or anxiety.^[116] Women are said to bear low birth weight or preterm infants from elevated stress or anxiety, and even more so with a lack of social support.^[116] In the aftermath, newborns become predisposed to issues, such poor physical development, from the mother's stress during pregnancy. With that being said, stress from racism not only affects mental and physical wellbeing, but disproportionately place black infants at a disadvantage for future attainment.

Racism in education has decreased significantly over the past century, however this does not help increase the income for black people, and increased incomes do not provide better health opportunities, especially for mothers and infants.^[114] Higher education and income levels for black mothers does not affect this mortality rate. There are also higher chances that a complication will occur during birth. Solomon argues that the 'toxin' of these rates is racism, which has created a toxic environment for minority groups to live in with multiple stressors that effect health.^[114]

In 2012, a study was conducted on early pregnancy women which followed their children from birth to 5 years old to determine the risk factors of obesity among low-income black children.^[117] However, the study showed that children of overweight and obese mothers are more than likely to become obese or overweight by the age of 5.^[117] According to the U.S. Department of Health and Human Services Office of Minority, African American women have the highest rates of obesity or being overweight compared to any other groups in the United States.^[118]

Cardiovascular disease

Research has explored the effect of encounters with racism or discrimination on physiological activity. Most of the research has focused on traits that cause exaggerated responses, such as neuroticism, strong racial identification, or hostility.^[119] Several studies suggest that higher blood pressure levels are associated with a tendency not to downplay racist and discriminatory incidents, or that directly addressing or challenging unfair situations reduces blood pressure.^[119] Personal experiences of racist behaviors increase stress and blood pressure.^[119]

Although the relationship racism and health is unclear and findings have been inconsistent, three likely mechanisms for cardiovascular damage have been identified:^[120]

Institutional racism leads to limited opportunities for socioeconomic mobility, differential access to goods and resources, and poor living conditions.
Personal experiences of racism acts as a stressor and can induce psychophysiological reactions that negatively affect cardiovascular health.
Negative self-evaluations and accepting negative cultural stereotypes as true (internalized racism) can harm cardiovascular health.

According to the U.S. Department of Health and Human Services Office of Minority Health, in 2018, African Americans were 30% more likely to die from heart disease than non-Hispanic whites.^[121]

Alzheimer's disease

Alzheimer's disease (AD) is a progressive, irreversible neurodegenerative disease and it is the leading cause of dementia.^[122] African Americans are disproportionately affected by Alzheimer's, with higher prevalence and incidence in African Americans than the overall average.^[123]^[124] Genetics are a huge risk factor for Alzheimer's, but known high-risk genes for the disease have different effect sizes in African Americans compared to other racial groups.^[125]

Many of the risk factors for Alzheimer's such as high blood pressure and diabetes are more prevalent in African American communities. Therefore making Alzheimer's disproportionately impact black communities within America. The Alzheimer's Impact Movement is an association that seeks to advance the care for those who have Alzheimer's and Dementia. The Washington Heights-Inwood Columbia Aging Project in 2020 collected data on the percentages of people aged 65 or older with Alzheimer's disease or other types of Dementia. For each demographic ages 65–74, 75-84, and 85+, the proportion of African Americans with Alzheimer's were two times larger than the proportion of white individuals within those age groups. Although African Americans are more likely to develop Alzheimer's, they are only 34% more likely to receive a diagnoses for their condition. If diagnosed, it's typical for the disease to have already developed into the later stages with further deteriorated cognition. As a result, African Americans tend to pay substantially more for health services.^[126] For African Americans in 2014 it was discovered that the average per-person Medicare payment was 35% higher than white individuals with Alzheimer's. Another study set on by The Chicago health and Aging project in 2018 found that the higher risk of Alzheimer's disease could stem from disparities within educational attainment. Findings from the study portray a contradiction between cognition decline and cognition and Dementia risk. The findings could reflect upon lacking cognitive reserves developed over their lifespan. Exposure to racism, access to resources, and exposures to neurotoxins have consequentially leading to poorer cognitive function and disproportionately develop Dementia.Cognitive aging in black and white Americans: Cognition, cognitive decline, and incidence of Alzheimer disease dementia^[127]

Fear of racism

It has been argued that while actual racism continues to harm health, fear of racism, due to historical precedents, can cause minority populations to avoid seeking medical help. For example, a 2003 study found that a large percentage of respondents perceived discrimination targeted at African American women in the area of reproductive health.^[128] Likewise beliefs such as "The government is trying to limit the Black population by encouraging the use of condoms" have also been studied as possible explanations for the different attitudes of whites and blacks towards efforts to prevent the spread of HIV/AIDS.^[129]

