Racial Disparities in Health in the United States

Health and longevity statistics differ markedly for racial and ethnic subgroups in the U.S. population (Kawachi, Daniels, & Robinson, 2005; Wang & Beydoun, 2007). These discrepancies follow a familiar pattern, mimicking the contours of inequalities in employment (Hout, 2017), wealth (Shapiro, 2017), earnings (Peterson, Snipp, & Cheung, 2017), and education (Reardon & Fahle, 2017). Specifically, White Americans are advantaged relative to most non-white racial groups (Johnson, 2017; Williams & Sternthal, 2010) with African Americans experiencing the greatest health disadvantages and American Indians also faring poorly compared to Whites (Beydoun et al., 2016; National Center for Health Statistics, 2017). Of non-White racial groups, only Asian Americans exhibit health outcomes that consistently compare favorably with Whites (National Center for Health Statistics, 2017; U.S. Department of Health and Human Services, 2018).

Disparities in Mortality

Health inequities are well-illustrated by mortality data (Beydoun et al., 2016; Borrell, Dallo, & Nguyen, 2010; Richardus & Kunst, 2001). The all-cause death rate for 2016 was 18 percent higher for non-Hispanic African Americans than non-Hispanic Whites (U.S. Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), 2018). Native Americans’ all-cause mortality rates were roughly seven percent higher than for white non-Hispanics (U.S. Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), 2018). Asian Americans had mortality rates 47 percent lower than non-Hispanic Whites (U.S. Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), 2018). Interestingly, people of Hispanic/Latino origin (of any race) had nearly 30 percent lower mortality rates than non-Latinos (of any race). This difference reflects the so-called “Latino paradox,” whereby Latinos do better than expected on various health outcomes despite relatively low socioeconomic status and poor access to healthcare (Borrell, Dallo, & Nguyen, 2010; Hummer et al., 2007; Markides & Coreil, 1986; Markides & Eschbach, 2005).

Although race disparities in mortality rates are present across the life span, the gap is most pronounced among juveniles and young adults. All-cause death rates for persons aged 65-plus were 7 percent higher for non-Hispanic Blacks than Whites (U.S. Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), 2018). For young people aged 1 to 24, the disparity was substantially greater with all-cause death rates 60 percent higher for African Americans than Whites (U.S. Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), 2018). Moreover, infant death rates (< 1 year of age) were 2.3 times greater for African Americans than Whites (U.S. Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), 2018). Given the preceding data, it is easy to understand why African Americans live, on average, four years fewer than Whites (Kochanek, Murphy, & Xu, 2015).

Disparities in Physical Disease

There are also marked racial disparities in the prevalence of many illnesses with Blacks again disadvantaged relative to Whites (Hayward & Heron, 1999; Johnson, 2017; Massoglia, 2008b). In general, this pattern holds for chronic non-infectious conditions such as diabetes, obesity, and heart disease (Centers for Disease Control, 2018; National Center for Health Statistics, 2017) and for serious infectious diseases including tuberculosis (Nahid et al., 2011), helicobacter pylori (McQuillan et al., 2004), HIV (Centers for Disease Control and Prevention, 2017a) and several STDs (Centers for Disease Control and Prevention, 2017b).

Racial/ethnic differences in disease prevalence occur for children and adolescents as well as adults. Asthma, one of the most common chronic conditions affecting U.S. youth, occurs at higher rates among Puerto Ricans and African Americans than among Whites or Mexican Americans (Price et al., 2013). Obesity is more prevalent for African American and Hispanic youth relative to White youth (Price et al., 2013; Singh, Siahpush, & Kogan, 2010). Prevalence of youth diabetes also differs by race, but the pattern depends on the disease type. Type 1 is most common among non-Hispanic White youths whereas Type II is most common for American Indian and African American youths (Centers for Disease Control and Prevention, 2018; Spanakis & Golden, 2013).

