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Health

HEALTH

The word "health" derives from Middle English helthe, meaning hale, hearty, sound in wind and limb. Dictionary definitions allude to soundness and efficient functioning and give the same meaning to financial health as to bodily health. Modern medical practice and public health are concerned about the health of individuals and populations. However, for most individuals and for many cultures, health is a philosophical and subjective concept, associated with contentment and often taken for granted when all is going well. Health in this sense is difficult to describe or define, but its absence is readily recognizable, even when replaced by minor departures from an accustomed level of health.

DEFINITIONS AND CONCEPTS OF HEALTH

In the preamble to the constitution of the World Health Organization (WHO) health is described as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." This description has often been criticized as being too vague. Further, it describes an ideal state rarely attained by most people, and it contains no ingredients that can be readily measured or counted, either at the individual or the population level.

Another definition, composed by specialists in preventive medicine, specifies some tangible components of health; calling it "a state characterized by anatomical, physiological, and psychological integrity; ability to perform personally valued family, work, and community roles; ability to deal with physical, biological, psychological, and social stress; a feeling of well-being; and freedom from the risk of disease and untimely death" (Stokes, Noren, and Shindell, 1982). Everything mentioned in this definition can be measured and counted at the individual and at the population level, although assessing "a feeling of well-being" may be a challenge, and "freedom from the risk of disease and untimely death" is not an achievable state.

An increasing level of interest in health promotion in the early 1980s inspired a WHO working group to compose a definition recognizing the role of individuals and communities in determining their own health status. They can be paraphrased to the extent to which an individual or a group is able to realize aspirations and satisfy needs and to change or cope with the environment. Health is a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social and personal resources as well as physical capabilities (Last, ed., 2000). This definition draws attention to the need for partnerships among individuals and communities, and to the importance of protecting the integrity of the environment in the cause of promoting good health. Moreover, many aspects of this definition are measurable.

The health of humans cannot be dissociated from the health of the life-supporting ecosystems with which humans interact and are interdependent. Moreover, no matter how healthy the present generation may be, the health of future generations is dependent upon the integrity and sustainability of these ecosystems. A definition of "sustainable health" that recognizes this interconnectedness states that health is a sustainable state of equilibrium among humans and other living things that share the earth (Last, ed., 2000). The key word in this definition is "equilibrium" meaning harmony. Human beings cannot long remain healthy in an environment in which they are out of harmony with other living things, or if other living things are dead or dying as a consequence of people's actions. This is true of all life forms, from the smallest microorganisms to the largest mammals. Since the midtwentieth century, medical professionals have been trying to "conquer" pathogenic microorganisms with antibiotics. This is a war that ultimately cannot be won because micro-organisms have very short generation times, measurable in minutes. Microorganisms can therefore adapt to the challenge of antibiotics by evolving and producing antibiotic-resistant strains much more rapidly than new antibiotics can be developed.

An alternative to antibiotics, which is perhaps insufficiently implemented, is based on the ecological concept that humans are an integral part of the global ecosystem. Immunization programs aimed at protecting people from diphtheria, tetanus, and other diseases have been very effective. The microorganisms responsible for these diseases are still there, in people's throats, in the soil, wherever is their usual habitat. But once protected by immunization, people can live in harmony with these otherwise dangerous microbes. The challenge is to develop methods that will enable humans to live in harmony with other dangerous microorganisms and insect vectors of disease. This is a more certain way to ensure long-term health for the population than the impossible goal of attempting to exterminate these other life forms. Pathogens that have no other host than humans can sometimes be eradicated, as the smallpox virus was, and as the polio virus could soon be, at least regionally if not globally; but eradication is not feasible with microorganisms that can survive out-side human hosts.

HEALTH THEORIES AND THEIR PRACTICAL APPLICATION

Beliefs about the foundations of good health are inseparable from theories of disease. Primitive beliefs about good and evil spirits; the benevolent or malevolent intervention of fate, gods, or ancestors; disease as a punishment for sin (Murdock, 1980); theories such as those of Aristotle and Galen about the balance of bodily fluids (humors) and about the effects of miasmas or "bad air" survive in the names by which we know some common diseases, including influenza, malaria, cholera, and rheumatism. A preference for holiday resorts and convalescent hospitals at the seaside or in the mountains reflects a belief in the notion that some environments are inherently healthier than othersas, indeed, abundant evidence demonstrates.

Scientists can trace the evolution of medical science in the changing nomenclature of disease. Some modern diagnostic labels indicate a precise understanding of the causal mechanisms of diseasestreptococal septicemia is, literally, the poisoning of the blood by streptococcus bacteria. Some that sound impressive, such as thrombocytopenic purpura (bruising associated with a deficiency of thrombocytes, or blood platelets) reveal partial knowledge: scientists know what causes the bleeding but not what causes the deficiency of platelets. Other disease names are deservedly vagueessential hypertension confesses out ignorance about what actually causes high blood pressure.

Modern medicine and public health embrace several theories that are confirmed by abundant empirical and experimental evidence, and medical professionals have an increasingly broad and deep understanding of the ways in which health of individuals and populations can be impaired, endangered, of permanently lost. Scientists know that many diseases are caused by invading pathogenic microorganisms, which are often communicable. Some diseases are due to a disruption or imbalance among endocrine glands that secrete hormones needed to ensure efficient bodily function, some are caused by dietary deficiency of essential vitamins or minerals, and others are caused by exposure to harmful chemicals or physical insults such as ionizing radiation or excessive noise. Some diseases are due to, or strongly associated with, emotional stress. There remains a residue of important, and sometimes common, diseases and causes of disability and premature death for which there is no known cause, although effective treatments have been developed for some of theses, often through trial and error or guesswork. High blood pressure is one such disease.

The activities of public health services aim to minimize the risk of serious departures from good health. The scope and methods of medical and public health practice demonstrate the depth and breadth of current understanding of the causes of disease, disability, and premature death, and also of the causes of good health.

Many who remain fit throughout a long lifetime attribute their good health (often incorrectly) to their behavior; whether it be to an ascetic or hedonistic way of life, to abstaining from (or indulging in) alcohol or tobacco, to vigorous exercise, or to leading a quiet, sedentary life. Some credit their parents or genetic heritagecertainly an important determinant of longevityalong with many environmental and behavioral factors. In fact, the causes of good health are as diverse and complex as the causes of disease.

Even literate, well-educated people sometimes have misguided views about what makes or keeps them healthy, often believing that regular daily exercise, regular bowel movements, or a specific dietary regime will alone suffice to preserve their good health. The Nobel laureate Linus Pauling believed that massive daily doses of Vitamin C preserved his health. Those who are less well educated and more gullible are easy prey to hucksters who purvey all manner of dubious nostrums to prolong life, enhance vitality or virility, promote fitness, and eliminate ailments ranging from halitosis and body odor to failing sexual potency and even cancer and heart disease.

Modern approaches to health education and health promotion make use of the Health Belief Model along with several other theoretical constructs to predict health-related behavior. These are based on assumptions derived from empirical studies of how people perceive their health and their understanding of what has to be done to preserve and protect their own health, or that of their children.

OBJECTIVE AND SUBJECTIVE PERCEPTIONS OF HEALTH

A well-trained physician, or an observant member of a family, can often tell at a glance that someone is unwell. There are obvious signspallor, sweating, unsteady gait, a bone-shaking cough. The converse is more challenging. Someone who appears to be outwardly perfectly fithale and hearty, sound in wind and limbmay harbor an early cancer that is eating away at a vital organ, or, when asked the right questions may reveal a potential mental health problem, though there is no physical evidence of a departure from excellent health. Health has many dimensions, and each must be assessed and measured on some sort of scale. This is what physicians do when conducting a routine medical history and physical examination, which includes various laboratory tests. The results of such an examination have a range of values that usually follow a normal distribution, and for many of these the decision that a particular value lies within or outside the range of normal is rather arbitrary, although it is based on empirical experience. For example, experience and follow-up of many sets of observations allow us to agree on what level of systolic and diastolic blood pressure give grounds for a confident recommendation that treatment is needed to reduce an excessively high pressure that could lead to a stroke or heart attack.

Conversely, many severely disabled people can function efficiently and cheerfully within their limited capacityparaplegics can perform with consummate speed and skill in road races in wheelchairs, and blind people can play chess and swim in competitive tournaments. The theoretical physicist Stephen Hawking, described in his book, A Brief History of Time (1988), the full and productive life he leads, though he is profoundly disabled physically by amyotrophic lateral sclerosis (Lou Gehrig's disease). Physical, mental, and emotional health are clearly three different dimensions of health.

Determinants of Health. Both individual and population health are determined by physical, biological, behavioral, social, and cultural factors. First among the physical factors is the radiant energy of the sun, which is ultimately essential for all life on earth. In Airs, Waters, and Places, Hippocrates identified climate, environmental topography, and aspects of behavior as determinants of health. Climate is assuming greater importance than hitherto due to the climate changes caused by increasing industrialization and energy consumption. Environmentally, the presence or absence of trace elements in the soil or water, such as fluorides to toughen dental enamel, iodine to stimulate the thyroid gland, and lead compounds that damage the developing brain, act to enhance or impair our health.

Biological determinants of health are inherent or acquired. Genetic heritage is a contributing factor to longevity, and to susceptibility or resistance to a wide range of diseases that include the pathogenic microorganisms responsible for some of the great plagues that have afflicted humans for millennia. Molecular geneticists have demonstrated that the interaction of human communities with the plague bacillus, the influenza and smallpox viruses, the malaria parasite, and with several other microorganisms, played a role in determining the differentiation and distribution of early races of humans in Africa and Asia. On a much shorter time scale, pathogenic microorganisms may be the most important biological determinants of health and disease. Immunity or resistance to pathogens is a very important determinant of good health. Immunity is enhanced by prior exposure, or by maternal exposure in the case of newborn infants, who acquire maternal (passive) immunity to some infections before they are born, and have it reinforced after birth by antibodies in breast milk. Routine immunization of infants and small children protects them from harm by many common and formerly dangerous pathogens including those that cause diphtheria, tetanus, measles, poliomyelitis, and whooping cough. Nutritional status is another important influence on resistance to infection. Individuals and populations are most vulnerable when they are malnourished or starved, which is why plagues often accompany famines.

Behavioral determinants have been much studied. An association of certain diseases with particular personality types has been observed empirically for centuries. An irascible temperament, for example, has been linked to occurrence of strokes, and an association has been demonstrated between high risk of coronary heart disease and a type A personality, marked by forceful and aggressive behavior. Research on mind-body interactions, which unites the disciplines of psychology, neurology, and immunology, made great progress in the last quarter of the twentieth century and began to clarify and explain these relationships.

Social factors that influence or determine health are also complex. There is epidemiologic evidence that good health is determined at least in part by social connectedness. Persons who have many and frequent interactions with other family members and with a network of friends have a more favorable health experience in many ways than those who are socially isolated, live alone, are estranged from their family, and have little or no family and social support systems. It is difficult however, to unravel social connectedness and personality factors that may encourage gregariousness or a solitary way of life. Position in the social hierarchy plays a role. Michael Marmot, a professor at University College in London, and his colleagues studied British civil servants, showing that top managers lead healthier lives than middle managers, who in turn are healthier than semi-skilled and unskilled clerical workers. Social networks and support systems, and social positions, are in part determined by factors beyond the control of individuals. While they are interrelated with personality factors, they are very complex and not well understood.

Studies have shown that economic conditions dramatically effect health and longevity. A consistently strong relationship has been demonstrated between income levels and health status in every country where the relationship has been examined. Many interactions between social, economic, and cultural factors also help to determine or influence community health.

Culture is defined as the set of customs, traditions, values, intellectual, and artistic qualities, and religious beliefs that distinguish one social group or nation from another. Culture influences behavior through customs such as use of or abstention from meat, alcohol, and tobacco; the practice of rituals such as circumcision; marital customs such as the prevailing age at which women marry; attitudes toward family size, childbearing, and child rearing; personal hygiene; disposal of the dead; and much else. People's values may be the most significant component of culture that affects behavior and through behavior, health. For example, since the late nineteenth century, an understanding of the importance of personal hygiene has become part of the value system of many cultures. In the late twentieth century, values in many nations shifted towards a rejection of tobacco smoking as a socially acceptable custom. In the 1960s, the oral contraceptive pill contributed to the sexually liberated values and behavior that encouraged casual promiscuity, and which was only partially overshadowed by the threat of infection with HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) in the 1980s and later.

