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The continuing legacy of poor health in African Americans, despite the overall improved conditions of their lives, is one compelling reason to take a closer look at the role discrimination may play. The health disparities that affect African Americans in this country arise from many sources, including cultural differences in lifestyle patterns, inherited health risks, and social inequalities that are reflected in discrepancies in access to health care, variations in health providers’ behaviors, differences in socioeconomic position (Fiscella & Williams 2004Krieger 19911999Krieger & Moss 1996Krieger et al. 1997Subramanian et al. 2005), and residential segregation (Massey 2004Schulz et al. 2000). The extent to which these health disparities are also shaped by the pernicious effects of race-based discrimination is of growing interest (Clark 2003Clark et al. 1999Cochran & Mays 1994Everson-Rose & Lewis 2005Geronimus et al. 1996Guyll et al. 2001Harrell et al. 2003Hertzman 2000Krieger & Sidney 1996Massey 2004Mays 1995Mays & Cochran 1998Mays et al. 1996McEwen 2000Mechanic 2005Morenoff & Lynch 2004Walker et al. 2004Williams et al. 2003).

From the perspective of discrimination models, the causal mechanism linking racial/ethnic minority status and health disadvantage is thought to lie in the harmful effects of chronic experiences with race-based discrimination, both actual and perceived. These experiences are thought to set into motion a process of physiological responses (e.g., elevated blood pressure and heart rate, production of biochemical reactions, hypervigilance) that eventually result in disease and mortality.

In attempting to elucidate the negative health outcome mechanisms of race-based discrimination, the effects of both overt and anticipated or perceived experiences of race-based discrimination have been examined. Studies of overt or manifest discrimination typically measure events occurring at the individual level by asking respondents if they have been “treated badly or unfairly,” “differently,” or are somehow “disadvantaged” relative to others based on their racial or ethnic background (Krieger et al. 2005). The foundation of this work came from the earlier stress research paradigm, where individual differences in vulnerability to stress were seen as key to the development of mental health morbidity (Kessler et al. 1999). Factors that were thought to predispose individuals to negative mental health outcomes include unfair treatment and social disadvantage as well as other social stressors, such as inadequate levels of social support, neuroticism, the occurrence of life events, and chronic role strain (Adler et al. 1994Brown & Harris 1989Henderson et al. 1981Kanner et al. 1991Lazarus 1993Pearlin et al. 1981Thoits 1983). Later studies examining the possible consequences of perceived discrimination began to document that simply the anticipation of being treated badly or unfairly had as powerful an impact on individuals as objectively measured experiences (Kessler et al. 1999). Both of these developments helped move the field toward hypothesizing that chronic experiences with perceived discrimination can have wide-ranging effects on individuals.

Several studies have now documented health effects of discrimination. In one study, experiences of perceived race-based discrimination were positively associated with raised blood pressure and poorer self-rated health (Krieger & Sidney 1996). Perceived race-based discrimination was also found to be the best predictor of smoking among African American adults in two studies (Landrine & Klonoff 2000). Moreover, smokers, as compared with nonsmokers, reported finding the experience of discrimination as subjectively more stressful. In fact, this appraisal of discrimination as stressful was a better predictor of smoking than was the measured status variables of education, gender, income, and age. Landrine & Klonoff (2000) have suggested that perceived race discrimination and the appraisal process may be key factors in explaining the Black-White differential in smoking prevalence, where smoking possibly acts as a means of coping with stress. The issue gains even greater relevance when one considers that the Black-White differential exists not only in smoking prevalence, but also in smoking-related morbidity, mortality (MMWR 1996Rivo et al. 1989), and death from respiratory cancers (CDC 1994USDHHS 1998). Similar findings in research on alcohol consumption among African Americans indicate that internalized racism (i.e., a belief that African Americans are inferior) is positively associated with alcohol use as well as psychological distress (Taylor & Williams 2003).

In the 1990s, the perspective in this field shifted somewhat to emphasize the importance of chronicity of discrimination exposure in negative mental health outcomes (Kessler et al. 1999). At the same time, interest in the effects of discrimination on health outcomes strengthened as the federal government released the Healthy People 2000 and Healthy People 2010 objectives, the yearly National Health Care Disparities Report (USDHHS 2005), and reports from the Institute of Medicine on Unequal Burden (Haynes & Smedley 1999) and Unequal Treatment (Smedley et al. 2003). Experts in health, social cognition, epidemiology, biology, neuroscience, and clinical psychology began to use new methodologies to study prejudice, discrimination, and racism (Everson-Rose & Lewis 2005Karlamangala et al. 2005Krieger 1990Krieger & Sidney 1996McEwen 19982005Morenoff & Lynch 2004). These studies focused on the perspective of the person being targeted (Eberhardt 2005Everson-Rose & Lewis 2005Golby et al. 2001Harrell et al. 2003Mays & Cochran 1998Meyer 2003) as well as on the characteristics of persons who target others (Eberhardt et al. 20032004Phelps et al. 20002003).

The result has been a great melding of disciplines, tools, and perspectives to identify the important components of the pathways linking race-based discrimination and negative health outcomes. For example, human brain imaging is now used to observe cognitive processing of experiences of social exclusion (Eisenberger & Lieberman 2004). Biological measures of race-based stress (allostatic load) reveal intricate relationships among the brain, immune system, autonomic nervous system, and the hypothalamic-pituitary-adrenal (HPA) axis (McEwen & Seeman 1999), as well as the ways in which unhealthy environmental stimuli can “get under the skin” of individuals to cause negative health outcomes (Massey 1985Taylor et al. 1997). Political scientists interested in racial inequalities of criminal behavior and in a number of other areas are looking at the interaction between environmental exposures and brain chemistry (Masters 2001).

ncbi.nlm.nih.gov

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