Disparities in Mental Illness

Evidence of racial disparity in the prevalence of mental illnesses also exists, but the pattern is not simple. In general, non-White racial groups have a lower prevalence of (any) mental illness than Whites (Budhwhani, Hearld, & Chavez-Yenter, 2015). But nuances appear in the story. First, despite lower overall mental illness prevalence, evidence indicates that non-Hispanic Blacks who become ill are more likely to experience a persistent disorder than non-Hispanic Whites (Breslau et al., 2005). In addition, while some depressive disorders like major depression are less common among African Americans than Whites other depressive disorders, like dysthymia, are more common for African Americans (Riolo et al., 2005). Finally, some research suggests that non-Hispanic Blacks have higher lifetime prevalence of post-traumatic stress disorder (PTSD) or are more likely to be diagnosed with schizophrenia than non-Hispanic Whites (Blow et al., 2004; Coleman et al., 2017; Eack et al., 2012; Roberts et al., 2011).

Racial and ethnic differences in mental health conditions also occur for adolescents. Kilpatrick and colleagues (2003) examined racial/ethnic differences in PTSD, major depressive episodes and substance abuse/dependence among a national sample of adolescents aged 12 to 17. They found significant differences for both PTSD and substance use/dependence. For the former, both African American and Hispanic adolescents had higher odds (odds ratios of 2.5 and 4.1, respectively) than White adolescents. For the latter, African American adolescents reported 74 percent lower odds than Whites. No statistically significant racial/ethnic differences were observed for major depression episodes.

Disparities in the Healthy Life-Span

Taken together, the preceding sections are strong evidence of racial differences in the prevalence of physical and mental illnesses. From this we can expect that racial groups differ in the share of their lives characterized by good health. One gauge of this difference is measured by “active life expectancy,” which estimates the average number of years one can expect to live without activity limitations (Centers for Disease Control and Prevention, 2013a). Using data from 2008, the CDC estimated that, on average, White Americans were expected to live around 67 years without activity limitations due to chronic illness. In comparison, Black Americans were expected to live only 61 years without limitations (Centers for Disease Control and Prevention, 2013a). These disparities also show up in survey measures of self-rated health. For example, data from the Behavioral Risk Factor Surveillance System shows that in comparison to non-Hispanic Whites, a significantly higher percentage of non-Hispanic Blacks report their health as “fair or poor” (23.3 percent vs. 13.3 percent). Moreover, African Americans also report significantly more physically and mentally unhealthy days in the last month that do White respondents (Centers for Disease Control and Prevention, 2013b).

In sum, for adults and juveniles, health outcomes clearly vary by race and ethnicity. Exacerbating these disparities is the fact that, on average, there are differences in healthcare. Evidence suggests that African Americans have lower access to and utilization of medical services than Whites (Artiga et al., 2016). Moreover, while the Affordable Care Act has lowered the overall share of the population lacking health insurance and reduced disparities in coverage, key racial/ethnic differences in access and utilization persist (Artiga et al., 2016; Artiga, Foutz, & Damico, 2018).

Common Cause Theories

Similarity in the racial patterning of health and criminal justice outcomes is potentially explained by theories of common cause. In general, these explanations assert that health and criminal justice system outcomes vary together because they respond to the same underlying causal forces. That which explains why Whites experience lower morbidity and mortality rates relative to people of color also explains why African Americans and Latinos are overexposed to incarceration. Specific mechanisms invoked by common cause theories vary but can broadly be distinguished based on whether they posit shared causes as features of the social structure or as characteristics or traits of individuals.