PREREQUISITES FOR HEALTH

Another way to consider conditions required for people's health to flourish was outlined by working groups of the World Health Organization Regional Office for Europe in the 1980s, during the development of targets to be met in order to achieve Health for All, a program conceived with the goal of assuring that essential health care is accessible to everyone through organized programs of health promotion. The prerequisites for health were identified as: freedom from the fear of war, equal opportunity for all, satisfaction of basic needs (food, education, clean water and sanitation, decent housing), secure work, a useful social role, and political will and public support. All these are embodied in one way or another in the determinants of health outlined above, but when expressed as they were by the WHO working groups, the relevance of human values to achievement of good health becomes more explicit. Ultimately, values may matter more than anything else in influencing health.

HEALTH PROMOTION AND HEALTH MAINTENANCE

The basic goals of health promotion and health maintenance are a safe environment, enhanced immunity, sensible behavior, good nutrition, well-born children, and prudent health care. Each of these merits a brief discussion.

Safe Environment. Among the fundamental requirements for good health are clean air, safe water, land free from toxic substances, and shelter that protects people against the elements. The term "filth diseases" coined in the midnineteenth century, summarizes many life-shortening environmental hazards that prevailed at that time. Unpolluted water, sanitary disposal of human wastes, and improved housing conditions transformed overall health by the end of the nineteenth century. Access to food and resources essential for survival, as well as freedom from threat of war, persecution, and discrimination, are included in the European Charter for Health Promotion. A high proportion of the world's people are in want of these essential requirements for good health.

Enhanced Immunity. Next in importance to the provision of pure water supplies and sanitary disposal of human waste is the protection of infants and children against lethal and crippling infectious diseases. By the middle of the twentieth century, immunization campaigns had virtually wiped out diphtheria, tetanus, and whooping cough. Smallpox was eradicated worldwide by 1980. Development in virus vaccines in the second half of the twentieth century added poliomyelitis, measles, rubella, and mumps, to the list of diseases preventable through vaccination. This list includes other dangerous diseases that are rare in Western industrial nations, including typhoid, typhus, and yellow fever.

Sensible Behavior. The way people behave influences their health in many ways, and behaving sensibly is an obvious requirement for good health. Health-related behavior is influenced by our values, which are determined by upbringing, by example, by experience, by the company one keeps, by the persuasive power of advertising (often a force of behavior that can harm health), and by effective health education. These influences affect everyoneespecially impressionable childrenand lead to good or poor health, depending on the predominance of sensible or risk-taking behaviors that result.

Good Nutrition. A balanced diet comprises a mixture of the main varieties of nutriments (protein, carbohydrates, fats, minerals, and vitamins). For many reasons, not everyone has easy access to or incentives to eat a balanced diet. Some cannot afford it, others are ignorant of what kinds of food are good for them and what kinds are not; many are attracted by the advertising, convenience, and low cost of junk foods. Nevertheless, those who eat a well-balanced diet are healthier than those who do not.

Well-Born Children. By this term we mean children who are free from genetic defects, safely and easily born to healthy mothers after a pregnancy of normal duration, and nurtured securely to ensure that they pass developmental milestones in a timely manner so they grow up fit and strong. A great many characteristics are summarized in that statement, and are discussed elsewhere in this encyclopedia.

Prudent Health Care. It has been said that, until about 1930, the average patient with the average disease consulting the average physician had a less than 50 percent chance of benefiting from the encounter. In some respects the situation has greatly improved since then, but doctors even now inadvertently harm some whom they attempt to help, and hospitals remain dangerous places where patients are at risk of infection by other patients and contaminated instruments, invasive procedures can go wrong, and medications can be administered to the wrong patient or given in wrong dosages.

HEALTH INDICATORS

The health of potential military recruits and applicants for life insurance is assessed by their past history of illness and harmful behavior (e.g., smoking), and by a physical examination that includes blood pressure, tests of exercise tolerance, and other measures. Similar methods can be used to assess the health of a nation. The physical examinations of military conscripts early in the twentieth century provided evidence of the poor health of the British working classes, and which in turn motivated the government to introduce the first tax-supported medical services. In the United States, the National Health Surveys provide information about the health status of Americans (such as the increasingly prevalent obesity among young people). But this is a costly way to assess a nation's health. Traditionally, health care professionals have relied on summary statistics, especially life expectancy, which is derived from the age distribution of the population as determined by a national census. Life expectancy at birth is particularly sensitive to infant mortality, which is another widely used indicator of a nation's level of health.

More sensitive indicators take into account the available evidence on commonly occurring disabling diseases to derive summary statistics such as disability-adjusted life years. Health measurement scales are more elaborate derivatives of disability-based health indicators. These require the use of questionnaires, interviews, and sometimes physical examination of individuals to derive a numerical score for particular aspects of health such as an ability to climb stairs, shop for food, prepare meals, get dressed unaided, or drive a car. Standardized interviews can also be used to derive a numerical score for aspects of mental health, social interaction with others, and employability. When all available health indicators are complied, various conclusions can be drawn. They show, for example, that Japan, Australia, Sweden, the Netherlands, and Canada are among the world's healthiest nations; while Sierra Leone, Mozambique, and Malawi are in many respects the least healthy. The United States is among the top twenty nations according to some indicators, and among the top twenty-five according to others. But no nation has a monopoly on indicators of good health. If athletic prowess is an indicator, African Americans consistently outperform all others in sprints, while Africans from Kenya outperform all others in middle- and long-distance running. Some small nations in the mountainous Caucasus region between the Caspian Sea and the Black Sea, in the

Table 1

The top 25 and the bottom 25 nations ranked according to Disability-Adjusted Life Expectancy (DALE)
Rank Nation DALE Rank Nation DALE
source: World Health Organization, 2000.
1 Japan 74.4 166 Djibouti 37.9
2 Australia 73.2 167 Guinea 37.8
3 France 73.1 168 Afghanistan 37.7
4 Sweden 73.0 169 Eritrea 37.7
5 Spain 72.8 170 Guinea-Bissau 37.2
6 Italy 72.7 171 Lesotho 36.9
7 Greece 72.5 172 Madagascar 36.6
8 Switzerland 72.5 173 Somalia 36.4
9 Monaco 72.4 174 Congo 36.3
10 Andorra 72.3 175 Central African Republic 36.0
11 San Marino 72.3 176 Tanzania 36.0
12 Canada 72.0 177 Namibia 35.6
13 Netherlands 72.0 178 Burkina Fasso 35.5
14 Britain 71.7 179 Burundi 34.6
15 Norway 71.7 180 Mozambique 34.4
16 Belgium 71.6 181 Liberia 34.0
17 Austria 71.6 182 Ethiopia 33.5
18 Luxembourg 71.1 183 Mali 33.1
19 Iceland 70.8 184 Zimbabwe 32.9
20 Finland 70.5 185 Rwanda 32.8
21 Malta 70.5 186 Uganda 32.7
22 Germany 70.4 187 Botswana 32.3
23 Israel 70.4 188 Zambia 30.3
24 United States 70.0 189 Malawi 29.4
25 Cyprus 69.8 190 Niger 29.1
191 Sierra Leone 25.9

foothills of Mount Ararat, are famous for many authenticated cases of extreme longevity, and they may have the world's highest proportion of persons surviving to ages over one hundred. Yet these same nations have relatively high infant and childhood mortality rates, as well as high death rates from causes associated with violence.

Determining which nations are healthy depends on which health indicators are looked at. The Netherlands, for example, ranks at the top using indicators of health qualityliteracy levels, low incidence of abortion and unwanted pregnancy, low incidence rates of impairments, disabilities, and handicapsthough other countries may rank higher in terms of longevity and other indicators.

Table 1 shows the ranking of various nations based on years of healthy life expectancy or disability-adjusted life years, the age to which on average people are expected to live in good health. This number is reached by subtracting the average years of ill health from the overall life expectancy. The top nations are Japan, Australia, and France; the bottom three are Malawi, Niger, and Sierra Leone. The United States is twenty-fourth on this list, though it is the richest nation on earth in terms of economic indicators. The poorest fifth of residents in the United States have a healthy life expectancy of just fifty-five years, compared to seventy years for the nation as a whole. Clearly there is room for considerable improvement.

CONCLUSION

Health is clearly a complex, multidimensional concept. Personal or individual health is largely subjective. It is possible to be physically robust, to be "the picture of good health," and yet have serious mental or emotional impairment. Conversely, an individual can be profoundly disabled physically yet have an intact mind and be emotionally well-adjusted. So while many facets of health can be identified, the assessment or measurement of individual health must take them all into account. Economists can derive a single numberthe net worth or gross domestic productas a measure of the economic status of an individual or a nation. But there is no comparable one-dimensional measurement scale for the health of an individual, much less a nation. At best, public health professionals can create community or national profiles using crude health indicators like life expectancy; infant mortality rates; death or sickness rates from specific causes like cancer, heart disease, suicide, and homicide; or surrogate measurements such as use of drugs, (prescribed or over-the-counter) and spells of hospital care.

Health is, ultimately, poorly defined and difficult to measure, despite impressive efforts by epidemiologists, vital statisticians, social scientists, and political economists. The dramatic differences in levels of health among the nations of the world only challenge public health professionals to pursue global health standards.

At the beginning of the twenty-first century the principal causes of premature death and departures from good health were violence, including violent armed conflict; smoking-related disease; automobile accidents; and overindulgence in high-calorie foods that are ill-suited to modern, sedentary lifestyles. All of these are ultimately associated with human behavior, which is greatly determined by values. Only by adopting values that support a healthy lifestyle can people improve their overall health.

John M. Last

(see also: Assessment of Health Status; Attitudes; Behavioral Determinants; Climate Change and Human Health; Community Health; Cultural Factors; Environmental Determinants of Health; Genetics and Health; Health Belief Model; Health Maintenance; Health Measurement Scales; Health Promotion and Education; Infant Mortality Rate; Lay Concepts of Health and Illness; Life Expectancy and Life Tables; Maternal and Child Health; Mental Health; Nutrition; Social Determinants; Sustainable Health; and articles on specified diseases mentioned herein )

Bibliography

Abelin, T.; Brzezinski, Z. J.; and Carstairs, V. D. L., eds. (1987). Measurement in Health Promotion and Protection. Copenhagen: World Health Organization.

Dubos, R. (1959). Mirage of Health. London: Allen and Unwin.

Helman, C. (1990). Culture, Health, and Illness, 2nd edition. Oxford: Butterworth-Heinemann.

King, M. (1990). "Health Is a Sustainable State." Lancet 336:664667.

Last, J. M. (1997). Public Health and Human Ecology, 2nd edition. Stamford, CT: Appleton and Lange.

Last, J. M., ed. (2000). Dictionary of Epidemiology, 4th edition. New York: Oxford University Press.

Marmot, M., and Wilkinson, R. G., eds. (1999). Determinants of Health. Oxford: Oxford University Press.

Murdock, G. P. (1980). Theories of Illness. Pittsburgh, PA: Pittsburgh University Press.

Stokes, J. III; Noren, J. J.; and Shindell, S. (1982). "Definitions of Terms and Concepts Applicable to Clinical Preventive Medicine." Journal of Community Health 8:3341.

World Health Organization (1948). Constitution and Charter. Geneva: Author.

(1978). Primary Health Care. Geneva: Author.

(1985). Targets for Health for All. Copenhagen: Author.

(1986). "Ottawa Charter for Health Promotion." Canada Journal of Public Health 77:425430.

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Health

Health

Disease and its causes

Three conceptions of health

Modern medical practice

Health beyond the individual

BIBLIOGRAPHY

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” according to the World Health Organization (1946). It will be the purpose of this article to develop some concepts about health and disease, exploring a few implications of the WHO definition in the context of both Western and non-Western medical ideas. First, notions of singular and multiple causation of disease will be contrasted. Second, three types of ideas about health will be defined. Finally, some applications of the health concept to units beyond the human individual will be mentioned.

