Journal of Health Politics, Policy and Law
Does Racism Affect Health?
Evidence from the United States
and the United Kingdom
Peter Muennig
Columbia University
Michael Murphy
London School of Economics
Abstract Blacks have worse overall health than whites in both the United States
and the United Kingdom. However, the relative difference in health between the two
groups within each cultural context differs between each context. In this article, we
attempt to glean insights into these health disparities. We do so by first examining
what is currently known about differences in morbidity and mortality for blacks and
whites in the United States and the United Kingdom. We then turn to medical examination data by race and country of birth in an attempt to further untangle the complex
interplay of socioeconomic status (SES), race, and racism as determinants of health in
the United States and the United Kingdom. We find that (1) longer exposure of blacks
to the recipient country is a risk for mortality in the United States but not in the United
Kingdom; (2) adjustment for SES matters a good deal for mortality in the United
States, but less so in the United Kingdom; (3) morbidity indicators do not paint a clear
picture of black disadvantage relative to whites in either context; and (4) were one to
consider medical examination data alone, differences between the two groups exist
only in the United States. Taken together, we conclude that it is possible that the “less
racist” United Kingdom provides a healthier environment for blacks than the United
States. However, there remain many mysteries that escape simple explanation. Our
findings raise more questions than they answer, and the health risks and health status
of blacks in the United States are much more complex than previously thought.
We would like to thank Celina Su for her contributions to both the conceptual framework and
the development of the article and Gary Younge for his thoughts. We would also like to thank
members of the LSE – Columbia Health Policy Group for their help and support in developing
this article.
Journal of Health Politics, Policy and Law, Vol. 36, No. 1, February 2011
DOI 10.1215/03616878-1191153 © 2011 by Duke University Press
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188 Journal of Health Politics, Policy and Law
Introduction
Race appears to be a stronger determinant of health in the United States
than in the United Kingdom (Nazroo 2003; Office of Population, Censuses, and Surveys 1990; Chaturvedi and Fuller 1996; Franks et al. 2006;
Williams 1999). In the United States, were those who identify as “black”
to live as long as whites, the average black would gain about 7 years, or
about 2.2 million additional years of life over the entire cohort of African
Americans (Franks et al. 2006). While overall mortality rates for blacks
in the United Kingdom are not available (Sproston and Mindell 2006),
mortality rates among African-­born people in the United Kingdom are
somewhat higher than for the native-­born, overwhelmingly white population (Bhopal 2007; Wild et al. 2007).
There are several possible reasons for these findings. They may reflect
the generally lower socioeconomic status (SES) of blacks, differences in
lifestyles, genetic characteristics, or some combination of these characteristics. A full elucidation of the relative contributions of these and other
possible explanations is beyond the scope of this article. Rather, we concentrate on one hypothesized factor, the impact of racism on health.
Various researchers have hypothesized that the poor health of black
Americans relative to white Americans can be attributed to racism (Williams 1997, 1999; Bhopal 1998; Jackson et al. 1996; Tull et al. 2005).
Primarily following Williams (1999), we define three forms of racism
that might affect health. The first is “institutional racism,” which arises
via structural factors that, in turn, arise from historical discriminatory
policies. For example, historical practices such as “redlining” (denying
loans to poor black communities) contributed to impoverishing black
communities in the United States, and this poverty has been transmitted
through generations. A second form can be broadly defined as “intentional
racism,” which occurs when one actor’s racist beliefs influence another
actor’s well-­being. For example, an employer might strongly prefer one
job candidate over a similarly qualified candidate based on his or her race.
A final form is “perceived racism,” which occurs when the individual
believes that he or she is being discriminated against when, in fact, no
discrimination is present. For instance, if a banker denies a loan to a black
person, that person may be more likely than a white person to attribute the
slight to his or her race. Clearly, each of these forms of racism overlaps.
For example, based on historical lending practices, U.S. blacks have reason to believe that they are being discriminated against even when they
are not. However, for simplicity, we use these broad definitions.
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Muennig and Murphy ■ Does Racism Affect Health? 189 To explore the possible impact of these various forms of racism on
health, we examine (1) cross-­national differences in institutional, intentional, and perceived racism between the United States and the United
Kingdom, and (2) differences in exposure to racism within each context
by comparing black-­white differences by nativity (Williams 1997, 1999;
Bhopal 1998; Jackson et al. 1996; Tull et al. 2005).
Since people living in the United Kingdom are healthier than those living in the United States, at least for ages fifty-­five to sixty-­four (Central
Intelligence Agency 2009; Banks et al. 2006), our discussion focuses on
the relative health and longevity differences between blacks and whites.
Relative comparisons help remove cross-­national differences other than
those attributable to race.
Conceptual Framework
To determine whether questions about the racism-­health linkage can be
answered via a cross-­national perspective, we must first establish that there
are, in fact, black-­white differences in morbidity and mortality between the
United States and the United Kingdom. Second, we must determine the
nature of racism in the context of the two countries. Third, we must demonstrate that our conceptual understanding of the psychosocial elements
of racism is plausibly translated into biological disease. Fourth, we must
examine whether there are alternate explanations for these health differences, such as distributional effects (e.g., blacks concentrated in areas that
happen to be less healthy in one country but not the other) or genetics. As
a final step, we attempt to meld what we have learned from our literature
review with a quantitative analysis of medical examination data.
