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C Ch ha ap pt te er r 2 29 9 Racial/Ethnic Disparities in Health and Health Care in the U.S.: A Geographic Overview FLORENCE M. MARGAI INTRODUCTION Recent research efforts to document the nature and scope of health disparities have focused on various segments of the U.S. population by race/ethnicity, gender, socio-economic status, language proficiency and geography (Geronimus, 2000; Liao et al., 2004; Kawachi et al., 2005; Moy et al., 2005; and Frist, 2005). By far, the most persistent inequities with potentially ominous consequences for the health of the nation as a whole are those based on the racial/ethnic profile of the population (Carter-Pokras and Woo, 1999; Kingston and Nickens, 2000). Minority groups, who, as we know, already face major economic and social disadvantages, encounter even greater challenges when it comes to their health status. When compared to the white majority, these groups, especially blacks, Latinos and Native Americans, face more chronic health conditions, greater risk factors , inequitable access to health care resources, and limited utilization of these services. Previous attempts to explain these disparities have focused on traditional biomedical factors such as genetic susceptibility and the personal responsibility of individuals including their behavioral, nutritional and occupational characteristics. However, it is increasingly apparent that the evaluation of these individual characteristics alone cannot fully explain the observed trends in racial and ethnic disparities (Kingston and Nickens, 2000). Rather, attempts to address these complex disparities must take place within a broader context to include the settlement geography of these groups, their immigration and generation histories, levels of acculturation and assimilation into the U.S. society, the institutional policies that impact their communities, including land use and zoning regulations, housing discrimination and neighborhood segregation patterns, and the negative impacts of environmental exposures to pollution. The purpose of this chapter is to describe the patterns of health inequalities among the major racial and ethnic minorities in the United States: African Americans, Latinos, Native Americans, and Asian Americans. These issues are addressed within a geographical context to illustrate the sociospatial experiences and health outcomes that are unique to each of these groups. An effort will also be made to document the key determinants , pathways, and mechanisms that account for these disparities, and outline some of the intervention strategies that are now being pursued by governmental agencies to promote health parity. HEALTH DISPARITIES AND INEQUITIES BY RACE, CLASS AND PLACE Central to the analysis of race-based differences in health are two keywords, health disparities and health inequities, which are used interchangeably in the literature yet have different implications for health pol- 380 Florence M. Margai icy. From a broad perspective, the term health disparities can be defined as the disproportionate burden of disease and disability between specific population groups and the rest of the population in the United States. But various agencies and researchers have portrayed it differently in the literature, some focusing on the disparate outcomes and others highlighting the underlying causes. For example, the U.S. Health Resources and Services Administration (HRSA, 2000) described health disparities as population-specific differences in the presence of disease, health outcomes or access to health care. The Institute of Medicine characterized disparities as differences that remain after accounting for patient’s needs, preferences, and availability of health care (Smedley et al., 2002). Others have described disparities as adverse health outcomes that result from personal responsibility, provider prejudices, and a complex mixture of systemic quality and access problems coupled with historical injuries (Frist, 2005; Moy et al., 2005). Throughout this chapter, we will adopt a three-pronged approach that blends these multiple perspectives through the description of differential health outcomes, the underlying causes and systemic factors that account for these patterns, and the responses that are currently being implemented to redress the problems. Hence our discussion will place more emphasis on the term health inequities to enable us to focus on all three areas. Specifically, the use of the term, health inequities will remind us that the differential outcomes in health are not only inequitable and morally unacceptable, they also require immediate governmental response. The root causes of these disparities must be acknowledged including the contrasts between the majority and minority groups and the socioeconomic advantage that one group continues to have over the others. We follow the path of Gatrell (2002), who argues that greater emphasis be placed on health inequities since health disparities are inevitable in any population whether they are spatially-based, temporal in nature , or based...

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