Social structure theories argue that broad features of the social organization of communities or places are what produce variations in health outcomes and determine differences in the risk of criminal justice system exposure. These theories emphasize that social, economic, political, and cultural conditions of communities create benefits or harms for resident populations. Deprivation theory is an example. It contends that the cause of many undesired outcomes, including poor health, high crime, and incarceration is socioeconomic deprivation. Populations in communities experiencing higher levels of poverty, unemployment, school dropout, family breakdown and civic disengagement (among others) are at greater risk for contracting diseases, more likely to experience diseases chronically, more likely to die early deaths from disease, more likely to engage in law-violating behavior, and more likely to be incarcerated for their criminal behavior. This is because these forms of economic, social, and political deprivation trigger greater exposure to risks factors (e.g., environmental toxins, infectious pathogens, inadequate childhood nutrition, stressful situations, criminal networks) and limit availability of protective factors (e.g., social supports, prosocial capital, health knowledge, medical care, legal resources), which proximally influence illness, crime, and related consequences (Barkan & Rocque, 2018; Cockerham, 2013; Link & Phelan, 1995). Supporting this argument, numerous studies report that resource deprivation measures are associated with the prevalence or rate of: physical and mental illness, health-risk behaviors, crime, arrests, and incarceration (Cohen et al., 2000; Ford & Browning, 2011, 2013; Kirk, 2008; Ousey, 2017; Ross, 2000; Sampson & Loeffler, 2010; Silver, Mulvey, & Swanson, 2002).

The deprivation theory also provides explanation of racial disparities in health and criminal justice system contact in the United States. According to the theory, rates of illness and criminal justice system contact should be greater for racial and ethnic groups experiencing higher rates of poverty and other forms of resource deprivation. Consistent with this argument, racial groups with the highest poverty rates (e.g., African Americans) have illness, mortality and incarceration rates substantially greater than groups with lower poverty rates (e.g., Whites, Asian Americans) (Carson, 2018; Macartney, Bishaw, & Fontenot, 2013; National Center for Health Statistics, 2016; Puzzanchera & Hockenberry, 2018; The Sentencing Project, 2017). Moreover, studies suggest that racial and ethnic disparities in crime, arrest, and health are associated with racial-ethnic differences in socioeconomic deprivation (Kirk, 2008; McNulty & Bellair, 2003; Williams & Sternthal, 2010).

A second common cause argument asserts that racial discrimination explains the disproportionate racial/ethnic concentration of disease, crime, arrests, and incarceration. It links historic and contemporary manifestations of systemic racism—slavery, Jim Crow, anti-miscegenation laws, school segregation, discriminatory bank-lending, gerrymandering, vote-suppression, white-flight, and residential segregation—to forms of racial inequality. Thus, it offers explanation for why the pattern of racial and ethnic disparities is similar for outcomes as diverse as health/illness and criminal justice system exposure (Phelan & Link, 2015; Barkan & Rocque, 2018; Burch, 2014; Ousey, 2017; Ousey & Lee, 2008; Williams & Collins, 2001; Kramer & Hogue, 2009). It also offers a theory of relative disadvantages faced by different racial and ethnic groups. In the United States, systemic racial discrimination has most severely impacted African Americans, accounting for why they tend to experience the greatest disadvantages in many social outcomes, including health and criminal justice. Finally, as was true for the resource deprivation perspective, this theory suggests that racial discrimination affects health and criminal justice outcomes through a host of intervening mechanisms, but clearly asserts systemic racism as the “fundamental” cause (Barkan & Rocque, 2018; Phelan & Link, 2015).

The theory of racial discrimination draws general empirical support from research which links a salient form of systemic racism, racial residential segregation, to various health and crime/criminal justice outcomes including: greater overall morbidity and mortality rates (Kramer & Hogue, 2009; Williams & Collins, 2001; Williams & Sternthal, 2010), higher rates of incarceration (Burch, 2014), elevated crime rates among African Americans (Feldmeyer, 2010; Krivo, Peterson, & Kuhl, 2009; Peterson & Krivo, 1993; Shihadeh & Flynn, 1996), greater between-race disparities in infant mortality and preterm births (Bird, 1995; LaVeist, 1989; Osypuk & Acevedo-Garcia, 2008; Polednak, 1991), more substantial racial disparity in homicide rates (Velez, Krivo, & Peterson, 2003), and greater black/white disparities in arrests for drug and weapons offenses (Ousey & Lee, 2008). Likewise, it is supported by scholarship showing that individuals with greater personal experiences and perceptions of racial discrimination are more likely to exhibit an array of mental and physical health problems (Williams & Mohammed, 2009), delinquency (Burt, Simons, & Gibbons, 2012), violence (Simons et al., 2006), problematic externalizing behaviors (Unnever, Cullen, & Barnes, 2016), and illegal drug use (Borrell et al., 2007; Gibbons et al., 2007).