This final step exploits various advantages of nationally representative medical examination data to help refine what we have learned from
our literature review. First, it allows for objective black-­white measures
of cross-­national medical examination outcomes. If the United States
is a less favorable environment for blacks, then we would expect to see
greater differences between the two groups in the United States than the
United Kingdom. Second, it allows for black-­white comparisons by nativity. This has the additional advantage of providing information on the
health effects of exposure to a given context. If the United States has more
intentional racism than the United Kingdom, then we would expect to see
larger foreign-­born black-­white differences in the United States than in
the United Kingdom. Third, it allows for black-­white comparisons before
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and after controlling for SES. If institutional racism plays a larger role
in the U.S. context, then we would expect to see black-­white differences
shrink to a greater extent in the United States than the United Kingdom
when SES is held constant. Finally, medical examination data provide
objective measures of health that are not influenced by self-­reporting (a
common problem with morbidity measures), and such data are not subject to cross-­national death coding differences or “salmon bias” (Abraido­Lanza et al. 1999). Salmon bias occurs when foreign-­born people return to
their country of origin. Because there is no record of their eventual death,
they become statistically immortalized in the host country. Salmon bias
could affect cross-­national comparisons because there are many fewer
undocumented African immigrants in the United States than in the United
Kingdom. Thus, in the United States, mortality statistics may undercount
denominator values, and the U.K. mortality statistics may undercount
numerator values.
In the first section, we provide an overview of what we know about
the health of blacks in the United States and in the United Kingdom. The
second section contains a review of the literature on cross-­national differences in racial experiences. Then, in the third section, we outline the specific pathways through which racism influences health. The fourth section
explores cross-­national differences unrelated to racism that might explain
black-­white differences in health. In the fifth section, we consider the role
of genetics and other factors that might be unrelated to racism. In the sixth
section, we present results on differences in health status between U.S.
and U.K. populations. We find that measures of health are generally better
among blacks in the United Kingdom and black immigrants to the United
States, and that education and income play only a limited role in both contexts. Finally, we conclude that on examining these data and the literature
to date, some, but not all, lines of evidence support the hypothesis that
racism is greater in the United States and that this racism is driving the
poor health outcomes of black Americans.
The History and Health of Blacks in the
United States and the United Kingdom
U.S. racism differs from racism in the United Kingdom primarily in terms
of historical discriminatory social policies that continue to ripple through
modern-­day American society. Blacks have been a significant part of the
demographic mix in the United States since the nation’s founding and have
a long history of exposure to everyday racism and governmental discrimi-
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Muennig and Murphy ■ Does Racism Affect Health? 191 natory policies. These include policies that kept black Americans living in
concentrated poverty with no access to financial institutions (“redlining”),
decreased access to jobs (“spatial mismatch”), and poorly funded schools
(Holmes and Horvitz 1994; Fernandez and Su 2004). These problems
have contributed to persistent socioeconomic disparities between blacks
and whites in the United States. These disparities, in turn, may account
for some or all of the large health disparities between these two groups in
the United States (Muennig et al. 2005; Muennig et al. 2010).
In the United Kingdom, blacks have become a significant portion of the
demographic mix only over the past two generations, and they remain a
relatively small portion of the population, being outnumbered by whites
by twenty-­five to one. This compares with a ratio of five to one for non­Hispanic whites to blacks in the United States. As a result, there are significantly fewer historical social practices and policies that prevent blacks
from accessing social goods and services today (Hills et al. 2010). Large­scale black immigration from the principal area of origin, the Caribbean,
was particularly concentrated from the mid-­1950s until 1962, when restrictions on entry were introduced (Spencer 1997; Hills et al. 2010; Bhopal
1998; Kunitz and Pesis-­Katz 2005).
Validity of Intergroup Comparisons
U.S.-­born blacks have a similar lineage to the native-­born black Caribbeans in the United Kingdom. Many of the ancestors of both groups were
abducted and brought from West Africa under extremely harsh conditions
to work as slaves (Curtin 1998). While the U.K. black population consists mainly of recent voluntary immigrants and their descendants, the
British Empire’s history is not so different from that of the United States
(slavery was fully abolished in the British Caribbean in 1838, less than
three decades before the United States). More recently, many of these
emancipated slaves or their descendants migrated; in the United States
from the rural South to the urban North, and from the Caribbean to the
urban United Kingdom in search of better lives. The initial Caribbean
migrants had full British passports including unrestricted right of entry
to, and abode in, the United Kingdom. In some cases they had been fully
participating members of the wartime British armed forces.
The second main group of blacks in both the United States and the
United Kingdom consists of immigrants from Africa and their descendants. In both cases, this is a demographically mixed group (U.S. Bureau
of the Census 2000; Office for National Statistics 2006). In the United
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States, immigrants form a small proportion of the black population.
However, black people who immigrate to the United States (a mixture of
Caribbean and African immigrants) tend to far outlive white Americans
(Fang, Madhavan, and Alderman 1996). The African-­born population in
the United Kingdom, on the other hand, who are often separately identified in the literature and further subdivided, show higher mortality (Wild
et al. 2007). This disaggregation is done, in part, because a high proportion of those born in East Africa are of South Asian rather than African
ancestry. However, the substantially greater longevity of African-­born
blacks in the United States relative to U.S.-­born whites may partly reflect
the greater overall longevity of whites in the United Kingdom relative to
whites in the United States (Banks et al. 2006).
Cross-­National Differences in
Racial Experiences
In his travelogue, the black U.K.-­b orn writer Gary Younge (1999)
describes his misadventures as he moves through the Southern United
States in search of a foreign black diaspora. He feels that in the United
States racism is built on official discrimination (e.g., segregation, redlining) and displays of public hatred (e.g., the Ku Klux Klan). In the United
Kingdom, he concludes, racism is mostly a private matter.
If Younge’s journalistic observations are right, then we might think
of U.S. racism as a combination of interpersonal beliefs and “structural”
ills, such as institutional limits on blacks’ educational potential, economic
opportunities, access to health care, and so forth. In the United Kingdom,
on the other hand, the structural component of racism for blacks is less
pronounced, if for no other reason than blacks have not been around long
enough for deep institutional racism to take root. However, this does not
mean that it is not pervasive in the United Kingdom, as shown in the
report following the racist murder of eighteen-­year-­old black student Stephen Lawrence in 1993 (Macpherson 1999).
