Race and health in the United States

A study by Christopher Murray contends the differences are so stark it is "as if there are eight separate Americas instead of one." Leading the nation in longevity are Asian-American women who live in Bergen County, N.J., and typically reach their 91st birthdays, concluded Murray's county-by-county analysis. On the opposite extreme are Native American men in swaths of South Dakota, who die around 58.

• Asian-Americans, average per capita income of $21,566, have a life expectancy of 84.9 years. (However Filipino Americans are slightly lower at 81.5 years)
• Northern low-income rural Whites, $17,758, 79 years.
• Middle America (mostly White), $24,640, 77.9 years.
• Low-income Whites in Appalachia, Mississippi Valley, and Texas $16,390, 75 years.
• Western Native Americans, $10,029, 72.7 years.
• Black Middle America, $15,412, 72.9 years.
• Southern low-income rural Blacks, $10,463, 71.2 years.
• High-risk urban Blacks, $14,800, 71.1 years.[11]

The risks for many diseases are elevated for socially, economically, and politically disadvantaged groups in the United States, suggesting that socioeconomic inequities are the root causes of most of the differences.[15][16] However, other dimensions of inequality than those reflected by socioeconomic status also affect racial disparities in health, because other forms of social adversity are also important factors.[17]

Disparities in health and life span among blacks and whites in the US have existed since before the period of slavery. 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.[35] 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.[36] 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.[37]

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.[38] Indications of the effect of these social forces on black-white differentials in health status have begun to surface in the research literature.[39]

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.[40] 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.[41][42]

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. 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.[43][44] 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.[45] 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.[46]

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 American's well being.[47] 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."[48]

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.[49]

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.[50]

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.[51] 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.[52]

Compared with white women, black women are twice as likely and Hispanic women are nearly three times as likely to be uninsured.[53] 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 Caucasians and African Americans.[54]

It has been argued that other cases 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.[55] Nancy Krieger contended that much modern research supported the assumptions needed to justify racism. Racism underlies unexplained inequities in health care, including treatment for heart disease,[56] renal failure,[57] bladder cancer,[58] and pneumonia.[59] 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.[60]

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.[61] 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".[62] 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 a 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.[62]

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.[63] Diabetes and obesity are more common among Native Americans living on U.S. reservations than among those living outside reservations.[64] 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.[65]

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.[66] 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."[67]

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.[68] 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.[69]

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.[70] 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.[71]

There are many barriers that exist in the relationship for African Americans accessing mental health. 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).[72] 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 inter- personal connection between the two individuals (Earl, Alegría, Mendieta, & Diaz Linhart, 2011[73]). 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 sociodemographics 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).[74] For example, there must be institutional efforts at a national and grass roots 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 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. “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.[75] Racism in education has decreased significantly over the past century, however this does not help increases in income for blacks, and increased incomes don’t provide better health opportunities, especially for mothers and infants.[75] 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. 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.[75]

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.[76] 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.[76] Personal experiences of racist behaviors increase stress and blood pressure.[76]

Although the relationship racism and health is unclear and findings have been inconsistent, three likely mechanisms for cardiovascular damage have been identified:[77]

• 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.

It has been argued that while actual racism continues to harm health, fear of racism, due to historical precedents, can also cause some 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.[78] 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.[79]

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 Blacks 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.[80]

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.[81]

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.[82]

Policies related to redlining and urban decay can also acts 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.[83] This may have an indirect affect health since young people have fewer places to play and adults have fewer opportunities for exercise.[83]

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.[84] 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.[84]

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.[85] 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 80s and 90s showing an insensitivity to ethnic diversity in prevention efforts and AIDS health services.[86]

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.[87] This means that black patients leave treatment centers with a significantly different health outcome.

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.[87]

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.[9] 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.[88]

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.[89]

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.[90] Moreover, segregation strongly influences premature mortality in the US.[91]

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".[92] This study conducted features the races of "African American/Black, Asian, Caucasian, and Hispanic" [92] Training for doctors to handle this type of prejudice at their work is very low.