Not all common cause explanations identify social-structural factors. An alternative suggests that specific individual-level characteristics produce greater risks of negative health outcomes and criminal justice system exposure. One example is Gottfredson and Hirschi’s (1990) self-control theory. It assumes individuals are motivated by self-interest and seek to satisfy needs and wants quickly. Unhealthy eating, improper hygiene, promiscuity, lying, stealing, and aggression can help satisfy short-term needs, but at the cost of increased risk of illness, of legal consequences, and of shortening the life-span. The person with low self-control has difficulty seeing and properly weighing those costs. Since our society values health, law abidance and longevity, its task is teaching individuals to respect those values and exercise constraints needed for their attainment. Individuals must learn to correctly weigh future costs against their desires for immediate pleasure. According to Gottfredson and Hirschi’s theory, self-control should emerge in kids between ages 5 and 10 as parents monitor their behavior and correct wrongdoing with appropriate sanctions. Proper parenting teaches that the pursuit of self-interest must be restrained in ways that limit risks of disease, jail and early death. However, because parenting is not always effective some individuals remain low in self-control and experience higher risks of criminal behavior, criminal justice exposure, and negative health consequences.

Empirical research supports the idea that self-control explains both crime involvement and poor health outcomes. Pratt & Cullen’s (2000) meta-analysis concluded that self-control was one of the strongest individual-level crime correlates. Numerous subsequent studies bolster that conclusion. Low self-control has been found predictive of various types of criminal offending across diverse samples varying by age, national origin, and economic disadvantage or crime-risk level (for review, see Hay & Meldrum, 2016, pp. 58–61). Moreover, research shows an association between self-control and various health indicators including: body mass index ( Crescioni et al., 2011; Schlam et al., 2013); exercise and good nutrition (Wills et al., 2007); depression, mental health, and psychiatric disorders (Boals, vanDellen, & Banks, 2011; Caspi et al., 1996; Miller, Barnes, & Beaver, 2011); an index of respiratory, periodontal, metabolic, inflammatory, and sexually transmitted infectious conditions (Moffitt et al., 2011); and early mortality (Kern & Friedman, 2008).

Gottfredson and Hirschi’s (1990) theory attributes racial and ethnic differences in crime to group differences in self-control, which are the result of: “potentially large differences among racial groups … in the elements of child-rearing” (153). And although their theory is not meant to explain health outcomes, its logic implies that White Americans experience lower disease prevalence and lower mortality rates because, on average, they have developed higher levels of self-control than African Americans and other people of color. Unfortunately, research addressing whether self-control theory explains racial disparities in crime or health outcomes is relatively scarce. Some basic support can be gleaned from studies that indicate Whites and non-Whites differ on measures of parenting practices or on self-control (Higgins & Ricketts, 2005; Pratt, Turner, & Piquero, 2004) and other studies which show that the experience of racism depletes self-control in racial minority groups (Gibbons et al., 2012). However, other research evidence runs counter to the idea that race-differences in self-control are responsible for race differences in crime and criminal justice system exposure. For example, some studies find that race remains a significant predictor of crime, even when race differences in self-control are controlled (Kirchner & Higgins, 2014; Longshore, 1998). And other work reports that self-control does not differ by race (Hay, 2001) or is not predictive of delinquency for Blacks (Higgins & Ricketts, 2005). Thus, at present, the research evidence is too shallow and findings too ambiguous to support strong conclusions about whether differences in self-control explain observed patterns of racial disparity in health and crime.