Structural Racism
There are some data to support this hypothesis. In the United States, poor
whites often reside in middle-­class areas (Fernandez and Su 2004). Poor
blacks, on the other hand, tend to live in mostly black pockets of concentrated poverty, with inadequate housing, unhealthy food options, no
opportunities for banking, poor access to public transit, and poor access
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Muennig and Murphy ■ Does Racism Affect Health? 193 to medical care (ibid.). These problems are propagated over generations
by failing schools. In New York City, at least one school begins lunch at
9:21 in the morning because of lack of space in the cafeteria (Gootman
2003). In some schools, it can take an hour to get through security such as
metal detectors, and other schools have no working bathrooms (Alonso,
Anderson, Su, and Theoharis 2009).
Blacks in U.K. schools do not often suffer from such stark disparities.
That said, in the United Kingdom, blacks are also disadvantaged in terms
of education, employment, income, housing, and location (Hills et al.
2010). Nonetheless, access to functioning schools, financial institutions,
health care, and transportation infrastructure is probably better for blacks
in the United Kingdom than for blacks in the United States, where federal
social welfare programs are much smaller in scope (Kunitz and Pesis-­Katz
2005). For instance, employment rates have been increasing for black men
in the United Kingdom, largely due to improvements in their educational
attainment (Hills et al. 2010). Moreover, they are not as geographically
concentrated, usually forming only a relatively small portion of the areas
they live in (ONS 2006), and educational achievement for blacks in the
United Kingdom is similar to that of white youths living in similar areas
(Cassen and Kingdon 2007). Like many first-­ and second-­generation
immigrant groups, blacks in the United Kingdom are not, on average, as
wealthy as U.K.-­born whites (Hills et al. 2010). As in the United States,
there is evidence that blacks sometimes face discrimination within the
National Health Service in the United Kingdom (Bhopal 1998).
If we accept that these direct and indirect forms of racial discrimination
explain the poor health outcomes of blacks in the United States, then we
would expect blacks in the United Kingdom, who have relatively smaller
health differences, to also be exposed to a narrower array of discriminatory practices.
Intentional Racism
Both countries suffer from day-­to-­day interpersonal discrimination. In one
experiment within the United States, job applicants with black-­sounding
names were found to be much less likely to be successful (Fryer and Levitt
2004). A similar situation with respect to employment of ethnic minority
groups is found in the United Kingdom, although it is more of an issue for
South Asian groups who are more readily identified (Roberts and Campbell 2006; Hills et al. 2010). It is difficult to compare employment rates
cross-­nationally, but blacks in the United States are half as likely to be
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employed as whites (Bureau of Labor Statistics 2010). In the United Kingdom, the differences are much smaller; blacks have only slightly lower
employment rates than whites, although their unemployment rates are
about twice those of whites (Hills et al. 2010). While blacks fare worse in
general than the white U.K.-­born population, on many indicators, blacks
are less disadvantaged than some other ethnic groups such as Bangladeshis (ibid.).
How Racism Might Affect Health
Racism is thought to explain the black-­white health differences observed
in the United States (Williams 1997, 1999). The effects of institutional
racism lead to economic deprivation, which is bad for one’s health for
a number of reasons, including poor housing, exposure to dangerous
neighborhoods, lack of access to healthy food, riskier work, and a lack of
health insurance (Adler and Ostrove 1999). The indirect effects of racial
discrimination are thought to affect health by effectively “stressing” the
individual, leading to neuroendocrine disruptions that affect one’s physical and mental health (McEwen 1998).
Intentional racism and perceived racism can serve as psychological
stressors. Public health researchers generally accept that psychological
stressors affect health by disrupting the body’s normal physiological feedback loops, a process called “allostatic load” (McEwen 1998; McEwen and
Mirsky 2002). Perceived racial discrimination has been added to the long
list of potentially harmful psychological stressors (Banks, Kohn-­Wood,
and Spencer 2006; Krieger and Sidney 1996; Ren, Amick, and Williams
1999; Williams 1999; McEwen 1998; Epel et al. 2004; McNeilly et al.
1995).
Institutional, intentional, and perceived racism overlap, of course; educational attainment is a strong predictor of poverty, and poverty increases
psychological stress via fear of crime, food insecurity, low job control
associated with poor working environments, poor housing conditions, illness, injury, and higher mortality among loved ones (Nord, Andrews, and
Carlson 2009; Adler and Ostrove 1999). These factors may compound any
adverse effects of the stress associated with racial discrimination.
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Muennig and Murphy ■ Does Racism Affect Health? 195 The Black-­White Health Differences in the
United States and the United Kingdom
What We Know about Black-­White Health
in the United States
Black-­W hite Mortality. Black mortality risks in the United States vary
greatly from place to place (Geronimus et al. 1996). While the mortality
rates of blacks in Queens or the Bronx in New York are comparable to
those of whites, black fifteen-­year-­old adolescent males living just a few
miles away in Harlem only had a 37 percent chance of surviving to retirement age (sixty-­five years) in 1990, the latest year for which data were
available.
Mortality also varies greatly depending on SES. Overall, whites live
about seven years longer than blacks in the United States, but this number shrinks to three years when income and education are held constant
(Franks, Muennig, Lubetkin, and Jia 2006). Data from a wide array of
sources corroborate these mortality findings (Williams 1999). Thus, when
we remove material deprivations, black-­white mortality differentials are
reduced, but blacks in the United States still tend to have shorter lives
than whites.
There are a number of explanations for these observations by SES and
geography. For instance, genetic differences could account for the residual mortality of blacks seen after adjusting for income and education.