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.[93] 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" and "94% of black victims were killed by blacks."[94] 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.[36]

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%.[95] 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.[43]

While Latinos and Hispanic populations are not considered a race category by the U.S. Census, this section of the article refers to Latinos or Hispanics as an ethnic group, as classified by the Census Bureau. References to the Latino and Hispanic community in the United States are frequently linked to discussions about immigration. The geographic origins of Hispanic and Latino influxes of immigration have changed through the years. During the 2010s Latin American and Caribbean countries have accounted for the main source of immigrant populations migrating towards the United States.[96]

The Hispanic Paradox is an important aspect of discussions around the history of the health of Latino and Hispanic populations in the United States. In 1986, Prof. Kyriakos Markides conceived the term “the Hispanic paradox” to refer to the epidemiological phenomenon that Hispanic individuals in the US live longer than their white non-Hispanic counterparts despite the general lower socioeconomic status of the population and their relative lack of access to healthcare. The US Centers for Disease Control and Prevention published a report on May 5^th 2015, relating to the general status and causes of deaths of Hispanic population in the United States. The report utilized mortality indicators and national health surveillance of Hispanic populations compared to their White counterparts to explore the possibility of Markides' paradox. Primarily results indicated that Hispanic deaths from diabetes, liver disease, and homicide were substantially higher than in non-Hispanic white populations. Nevertheless, Hispanics generally had a 24% lower risk of all-cause mortality and lower risks of nine of the leading 15 causes of death in the USA (most notably, cancer and heart disease).[97]  

Tied to the health status of Latinos and Hispanic in the United States is an observed mistrust of doctors and the health system. This mistrust can stem from language barriers, threat of discrimination and historical events that dismissed the consent of patients like the sterilization of Latina women in California until 1979. According to a study conducted by the United States Census Bureau, Hispanics were the population that was most likely to have never visited a medical provider, with 42.3 percent reporting that they had never done so.[98]

In many Hispanic and Latino communities, mental health problems are viewed as a sign of weakness and are not necessarily validated. Hispanics/Latinos are often cited as a high-risk group for mental health issues, particularly for substance abuse, depression, and anxiety.[99] A study conducted from 2008 to 2011, sampled more than 16,000 Hispanics/Latinos ages 18 to 74 in four diverse communities in the states of New York, Chicago, San Diego, and Miami. The findings demonstrated that 27 percent of Hispanics/Latinos in the study reported high levels of depressive symptoms.[100]

Research have signaled multiple sources of stress that could potentially impact mental health outcomes in Hispanic/Latino communities. For example, language influences the way patients are evaluated. Several studies have found that bilingual patients are evaluated differently when interviewed in English as opposed to Spanish and that Hispanics are more frequently undertreated.[101] Furthermore, Hispanics/Latinos are more likely to report poor communication with their health provider.[102] Income has also proven to be a significant factor that impacts the mental health of Latino communities, as low-income individuals may have limited access to mental health services.[99] Only 1 in 10 Hispanics with a mental disorder utilizes mental health services from a general health care provider.  Moreover, only 1 in 20 Hispanic individuals receives such services from a mental health specialist.[103]

According to the Census Bureau, while the number of non-Hispanic white women of childbearing age (15-44 years) is projected to decrease from 36.5 million in 2010 to 35.2 million in 2020, the number of Hispanic women of childbearing age is projected to increase from 11.8 million in 2010 to more than 13.8 million Hispanic women. The increase in the Hispanic population in the United States is driven in part by high fertility rates. During 2012, the fertility rate for Hispanic identifying women was 74.4 births per 1,000 women of ages 15-44.[104] In 2012, Hispanic women accounted for 23 percent or 907,677 of all of the 3,952,841 live births in the United States. Within the Hispanic population, the majority of births occurred among those of Mexican descent (61.2%), followed by Central/South American (14.5%), Puerto Rican (7.4%), and Cuban (1.9%).[104]