Disease and its causes

Illness is a disvalued process that impairs the functioning or appearance of a human person and may ultimately lead to death. The definition of health given by the WHO includes social as well as physical and mental well-being. This reflects a concern with the person as a member of human groups—an entity certainly not limited to the body of that person. The components of an individual (e.g., blood, body, soul, spirit, shadow, name, etc.) are defined differently from one culture to the next. The death of the organism, however, is a biological constant which is taken into account conceptually in all cultures, and customs prescribe how the disposition of the corpse is to be arranged. Different components of the individual may be thought to depart from the presence of the living at different times, and these various departures are marked by a series of ceremonies (van Gennep [1909] 1960, pp. 146 ff.). Some components, such as the “soul,” may be thought never to cease existing entirely but to remain near the living or in some locality specially set aside for its kind.

Disease, then, may involve a temporary or permanent impairment in the functioning of any single component, or of the relationship between components making up the individual. An impairment of a person, furthermore, need not be re stricted to a decrease in his ability to function in his ordinary ways: for example, among the Ashanti of West Africa, a congenital birthmark which leads to no discomfort or danger of death can be considered a sufficiently severe fault to disqualify a man from the office of chief. In many cultures, theories of disease will include explanations of congenital defects or imperfections, and the distinction between these and other illnesses may become relevant for further analysis (Polgar 1963).

Explanations of illness are not only useful to reaffirm the values of a social unit or to make death psychologically more tolerable for the next of kin but serve most immediately to indicate courses of preventive and curative action. To effect prevention or cure one should identify a course of events which presumably has produced the impairment. Herein lies the rationale of diagnosis, which is one of the three basic elements of all medical systems (the other two being therapy and prophylaxis).

Notions of singular causation

During the last decades of the nineteenth and the early part of the twentieth century, Western medicine was heavily dominated by the notion that most diseases are a result of infection caused by microorganisms. This type of conception—that disease simply results from the entry by a foreign agency into the body of the patient—is paralleled by the ideas found among many tribal people that illness is caused by “object intrusion” or “spirit possession.” Walther Riese has drawn attention to this similarity of ideas in stating that “ontologic” etiology (a conception of disease as caused by a monadic “alien-ferment”) “in its crudest form …identifies these agents, if not the diseases themselves, with demons, in its scientific form, with germs” (Riese 1953, pp. 66-67). He does not imply, of course, that demons and germs are equally valid concepts in an empirical sense.

The emergence of the “doctrine of specific etiology of disease” (Dubos [1959] 1961, p. 90) as the dominant idea in medicine is related to the mechanistic world view prevalent in the late nineteenth century. Far older features of Western thought, such as the grammatical dualism of subject and predicate, the Judeo-Christian and Platonic mind-body dichotomy, and the experimental approach of the alchemists, provided a suitable background for the development of this “doctrine.” Of the greatest immediate relevance to it were the discoveries of Pasteur and Koch in the realm of bacteriology. Instead of emphasizing the patient and his total environment, as Western medical traditions had done previously, proponents of this “doctrine” spread the notion that all important infections could be controlled by therapeutic serums and preventive vaccines specific for all microbes (Dubos [1959] 1961, p. 130). Although a number of vaccines and antitoxins had been developed before the turn of the century, it was not until the 1930s that the sulfa drugs were discovered, and it was another decade later that penicillin came to be used. The great decreases in the mortality of children and young adults, which are nowadays often attributed to clinical medicine and the use of specific drugs, actually preceded these discoveries and mostly resulted from better nutrition and the hygienic measures carried out under the leadership of medical reformers, many of whom had even opposed the germ theory of disease (Rosen 1958, pp. 225 ff.; Dubos [1959] 1961, p. 131).

In the contemporary practice of clinical medi cine, the inadequate care often received by patients unfortunate enough to suffer from a disability for which no specific etiology can be identified is symptomatic of the legacy of the bacteriological era. Von Mering and Earley (1965) trace the difficulties of such problem patients to, among other factors, the hospital as the main locale for diagnosis and treatment, as well as to the “growth of medicine as a science of tests and measurements rather than an art involving the five senses.” These authors find that “the clinic physician and general practitioner share a kind of ’molecular man’ orientation which seems to predispose them to be more concerned with the specifics of the presenting complaint, and to look eagerly for major disease in every bed or consulting room” (von Mering & Earley 1965, p. 199; see also Pflanz 1964).

Multicausal conceptions of disease

The recent theoretical developments away from the doctrine of specific etiology are spearheaded by advocates of comprehensive medical care and psychosomatic medicine and by some epidemiologists. All three of these segments of the medical community regard illness as an interaction of many factors and, cor respondingly, favor treatment of patients once more as total organisms in a complex setting. One of the foremost modern exponents of this view is the epidemiologist John Gordon, who has shown the interplay of the host, the agent, and the (physi cal, biological, and social) environment in the spread of a good number of both infectious and noninfectious diseases (see, for example, Gordon 1958). The studies of John Cassel, another noted epidemiologist, on the spectrum of health disorders resulting from independently documented socio-cultural processes exemplify a further step away from the one cause-one disease manner of thinking (Cassel 1964). Although writers in the psycho somatic tradition of medicine often use concepts like “stress” or “conflict” as if they were specific causes of illness, the emphasis in this school of thought is on the patient’s physical and mental well-being, and consideration is often given to his social milieu as well (King 1963). Comprehensive medical care is more than a movement to improve the institutional means by which patients and sometimes families are medically supervised. The theory that underlies these arrangements includes rejection of both the dominant disease orientation of modern Western medicine and the organic-functional dichotomy, and it places a strong em phasis on the patient as a person (Steiger et al. 1962).

Multicausal conceptions of disease are neither new in the Western medical tradition nor unique to it. One main theme in the Hippocratic writings is that disease is to be traced to an imbalance be tween the person and his external environment; much emphasis is also given to the relationships among different environmental factors, such as exercise and diet, and to the connections between disturbances in an organ and the whole body (Sigerist 1951-1961, vol. 2, pp. 317 ff.; Dubos [1959] 1961, pp. 117 ff.). In non-Western socie ties there are many multicausal ideas about disease. The distinction between conditions that make persons particularly susceptible and events that precipitate the onset of the disease is particularly common: for example, the Maori of New Zealand see “bad acts” by the patient as predisposing to, and external spirits or objects as the immediate cause of, an illness episode (Newell 1957); in the Middle East, a well-formed male child is identified as especially susceptible to attack by the “evil eye” (Shiloh 1958).

Related to this division between predisposing and precipitating factors is the division between the reasons why a particular person becomes ill at a particular time and the explanation of the way in which it happens. These latter two types of causes may be termed incidence notions and etiological notions (Polgar 1962, pp. 166 ff.); they also bear some similarity to the Aristotelian efficient and material causes (Riese 1953, pp. 66 ff.). In some non-Western medical systems there are categories for “natural” diseases—usually minor ills such as the digestive problems of infants (Nurge 1958)— which do not require an explanation for the occur rence of the disability in the particular instance and hence do not raise questions about who is “re sponsible.” In urbanized as well as nonurban societies, however, the search for the transgression of the patient himself or the malevolent action of another being (human or supernatural) is a major element of the diagnostic process.

In small tribal or peasant communities, the as signment of responsibility for illness to a relative or neighbor (whose departure from prescribed norms of behavior is pinpointed as a breach of taboo, witchcraft, irresponsibility, or sin) helps to bring latent interpersonal conflicts into the open where they are more easily resolved (Paul 1953; Firth 1959, pp. 135 ff.). Similarly in the Judeo-Christian tradition the attribution of illness to sin ful behavior served to reinforce the mores of the society. With increasing secularization, this diag nostic category became less satisfactory, and in scientific medicine it was replaced by “naturalistic” explanations. However, residues of this earlier concept of sin still affect attitudes toward disease; for patients and their families, a physician’s diagnosis which fails to blame anyone for the occurrence of the illness also fails to deal with the sense of guilt they often have and leaves them vaguely dissatisfied (Sigerist 1951-1961, vol. 1, p. 157).

Three conceptions of health

If disease is seen as an individual’s departure from perfectly well-meshed social or physiological performance, health, by contrast, becomes an asymptote—an ideal that can be approached but never attained in actuality. In the WHO definition, the expression “complete physical, mental and social well-being” [emphasis added] echoes this type of conception.

Variants of the asymptotic concept

Two main variants of the asymptotic notion about health can be identified. One variant, the harmonious working together of disparate elements, is a dominant theme in the Indo-European tradition, antedating Galen’s notion of the “four fluids” and manifest today in the influence of Walter B. Cannon’s ideas about homeostasis. The yang and yin of Chinese philosophy also indicate a search for balance, the restoration of which is one of the healer’s primary goals (Huard & Wong 1959, pp. 105 ff.). Grand designs of physiological, physical, and metaphysical order —each replicating the elements of the other—are typical of classical times.

The second type of asymptotic conception is a backward-looking romanticism, which has been described by Dubos in his chapter “The Gardens of Eden” ([1959] 1961, pp. 1-25). For Rousseau and his followers, the ills that beset Western society are consequences of the departure from a perfect state of harmony with nature that is entailed in the process of becoming civilized. Freud also accepted the myth of a precursor of modern man who was exempt from the latter’s neuroses, since this imaginary “savage” did not inhibit the biological drives toward aggression and sexuality (Riese 1953, pp. 14 ff.). Remnants of ideas about “primitive man’s” closeness to “nature” remain today in such medical folklore as the myth of easier parturition among American Indians and the “innate” superiority of their sense organs. When this theme is transposed to the life cycle of individuals, children may be seen romantically (for example, by the poet Wordsworth) as endowed with sensitive understanding which they gradually lose by exposure to the eroding influence of the “civilized” ways of adults.

In operational terms, the asymptotic definition of health is mostly negative; it implies the absenceof manifest disturbance. While this notion has advantages in focusing attention on the nonexistence of a clear break between the presence or absence of disease, by the same token it makes for difficulties in conducting health surveys and planning for medical facilities (Lewis 1953; U.S. Department of Health …1966).

The elastic concept

Another set of notions about health centers on the accumulation of resistance to potential danger. This may be termed the elastic concept. Examples of health behavior derived from this manner of thinking include restricting the water intake of children to make them hardy, homeopathic medicine, and variolation (of differing empirical value, of course). Adversity is not regarded here as a disruption of some prior or ultimate harmony but rather as an ordinary and expected circumstance for which preparations can and should be made. This manner of regarding health seems to play a substantial part in modern preventive medicine. Another good contemporary example of an application of the elastic view of health is psychoprophylactic training for childbirth, by which women are taught to cope with the hardships of delivery through psychological conditioning together with certain exercises (Bing et al. 1961). Some accumulated resistance potentials can be measured operationally in the scientific laboratory by testing an individual’s capacity to produce specific antibodies when challenged by an antigenic substance or his capacity for continued adequate performance of sensory tasks under controlled changes in temperature, humidity, pressure, and other conditions.

The open-ended concept

The outstanding difficulty with the asymptotic notion of health (which is circumvented by elastic conceptions) is its unattainability. By turning the argument around, one can start with death as a kind of absolute zero and fix no upper limit for human functioning (Bates 1959, p. 59). This may be termed the open-ended conception of health. The outstanding example of this ideology is involved in the attempts to formu late a philosophy of “positive mental health.” While some concepts used by the writers in this tradition, such as “self-actualization,” would fall in the category of asymptotic notions, the criteria of growth, zest, and creativity clearly belong under the open-ended rubric. The theorists of positive mental health share with the authors of the WHO definition and others mentioned above the desire to construct a manner of looking at health which is based “not merely on the absence of disease or in firmity.” However, they go beyond the WHO view of health, and beyond most of preventive medicine generally, in their search for positive goals which are independent of disease (Jahoda 1958). Health promotion in nutrition, for example, aims to pre vent deficiency diseases (a goal which is of the “elastic” type) or persuade people to consume recommended daily norms of nutrients (an asymp totic-type idea). By contrast, “zestful living” does not reach an optimum at certain levels of energy expenditure and could even make people occasionally more prone to injury or disease.