Likewise, these residual differences could be due to lifestyle differences
unassociated with SES, or they could just be a statistical artifact arising
from the fact that we do not have comprehensive measures of material
deprivation. They may also be explained by perceptual factors; the stress
associated with feeling discriminated against has a measurable impact
on health. Thus, if we were able to compare directly blacks and whites
of the same income and educational attainment, we might see a difference in mortality because perceived racism harms health across the class
spectrum. Perceptual differences could also explain geographical variation. Indeed, blacks born in the southern United States do significantly
worse than blacks born in the North even for those who relocated to the
North later in life (Fang, Madhavan, and Alderman 1996). Differences in
lifestyles could also explain geographical variation. For instance, those in
the “stroke belt” of the southeast United States tend to eat less healthfully
than in other parts of the country (Casper et al. 1995).
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Black-­White Differences in Morbidity. While one cannot be a little dead
or a little pregnant, one can have varying degrees and types of sickness.
This presents challenges when summarizing black-­white differences in
morbidity. One approach is to simply report the black-­white incidence
rates of different diseases. Another approach is to use a summary measure
of morbidity, which is derived from self-­report questionnaires. Such measures group different dimensions of health (e.g., the ability to get around
or pain and suffering) into a single number.
Analyses of one such summary measure, the SF-­20, suggest that black­white differences exist with respect to health perceptions, physical function, and role function but not mental health (Franks, Gold, and Fiscella
2003). These differences are relatively modest overall — about the same
as the differences in mortality between men and women. Notably, in this
study, controlling for health at the time of the interview had no effect on
black-­white mortality later in life. This suggests that blacks might be more
likely to die prematurely than they are to get sick. (A similar issue arises
with gender; women are much more likely than men to get sick, but they
live longer, on average, than men.)
Summary measures are better at providing information about one’s
overall health and would therefore generally be preferred. However, they
can be biased by self-­reporting (Gold et al. 1996). The primary source of
self-­reporting bias in this measure is differential item functioning, which
occurs when the two comparison groups differ in ideas or beliefs about
health states. For instance, a group of white Americans and black Americans with the same health status may, on average, report their health states
differently because of differences in subcultural norms (Fleishman and
Lawrence 2003; Baker, Stabile, and Deri 2004).
One way around the problem of differential item functioning is to look
at disease-­specific self-­reporting data and cause-­specific mortality data.
For example, such a measure might require a respondent to report whether
he or she has a lot of pain, a little pain, or no pain. While this requires
a qualitative judgment, responding to a question about the presence or
absence of cancer does not and may therefore be less susceptible to differential item functioning. Blacks in the United States generally have less
favorable reports of morbidity and mortality than whites, but these are not
consistent across all diseases (Lillie-­Blanton et al. 1996). This is generally
true of cause-­specific mortality data as well. As one example, when mortality data are examined by cause, cardio­vascular disease risk is higher in
black women relative only to white women. For men, blacks in the United
States have a lower risk than whites (Gillum, Mussolino, and Madans
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Muennig and Murphy ■ Does Racism Affect Health? 197 1997). For cancer (when all cancers are considered together), the situation is reversed; black women have a lower incidence (rate of new cases
diagnosed) of cancer than white women, but black men have a higher
incidence than white men. Cancer is the second-­leading cause of death
behind cardiovascular disease in blacks, and both black men and women
have a higher risk of death from cancer than white men and women (Mandelblatt et al. 2004). This suggests that black women are getting diagnosed
later, have a much higher death rate once diagnosed, or both (Jemal et al.
2004; Smedly, Stith, and Nelson 2002). Because black-­white differentials
in morbidity and mortality are inconsistent across diseases in the United
States, it also suggests that differences in health risks by race are more
nuanced than the overall differences imply (Lillie-­Blanton et al. 1996).
The National Health Interview Survey, a nationally representative U.S.
database that contains self-­reported disease prevalence, suggests that there
is a lot of variation in morbidity by race and that it is not consistently higher
in blacks (National Center for Health Statistics 2010b). For instance, while
hypertension and diabetes rates are higher among blacks, cardiovascular
disease is generally lower when averaged across genders. Likewise, ulcers,
liver disease, hearing difficulties, and arthritic symptoms tend to be lower
among blacks than whites.
A pattern of similar black-­white morbidity coupled with higher black­white mortality would suggest that the institutional racism model is a dominant determinant of black-­white health differentials. If intentional or perceived racism dominated, we would expect to see higher black-­white rates of
morbidity. Everything that we know about black-­white morbidity and mortality is, however, derived from correlational data. It is therefore difficult to
pinpoint racism as a dominant factor in explaining black-­white differences
in health. One can do better than simply comparing black-­white differences
in morbidity and mortality using Oaxaca decompositions.
Data from Oaxaca Decompositions. It is unethical and probably not possible to randomly expose one group of people to racism and another to a
racism-­free environment. When forced to make comparisons between two
groups using nationally representative data, one alternative approach is to
apply the coefficient of a reference population (whites) to the covariate
values from the risk-­factor-­present population (blacks) to predict morbidity and mortality (Oaxaca 1973). This approach has been widely used
to estimate wage discrimination by gender and race. When applied to
black-­white mortality differences, risks are essentially identical to those
predicted by simple regressions (Muennig et al. 2010). However, when
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we employ a comprehensive measure of morbidity (in this case the EuroQol 5D, which measures a domain of mental health, pain, mobility, usual
activities, and self-­care), we find that there is not a black-­white difference
in health. After adjusting for SES, blacks become healthier than whites.
It should be noted that while the Oaxaca decomposition is superior to
simple intergroup comparisons, it is just as susceptible to differential item
functioning as other approaches.
Black-­White Differences by Nativity. Finally, not all black groups in the
United States do, in fact, die at a younger age than whites. Black immigrants to the United States, for instance, have a life expectancy that is
much higher than native-­born whites in the United States (Fang, Madhavan, and Alderman 1996). This is consistent with the “healthy immigrant
effect”; African-­born immigrants’ longer life expectancy is comparable to
other groups, such as Latinos (Singh and Siahpush 2001; Singh and Miller
2004; Muennig and Fahs 2002).