Examining the data from 2010, the infant mortality rate (death during the first year of life) among Hispanic women was 5.3 per 1,000 live births. This rate accounted for more than 20 percent of all infant deaths in the United States during the year 2010. According to the National Center for Health Statistics, “when specific causes of infant mortality are examined the leading cause of infant deaths in 2010 among Hispanics was birth defects (136.5 per 100,000 live births), followed by prematurity/low birth-weight (85.0 per 100,000 live births), maternal complications of pregnancy (32.3 per 100,000 live births), and Sudden Infant Death Syndrome (31.4 per 100,000 live births)”.[105]

American Indian and Alaska Native populations in the United States have experienced disproportionately negative health outcomes compared to non-Hispanic whites since colonists arrived at the continent in the 15th century, particularly due to epidemics introduced by colonial groups and violent encounters with colonists.[106] A disparity in health outcomes between American Indians and Alaska Natives and the general U.S. population persists today, largely due to a lack of access to adequate medical care, language barriers, and decreased quality of medical services in regions with significant American Indian and Alaska Native populations.

The Indian Health Service (IHS) is a federal agency committed to serving the health needs of American Indian and Alaska Native populations. Two pieces of legislation, the Snyder Act of 1921 and Indian Health Care Improvement Act of 1976, obligated the United States government to provide healthcare to federally recognized Native American tribes.[107] This responsibility moved to the IHS, housed under the U.S. Department of Health and Human Services, in 1955.[108] The IHS currently serves over 2.3 million American Indians and Alaska Natives population from 573 different federally-recognized tribes.[109]

Since its implementation, IHS has been criticized for its treatment of patients. Most notably, throughout the 1960s and 1970s, IHS forcibly sterilized thousands of American Indian and Alaska Native women.[110] A study by the General Accounting Office of the United States government found that, between the years of 1973 and 1976, physicians at four IHS facilities – those in Albuquerque, Oklahoma City, Phoenix, and Aberdeen, South Dakota – sterilized a total of 3406 women, 3001 of which were of childbearing age at the time of sterilization.[110]

The federal government has also been criticized for the lack of funding granted to IHS. Expenditures per capita for IHS have been substantially lower than those for other federally funded healthcare programs.[108] Studies have found that physicians employed by IHS express a need for increased funding for the agency to adequately meet the healthcare needs of American Indians and Alaska Natives in the United States.[108]

Because IHS serves only federally-recognized tribes, not all people in the United States that identify with this racial group have access to IHS resources. The American Indian and Alaska Native population includes, but is not limited to, those who are affiliated with federally recognized tribes – there are also state recognized tribes and unrecognized tribes, and individuals who do not live on tribal lands but identify as Native American.[109] Thus, while IHS plays a role in the health outcomes of American Indian and Alaska Native identifying people in the United States, it is not the sole determinant of health outcomes for this census group.

American Indian and Alaska Native identifying people are more likely to have unmet mental health needs and to experience major depressive episodes than the non-Hispanic white population. Compared to only 5.4% of the non-Hispanic white population, 6.7% of American Indian and Alaska Native adults reported having needs for mental health services that had been unmet in the last twelve months. Furthermore, 8.3% of American Indian and Alaska Native adults reported experiencing a major depressive episode in the past twelve months, whereas only 7.4% non-Hispanic white adults did so.[111] American Indian and Alaska Native adolescents are also more likely to have experienced a major depressive episode in their lifetime, with 16.7% of adolescents reporting such an episode compared to 14.4 of non-Hispanic white adolescents.[111] Rates of post-traumatic stress disorder (PTSD) are also higher for American Indians and Alaska Natives than the general United States population.[112]

Some critics of current mental health practices have argued that mental health professionals working with American Indian and Alaska Native communities should adjust their practices to patients' cultures, particularly by increasing attention to spirituality.[111] There have also been efforts to increase understanding of how the symptoms of DSM-recognized disorders may differ in indigenous communities as a result of different cultural practices.[111]

American Indian and Alaska Native youth are slightly less likely than non-Hispanic white youth to receive specialty mental health services, they are significantly more likely to receive non-specialty mental health services such as counseling from social workers, school counselors, and pediatricians.[111]