Infamous examples of real racism in the past, such as the Tuskegee Syphilis Study (1932–1972), have injured the level of trust in the Black community towards public health efforts. The Tuskegee study deliberately left Black men diagnosed with syphilis untreated for 40 years. It was the longest nontherapeutic experiment on human beings in medical history. The AIDS epidemic has exposed the Tuskegee study as a historical marker for the legitimate discontent of Black people with the public health system. The false belief that AIDS is a form of genocide is rooted in recent experiences of real racism. These theories range from the belief that the government promotes drug abuse in Black communities to the belief that HIV is a manmade weapon of racial warfare. Researchers in public health hope that open and honest conversations about racism in the past can help rebuild trust and improve the health of people in these communities.^[130] In 2001 the Journal of the National Medical Association has concluded that this fear causes those within the African American community to avoid clinical trials. Although these trials are now set up to protect participants, black communities remain wary. This also has its downsides, as it's impossible to know if drugs will impact white and colored persons the same without these trials.^[131] Past medical malpractice has led to distrust, which in turn makes creating necessary medicine for the black community more difficult. Perpetuating the lack of resources and health care available to black communities. The experimentation and abuse set onto black bodies in the pursuit of medical development has a long and treacherous history. The Tuskegee experiment is one of the more well known experiment, where black men with Syphilis were left untreated to ease the doctors' curiosities concerning the natural course of the disease when left untreated. Many of the men were told that their study was concerning "bad blood" and nothing more. The doctors would dissuade these individuals from seeking outside help, while performing blood draws, spinal taps, and autopsies.^[132] The Tuskegee experiments have had generational consequences in the belief of health care. There are many in the black community who believe the government injected syphilis virus into those men in the experiment. Although this has not been factually proven, rumors within the community were enough to create long withstanding distrust. The same goes for agreeing to being an organ donor on a drivers license. Many African Americans will immediately say no, as there's a belief that their organs will be misused.^[133]

Many of the violent and inhuman actions taken towards people of color have shaped how African Americans within the U.S view health care. The Mississippi Appendectomy is where many black slaves were used as test subjects to treat vesicovaginal fistulas, an experiment performed by Dr. James Marion Sims. Dr. Sims was heralded as a brilliant physician, despite his inhumane experimentation on black women to further his career. Experiments such as these transformed after the 15th Amendment, where many white citizens were afraid of black populations gaining too much power. The forceful sterilization of black women without their knowledge is one of the many examples of white Americans attempting to regulate and control populations within black communities. Although injustice like this has become illegal in recent years, the fear it has created remains, resulting in the distrust of health care professionals and birth control methods. Many woman have not received justice for the things done to them.^[134] Medical research has historically been a form of violence for black communities living within the United States.

In 2001 the Journal of the National Medical Association has concluded that this fear causes those within the African American community to avoid clinical trials. Although these trials are now set up to protect participants, black communities remain wary. This also has its downsides, as it's impossible to know if drugs will impact white and colored persons the same without these trials.^[131] Past medical malpractice has led to distrust, which in turn makes creating necessary medicine for the black community more difficult. Perpetuating the lack of resources and health care available to black communities. The experimentation and abuse set onto black bodies in the pursuit of medical development has a long and treacherous history. The Tuskegee experiment is one of the more well known experiment, where black men with Syphilis were left untreated to ease the doctors' curiosities concerning the natural course of the disease when left untreated. Many of the men were told that their study was concerning "bad blood" and nothing more. The doctors would dissuade these individuals from seeking outside help, while performing blood draws, spinal taps, and autopsies.^[132] The Tuskegee experiments have had generational consequences in the belief of health care. There are many in the black community who believe the government injected syphilis virus into those men in the experiment. Although this has not been factually proven, rumors within the community were enough to create long withstanding distrust. The same goes for agreeing to being an organ donor on a drivers license. Many African Americans will immediately say no, as there's a belief that their organs will be misused.^[133]

Hospitals have long been spaces that have made black persons within the United States feel unwelcomed. Hospitals that were available to black communities have a history of being underfunded and racially discriminatory environments. A study performed in early 2022 by Lown Institute identified hospitals which still used segregation practices that would underserve patients from colored communities. Meanwhile, some of the more inclusive hospitals gain less revenue than these hospitals with exclusionist practices.^[135] Many of these hospitals receive lower payments for patient care. This could be the direct result of the present wealth imbalances between races within the United States. Research done by the Journal of General Internal Medicine has determined that persevering funding disparities have led to less quality resources for hospitals that predominantly serve black patients.^[136]

Studies by the Health and Human Rights Journal in 2020 have determined widening health disparities in the wake of COVID-19. Testing kits were initially provided equally among the labs within the U.S., however, there was a lack of consideration of population density within those communities. It was determined that many African Americans lacked access to these tests. Within Kansas, out of roughly 94,780 tests, only 4,854 were used by African Americans, while 50,070 were used by white individuals. African Americans within the state made up roughly one third of all COVID-19 related deaths, demonstrating how Black communities were disproportionately impacted. The predisposal of low wage jobs to communities of color impact the ability to access necessary health resources. Black communities' fear and distrust within health professionals has led to underlying health issues becoming untreated. When a person with these health issues comes into contact with COVID-19, it becomes a much more lethal situation.^[137]