What We Know about Black Health in the
United Kingdom
Mortality statistics for blacks in the United Kingdom overall are not
available. However, country of birth can be used as a proxy. Unlike in
the United States, all-­cause black-­white mortality differences are higher
among African-­born people in general (including immigrants from West
Africa, who are largely black). Stroke mortality is also higher among black
men born in the West Indies but living in the United Kingdom (Chaturvedi
and Fuller 1996; OPCS 1990). Regardless of place of birth, black men in
the United Kingdom self-­report better health, less respiratory disease, and
less circulatory and heart disease than whites, but more hypertension,
diabetes, depression, and psychosis (Nazroo 2003; Chaturvedi and Fuller
1996; Rogers 1992; National Institute for Clinical Effectiveness 1999;
Sproston and Mindell 2006). Black women, on the other hand, tend to
have worse outcomes for most of these indicators.
Black-­white differences in cardiovascular disease and cancer measures
in the United Kingdom are less dramatic than those in the United States
(Chaturvedi and Fuller 1996; OPCS 1990). As in the United States, when
a measure of one’s SES is controlled for, the harms of being black tend
to shrink. But in the case of the United Kingdom, they largely disappear.
Analysis of evidence for the recent Marmot Review for England led the
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Muennig and Murphy ■ Does Racism Affect Health? 199 authors to conclude that “much, if not all, of ethnic inequalities in health
in the UK are the product of socio-­economic inequalities” (Piachaud et
al. 2009).
Lessons for Cross-­National Comparisons
Mortality data are limited in the United Kingdom, and morbidity data are
difficult to summarize in either context. The absence of a residual health
effect when SES is held constant in the United Kingdom argues against
the institutional racism hypothesis. The presence of a residual black-­white
health effect in the United States supports the hypothesis that intentional
or perceived racism matters in the United States. However, the more favorable black-­white health ratio among immigrants to the United States than
among immigrants to the United Kingdom runs counter to this hypothesis. It is therefore not possible to draw meaningful conclusions about racism and health when using existing cross-­national morbidity and mortality
data by race in the United States and United Kingdom. Before moving on
to our cross-­national analysis of medical examination data, however, it is
important to address potential confounders in the racism-­health relationship that are unrelated to racism.
Cross-­National Risks Unrelated to Racism
Social Welfare Programs
A number of studies have investigated wider cross-­national differences
(Kunitz and Pesis-­Katz 2005; Lieberman 2005). Given that blacks have
lower income in both countries, it is possible that differential exposure to
better “safety net” programs in the United Kingdom could explain some
of the cross-­national differences in the health of blacks (Besser and Dannenberg 2005). The quality and inclusiveness of some public programs
may be superior in the United Kingdom relative to the United States (Lieberman 2005). For instance, while the National Health Service provides
universal and mainly free health care, in the United States, 20 percent of
blacks lack health insurance compared with 11 percent of non-­Hispanic
whites (Denavas-­Walt, Proctor, and Lee 2005).
Another hypothesis is that U.S. policy attempts to remedy historical
discriminatory policies have backfired. This line of thinking is that U.S.
welfare programs create dependency and this dependency is transmitted
between generations (Antel 1992). Others have argued that affirmative
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action — a program that seeks to increase the representation of black
Americans in professional spheres — delays the onset of truly color-­blind
policies (Kennedy 1985).
Genetic Factors
We know at face value that racism, especially historical racism, is one
reason for greater socioeconomic deprivations experienced by blacks, on
average, relative to whites. We also believe that there are many health
risks associated with such socioeconomic deprivations (Adler and Ostrove
1999). Finally, there is evidence to support an indirect role for the effect of
racism on health (Williams 1999). However, we have no way to quantify
the extent to which these factors would simply vanish in a hypothetical
society that does not have racism and has never had a history of racism.
The major countervailing explanation for why longevity differs between
blacks and whites is that those of African origin have a different core
genetic makeup that limits health, intellectual, and economic opportunities of blacks. “Cultural” factors may also play a role, but these, too, are
tightly linked to notions of race and racism (Pearce et al. 2004). Thus
it is possible that the poor longevity of blacks could arise directly from
genetic factors or could arise indirectly through poor academic performance. However, there is little evidence that this is so, and there are much
more apparent explanations (Williams 1997, 1999; Turkheimer et al. 2003;
Steele and Aronson 1995; Pearce et al. 2004).
Genes do partly determine risk factors for disease, academic performance, and, possibly, even factors such as one’s tendency to look to the
future or avoid risk taking. However, gene expression is determined by
a complex interplay between the gene and the environment (Lewontin
1982). Only a tiny number of genes determine one’s phenotype (Gould
1977), and race or ethnicity is not a good predictor of one’s genetic makeup
(Gould 1977; Pearce et al. 2004). Thus while sickle-­cell anemia may be
more prevalent in blacks and cystic fibrosis may be more prevalent in
whites, race is not a good predictor of overall genetic variation in known
genetically determined disease risk factors.
Among poor families, well over half of the variation in IQ is attributed
to shared environment, and genetics play virtually no role at all (Turk­
heimer et al. 2003). One example of shared environments is differences in
property taxes, an important determinant of school quality in the United
States. Blacks are much more likely to live in such deprived areas and
consequently to attend failing schools in the United States today, present-
Published by Duke University Press
Journal of Health Politics, Policy and Law
Muennig and Murphy ■ Does Racism Affect Health? 201 ing huge barriers to economic success (Levin and Belfield 2007). Thus
students attending elite private universities largely compete based on their
ability to perform well academically. But for poor students, factors such as
access to decent schools and the home environment play a decisive role.
Subcultural Norms
In the United States, there is a good deal of debate about the role of black
culture as a determinant of lower academic achievement and economic
performance of blacks in the United States. This is most prominently seen
in the debate between Bill Cosby and Michael Eric Dyson (Su 2009).
If subcultural norms, on average, hinder economic prosperity, then they
should also increase the black-­white health gap before adjusting for SES.