Modern medical practice

In terms of actual health behavior in urban societies, open-ended conceptions are more likey to be put into practice in national parks, beauty parlors, bathrooms, or athletic studios than in the offices of doctors or psychologists. Physicians may recommend vacations, walks in the “fresh air,” or other types of exercise, but this is usually pre scribed for incipient illness or problems of overweight rather than for promoting health as such. In non-Western societies one may find practices aimed at increasing supernatural power, physical strength, prosperity, wisdom, virility, or femininity, which are conceptually and behaviorally integrated with actions to prevent or cure disease. In indus trialized societies, however, increased specialization results in the separation of medical institutions from the religious, esthetic, recreational, and economic spheres. As mentioned above, the focus of Western medicine narrowed as the doctrine of specific etiology of disease became the dominant view. Thus, health promotion through such cus toms as taking cold showers, swallowing vitamin pills to “pep you up,” giving laxatives routinely to children, taking walks, and the like is seldom trans mitted as part of the professional medical system but rather is passed on through relatives, friends, or the mass media.

The attempt of the mental hygienists to develop a new and positive content for the concept of health is further limited by concern for the possibility of their encroachment on other institutions. Brewster Smith (1961, p. 301) has commented on the difficult position of the psychologist who is asked to provide notions of mental health as substitutes for weakened religious values; and Freidson (1961/1962, pp. 125 ff.) has warned about the dangers of bringing questions of nonconformity to moral, legal, or political norms under the umbrella of medicine. In spite of these problems, it may be predicted that scientific medicine will gradually adopt a more open-ended conception of health as the technological tasks of health maintenance in a population with increasing proportions of older people are accomplished and as the relationship between people and their environment once again becomes the central arena of medical concern.

Health beyond the individual

The WHO definition does not specify whether its terms apply only to the health of the individual. In the Greek medical system of the fifth century B.C. and that of some modern Western physicians, as described above, health is seen as an interaction between a person and his surroundings. This type of conception is carried even further in the ideas of many non-Western peoples. Margaret Mead (World Federation for Mental Health 1953, pp. 217 ff.) mentions several examples of “continuity” between the well-being of man and of the soil and between the body and “other bodies of the social unit.” It is but a short step from a focus on these interrelationships to a consideration of the larger unit itself, without necessarily looking at the individual within it at all times.

As the student in schools of public health is often reminded, his “patient” will usually be a community. Public health is thus not only the name of a medical specialty but also refers to the well-being of various publics (Brockington 1958, pp. 19 ff.). The health of other entities, such as families, so cieties, the human species, or the entire ecosphere of this planet, has also been discussed.

The resistance potential of a human collectivity to an epidemic of infectious disease cannot be described as the sum or the average of individual immunity: the degree of resistance in different age groups or the spatial dispersion of the population are crucial in estimating the level of “herd immunity” (Gordon 1958). Mental illness is re garded by a number of psychologists and psychiatrists as a pathological state of an entire family. The illness may be discovered through the request for treatment of a single member who acts as the “messenger boy,” carrying the information about the trouble to the outside world, although he is neither the only one sick nor necessarily the one most seriously disturbed (Gruenberg 1957). There are also some writers who consider it appropriate to label entire societies (for example, Nazi Ger many) as pathological and to wonder if any “healthy adjustment” is possible for individuals living in them (Devereux 1956).

Western medical practitioners almost inevitably put a higher value on prolonging individual life than on the health of the social unit—witness the grotesque situation where catheters, sedatives, exorbitant hospital bills, and oxygen tents prevent a dying man from making a decent and meaningful departure from his relatives. Under different cultural circumstances the reverse evaluation may predominate, as among the Navajo Indians of the southwestern United States, who are more concerned with the well-being of the entire kin group than with the maximum comfort of, say, a congenitally malformed infant (Levy 1962).

For an entire species, health may be regarded as a matter of Darwinian “fitness” for continued survival. Unless a species is approaching death through extinction, however, it may be impossible to diagnose its current degree of fitness. The possibility of using modern medicine to keep alive individuals with genetically inherited diseases and the higher reproductive rate of the impoverished classes have been a focus for alarm by some eugenicists. Whether any real danger of “deterioration” exists for the gene pool of the whole human species is debatable (Medawar I960); but, of course, conceptions of health which regard the proliferation of a “chosen people” as good and their relative submergence by “heathens” or other out-groups as bad are not a recent development (Haller 1963).

The health of the entire ecological system that exists on the surface of the earth can also be evaluated in terms of the survival potential of “life.” Evolution on this planet—inorganic, biological, and social—has in the past moved toward increasing degrees of entropy retardation (Polgar 1961). The catastrophe of nuclear war or the slower but equally irreparable consequences of accelerating population growth are threats to the survival not only of “civilized” man but also of the energy balance of our entire terrestrial ecosystem. According to this view, our future well-being in this world as we know it depends on mankind’s acting deliberately to safeguard and to continue accumulating the ordered energy and information that evolution represents.

Steven Polgar

[See alsoIllness; Medical Care; Mental Health; Public Health. Other relevant material may be found in the articles onCreativity; Epidemiology; Eugenics; Psychosomatic Illness; Social Dar Winism.]

BIBLIOGRAPHY

Bates, Marston 1959 The Ecology of Health. Pages 56-77 in Iago Galdston (editor), Medicine and Anthropology. New York: International Universities Press. → The health of human individuals and collectivities seen in relation to the rest of living organisms on the planet. A primary source.

Bing, Elizabeth D.; Karmel, Marjorie; and Tanz, Alfred 1961 A Practical Training Course for the Psychoprophylactic Method of Childbirth. New York: American Society for Psycho-prophylaxis in Obstetrics.

Brockington, C. Fraser 1958 World Health. Harmondsworth (England): Penguin. → A compendium on diseases and the organizations involved in public health. An excellent basic volume.

Cassel, John 1964 Social Science Theory as a Source of Hypotheses in Epidemiological Research. American Journal of Public Health 54, no. 9:1482–1488.

Devereux, George 1956 Normal and Abnormal: The Key Problem in Psychiatric Anthropology. Pages 23-48 in Anthropological Society of Washington, Some Uses of Anthropology: Theoretical and Applied. Washington: The Society. → Discusses the usefulness of the culture concept, with particular emphasis on the shaman. A unique and illuminating essay.

Dubos, Renej. (1959)1961 Mirage of Health, Utopias, Progress, and Biological Change. New York: Harper. → A discourse on health and disease—their history, treatment and characteristics—by an eminent biologist. A primary source.

Firth, Raymond 1959 Acculturation in Relation to Concepts of Health and Disease. Pages 129-165 in Iago Galdston (editor), Medicine and Anthropology. New York: International Universities Press. → A fine essay on the sociocultural context of medical practice. A primary source.

Freidson, Eliot 1961/1962 The Sociology of Medicine: A Trend Report and Bibliography. Current Sociology 10/11: 123–192. → The best sociological summary.

Gennep, Arnold van (1909) 1960 The Rites of Pas sage. London: Routledge; Univ. of Chicago Press. → First published in French. A classic anthropological essay on birth, puberty, marriage, childbirth, and death.

Gordon, John E. 1958 Medical Ecology and the Public Health. American Journal of the Medical Sciences 235:337–359. → A summary of Gordon’s views, with examples from numerous investigations.

Gruenberg, Ernest M. 1957 Socially Shared Psychopathology. Pages 201-225 in Explorations in Social Psychiatry. Edited by A. L. Leighton et al. New York: Basic Books.

Haller, Mark H. 1963 Eugenics: Hereditarian Attitudes in American Thought. New Brunswick, N.J.: Rutgers Univ. Press. History and evaluation of the eugenics movement in the United States.

Huard, Pierre A.; and Wong, Ming 1959 La medecine chinoise au cours des siecles. Paris: Dacosta. → The best contemporary summary of Chinese medicine in a Western language.

Jahoda, Marie 1958 Current Concepts of Positive Men tal Health. New York: Basic Books. → A good synopsis of the field.

King, Stanley H. 1963 Social Psychological Factors in Illness. Pages 99-121 in Handbook of Medical Sociology. Edited by H. E. Freeman et al. Englewood Cliffs, N.J.: Prentice-Hall. → Psychological aspects of doctorpatient relations, as well as of illness.

Levy, Jerrold E. 1962 Comment on “Health and Hu man Behavior” by Steven Polgar. Current Anthropology 3:186–187.

Lewis, Aubrey 1953 Health as a Social Concept. Brit ish Journal of Sociology 4:109–124. → Separates health from social well-being, delineating operational criteria for physical and mental illness in the “asymptotic” tradition.

Medawar, Peter B. 1960 The Future of Man. New York: Basic Books; London: Methuen. → An essay on human genetics; grapples with many difficult and fundamental value problems.

Mering, Otto Von; and Earley, L. William 1965 Major Changes in the Western Medical Environment: Impact of Changes in Care of Undifferentiated Disorders. Archives of General Psychiatry 13:195–201.

Newell, Kenneth W. 1957 Medical Development Within a Maori Community. Health Education Jour nal 15:83–90.

Nurge, Ethel 1958 Etiology of Illness in Guinhangdan. American Anthropologist New Series 60:1158—1172.

Paul, Benjamin D. 1953 Mental Disorder and Self-regulating Processes in Culture: A Guatemalan Illustration. Pages 51-68 in Milbank Memorial Fund, Interrelations Between the Social Environment and Psychiatric Disorders. Proceedings, No. 29. New York: The Fund. → Describes the sequence of events in serving patients and their significance for treating disturbances in social relationships.

Pflanz, Manfred 1964 Der unklare Fall. Miinchener medizinische Wochenschrift 106:1649–1655. → A discussion of the characteristics of patients, physicians, and medical thought, as these bear on the frequency of undifferentiated diagnoses in medical practice.

Polgar, Steven 1961 Evolution and the Thermody-namic Imperative. Human Biology 33:99–109. → A development of four principles in organic and social evolution, from which a value position is derived.

Polgar, Steven 1962 Health and Human Behavior: Areas of Interest Common to the Social and Medical Sciences. Current Anthropology 3:159–205. → A charting of the field, with an extensive bibliography.

Polgar, Steven 1963 Health Action in Cross-cultural Perspective. Pages 397-419 in Handbook of Medical Sociology. Edited by H. E. Freeman et al. Englewood Cliffs, N.J.: Prentice-Hall. → An essay-review on the values and notions relevant to health, on medical practitioners, and on cross-cultural health programs.

Riese, Walther 1953 The Conception of Disease: Its History, Its Versions and Its Nature. New York: Philo sophical Library. → Fourteen types of disease conceptions, almost exclusively from the Western tradition.

Rosen, George 1958 A History of Public Health. New York: Md Publications..

Shiloh, A. 1958 Middle East Culture and Health. Health Education Journal 16:232–244.

Sigerist, Henry 1951-1961 A History of Medicine. 2 vols. New York: Oxford Univ. Press. → Volume 1: Primitive and Archaic Medicine. Volume 2: Early Greek, Hindu, and Persian Medicine. A lucid, scholarly, and thorough history.

Smith, M. Brewster 1961 “Mental Health” Reconsidered: A Special Case of the Problem of Values in Psychology. American Psychologist 16:299–306. → An excellent attempt to cut through the conceptual dilemma in order to arrive at operational guidelines for applied psychology.

Steiger, W. A. et al. 1962 A Definition of Comprehensive Medicine. Journal of Health and Human Behavior 1:83–86.

U.S. Department Of Health, Education, And Welfare, Division Of Vital Statistics 1966 ConceptualProblems in Developing an Index of Health, by Daniel F. Sullivan. Washington: Government printing office.

World Federation for Mental health (1953) 1955 Cultural Patterns and Technical Change. Edited by Margaret Mead. New York: New American Library.→ A very useful overview in the form of a collage of case histories and topical discussions.

World Health Organization 1946 Constitution of the World Health Organization. Geneva: The Organization.

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Health and Disease

HEALTH AND DISEASE

HEALTH AND DISEASE. The relationships among food, health, and disease are myriad and complex. We consume food every day, and it provides the resources we need to carry out life-sustaining functions. Hence it comes as no surprise that one's diet can affect profoundly one's daily and long-term physiological health and wellbeing. Qualities of a diet and the foods that comprise it have the potential to make one sick, but they also can act to reduce one's risk of acute or chronic diseases.