Maternal mortality rates are 4.5 times higher for American Indian and Alaska Native women than they are for non-Hispanic white women in the United States.[111] Between 2008 and 2012, 5.3% of American Indian and Alaska Native women giving birth were diagnosed with gestational diabetes compared to just 3.7% of non-Hispanic white women.[111]

American Indian and Alaska Native women also are less likely to receive prenatal care than non-Hispanic white women in the United States. Only 60.4% of American Indian and Alaska Native women receive prenatal care in their first trimester, compared to 81.6% of non-Hispanic white women. Additionally, American Indian and Alaska Native women are significantly more likely to not begin receiving prenatal care until their third trimester – 9.3% of American Indian and Alaska Native women compared to 2.9% of non-Hispanic white women. Whereas only 0.8% of non-Hispanic white women do not receive any prenatal care throughout their pregnancy, 2.3% of American Indian and Alaska Native women go entirely without prenatal care.[111]

The infant mortality rate for American Indian and Alaska Native populations also exceeds that of non-Hispanic white identifying people in the United States. American Indians and Alaska Natives experience an infant mortality rate of 8.4 per 1000 live births, compared to 4.1 per 1000 non-Hispanic white live births. Additionally, 15.2% of infants born to American Indian and Alaska Native women are born prematurely compared to just 10.7% of infants born to non-Hispanic white women.[111]

Asian Americans have been a prominent group in the United States for the past 200 years. According to the U.S. Census Bureau, there were estimated to be more than 22 million Asian Americans in the United States as of 2018.[113] The five most prominent subgroups amongst Asian Americans are: Chinese Americans, Indian Americans, Filipino Americans, Vietnamese Americans and Korean Americans.[114]

Asian immigration in large numbers began in the 19th century with significant populations of Chinese Americans, Korean Americans and Japanese Americans entering the United States. However, in the 20th centuries, other groups such as Indian Americans began to immigrate in larger numbers due to more specialized jobs available in the United States.[115]

Asian Americans have often been subject to racism like other minority groups within the United States. This can be seen in events like the Japanese Internment camps like Camp Manzanar that were built during World War II for Japanese Americans to live in and were subject to inhumane treatment.[116]

As Asian Americans have not been coming to America in the numbers of Hispanic immigrants and African Americans, there have been less instances in which they have been used in medical trials and unfairly compensated. In addition, as the wave of migration of Asians to the United States has happened more recently, the history of this group in the United States is relatively young. As a result, there have not been governmental efforts to address health disparities between Asian Americans and the general populations like there have been with other groups like Hispanic Americans, African Americans, and Native Americans.[117]

In 2002, it was reported that Asian American births accounted for 5.2% of the births in the United States. One study that compared births among Indian Americans and non-Hispanic white Americans revealed that Indian Americans had significantly lower birth weights than did non-Hispanic white Americans. It was also revealed that Indian American mothers and non-Hispanic white American mothers had similar rates of adequate prenatal care.[118] In addition, when the infant mortality rates were compared between the groups, Asian Americans (excluding Pacific Islanders) had a lower rate than did non-Hispanic white Americans. However, Pacific Islanders had an infant mortality rate that was much higher than did the Asian Americans and the non-Hispanic white Americans.[119] Similarly, Asian Americans had a maternal mortality rate that was lower than that of non-Hispanic whites as well as the national average in the United States.

There are not many studies concerning mental health outcomes among Asian Americans. Mental health in this group is reported to be relatively better than that of the general population. The Chinese American Psychiatric Epidemiological Study (CAPES) was commissioned to determine the incidence of mental health problems in the DSM III in Chinese American populations. The results of the study showed that roughly 4.9% of the population of Chinese Americans experienced depression this compares to 17.1% of White Americans were classified as clinically depressed.[120] However, this may not be entirely indicative of the true trends with respect to mental health in the population of Asian Americans. According to the NGO Mental Health in America, 5.4% of Americans identify as Asian American, and 13% of this population reported having a diagnosable mental illness in the past year.[121] This proportion of Asian Americans experiencing depression is lower than that of non-Hispanic white Americans. This may be a result of underreporting or lack of diagnoses in the Asian American community due to cultural stigmas surrounding mental health. [122]