Environmental racism

Environmental racism is the intentional or unintentional targeting of minority communities for the siting of polluting industries such as toxic waste disposal, through the race-based differential enforcement of environmental rules and regulations and exclusion of people of color from public and private boards and regulatory bodies, resulting in greater exposure of the community to pollution. RD Bullard writes that a growing body of evidence reveals that people of color and low-income persons have borne greater environmental and health risks than the society at large in their neighbourhoods, workplaces and playgrounds.^[138]

Environmental racism stems from the environmental movement of the 1960s and 1970s, which focused on environmental reform and wildlife preservation and protection, and was led primarily by the middle class. The early environmental movement largely ignored the plight of poor people and people of color who, even in the mid-20th century, were increasingly exposed to environmental hazards.^[139]

Policies related to redlining and urban decay can also act as a form of environmental racism, and in turn, affect public health. Urban minority communities may face environmental racism in the form of parks that are smaller, less accessible and of poorer quality than those in more affluent or white areas in some cities.^[140] This may have an indirect effect on health since young people have fewer places to play and adults have fewer opportunities for exercise.^[140]

Although impoverished or underdeveloped communities are at greater risk of contracting illnesses from public areas and disposal sites, they are also less likely to be located near a distinguished hospital or treatment center. Hospitals relocate to wealthier areas where the majority of patients are privately insured, thus reducing the number of low-income patients.^[141] Whereas hospitals were previously established in the areas with the greatest need, most are now focused on economic gain from private insurance companies, and are threatened by Medicare funding cuts.^[141]

Robert Wallace writes that the pattern of the AIDS outbreak during the 80s was affected by the outcomes of a program of 'planned shrinkage' directed in African-American and Hispanic communities, and implemented through systematic denial of municipal services, particularly fire extinguishment resources, essential for maintaining urban levels of population density and ensuring community stability.^[142] Institutionalized racism affects general health care as well as the quality of AIDS health intervention and services in minority communities. The overrepresentation of minorities in various disease categories, including AIDS, is partially related to environmental racism. The national response to the AIDS epidemic in minority communities was slow during the 1980s and '90s showing an insensitivity to ethnic diversity in prevention efforts and AIDS health services.^[143]

Institutionalized racism

A major downfall of the U.S. healthcare system is the unconscious racial biases held by many white American doctors, often resulting in decreased quality of care for African American patients. One such example is the discrepancy in cardiovascular surgical procedures between white and black patients. Compared to their white counterparts, black patients are less likely to receive necessary coronary bypass surgeries and lipid-lowering medications upon discharge from the hospital.^[144] This means that black patients leave treatment centers with a significantly different health outcome. African American patients are also less likely to receive a referral for Cardiac rehabilitation following a cardiac event and/or surgery.^[145] As a result, this potentially exacerbates other issues, creates development of ancillary conditions, disability, or even death from a lack of care due to subliminal racism. It is actions like these from White doctors that contribute to the higher incidence of non-communicable disease, such as heart disease, in the black community and shorter life expectancy. Some White health care providers also maintain problematic, overt ideas about their Black patients, with being seen as less intelligent, less able to abide by treatment regimens, and more inclined to be subjects of risky behavior than their White counterparts.^[146] Institutionalized racism exhibits itself both in material conditions and in access to power.^[147] Whether through differential delivery and access to a quality education, appropriate housing, necessary employment, or any others that are regarded as the basics or necessities in life, reflect material conditions.^[147] An education is foundational to being able to achieve and attain for a better standards of living and longevity in life. However, with inequity in an education comes being place at a disadvantage, which doesn't level the playing ground for equal attainment. In the case of the black community, not only is the population discriminated against on the basis of race, but socioeconomic status, which gives rise to even greater inequality. In the aspect of access to power, examples include differential access to information (including one's own history), resources and expressing concerns or rights as equal members of the public.