All of the formal medical traditions of the world recognize a close connection between diet and an individual's health. One theme common to Mediterranean, Middle Eastern, and South and East Asian traditional medical systems is the ascription of humoral qualities to foods (for example, foods that are "heating" or "cooling" to the body). In these traditional systems, an individual's diet is manipulated to include or exclude foods with specific properties in order to correct putative humoral imbalances or disease states. In contemporary biomedicine, the link between food and disease most often is articulated with regard to the compositional qualities of foods and the ways that diets high or low in specific foods (and hence nutrients and other plant constituents) have harmful or beneficial effects on the body.

Benefits of Nutrient Diversity

There are numerous ways in which diets comprised of specific foods containing or lacking a given nutrient contribute to health or disease. For example, a diet that includes few or no animal products may result in anemia due to a deficiency in iron and/or vitamin B12. On the other hand, a diet high in animal products but low in fruits and vegetables may contribute to specific vitamin deficiencies. Scurvy (a disease caused by vitamin C deficiency) was recognized first among sailors on long-distance sea voyages, as they had no source of fresh fruits or vegetables. An unprocessed corn-based diet is known to result in the disease pellagra, caused by a deficiency of niacin, one of the B vitamins. Up through the early twentieth century, there was a well-defined "pellagra belt" through the southern United States, where corn was consumed widely.

A diet comprised of diverse foods generally is considered to be the best way to prevent nutrient-deficiency diseases. Early humans lived by hunting and gathering, and they ate a broad array of plant and animal foods, although this varied by season and geography. Modern hunter-gatherers of the Kalahari Desert in southern Africa are known to exploit more than eighty species of plant foods, and no specific nutrient deficiencies have been reported among these groups. However, with the transition to agriculture, which happened in many parts of the world around 10,000 years ago, dietary diversity declined notably as populations began to cultivate a narrow array of staple crops (such as wheat, rice, potatoes, and millet). Iron deficiencies and severe growth deficits due to undernutrition become apparent in the skeletons of early farmers.

Effects of Food Processing

Some of these nutritional problems were resolved as populations evolved different means of processing staple foods that enhanced dietary nutrient profiles. Indeed, in the postagricultural period, food-processing techniques became crucial for reducing the negative health impacts of reliance on a few foods. Native populations of the Americas that had a long tradition of reliance on maize (corn) prepared it in such a way as to avoid the problem of niacin deficiency. Corn was boiled in a solution containing lime (calcium carbonate, ash, etc.); this process resulted in the liberation of niacin from an undigestible complex, and also improved the food's amino-acid balances. When corn was introduced to Europe during the Columbian period, the lack of a tradition for its processing led to outbreaks of pellagra. A similar example is the leavening of wheat to make bread, or fermentation to make beer. Both of these processes increase the bioavailability of the minerals calcium, iron, and zinc. When soybeans are processed into bean curd, as is common in East Asia, they lose their protease inhibitors, which interfere with protein digestion.

On the other hand, it is also the case that some food-processing techniquessuch as heating, boiling, or dryingcan destroy vitamins in foods. Vitamin C degrades in the presence of heat and aridity; folic acid and thiamine likewise are sensitive to heat. Some of the other B vitamins break down in the presence of alkaline or acidic conditions. Others, such as vitamins B6 and B12, are quite stable under most cooking conditions. Milling and polishing rice into smooth white grains, which are valued highly in East Asian cuisine, reduce the protein and thiamine content of rice, and contribute to the risk of the disease beriberi (thiamine deficiency). Industrial processing of foods often reduces their nutrient profile, but many foods, especially those that are consumed widely such as cereals, are enriched to replace lost nutrients. In addition, grilling or broiling meats until they are well-charred has been associated with the production of the chemical compound Benzo(a)pyrene, which has been linked to gastrointestinal cancers.

Nonnutritive Food Components

When diets are derived largely from plant foods, particular combinations of food are known to improve the overall dietary quality, particularly with respect to the balance of essential amino acids. Corn, for example, is low in the amino acids lysine and tryptophan, but in native American cuisine, corn is often combined with legumes that are rich in those amino acids. Likewise, the combination of rice and legumes can provide the full array of essential amino acids. A peanut butter sandwich, a staple in the diet of many American children, contains complementary amino acids from the wheat and peanuts.

However, it is not only the nutrient composition of foods that is relevant to disease. Other qualities of foods especially plant foodsrecently have been found to contain other chemicals that reduce the risk of certain diseases. Phytochemicals derived from plant foods may reduce the risk of some cancers, while others may protect against heart disease and/or diabetes. Some potentially important phytochemicals include polyphenols (in red wine and green tea) and carotenoids (in orange, yellow, and green vegetables). Many of these have been found to have antioxidant effects and may prevent cell damage from oxygen-free radicals. Widespread consumption of red wine has been credited by some with the "French Paradox," the observation that, although the French tend to eat foods high in fat, their consumption of red wine may offset some of the risk of cardiovascular disease usually associated with such diets. Phytoestrogens, a form of isoflavones found in legumes such as soybeans, may reduce the risk of many cancers, especially breast cancer, by binding to estrogen receptors, and these also may reduce bone loss associated with osteoporosis. Proteins in soybeans also may reduce cholesterol levels and thus reduce the risk of heart disease. The organosulfur constituents of garlic may inhibit platelet aggregation and reduce blood lipids, thereby reducing the risk of coronary heart disease. Tannins (found in tea, coffee, cocoa, red wine, and some legumes and grains) and phytates are hypoglycemic, and may contribute to reduced risk of diabetes.

Other plant compounds have links to infectious disease, such as the protozoan disease malaria, which is a common disease (and often life-threatening) in tropical and semitropical areas. Manioc (Manihot esculenta ; also called cassava or yuca), a widely cultivated root crop in the tropics, contains cyanogens, which appear to inhibit the growth of the malaria parasite in red blood cells. Likewise, fava beans contain vicine, a potent oxidant that disrupts malarial reproduction in red blood cells. However, individuals who are deficient in the enzyme G-6PD (a deficiency most common in Mediterranean populations) are susceptible to the potentially fatal anemia, favism, because their red blood cells are extremely vulnerable to destruction by potent oxidants such as vicine.

Many secondary compounds in plants do not have such salutary effects, or their benefits are tempered by potential negative effects on health. The cyanogens in manioc, lima beans, and other foods can interfere with thyroid function, glucose metabolism, growth and development, and other important physiological functions. Cruciferous vegetables such as cabbage contain thiocyanate compounds that act as goitrogens, and thereby contribute to thyroid disease. Tannins, which are distributed widely among plant foods, inhibit protein digestion and interfere with iron absorption. The ingestion of solanine, a glycoalkaloid found in commercial strains of potatoes that have been exposed to light, or in many wild varieties, can lead to serious gastrointestinal and neurological symptoms. Interestingly, traditional modes of consuming potatoes among Andean populations appear to reduce the risk of solanine exposure; their potatoes are consumed often with a clay-based slurry, which effectively detoxifies them.

Food-Consumption Concerns Linked to Population Profiles

There are cases in which the health effects associated with the consumption of particular foods vary in significant ways among diverse populations. For example, the ability to produce the enzyme lactase (which breaks down the milk sugar lactose) in adulthood is rare among human populations. This ability persists in highest frequencies through adulthood among northern Europeans and pastoral populations in Africa and other areas. Fresh milk consumption played an important role in maintaining health in the history of these populations, and they evolved lactase persistence as a dietary adaptation. When adults with low levels of small-intestinal lactase activity consume fresh milk (the food highest in lactose), they often experience cramps, bloating, diarrhea, and other forms of gastrointestinal distress. This is less of a problem when milk is consumed after processing into yogurt or cheese, as lactose is either fermented or removed during their production.

In populations that only recently have begun relying on wheat production there is a high frequency of celiac disease, an allergic response to wheat protein (gluten). There is some suggestion that African Americans may be more sensitive to salt than are other sectors of the population, and that, consequently, salt consumption by African Americans increases blood pressure and contributes to an incidence of hypertension greater than in other groups.

In the most general sense, both underconsumption and overconsumption of foods can lead to chronic disease. Not surprisingly, these two ends of the consumption spectrum tend to occur in poor and wealthy populations, respectively. It is estimated that more than 1.2 billion people suffer from deficiencies of calories and protein. A similar number suffer from problems related to the overconsumption of calories. Both are associated with deficiencies of micronutrients. It has been suggested that more than half of the world's disease burden derives from nutrition-related sources.

Overconsumption of calorie-rich foods became the norm in wealthy countries during the late twentieth century. Such foods became mass produced, more readily available, and relatively inexpensive. Today supermarket shelves are lined with potato chips, candy, cookies, crackers, soda, and all kinds of other calorie-dense foods. Fast-food restaurants specialize in ever-larger servings of high-calorie foods that are quickly prepared and consumed. Most of these are highly processed, and although they are rich in calories, they are often low in vitamins, minerals, and phytochemicals. It is widely accepted that, when combined with a sedentary lifestyle, diets high in such foods contribute to a broad array of chronic health conditions, most significantly cardiovascular disease (CVD), diabetes, cancer, and hypertension. It is now estimated that more than half of Americans are overweight, and almost one-quarter are obese, which is itself a risk factor for these diseases. In addition, an increasing number of children are now obese, and "adult-onset" (Type 2) diabetes is appearing with alarming frequency in adolescents. More than 75 percent of all mortality in the United States is due to CVD and cancer, but death rates from stroke and heart attacks have declined since the 1970s. This has been attributed, in part, to reduced consumption of saturated fat from red meat, whole milk, butter, and lard. There are several studies indicating that a low-fat diet based largely on vegetables, fruits, whole grains, legumes, with relatively small amounts of animal protein (especially from fish) is associated with increased longevity and reduced risk of chronic disease.

Problems related to the overconsumption of high-calorie foods are not unique to the industrialized world. As countries are integrated into the global economy and populations increasingly become urbanized, there has been a global shift in dietary patterns and health conditions that appear to accompany those new consumption habits. Interestingly, such changes are remarkably consistent across countries, and may reflect a panhuman preference for foods rich in calories, which historically have been quite limited in the diet. Generally the consumption of fats and sweets has increased, and the use of traditional whole-grain foods and traditional modes of processing has declined. Fast-food outlets such as Kentucky Fried Chicken and McDonalds have become ubiquitous in urban centers throughout the world. Active lifestyles are being replaced with sedentism, as people move away from subsistence agriculture into clerical and factory jobs. As a result, the chronic diseases that heretofore had predominated in wealthy industrialized countries are becoming globalized. For example, the global diabetes rates seen in 2000 are expected to double by 2025, with the majority of that growth occurring in developing countries.

On the other hand, undernutrition, also referred to as protein-energy malnutrition (PEM), often occurs under conditions of food scarcity and is associated with a wide range of negative health effects. More than 10 percent of the world's population suffers from chronic hunger, and undernutrition may be responsible for as many as twenty million deaths per year. It is important to realize that hunger is not the result of too little food being produced for too many people in the world; it is essentially a problem with the way that food is distributed unevenly among the world's populations. Children are especially vulnerable to PEM, as they have higher protein and energy needs per unit of body weight than do adults. When calories and protein are chronically scarce in childhood, permanent stunting and retarded development occur. In its acute form, PEM results in wasting (dramatically reduced weight relative to height) and it is potentially fatal. More routinely, PEM increases vulnerability to infectious disease, since energy, protein, and certain vitamins and minerals play crucial roles in immune function. In environmental contexts in which infectious disease (especially diarrheal disease) is common, the combination of PEM and infection can provoke a rapid deterioration of health that can lead to death. A common stage for this progression to manifest itself is weaning, the period when children make the transition away from breast milk (which contains nutrients and disease-suppressing maternal immunoglobulins) to an adult-type diet. It is not uncommon for children to become more vulnerable to infection when they are weaned prematurely and are unable to consume sufficient nutrientdense foods to maintain growth.

