Health, ethnicity and culture are inextricably linked, no matter where people come from or what life they choose. Yet, in the United States, assessing the health of groups defined almost exclusively by skin color is still a common public health practice. This means that the extraordinarily complex genetic inheritances of Africans, Jamaicans, Trinidadians, as well as people of many other nationalities, are simply counted as Black and non-Hispanic when vital statistics are gathered or populations are selected for research.
That one-definition-fits-all approach “leads to an inaccurate and incomplete picture of the factors that influence the health of Blacks living in America and around the world,” explains Robert Wood Johnson Foundation (RWJF) Health & Society Scholar (2007-2009) Tiffany Green, PhD.
“Much of the biomedical literature is predicated on the assumption that people of African descent, no matter where they reside, are a biological race,” according to geneticist Rick A. Kittles, PhD.
But, Green says, “we need to think more broadly about health disparities, acknowledging the different influences that affect the health of Blacks from different backgrounds.”
The Immigrant Birth Outcome Puzzle
For her part, says Green, an economist and assistant professor in the department of healthcare, policy and research at Virginia Commonwealth University School of Medicine, “I’m very passionate about focusing on children’s health, because it’s clear that disparities begin to effect health very early in life. Poor birth outcomes among Blacks also play a key role in health policy decisions in the United States, but there’s very little research separating birth outcomes for foreign-born Black mothers from those of U.S.-born Black mothers.”
To gain a better understanding of the relationship between a mother’s geographic origin and birthweight, Green analyzed a population of Black and non-Black infants born in the United States to women from a range of countries. She reported her results in “Black and Immigrant: Exploring the Effects of Ethnicity and Foreign-Born Status on Infant Health,” a September 2012 publication of the Migration Policy Institute’s National Center on Immigrant Integration Policy.
“I compared data on non-Hispanic Black immigrant mothers, non-Black immigrant mothers, and U.S.-born mothers, both Black and non-Black,” Green says. She found that Black immigrant mothers were less likely to give birth to preterm or low-birthweight infants than U.S.-born Black women, yet more likely to experience these adverse birth outcomes than other groups of non-Black, immigrant and U.S.-born women.
Green also found that although Black immigrant mothers are the least likely of any group, U.S. or foreign-born, to smoke, they also have the lowest rates of first trimester prenatal care initiation. But she discovered that including smoking behavior and prenatal care initiation in her research model did not fully explain the relatively poor infant health outcomes found among non-Hispanic Black immigrant mothers compared to their non-Black immigrant counterparts.
“While birthweight has become a standard measure of infant health, it may not always be the answer. In Asian populations, for example, it does not correlate with higher infant mortality, the way it does among Blacks. We also need to keep building on population health data, with an eye toward the effects of poverty and discrimination on health,” says Green, whose next study will follow this infant population through the first year of life.
“I’ve always been interested in using economic modeling to better understand health disparities in children, but I can’t even imagine how I would approach this work without my Health & Society Scholar program background in population health,” Green adds. “It was also helpful to hear perspectives from people outside of my academic discipline.”
Education, Income and Adult Black Immigrant Health
“It is also common practice, when reporting health outcomes, to compare Black and White disparities, but not disparities between ethnic groups,” reported Eleanor Fleming, PhD, DDS, an epidemic intelligence service officer at the Centers for Disease Control and Prevention, in her August 2012 presentation at the International Conference on Health in the African Diaspora (ICHAD). “It’s important to realize that Blacks are not a monolithic group, so relying on data gathered in this way can present an incomplete picture of the role of the social determinants of health in chronic diseases in this population.”
Fleming, a former fellow at the Robert Wood Johnson Foundation Center for Health Policy at Meharry Medical College, recently studied a national sample of Blacks born in the Caribbean, Africa, Central or South America and North America, living in the United States, with different levels of education and income, to see how they performed on several health indicators.
Fleming’s research revealed that health-related behavior varied by age group as well as geographic origin in her study sample, but the most consistent trends showed that U.S.-born Blacks had the highest level of high-risk behavior in connection with HIV/AIDS (four times that of Africa-born Blacks and double that of those from Central and South America). However Africa and Central- and South America-born Blacks were more likely to get tested for the disease.
U.S.-born Blacks were also more likely to report their health status as fair to poor (a rate more than double that of Africa-born blacks, but about the same as Central and South America-born Blacks). Yet, U.S.-born Blacks were much more likely to have seen a physician in the year preceding the study (71%, as opposed to 50% for Africa-born Blacks and 66% for Central and South America-born Blacks.)
Overall, Fleming reported, all of the health behaviors studied were affected by having lower levels of educational attainment (less than a high school diploma), but it seemed to have the greatest impact on the health behaviors of U.S.-born Blacks. Fleming suggested that her findings could help shape more effective methods of addressing the social determinants of health in the Black American population, perhaps through education programs.
The Science of “Me”
Current RWJF Center for Health Policy at Meharry Medical College fellow Helena Dagadu, MPH, is very excited about the work of Green, Fleming and other researchers for both professional and personal reasons. “I was born in Ghana, but I came to Maryland around age 7,” Dagadu recalls. “So my research comparing the health outcomes of U.S.-born Blacks and foreign-born Blacks is based, in part, on my own experiences. One of my mentors calls this type of work ‘me research.’”
Dagadu’s Meharry project examines diversity within the U.S. Black population as it relates to health. “We know that foreign-born Blacks often have better health outcomes than U.S.-born Blacks. This may be because foreign-born Blacks often have more resources or it may be that they are not exposed to the same risk factors for poor health as their U.S. counterparts,” Dagadu says.
She is investigating how the social environment contributes to cardiovascular disease in Blacks. “I want to find out how factors like identity link to health outcomes like heart disease. I compare U.S.-born Blacks and Caribbean-born Blacks. So far, my findings are consistent with prior research showing that Caribbean Blacks have a significantly lower risk for cardiovascular disease than U.S.-born Blacks.”
Dagadu also found that for both U.S. and Caribbean-born Blacks, having positive beliefs about being Black reduced the risk for heart disease. “This means that although there are differences among Blacks living in the U.S., there are also important commonalities that we can promote to reduce the risk of cardiovascular disease,” she says.
Green, Fleming and Dagadu are at the forefront of a trend toward recognizing the rich, genetic diversity in populations once thought to be homogeneous. “As researchers trying to understand health and health care disparities, we have to be more conscientious about how we categorize people. Work such as the Human Genome Project suggests that there is more genetic variability among Black people than any other race category,” Dagadu says. “More relevant for me is the recognition that social conditions play a critical role in determining whether and how certain genetic inheritances affect health.”
Learn more about the RWJF Center for Health Policy at Meharry Medical College.
Learn more about the RWJF Health & Society Scholars.
For an overview of RWJF scholar and fellow opportunities, visit www.RWJFLeaders.org.
As the social, economic and cultural map of the United States shifts dramatically, finding solutions to the nation’s growing health disparities means learning to understand the risks that threaten all Americans. Increasingly, education, income, and employment status rival race and ethnicity as key indicators of who will live a long and healthy life. This series—Challenging Disparities—highlights the research of Robert Wood Johnson Foundation Human Capital grantees who are taking on this important work.View all