Quantitative Comparisons
We use data from two medical examination datasets — the National
Health and Nutrition Examination Survey in the United States and the
Health Survey for England — to further examine the extent to which racism influences the black-­white differential in health.
Cross-­National Differences in Definitions
In the United Kingdom, “ethnic minority group” is more commonly used
than “race.” The classifications vary between sources and are often further subclassified by their self-­identification with a particular geographical
region, the largest being the Caribbean and Africa, such as “Black Caribbean,” “Black African,” “Black other,” “Black British,” and sometimes
“Black mixed” (ONS 2006). To maximize comparability with U.S. data,
we include all groups that contain the word black.
Approach
In this quantitative analysis, we address confounders in a number of ways.
First, we filter out effects due to differences in self-­reporting or health
system performance by using nationally representative datasets containing medical examination data. Second, because the United Kingdom is a
healthier society than the United States, we attempt to measure health outcomes using two internal reference groups: whites and black immigrants.
We hypothesize that (1) the ratio of black-­white differences in biomarker
Published by Duke University Press
Journal of Health Politics, Policy and Law
202 Journal of Health Politics, Policy and Law
profiles will be closer to 1.0 in the United Kingdom than in the United
States and (2) that the ratio of native-­born – foreign-­born biomarker profiles among blacks will be closer to 1.0 in the United Kingdom than in the
United States. Finally, given that historical racism may be less of a threat
in the United Kingdom, we hypothesize that SES will explain much less
of the black-­white difference in measures of health in the United Kingdom
than in the United States, where blacks are subject to the double burden of
entrenched racism and socioeconomic disadvantage.
We limit our outcome measures to those available in both countries:
height, weight, body mass index (kg/m2), blood sugar (hemoglobin A1c),
cholesterol (both high-­density and low-­density lipoproteins), triglycerides,
fibrinogen, C-­reactive protein (CRP), systolic blood pressure, and diastolic
blood pressure. These biomarkers are also thought to be implicated in the
body’s response to psychological stress, a key ingredient of the putative
link between racism and health (McEwen 1998). By focusing on medical
examination data, we factor out problems associated with cross-­cultural
differences in self-­reported illness while avoiding many of the categorization problems associated with mortality data.
Data
Data for the United Kingdom were obtained using the 2004 and 2006
Health Survey for England (HSE) (Sproston and Mindell 2006), which
exclude the remaining one-­sixth of the U.K. population, since the sponsoring body is responsible for health only in England. This survey includes
a special topic each year, including the health of ethnic minority groups
in 1999 and 2004. The 2004 survey included a “boost” sample designed
to include additional interviews with members of the seven largest minority ethnic groups in England, including blacks. A complex oversampling
design was employed at the household level (ibid.). The final boost sample
survey included 6,816 adults from minority ethnic groups.
Medical exam data were collected by a nurse and included height,
weight, blood pressure, and serum biomarkers, including fasting blood
sugar. Because information on the biomarkers identified above is not
available for the general population in the 2004 survey, we also utilize
the 2006 survey to obtain data for the white population. This sample was
missing LDL cholesterol and hemoglobin A1c. In 2006, interviews were
held with 14,142 adults aged sixteen and older. Interviews in both surveys
were carried out for 68 to 69 percent of households in the general population sample, and 88 percent of adults in cooperating households were
Published by Duke University Press
Journal of Health Politics, Policy and Law
Muennig and Murphy ■ Does Racism Affect Health? 203 interviewed. However, response rates to some sections were much lower
(e.g., less than 20 percent for fasting blood samples in the 2004 survey),
and these results should therefore be treated with caution (ibid.).
Data for the United States were obtained from the National Health and
Nutrition Examination Survey (NHANES), a nationally representative
sample of the U.S. civilian noninstitutionalized population (NCHS 2010a).
Data from 1999 to 2006 were combined to create a dataset containing
20,311 adults aged sixteen years and older. (This age group was chosen
for consistency with the HSE.) Subjects were included if their assessments
contained interview, medical examination, and laboratory data. As some
laboratory tests were administered only to a random subsample, several
outcomes have smaller overall sample sizes. The NHANES utilizes a
complex sampling design with oversampling of various groups in different survey years.
We examined outcomes by country of birth and race among those
reporting non-­H ispanic origin. Table 1 describes the final sample in
both datasets, including sample size, by variable after excluding missing
values.
Statistical Analyses
All analyses were conducted using the survey package in the R statistical
system, which allows for the complex sample design, and were weighted
to produce representative estimates of adult populations for the United
States and for the United Kingdom within each subpopulation. To understand the relationship between nativity status and several biomarkers, we
performed a series of regressions. Each model controls for age, gender,
income, and educational attainment.
Results
Descriptive Data. Table 1 presents the results of these analyses. In the
United Kingdom, a higher proportion of the population is white (the
sample numbers in 2004 and 2006 do not reflect the relative population
sizes). While both countries have a black population of survey informants
that is disproportionately female, the U.K. black population has a slightly
higher proportion of females (possibly artifacts of low survey participation
by black males because of nonresponse, differences in self-­attribution of
racial group, and in the United States, incarceration or enrollment in the
Published by Duke University Press
Black
Native
Born
Black
Foreign
Born
N
White
U.S.