In the 1800s, baby bottles were developed and cow's milk was developed into infant formula as an alternative to breast milk. The practice of formula-feeding peaked in the United States in the years following World War II; breast-feeding is now on the rise again in most parts of the world, although it remains uncommon past the early months in most industrialized countries. Most research amply demonstrates the health benefits of breastfeeding: substitution of formula for breast milk is associated with increased risks of numerous health problems including SIDS (sudden infant death syndrome), ear infections, diabetes, breast cancer, and allergies.

Controversy erupted in the early 1970s over the promotion of formula by multinational corporations in the developing world. Formula was marketed heavily and inappropriately, and health personnel began to encourage mothers to feed their children formula rather than nurse them. Formula, which was costly, often was prepared in dilute form with contaminated water. Its use in this way increased infant morbidity and mortality and generated much attention among the media and international health organizations, ultimately resulting in a ban on formula promotion by multinational corporations.

As the links between diet and disease have become more widely known, there has been a trend toward more healthful eating habits in industrialized societies. However, this trend is not uniform within such populations. Numerous studies have shown that obesity, the eating habits that contribute to it, and the diseases associated with it, especially diabetes, have increased among lower socioeconomic groups. The reasons behind this trend are complex, but as noted above, foods high in starches, fats, and sugars are now cheap and readily available. Those high in protein (meat, dairy products) and fresh fruits and vegetables are relatively less accessible and more expensive, and are consumed less commonly by the poor. Moreover, in the United States, fast-food outlets are locating preferentially in areas serving poorer communities. This has led to the curious, yet commonplace, phenomenon in wealthy countries whereby weight is correlated inversely with wealth. Historically, of course, the reverse would have been the case, as is still evident in many developing countries.

See also Anthropology and Food; Baby Food; Disease: Metabolic Diseases; Fast Food; Food Politics: United States; Lactation; Malnutrition; Medicine; Milk, Human; Niacin Deficiency (Pellagra); Nutrients; Nutrition; Obesity; Paleonutrition, Methods of; Political Economy; Population and Demographics; Salt; Sodium; Vitamins.

BIBLIOGRAPHY

Cohen, Mark Nathan. Health and the Rise of Civilization. New Haven, Conn.: Yale University Press, 1991.

Diamond, Jared. "The Saltshaker's Curse." Natural History (October 1991): 2226.

Gardner, Gary, and Brian Halweil. Underfed and Overfed: The Global Epidemic of Malnutrition, edited by Jane A. Peterson. Worldwatch Paper 150. Washington, D.C.: Worldwatch Institute, 2000.

Jackson, Fatimah Linda Collier. "Secondary Compounds in Plants (Allelochemicals) as Promoters of Human Biological Variability." Annual Review of Anthropology 202 (1991): 505546.

Johns, Timothy. "The Chemical Ecology of Human Ingestive Behaviors." Annual Review of Anthropology 28 (1999): 2750.

Katz, Solomon H. "Food and Biocultural Evolution: A Model for the Investigation of Modern Nutritional Problems." In Nutritional Anthropology, edited by F. E. Johnston. New York: Alan R. Liss, 1987.

Lappé, Frances Moore, Joseph Collins, and Peter Rosset. World Hunger: Twelve Myths. New York: Grove Press, 1998.

Lee, Richard B. "What Hunters Do for a Living, or, How to Make Out on Scarce Resources." In Man the Hunter, edited by Richard B. Lee and Irven DeVore. Chicago: Aldine, 1969.

Liebman, Bonnie, and David Schardt. "Diet and Health: Ten Megatrends." Nutrition Action 28, no. 1 (January/February 2001): 312.

Martorell, Reynaldo. "Interrelationship between Diet, Infectious Disease, and Nutritional Status." In Social and Biological Predictors of Nutritional Status, Physical Growth, and Neurological Development, edited by Lawrence S. Greene and Francis S. Johnston. New York: Academic Press, 1980.

McGee, Harold. On Food and Cooking: The Science and Lore of the Kitchen. New York: Simon and Schuster, 1984.

Stuart-Macadam, Patricia, and Katherine A. Dettwyler, eds. Breastfeeding: Biocultural Perspectives. New York: Aldine de Gruyter, 1995.

Van Esterik, Penny. Beyond the Breast-Bottle Controversy. New Brunswick, N.J.: Rutgers University Press, 1989.

Wardlaw, Gordon M., and Paul M. Insel. Perspectives in Nutrition. New York: Mosby, 1996.

Andrea S. Wiley

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Health and Disease

HEALTH AND DISEASE.

Health and disease seem at first glance to be obvious and opposing concepts. We are either healthy or suffering from some disease. In practice, however, health and disease are neither clearly defined nor mutually exclusive. Asthmatics and diabetics have won Olympic gold medals, and amputees can live to a ripe old age. "Healthy" people in their eighties cannot do things they could easily have done half a century before; they may still be able to perform tasks they could not have as healthy infants. Conditions that would be perceived as a disease in one society might be considered perfectly normal in another.

Health is a more problematic and conditional state than is disease, and it is generally less visible historically. It is less likely to be noticed by the individual or commented on by healers or philosophers. Often, health is simply the default mode, the condition to which people revert after they recover from some illness. Illness is of course not the same as disease. The former is a subjective experience, suffered by a person; the latter is more objective, in that others, especially medical practitioners, share in its conceptualization. The diagnosis, or naming, of the disease generally presupposes some notion of its cause. There may be different frameworks of putative causation operating between patients and their healers. The patient may believe he or she fell ill because of exposure to the cold or consumption of the wrong kind of food. The doctor may have other ideas. For most of human history, however, doctors and patients shared similar causative cosmologies. With the rise of modern biomedicine, the potential divergence of the explanatory frameworks increased. This separation of the conceptual worlds of doctor and patient is part of the power, and the problems, of modern medicine.

More constant are the normative dimensions of health and disease. Health, however conceived, has positive qualities, disease negative ones. Aesthetics plays a large part in contemporary judgments on these matters. Sumo wrestlers and weight lifters are perceived as healthy, even if their life expectancies may be less than those of ninety-pound weaklings. Straight teeth are considered healthier than crooked ones. Plump women in some cultures are considered healthier than their leaner sisters; in other times and places, the reverse is the case. Sunbathing is a relatively recent phenomenon among the lighter skinned races; malignant melanoma has caused a reevaluation of the relative merits of the aesthetic and the medical.

All of these examples point to the complexity and historical contingency of perceptions of health and disease. Following Alexander Pope's dictum, "this long disease, my life," this essay will use disease as the standard and assume that notions of health are somehow implicit in the historical perception of disease.

Beginnings

In preliterate societies, disease was often assumed to be the product of one of two opposing occurrences: object intrusion or spirit loss. The intrusion of some foreign object was invoked to explain diseases marked by pain, restlessness, and other acute symptoms. Spirit loss resulted in wasting, lethargy, and other signs of debility. These grand divisions, corresponding very roughly to "noisy" (acute) diseases and "quiet" (chronic) ones, recur throughout history. In preliterate societies, the explanations were embedded within magico-religious frameworks, and the remote causes of disease might be witchcraft, malevolent spirits, or individual transgression of some cultural taboo. Healing was often a communal affair, and the principal healer generally combined the offices of priest and doctor. While the conceptual framework was religious or magical or both, the steps toward healing, or disease prevention, rationally followed the assigned causes. Notions of health generally incorporated aspects of fecundity or potency and are reflected in famous prehistoric works of art.

Literate Near Eastern communities in Egypt, Mesopotamia, and elsewhere developed medical systems that indissolubly mixed the religious and the medical, and the priest-physician was a central figure in them all. Myths of a golden age, when disease did not exist, were common, as was the tacit assumption that individual transgression could be implicated as the root cause of disease.

Three great systems of medicine with great staying power developed in the centuries before the Common Era. These arose in Greece, India, and China. Modern Western biomedicine can be traced to the work of Hippocrates and his followers. The ayurvedic system in India developed autonomously, as did Chinese medicine. The latter two systems still have many followers and have been more impervious to change than has Hippocratic medicine. There are a few, probably incidental, commonalties in the three systems. In each of them, bodily fluids (humors) and spirits (pneuma) were more important than the solid parts in determining health and disease. Longevity was a more explicit goal of health than was fertility or potency. Notions of balance were central to each system.

There are also important differences. The Chinese associated health with plumpness (Buddha is always depicted as rotund), whereas Greek sculptures of idealized athletes show the taut muscular development that Western values still identify with health and vitality. The Chinese polar principles of yin and yang have no obvious parallels in Western thought. The three Indian humors (dosa ) of wind, bile, and phlegm cannot be equated to the four humors of Greek medicine.

The series of treatises written between the fifth and second centuries b.c.e. by Hippocrates and his followers provide the touchstone of modern Western biomedicine. So powerful is this legacy that both the dominant scientific biomedicine and the alternative Western medical cosmologies, such as homeopathy, naturopathy, osteopathy, chiropractic, and hydropathy, all claim descent from this "father" of Western medicine. The Hippocratics naturalized disease, making it part of ordinary human existence, rather than the result of supernatural forces. They also reinforced the notion of health as a balance of the four humors, disease occurring when one or more of the humors was in excess or deficiency.

Greek humoralism was one of the most powerful explanatory systems ever devised within medicine. It was linked to Greek natural philosophy (the four humors having their counterparts in the four elements, air, earth, fire, and water) and contained a framework that made good sense of the human life cycle, individual temperament, and the role of the environment in health and disease. One Hippocratic treatise, Airs, Waters, Places, is simultaneously a subtle treatise on environmental medicine and a foundation document on the formative role of place and topography on human culture.

The Hippocratics always insisted that the physician was the servant of nature. Through their important doctrine of the healing power of nature (vis medicatrix naturae), they interpreted the phenomena of the bedsidesweating, vomiting, diarrhea, jaundice, productive coughsas evidence that the body was trying to rid itself of its excessive humors or to restore defective or deficient ones. Disease was for them an individual affair, based on the person's stage in the life cycle, normal temperament, sex, occupation, and other individualized factors. They elaborated a system of hygiene, advice to the individual on how he or she might preserve health and achieve longevity, through diet, exercise, and mode of living. Humoral medicine made no sharp distinction between mental and bodily disorder, explicating melancholy, mania, and hysteria along identical lines as fevers, cancer, or chronic wasting diseases such as phthisis.

Hippocratic humoralism was by no means the only medical system developed during the Mediterranean antiquity, but it was the most influential one, especially after Galen (c. 129c. 199/216) identified with it and consolidated and extended its nuances. Hippocrates and Galen enjoyed positions of un-rivalled prestige for more than a millennium. Galen's monotheism and philosophical bent especially appealed to elite physicians after Christianity became the dominant religion of the West. The otherworldly dimension of Christianity during the medieval period meant that bodily health and disease could be devalued, in pursuit of the eternal felicity of the other world, but medical orthodoxy still operated within the humoral framework. Both religion and magic also offered important alternative interpretations, and both cause and cure of disease could be sought in the realms of the supernatural. Holy shrines and pilgrimages became part of the simultaneous expiation of sin and restoration of health. Several of the seven deadly sins (gluttony and sloth, for example) were also intertwined with causative explanations of disease. Indeed, sloth (also called acedia) was actually medicalized into a diagnostic category and seemed to be especially common among monks who found it difficult to leave their warm beds for early-morning prayers.

Early Modern Concepts

The early modern period witnessed great changes in physical science, with the decline of Aristotelianism and the mechanization of the world picture during the period dubbed the scientific revolution. Notions of health and disease reflected some of these developments, although continuities are also obvious. Manuals of health and longevity became popular, as health became a desirable goal in societies now concerned with investigating the wider world and the stars above. As always, health was generally associated with moderation, especially through the regulation of what were called the six "nonnaturals": air, food and drink, sleep and wakefulness, retentions and excretions, motion and rest, and the affections of the mind. An Italian nobleman, Luigi Cornaro (c. 14631566), wrote in his old age a treatise on hygiene, based on his own experience of moderate living. It was widely translated and remained in print for several centuries. Although the explanatory framework would differ today, Cornaro's treatise is filled with advice that would not be out of place in a contemporary lifestyle medical manual.