Health Effects on Incarceration

Do health conditions play a role in the genesis of crime and criminal justice exposure? And do racial disparities in health contribute to racial disparities in incarceration? Until recently, criminological scholarship neglected this connection. However, there is now growing scholarly interest in connections between health, crime and criminal justice (Jackson & Vaughn, 2018b).

Health conditions occurring in the earliest stages of life are one avenue linking health and criminal behavior. It is known that maternal prenatal health problems, including the experience of high levels of stress, negatively impact fetal health and development (Dunkel Schetter, 2011; Gourounti, Karpathiotaki, & Vaslamatzis, 2015; Weinstock, 2008). Moreover, maternal health risks also are associated with problematic externalizing behaviors in offspring. Jackson and Vaughn (2018a) report that male offspring exposed to a greater accumulation of maternal health factors (e.g., anemia, cardiac or lung disease, diabetes, preeclampsia, obesity) during the prenatal period have a significantly greater likelihood of developing persistent externalizing behavior problems (e.g., impulsivity, aggression, provocation, hyperactivity) during preschool and kindergarten ages. Reasons are not completely clear, but stress/anxiety processes, neuropsychological functions, and temperament are potentially salient intervening mechanisms for the observed effects (Jackson & Vaughn, 2018a).

Exposure to environmental toxins is another health risk that may affect criminal behavior. Research by Needleman and colleagues (Needleman, 2004; Needleman et al., 1979, 1996) showed that low levels of lead exposure creates health and behavioral consequences, especially for young children. Problems with neurological development, motor function, learning, cognition, and attention-deficits all appear at elevated rates in children with greater lead exposure (Needleman, 2004). Building on this work, a growing research literature suggests that lead exposure may help explain juvenile delinquency and violent crime (Dietrich et al., 2001; Martin & Wolfe, 2018; Needleman et al., 2002, 1996; Nevin, 2007; Reyes, 2007, 2015; Stretesky & Lynch, 2001, 2004; Wright et al., 2008).

Research also suggests that traumatic brain injuries (TBI) produce short- and long-term behavioral effects (LeÓn-CarriÓn & Ramos, 2003; Li & Liu, 2013). Prior brain injury is up to ten times more common among incarcerated than general populations (Schwartz, Connolly, & Valgardson, 2018). In addition, research from Sweden indicates that individuals who experienced TBI had more than three times the odds of violent behavior than individuals with no TBI (Fazel et al., 2011). Sibling comparisons revealed that the odds of violence were double for siblings with a TBI history relative to siblings without a TBI history (Fazel et al., 2011). However, some recent research suggests that while correlated, brain injury does not cause subsequent involvement in criminal behavior (Schwartz, Connolly, & Valgardson, 2018).

Adverse child experiences (ACE) include unhealthy social experiences such as physical, sexual and emotional abuse, physical or emotional neglect, and witnessing violence in the household or neighborhood context. They may contribute to an elevated prevalence of mental health problems and greater involvement with crime and the criminal justice system. Consistent with that argument, evidence indicates that individuals in the criminal justice system report higher levels of ACE (Reavis et al., 2013) and greater evidence of PTSD and other psychiatric disorders (Briere, Agee, & Dietrich, 2016) than general/non-incarcerated populations. Moreover, some research reports that ACE and related trauma exposures are associated with subsequent behavioral problems (Wolff & Shi, 2012), including violence (Duke et al., 2010). However, recent research suggests that the relationship between ACE and antisocial behavior may be non-causal (Connolly, 2018).

A major consequence of the behavioral effects linked to the negative health conditions noted above is racial disparity in the risk of incarceration, especially for African Americans. Race differences in exposure to lead, poor prenatal health, TBI and ACE are likely to produce group differences in the prevalence of negative behaviors, which subsequently yield racial disparities in criminal justice system exposure. Because of systemic racism, racial residential segregation has concentrated many African Americans in residential spaces with greater exposure to toxic environments. Indeed, research indicates communities with higher African American population shares have higher levels of exposure to lead (Sampson & Winter, 2016; Stretesky, 2003), concentrated poverty (DeNavas-Walt, Proctor, & Smith, 2014; Logan, 2014) and racial discrimination which are likely to negatively impact prenatal and early childhood health through increased exposure to stress, ACE or other traumatic events (Bruner, 2017; Nagahawatte & Goldenberg, 2008). Not surprisingly, Eitle and Turner (2003) found that African Americans had higher rates of lifetime stress, leading to race differences in offending (Eitle & Turner, 2003).