Black
Native
Born
Black
Foreign
Born
England
N
11,484
5,022
462
16,968
12,834
654
1,256
14,744
Sample Size
Sex (Column %) Male
48.5
43.9
52.1
8,186
48.2
41.9
43.1
6,531
51.5
56.1
47.9
8,782
51.8
58.1
56.9
8,213
Female
Age Group (Column %) 31.8
42.0
39.7
6,507
30.0
58.7
32.6
3,887
16–35
36–55
38.7
37.3
46.9
4,419
35.0
40.6
39.2
5,262
56–65
12.1
9.9
8.4
1,907
15.0
0.4
12.9
2,389
17.4
10.8
5.0
4,135
20.0
0.3
15.3
3,206
66 and over
Highest Educational Qualification (Column %)a
1
56.2
40.5
50.2
7,589
30.2
35.6
33.4
4,427
2
27.0
23.4
20.6
4,246
44.2
52.4
31.0
6,165
3
16.7
36.1
29.1
5,090
25.6
12.0
35.6
4,127
Self-Reported General Health (Column %)b
1
22.4
18.6
25.7
3,590
32.6
32.5
30.9
4,623
2
34.5
23.2
24.3
5,032
42.7
46.8
38.3
6,188
3
29.2
35.1
36.1
5,292
18.1
16.8
20.4
2,846
4
10.6
18.6
11.9
2,347
5.0
3.7
8.4
844
3.3
4.5
2.0
697
1.5
0.2
2.0
238
5
(continued)
White
Table 1 Basic Demographic Characteristics of the U.S. and English Cohorts of Blacks by Nativity
Journal of Health Politics, Policy and Law
Published by Duke University Press
Black
Native
Born
Black
Foreign
Born
N
White
U.S.
Black
Native
Born
Black
Foreign
Born
England
N
Sources: NCHS 2010a; Sproston and Mindell 2006
aU.S.: 1 = college, 2 = high school, 3 = below high school; England: 1 = higher, 2 = intermediate/foreign, 3 = none
bU.S.: 1 = excellent, 2 = very good, 3 = good, 4 = fair, 5 = poor; England: 1 = very good, 2 = good, 3 = fair, 4 = bad, 5 = very bad
Anthropomorphic and Biomarker Data Weight (kg)
80.6
85.4
76.9
15,550
77.0
76.3
78.8 12,692
Height (cm)
170.1
169.2
169.4
15,585
168.5
169.2
165.9 12,843
Body Mass Index (kg/m2)
27.8
29.9
26.8
15,437
27.1
26.8
28.7 12,365
0.40
0.55
0.35
14,904
0.34
0.25
0.31
7522
C-Reactive Protein (mg/dl)
Glycohemoglobin (%)
5.4
5.6
5.6
15,030
5.5
5.2
5.6
7,411
HDL Cholesterol (mg/dl)
51.1
54.5
51.8
7028
58.2
56.5
56.7
6,638
118.7
112.9
116.4
6,771
NA
123.1
132.3
1,199
LDL Cholesterol (mg/dl)
Systolic Blood Pressure (mm Hg)
121.9
125.2
123.0
11,155
131.0
125.1
130.3
8,792
71.6
72.6
74.5
11,062
71.5
70.8
72.8
8,792
Diastolic Blood Pressure (mm Hg)
Fibrinogen (mg/dl)
363.2
394.3
367.3
3,997
294.8
279.4
288.9
6,140
Triglyceride (mg/dl)
147.9
109.6
99.4
7,239
NA
111.3
121.4
1,214
White
Table 1 (Continued)
Journal of Health Politics, Policy and Law
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Journal of Health Politics, Policy and Law
206 Journal of Health Politics, Policy and Law
110
Black native adjusted
Black foreign adjusted
Black native fully adjusted
Black foreign fully adjusted
percent
105
100
2
Bo
dy
m
as
s
in
d
ex
(k
W
ei
gh
t(
g/
m
kg
)
)
)
H
ei
gh
t(
g/
m
H
D
L
G
ch
ol
es
te
ro
lr
es
ul
t(
re
s
hb
ly
ca
te
d
cm
dl
)
)
ul
t(
g/
m
ul
t(
re
s
n
in
og
e
Fi
br
%
dl
)
re
su
pr
es
lo
od
pr
es
st
ol
ic
b
Sy
lo
od
ia
st
ol
ic
b
D
C
RP
Bo
x−
C
ox
tr
an
s
fo
rm
su
re
ed
95
Figure 1 Percentage Change in Medical Examination Outcome
Measures by Race and Place of Birth for Blacks in England
Source: Department of Health 2007
Note: Adjusted for sex and age and fully adjusted also for income and education. All dependent variables log transformed, and C-reactive protein Box-Cox transformed.
military). Blacks in both nations tend to be much younger than whites and
to have less educational attainment than whites at equivalent ages.
Analytical Data. The figures show the medical examination data outcomes by race and country of birth for England (see fig. 1) and the United
States (see fig. 2) before and after adjusting for income and educational
attainment. We estimate the proportionate change in the various indicators associated with being a native-­born or foreign-­born black compared
with the white population. In England (see fig. 1), the only significant
differences are for anthropomorphic measures. Specifically, foreign-­born
blacks are shorter, heavier, and have a higher body mass index than native­born whites. Native-­born blacks also have a higher body mass index than
native-­born whites after covariate adjustment. There is no clear pattern
of differences between blacks and whites in outcome measures or differences by country of birth overall. Moreover, adjustment for income and
education produces little change in the mean values.
In the United States, on the other hand, there are clear black-­white and
foreign-­native differences for many of the outcome measures. As in the
United Kingdom, differences after correction for income and education are
generally not significant. Specifically, relative to native-­born U.S. whites,
Published by Duke University Press
Journal of Health Politics, Policy and Law
Muennig and Murphy ■ Does Racism Affect Health? 207 110
percent
100
90
80
2
)
)
)
/m
(k
g
(k
g
ht
ex
nd
si
ht
ei
g
W
ei
g
dl
g/
as
m
dy
es
t
ol
ch
D
L
Bo
ca
er
ol
H
(m
re
su
lt
re
s
hb
te
d
(c
m
)
)
t(
%
)
ul
g/
(m
G
ly
Tr
ig
ly
ce
rid
e
H
LD
L
ch
ol
dl
dl
g/
(m
lt
re
su
er
ol
es
t
og
in
br
Fi
)
)
g/
(m
lt
re
su
en
bl
Sy
st
ol
ic
ic
ol
dl
ur
e
pr
es
s
oo
oo
bl
tr
st
ia
D
x−
C
ox
Bo
C
RP
d
d
an
sf
or
pr
es
s
m
ed
60
ur
e
Black native adjusted
Black foreign adjusted
Black native fully adjusted
Black foreign fully adjusted
70
Figure 2 Percentage Change in Medical Examination Outcome
Measures by Race and Place of Birth for Blacks in the United States
Source: NCHS 2010a
Note: Adjusted for sex and age and fully adjusted also for income and education. All dependent variables log transformed, and C-reactive protein Box-Cox transformed.