One potential cause of this discrepancy in treatment is the systematic racism present in the medical field that targets the work of African American scientists. Research shows that doctors and scientists of color are significantly underfunded in the medical community, and are less likely than their white colleagues to win research awards from the National Institute of Health (NIH). Since patients of color are often treated by white doctors, miscommunication is common; research shows that many Americans feel their doctors do not listen to their questions or concerns, or are too uncomfortable to ask certain medical questions.^[144]

To help build trust in the health care system amongst the African American community one step would be the need to address the lack of African American doctors. Studies have shown that African Americans make up thirteen percent of the United States population and only represent four percent of doctors in the country. One example is the lack of "Black" OGBYN. Many African American women have stated that their preference for a black doctor is derived from adverse issues coming from childbirth, and Black women are three times more likely to die from complications of childbirth than white women. This is only one example among many where the lack of representation is hurting a community that makes up a high percentage of the United States healthcare cases.^[148]

Segregation

Some researchers suggest that racial segregation may lead to disparities in health and mortality. Thomas LaVeis (1989; 1993) tested the hypothesis that segregation would aid in explaining race differences in infant mortality rates across cities. Analyzing 176 large and midsized cities, LaVeist found support for the hypothesis. Since LaVeist's studies, segregation has received increased attention as a determinant of race disparities in mortality.^[17] Studies have shown that mortality rates for male and female African Americans are lower in areas with lower levels of residential segregation. Mortality for male and female European Americans was not associated in either direction with residential segregation.^[149]

In a study by Sharon A. Jackson, Roger T. Anderson, Norman J. Johnson and Paul D. Sorlie the researchers found that, after adjustment for family income, mortality risk increased with increasing minority residential segregation among Blacks aged 25 to 44 years and non-Blacks aged 45 to 64 years. In most age/race/gender groups, the highest and lowest mortality risks occurred in the highest and lowest categories of residential segregation, respectively. These results suggest that minority residential segregation may influence mortality risk and underscore the traditional emphasis on the social underpinnings of disease and death.^[150]

Rates of heart disease among African Americans are associated with the segregation patterns in the neighborhoods where they live (Fang et al. 1998). Stephanie A. Bond Huie writes that neighborhoods affect health and mortality outcomes primarily in an indirect fashion through environmental factors such as smoking, diet, exercise, stress, and access to health insurance and medical providers.^[151] Moreover, segregation strongly influences premature mortality in the US.^[152]

A 2024 study found that residential segregation resulted in negative birth outcomes for non-Hispanic Black infant populations in the area, while no comparable effects were detected for non-Hispanic White infant populations. ^[153]

Racism towards doctors and health care professionals

Many healthcare professionals have experienced hate and racist remarks towards them at work. Whether it be at a hospital, a walk-in clinic, or a family doctor's office, people are hit with bias-based comments concerning "general bias, ethnicity / national origin, race, age, gender, accent, religion, political views, weight, medical education from outside the US, sexual orientation, and more".^[154] This study conducted features the races of "African American/Black, Asian, Caucasian, and Hispanic"^[154] Training for doctors to handle this type of prejudice at their work is very low. The even greater downfall are men and women who become faced with bigotry from unruly, demeaning, and complicated patients that disrupt delivery of care. Doctors and healthcare professionals could feel years of education could have been unworthy of such circumstances, unappreciated, and uninspired for continued service. Although all healthcare professionals could be at risk for discrimination from patients, some populations come to experience it a greater rate. While the number of doctors and other critical healthcare professionals are in need, the thoughts of dealing with racism or any other prejudice can be discouraging.

The group that comes to greatest experience racism are black healthcare professionals, such as doctors and nurses that are tasked with the duty of providing care to the general public. Like much of the views held by white doctors regarding black patients, reflect the same perspectives of white patients regarding black doctors. A patient's denial of care based on the attending physician's race or background can raise thorny ethic, legal, and clinical issues that could have been avoided in the first place. Even more, black faculty members have encountered a lack of mentorship and sponsorship, barriers to promotion and advancement, and lack of supportive, alongside hostile, work environments as factors in attrition from academic medical centers. Experiencing discrimination is associated with several negatives including career outcomes and an unwelcoming work environment. Professionals can often feel alone and reluctant to be accepting of racism as a part of the profession. A greater initiative from healthcare organizations surrounding policy that protects not only black doctors, but other professionals that deliver unsurpassed care retains the much needed diversity and leadership in medicine.

Homicide

Homicide plays a significant role in the racial gap in life expectancy. In 2008, homicide accounted for 19% of the gap among black men, though it did not play a significant role in the decline in the gap from 2003 to 2008.^[155] A report from the U.S. Department of Justice states "In 2005, homicide victimization rates for blacks were 6 times higher than the rates for whites."^[156] Research by Robert J. Sampson indicates that the high degree of residential segregation in African American neighborhoods is responsible for the high homicide rate among African Americans.^[55]

Trends

Based on data for 1945 to 1999, forecasts for relative black: white age-adjusted, all-cause mortality and white: black life expectancy at birth showed trends toward increasing disparities. From 1980 to 1998, average numbers of excess deaths per day among American blacks relative to whites increased by 20%.^[157] David Williams writes that higher disease rates for blacks (or African Americans) compared to whites are pervasive and persistent over time, with the racial gap in mortality widening in recent years for multiple causes of death.^[69] Junk food advertisements target African Americans.^[158]

Sexually transmitted diseases

African Americans have higher rates of HIV and other STDs.^[159]