There was much continuity in advice manuals on health for a long time after Cornaro, but ideas about the causes and mechanisms of disease began to change. Hippocratic humoralism had much staying power, but doctors such as Paracelsus (14931541) and Jan Baptista van Helmont (15791644) elaborated new medical systems. Van Helmont linked physiological function in both health and disease with a vital power that he identified with the archeus, a principle he associated with each organ. It had the effect of separating the disease from the body of the individual sufferer, as the archeus had some sort of independent existence. Van Helmont inclined toward chemical explanations of disease, but other doctors leaned toward mechanical models of both normal and pathological functions, following in the wake of the triumphant natural philosophers such as Galileo Galilei (15641642) and Isaac Newton (16421727). Iatrochemists and iatromechanists, as they were called, vied with each other for theoretical dominance from the late seventeenth century.

In the midst of all these theoretical concerns, one clinician remained true to Hippocratic humoralism. Thomas Sydenham (16241689), the "English Hippocrates," approached clinical medicine without much concern for the newfangled chemistry or mechanical physiology. He left superb descriptions of a number of diseases, including gout, smallpox, and hysteria, insisting that medicine was an empirical affair, ultimately based on careful observation and the trial-and-error use of remedies. One such remedy, Peruvian bark (which contains quinine), so impressed him in its capacity to extirpate "agues" (malarial fevers), that he came to believe that diseases could be classified in the same way that naturalists classified plants and animals. Nosology, or disease classification, became a preoccupation among eighteenth-century physicians. It came to be based primarily on symptoms, and the number of disease categories multiplied. Sydenham's remarks on the specificity of diseases came into their own in the late nineteenth century, when germ theorists began to identify the disease with the germ that was proposed as its causative agent.

Hippocratic humoralism gradually lost its persuasiveness during the eighteenth century, as doctors turned to the blood, nervous system, or glands as the primary foci of disease causation. At the same time, pathologists such as Giovanni Morgagni (16821771) began to note consistent patterns of structural changes in the bodies of patients they autopsied and to attempt to correlate these changes in the organs and tissues with the diseases they had diagnosed and the symptoms that the patient had suffered from during life. This clinicopathological correlation became the basis of the hospital medicine that flourished in Paris after the French Revolution.

The Modern Period

In order better to follow the course of disease in the living, French clinicians routinized systematic physical examinations of their patients. Jean Corvisart (17551821) developed percussion, tapping on the thorax and abdomen, to demarcate enlarged organs, collections of fluid, or tumors, and René Laennec [17811826] invented the stethoscope in 1816. Paris itself became a world center of medical education, and foreign students exported the French way of doing things throughout the Western world. French medicine was based primarily on the diseases of the organs, such as the heart, lungs, or liver. The development of better microscopes in the 1820s encouraged doctors to push pathological analysis into the tissues (a concept popularized by the French clinician M. F. X. Bichat [17711802]), and by the late 1830s, cell theories had been elaborated by German scientists such as Matthias Jakob Schleiden (18041881), for plants, and Theodor Schwann (18101882), for all living organisms. Rudolf Virchow's (18211902) Cellular Pathology (1858) put the cell at the heart of medical reasoning.

At about the same time, the work of microbiologists such as Louis Pasteur (18221895) and Robert Koch (18431910) showed the causative importance of bacteria and other microorganisms in a host of diseases. The germ theory of disease had dramatic practical spin-offs for medicine and public health, but it also separated the "disease" (the microorganism) and the victim of disease. Without the tubercle bacillus, there could be no tuberculosis. For some doctors, the disease could now be equated with its causative organism.

The germ theory was never without problems. Many clinicians considered germs as either incidental to or the result of disease, rather than its cause. Enthusiastic researchers found germs for many diseases, such as pellagra and cancer, which subsequent investigations would disprove. Some social activists complained that obsession with germs deflected concern from other factors that also influenced health, such as housing or inequalities of wealth. Why two individuals exposed to the same germ might have completely different reactions highlighted important host-parasite interactions. The range of agents causally associated with disease has been extended from the bacteria to include worms, plasmodia, amoebas, viruses, and, more recently, prions. Always, anomalies have driven researchers back to the bedside, community, or laboratory.

Since the mid-nineteenth century, the thrust of biomedical levels of disease explanation has been toward ever more minute categories: intracellular elements, chemicals, and molecules with known compositions and structures. Molecular biology is the preeminent science of the present day, created just before, but reaching powerful maturity after, the elucidation of the structure of DNA in 1953 by James Watson and Francis Crick. The biological importance of DNA had been recognized before Watson and Crick's work, but understanding its structure provided a model of how this long-chained molecule, found in the chromosomes of the cell's nucleus, controlled the inherited continuity that is characteristic of living organisms.

Modern biomedical research has revealed many of the mechanisms of disease at the molecular level. The first "molecular disease," sickle-cell anemia, was identified by Linus Pauling in 1949 as the result of a minor structural (but large functional) change in the hemoglobin molecule. Molecular medicine has progressed rapidly since the mid-twentieth century, with the Human Genome Project offering the prospect of much greater knowledge about the role of genetic factors in health and disease. Genetic information also creates a host of ethical problems, such as confidentiality, insurance premiums, employability, and advice on parenthood. Critics argue that it is eugenics in new dress; advocates insist that the knowledge itself is neutral and its use is a matter for society to sort out.

By the twenty-first century the concept of disease had been diluted, as we have all been medicalized. Acts, desires, and choices that in previous generations would have been conceptualized within moral, religious, or legal frameworks could now be attributed to disease. Eating disorders, suicide, many forms of criminality or deviancy, stress, and many other "facts" of modern life are often included within disease categories. Homosexuality has been a normal stage of the life cycle, a sin, a crime, a disease, and a life choice in different periods within Western society. "Mental" diseases continue to carry a moral burden.

If modern medicine has been expansionist in the field of disease, it has been less successful in assimilating health into its orbit. The more we know, the more prevalent disease, or potential disease, seems to be. Orthodox medical advice about health is largely statistical in its foundations and behavioral, not medical, in its recommendations. The Hippocratic injunction to moderation is still at the heart of Western medicine. What is "normal"that is, healthyis often based on epidemiological surveys, actuarial information, and cultural values. Despite the enormous power of modern biomedicine, health and disease still have important cultural, aesthetic, and moral dimensions to them.

See also Biology ; Eugenics ; Hygiene ; Medicine ; Psychology and Psychiatry ; Scientific Revolution .

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W. F. Bynum

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health

health is commonly thought of as the absence of disease, and indeed it is difficult to discuss one without the other. Equally problematic is the consideration of the health of the body apart from the state of the mind or the spirit, because historically the topics were closely connected, especially before the seventeenth century. Even with these difficulties in mind, it is still possible to focus on certain notions about the health of the human body as a natural state and about how this natural state could be restored or maintained.

One idea about health that unites many cultures, from the classical Indian, Mesopotamian, Egyptian, ancient Greek, sub-Saharan African, Semitic, and native American, is the notion that there was a time when the human body existed in a perfect state of health and when no diseases beset it. People lived in harmony with nature, in a childlike state of material plenty and spiritual obedience. Bodily ills came into the world, so many stories go, when a ‘sin’, often one of disobedience, angered divine authority. One thinks of the myth of Pandora's box or the expulsion of Adam and Eve from the Garden of Eden, as told in Genesis, as examples, but other cultures provide many more such tales. Stories about original sin and the fall from grace are, in short, as common as creation myths in their explanations for why humanity no longer experiences natural health and, in some cases, long physical life.

Such myths carry in them crucial meanings for understanding the history of the body and its health that are with us still. The idea that there was a time when perfect health existed naturally is a powerful one. The author of Genesis wrote of painless childbirth before the Fall, and of, even after it, the remarkable age and sexual prowess of the Patriarchs. These stories also link health, or lack of it, to moral or religious conduct, and often join good health to a vigorous old age.

If perfect bodily health existed once, some argued, it could exist again. The restoration of balance and harmony with nature and with the divine was commonly offered as a way to achieve this restoration. Taoist thought sees good health as a balance between the opposing forces of Yin and Yang, which exist in the individual as well as in the world at large. The ancient Greeks viewed good bodily health as the duty of the aristocracy, along with military service and good governance. Medical texts are among the earliest surviving philosophical writings of the Greeks, indicating an eager audience for this type of advice.

Ancient Greek notions are perhaps the most important for defining how health would be regarded, at least in European and Islamic cultures. Most important is the nearly universal idea of microcosm and macrocosm. Very simply put, the body (microcosm) was thought of as a part of the larger world of nature (macrocosm). The four elements of nature: earth, air, fire, and water, and the four qualities: hot, cold, moist, and dry, found their counterparts within the body in the four humours: blood, which was hot and moist; choler, which was hot and dry; phlegm, which was cold and moist; and melancholy, which was cold and dry. Health lay in balancing these humours within the body through a regimen consisting of diet, exercise, and regulation of the emotions. Moderation and balance in all these natural factors was the road to good health and long life. Indeed, the Greeks counted gymnastics among the liberal arts, along with rhetoric and logic, as activities proper to a gentleman and ones leading to moral virtue.

Roman Stoic philosophers and Christian thinkers who followed after them held physical health in rather less esteem. Stoics sought to free themselves from bodily concerns by philosophical contemplation, while some Christians found value in mortifying the flesh, thereby turning their thoughts to the immortality of the soul. Medieval Islamic culture elaborated the Greek ideal of the healthy, happy aristocrat, and cultivated royal doctors famous for entertaining stories and jokes. It also promoted musicians, all to preserve the health of noble patrons. Medieval scholastic philosophers, rather surprisingly, took up another Islamic pursuit, alchemy. From the thirteenth century the Pope, who ideally ruled for life, patronized Christian alchemists. They argued that the recovery of knowledge about the philosophers' stone (which was known to the ancients) would not only make one rich, but return the body to its pristine state before original sin brought disease and the ravages of old age into the world.

The rage for medical alchemy, which only grew during the Renaissance, brought into focus the importance of philosophical thinking, drawing upon the ideas of many cultures, to the development of notions about bodily health. Rationality, a peculiar obsession of the Greeks, contributed to the separation of bodily concerns from those of the spirit. Although ancient Greek physicians called themselves philosophers, they excluded from philosophical/medical consideration supernatural causes of disease as being the province of magicians, because they were anxious to define their young profession as different, and better, than that of the faith healer. Medieval Christian and Islamic physicians admitted that lack of health could be associated with sin or magic, but dismissed these factors as outside the realm of Aristotelian medical practice. The seventeenth-century thinker Descartes (1596–1650), as part of a larger mechanical philosophy, made a separation between mind and body that was total. For Descartes, and other mechanists who followed after him, the healthy body was nothing more than a well-functioning machine, soulless and subject to chemical and mechanical remedies.

Cartesian medical philosophy not only excluded religious concerns from the proper duty of the learned physician, but also made easy the postulation of ‘mental’ illnesses and ‘mental’ health as being separate from the state of the body. Vitalist views of the body and health did not fade from consideration all at once. Individualized, pastoral-style medical care of the whole person experiences periodic revivals, especially when Westerners study subcontinental and far-Eastern methods of healing. But the notion of the body as a machine emphasized the sameness of all bodies rather than their uniqueness. The remarkable growth in medical technology from the end of the eighteenth century allowed medical scientists to ‘look inside’ the normal, living body and define its typical characteristics as never before. For example, the discovery of auscultation and later the stethoscope made individual patient reports of symptoms less important than the physician's own collection of diagnostic signs. Doctors could listen to the internal sounds made by hundreds of healthy bodies and easily isolate the ‘abnormal’, leading to a kind of medical objectivity never imagined before. The modern diagnostic laboratory of today allows the isolation of ungendered, raceless, classless tissue samples from subjective judgement and, for better or worse, minimizes the patient's own assessment of his or her state of health.

Nostalgia for a lost golden age never disappears from the medical scene, of course. Nineteenth-century Romantic thinkers offered the ‘noble savage’ or the ‘primitive’ hunter-gatherer as an ideal of bodily (and sometimes of moral) health. Even today, experimental studies with animals suggest that living in a state of near-starvation the way our ancestors were forced to do would lead to longer life and greater health — as if such a life would be worth prolonging. ‘Quality of life’ considerations will always be foremost in the mind of the patient, and this is an aspect of health that technologically-based scientific medicine, almost by definition, may appear to neglect. But in the contexts of clinical trials and medical audit the profession increasingly acknowledges the importance of quality of life as a component of outcome assessment.