native-­born U.S. blacks have higher serum levels of CRP, fibrinogen, and
glycohemoglobin. Both foreign-­and native-­born blacks have a higher systolic and diastolic blood pressure than native-­born whites, although differences become insignificant for foreign-­born blacks after covariate adjustment. Low-­density lipoprotein, high-­density lipoprotein, and triglyceride
levels are protective for native-­born black groups in the United States. For
foreign-­born blacks, triglyceride levels are protective, and high-­density
lipoprotein levels are protective after adjustment for income and education. Foreign-­born blacks in the United States are shorter, lighter, and have
a lower body mass index than native-­born whites. Analyses by gender
revealed no marked differences in these overall trends.1
Conclusions
We hypothesize that international differences in a given nation’s legacy of
discrimination might have enduring effects on health. Unlike the United
States, the vast majority of blacks in the United Kingdom are first-­, second-­,
or third-­generation migrants. Therefore, there is less of a legacy of statu1. Data available upon request.
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Journal of Health Politics, Policy and Law
208 Journal of Health Politics, Policy and Law
tory discriminatory practices in the United Kingdom. We also hypothesize that the length of exposure to a racist culture over one’s lifetime is
an important determinant of health. Our critical analysis of the academic
literature on the health of blacks, racial environments, and racial relations
in the United States and the United Kingdom coupled with our analysis
of medical examination data produce some surprising results that are not
entirely consistent with these two hypotheses.
First, despite their similar origins, black immigrants seem to live longer
in the United States than in the United Kingdom. There is ample evidence
that the United States is a highly unfavorable environment for blacks in
general, but this does not seem to affect the health of black immigrants.
Of course, it could be that black immigrants to the United States tend
to live in less adverse areas, such as in niche communities. There could
also be larger socioeconomic differences between the blacks who recently
migrated to the United States and those who migrated to the United Kingdom such that the former are a healthier group on arrival (e.g., there are
more who work for the UN or for international organizations and fewer
refugees and asylum seekers). Finally, it could be that lifelong exposures
to the adverse environment in the United States are needed for racism to
affect health in any appreciable way.
Second, immigrant blacks in the United Kingdom do not necessarily
fare better than blacks in the United Kingdom who have had a lifetime
of exposure to racism. This may be simply attributable to differences
between groups who immigrated in the 1950s and 1960s and those who
are predominantly immigrating today. But our finding that black-­white
health outcomes are worse for immigrants than native-­born blacks puts
a dent in the hypothesis that the health effects of exposure to racism are
cumulative over the life course.
Third, we cannot definitively say that black-­white differences in morbidity exist on a gross scale in either country. It has long been recognized
that black women in the United States are much less likely than white
women to develop breast cancer but are much more likely to die of the
disease (Mandelblatt et al. 2004). One comprehensive and standardized
measure of self-­reported morbidity, the EQ-­5D, suggests that U.S. blacks
may even be healthier than U.S. whites overall.
However, whether one looks at disease-­specific morbidity statistics or
medical examination data, it becomes clear that major differences exist
for specific diseases and conditions. For instance, the risk of hypertension, diabetes, and a measure of inflammation are all significantly higher
for native-­born U.S. blacks than for native-­born U.S. whites, and lipid
Published by Duke University Press
Journal of Health Politics, Policy and Law
Muennig and Murphy ■ Does Racism Affect Health? 209 profiles are generally better for U.S. blacks. The remarkable congruence
between foreign-­born and native-­born blacks in the United States might
reflect genetic differences or differences in risk exposure. For example,
in the United States, blacks have been less likely historically to smoke
than whites (NCHS 2010b). Blacks do have higher than mean (though
not significantly so) blood pressures in the U.K. sample, making a genetic
predisposition possible. However, there is no such trend for any of the
other markers under study.
Fourth, SES seems to be a relatively unimportant determinant of medical examination outcomes when comparing blacks relative to whites in
either the United States or the United Kingdom. It is unclear to us why
SES would not influence the major risk factors for the leading cause of
death among blacks but would explain a large portion of differences in
mortality (Wong et al. 2002).
The lines of evidence that we explore here suggest that blacks in the
United Kingdom are significantly healthier than blacks in the United
States when compared with whites. This supports the hypothesis that the
“less racist” United Kingdom provides a healthier environment than the
United States. However, the finding that black-­white differences in income
and educational attainment do not explain differences in medical examination outcomes in either context runs counter to the notion that historical
racist policies contribute to contemporary health disparities. It also runs
counter to previously elucidated differences in mortality. Finally, we also
find mixed evidence supporting the hypothesis that one’s length of exposure to racism is a major determinant of one’s health and longevity; exposure seems to matter in the United States but not in the United Kingdom.
Our cross-­national analysis of the effect of racism on health has a number of important limitations. First, we have sufficient data to provide only
a rough sketch of the exposures to racism and health risks of blacks in
each context. Second, we are highly limited with respect to the types of
cross-­national data that are available. For instance, while we do have data
for foreign-­born blacks, we do not know differences in overall black-­white
mortality in the United Kingdom.
In sum, our findings raise more questions than they answer. We do find
that the United Kingdom appears to be a society that is not only healthier
to live in overall but also a much healthier place to be if one is black. But
we also find that the health risks and health status of blacks in the United
States are a lot more complex than were previously thought.
Published by Duke University Press
Journal of Health Politics, Policy and Law
210 Journal of Health Politics, Policy and Law
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