Incarceration Effects on Health

Extant research indicates that risks of chronic physical disease are disproportionately elevated among correctional populations relative to the general population (Binswanger, Krueger, & Steiner, 2009; Cloud, 2014; National Commission on Correctional Health Care, 2002). Some of this disproportion may be the result of selection effects in which people with poor health are more likely to commit crime and face incarceration, but there is also reason to believe that incarceration negatively impacts health outcomes (Schnittker & John, 2007). Because incarceration rates are substantially greater for African Americans than Whites, it follows that racial disparities in health may be, in part, influenced by race differences in incarceration.

The impact of incarceration on health can play out in several ways. First, incarceration may increase exposure to infectious diseases (Cloud, 2014; Massoglia, 2008a, 2008b; National Commission on Correctional Health Care, 2002). Second, incarceration is a major life event and chronic stressor, both of which negatively impact health functioning (Massoglia, 2008a). Third, incarceration negatively impacts employment opportunities and disrupts family connections, which are associated with health (Massoglia, 2008b; Ross & Mirowsky, 1995; Ross, Mirowsky, & Goldsteen, 1990). Fourth, incarceration may negatively impact mental health conditions, such as mood disorders (Schnittker, Massoglia, & Uggen, 2012). Finally, incarceration effects on health may extend to the families and broader communities of incarcerated individuals. Several studies indicate that incarceration is associated with higher rates of infectious disease (Johnson & Raphael, 2009; Stuckler et al., 2008; Thomas & Torrone, 2008). Others show that parental incarceration is associated with elevated risks of behavioral problems and mental health issues among children (Turney, 2014; Wakefield & Wildeman, 2011). With over 2.7 million children experiencing the incarceration of a parent (Pew Charitable Trusts, 2010), it is a serious health concern.

The burden of incarceration is most heavily experienced by people of color (Massoglia, 2008b; Petit & Western, 2004). Moreover, evidence suggests that the health status of blacks has worsened relative to whites during the period of rising incarceration rates (Massoglia, 2008b). Consequently, race differences in exposure to incarceration may partly explain the persistent and growing health disparities between Blacks and Whites. Direct research evidence on this issue remains limited, but findings are suggestive. Massoglia (2008b) examines the effects of incarceration on race disparities in general health functioning. He reports that incarceration is associated with poorer general health functioning and that a substantial proportion of the racial disparity in general health functioning is explained by race differences in incarceration exposure. Additional evidence in Johnson and Raphael (2009) shows that higher black male incarceration rates explain much of the racial disparity in AIDS infection among women.

Beyond empirical evidence, there are logical reasons to expect that incarceration plays a role in racial disparities in health. Incarceration is selective; it disproportionally affects high-poverty, high minority communities (Burch, 2014). Moreover, incarceration destabilizes communities by escalating strains, reducing employment prospects and damaging the prosocial family relationships that are critical for economic viability and social organization (Clear, 2007; Rose & Clear, 1998). For example, high incarceration rates reduce the number of men, destabilizing marriage markets (Wolfers, Leonhardt, & Quealy, 2015) and depressing the prevalence of a key community-level protective factor. In addition, communities destabilized by incarceration likely result in feelings of stress and despair, particularly for juveniles. Consistent with this argument, research indicates that African American teenagers are less likely to believe their lives will extend to the age of 35 and beyond (Warner & Swisher, 2015). In sum, there are strong empirical and logical reasons behind the view that dramatic racial disparities in incarceration in the United States contribute to racial differences in disease prevalence and overall health.