Faye Getz

Bibliography

Ackerknecht, E. H. (1982). A short history of medicine. Johns Hopkins University Press, Baltimore and London.
Bynum, C. W. (1995). The resurrection of the body in Western Christianity, 200–1336. Columbia University Press, New York.
Temkin, O. (1991). Hippocrates in a world of Pagans and Christians. Johns Hopkins University Press, Baltimore and London.


See also creation myths; illness; medicine.

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health

health. Efforts to attain and maintain good health have a long history. A plea for good health remained an important theme for prayers from ancient times until the present day, and was often the occasion for pilgrimages. The alleged curative powers of springs precipitated the establishment of spas where wealthy visitors came to take the waters and which may be considered the forerunners of modern health farms. Poorer people sought good health through folk medicine, using herbal remedies and techniques such as the laying-on of hands. Until the 19th cent. many believed the king's touch would cure scrofula. Caring for the sick had the blessing of the Christian churches, which urged their members both to be charitable and to care for those suffering. State intervention on a large scale in the 19th and 20th cents. aimed to promote good health amongst the population. This period also saw the development of professions and occupations, such as medicine, nursing, paramedical services, and environmental health.

The general health of people during the Middle Ages was discussed only obliquely in historical accounts and it was taken for granted that everyone suffered from the effects of seasonal food shortages. However, recent studies have suggested that larger towns were especially unhealthy because of poor sanitation and that their growth often depended on continuous migration from rural areas. Even the well-off in towns did not escape from health problems. Life expectation was relatively short. More has been recorded about the outbreak of spectacularly lethal diseases such as bubonic plague (known as the Black Death) during the mid-14th cent. and the Great Plague in 1665.

The first systematic attempt to devise indicators of the health of some groups of the population, particularly the upper and middle classes, was made by life assurance companies in the 18th cent. Measuring the size of these populations and their composition had commercial significance. Statistics about the entire population began with the establishment of the nation-wide decennial census in 1801. Censuses became increasingly sophisticated in the range of data collected. The compulsory registration of births, marriages, and deaths in 1837 made it possible to identify and analyse important overall trends in the population. For example, the government gained information about the total number of men available for national service and it was possible to start to analyse the increase in the total population.

The population of Great Britain rose from about 10 million in 1801 to over 56 million in 1991. Within these totals the distributions of age groups varied. During the 19th cent. children under the age of 15 years accounted for more than a third of the population whereas during the later 20th cent. they formed only a quarter of the total. Throughout the 19th cent. about a twentieth of the population was aged over 65 years whereas by the late 20th cent. they accounted for almost one-fifth of the total. These changes, particularly the greater life expectation, arose for several reasons: rising incomes, environmental improvements, and healthier diets.

One of the most sensitive indicators of a nation's health is that of infant mortality, the death rate of children under 1 year of age. Infant mortality rates remained well over 100 in every 1,000 live births for almost the whole of the 19th cent. By the late 20th cent. the rate had declined to about 12 in 1,000 births. Within the British Isles there were geographical variations, with the highest mortality rates in the most densely populated areas. There were differences between social class with the highest rates amongst children whose fathers were in unskilled work and the lowest amongst the children of fathers in professional occupations. Relevant factors in explaining these rates appear to have been incomes, quality and quantity of food, heating, clothing, and housing.

Public health became a matter for government intervention during the 19th cent., partly precipitated by an outbreak of cholera in 1831 whose virulence paid no respect to social class. Interventions were based on theories about the link between health, clean water supplies, and adequate sanitation. The Public Health Act of 1848 required districts with above-average death rates to have a public health board with powers to raise loans and levy rates to pay for pure water supplies, drains, and sewers. These powers were extended subsequently to all parts of the country. Advances in the biological sciences with regard to the transmission of disease and the need for high standards of hygiene were incorporated into legislation after the middle of the 19th cent. Then, as now, such developments were controversial. Nineteenth-cent. debates about compulsory vaccination, immunization, and drug-taking can be compared with modern debates about fluoridation and smoking.

Efforts to improve the health of the school population began at the end of the 19th cent. They started with ‘drill’ and evolved later into physical education, emphasizing gymnastics, swimming, athletics, and games. From the end of the 19th cent., the curriculum for girls included cookery, later domestic science, and more recently home economics, whose purposes included imparting some basic knowledge of personal and household hygiene as well as dietary information. With the establishment of the national curriculum in the early 1990s, health studies became an optional subject for all.

During the 19th cent. there was an expansion in medical knowledge and in the variety and range of occupations devoted to the care of the sick. In the 20th cent. the care of the sick became increasingly likely to take place in hospital rather than at home. The establishment of the welfare state, in particular the National Health Service in 1948, indicated the political will to find resources for public health.

Evidence indicates that the health of the population has improved through the control of infectious diseases, public health provisions, such as clean water and sanitation, and effective legislation about the quality of food and drink. There has also been an expansion of medical services. A major controversy about the evidence of improved health of the general population is whether medical interventions, including public health measures, contributed as much as adequate nutrition, shelter, clothing, and heating.

Ian John Ernest Keil

Bibliography

McKeown, T. , The Rise of Modern Population (1976);
Oddy, D. J. , ‘The Health of the People’, in Barker, T., and Drake, M. (eds.), Population and Society in Britain 1850–1980 (1982);
Porter, R. , Disease, Medicine and Society in England (2nd edn. 1993);
Smith, F. B. , The People's Health, 1830–1910 (1979).

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Health

Health

For many years, health was defined merely as the absence of disease. However, it has become clear that health is an active process that depends on the supportive interaction of all the body's systems. Reflecting this concept, the World Health Organization (WHO) defines health as "the state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." Many groups, such as the American Public Health Association, Worksite Health Promotion, and the National Wellness Association, have expanded the concept of health further to encompass wellness: the spiritual, social, mental, physical, and occupational needs for one to live life to the fullest.

In either sense, health is a state of action that includes prevention, care, and individual responsibility to achieve optimal health. The U.S. Department of Health and Human Services (HHS), in Healthy People 2010, divides the ten leading factors affecting health into two major themes. The first, lifestyle challenges, includes physical activity, avoidance of excess weight and obesity, abstinence from tobacco use or substance abuse, and responsible sexual behavior. The second, system enhancement challenges, include mental health, freedom from injury and violence, good environmental quality, immunization, and equal access to health care.

Homeostasis

The state of health reflects the body's homeostasis, its attempt to maintain a relatively stable internal environment while confronted with changes in the external environment. One's ability to handle stress depends on the body's success in maintaining or returning to homeostasis. Failure to do so can result in abnormal function and disease.

Homeostasis involves negative feedback systems. The analogy to home heating and cooling systems is often made. When a house falls below a certain temperature, the system turns on to heat the house back to the set level. If it gets too warm, another system effects a change to cool the home off. Similarly, the human body senses changes from ideal conditions in variables, such as blood glucose , dehydration, blood calcium, carbon dioxide, heart rate, breathing rate, and fat deposition. The body also detects the presence of pathogens that alter homeostasis. When such factors disturb homeostasis, the body releases substances such as hormones , neurotransmitters , and antibodies to return conditions to normal.

Why is health important? The WHO states that it is fundamental to world peace and security as political strife can stem from inadequate food, medicine, or other resources. For the United States and other industrialized nations, the large increase in the older population calls for strategies to increase the number of quality years as people age. Living longer is not a positive goal if it means living longer with disease. HHS has made this one of two major goals in Healthy People 2010. The other is to eliminate disparities in health based on race or ethnicity. Too many segments of American society are not reaping the benefits from advances in medicine, technology, and health care.


The National Institutes of Health (NIH) is one of eight health agencies of the U.S. Public Health Service. The NIH was founded in 1887 with the goal to acquire new knowledge to help prevent, detect, diagnose, and treat diseases and disabilities. As one of the world's fore-most medical research centers, the NIH conducts research, supports research elsewhere, helps train researchers, and fosters communication about medical and health sciences information.


Individual choices are important to health outcomes. Preventive medicine includes stress reduction, good nutrition, exercise, wearing seat belts and helmets, and having routine dental and physical screenings (for cholesterol level and blood pressure, for example). As science progresses in genetic engineering, important choices will be made about changing genes, thus altering the inheritance of many diseases.

see also Alcohol and Health; Cardiovascular Diseases; Disease; Environmental Health; History of Medicine; Homeostasis; Public Health Careers; Sexually Transmitted Diseases; Smoking and Health

Karen E. Jensen

Bibliography

Donatelle, Rebecca J. Health: The Basics. Boston: Allyn and Bacon, 2001.

National Institutes of Health. <http://www.nih.gov>.

World Health Organization. <http://www.who>.

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Health

197. Health

See also 122. DISEASE and ILLNESS .

analgesia, analgesy
the absence of pain. analgesic, analgetic, adj.
analogism
Medicine. diagnosis of a condition on the basis of its resemblance to other conditions.
anatripsology
the use of friction, especially rubbing, in therapy or as a remedy.
anesthesia, anaesthesia, anesthesis, anaesthesis
the absence of physical sensation. anesthesiologist, anaesthesiologist, anaesthetist, n. anesthetic, anaesthetic, n., adj.
antisepsis
the destruction of microorganisms that cause infection. antiseptic, adj.
bacteriostasis
the process of preventing the growth or spread of bacteria. bacteriostat, n. bacteriostatic, adj.
cachexia, cachexy
general physical or mental poor health; weakness or malnutrition.
dyscrasia
Medicine. an unhealthy condition, especially an imbalance of physiologic or constitutional elements, often of the blood. Cf. eucrasia. dyscrasic, dyscratic, adj.
epulosis
the formation of scar tissue as part of the healing process. epulotic, adj.
eucrasia
1. Medicine. a normal state of health; good health.
2. physical well-being. Cf. dyscrasia. eucrasic, eucratic, adj.
eupepsia, eupepsy
a condition of good digestion. eupeptic, adj.
evectics, euectics
the theory of the achievement and maintenance of good health. evectic, euectic, adj.
germicide
any substance for killing germs, especially bacteria. germicidal, adj.
hygeist, hygieist
a hygienist.
hygiastics
Rare. hygienics. Also called hygiantics.
hygienics
1. the branch of medical science that studies health and its preservation; hygiene.
2. a system of principles for promoting health. hygienist, n. hygienic, adj.
hygieology, hygiology
Rare. the science of hygiene; hygienics.
hypochondriacism, hypochondriasis
1. Psychiatry. an abnormal state characterized by emotional depression and imagined ill health, often accompanied by symptoms untraceable to any organic disease.
2. excessive concern and conversation about ones health. Also called hypochondria, nosomania . hypochondriac, n. hypochondriacal, adj.
invalescence
Obsolete, a state of good health; strength.
lysis
the gradual process of a disease, ending in the recovery of the patient. See also 72. CELLS . lyterian, lytic, adj.
prophylaxis
protection from or prevention of disease. prophylactic, adj.
sanability
Rare. the state or condition of being curable; susceptibility to remedy. sanable, adj.
soteriology
Rare. 1. a treatise on health.
2. the science of attaining and maintaining good health. soteriological, adj.
synteresis
preventive or preservative treatment or measures; prophylaxis. See also 145. ETHICS .
tonicity
the state or quality of having good muscular tone or tension. tonic, adj.
trypanophobia
an abnormal fear of vaccines and vaccination. Also called vaccinophobia.
valetudinarianism
1. a condition of poor health.
2. a state of being concerned with health, often excessively.
3. invalidism. valetudinarian, n., adj.

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Health

Health

Health is a measure of quality of life that is difficult to define and measure. In the 1940s, the World Health Organization (WHO) defined health as a "state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." At the first International Conference on Health Promotion in Ottawa, Canada (1986), the Ottawa Charter for Health Promotion built on the WHO's concept and further defined health as "a resource for everyday life ... a positive concept emphasizing social and personal resources, as well as physical capabilities." Good health enables one to function independently within a changing environment.

see also Health Communication; Health Education; Health Promotion; Healthy People 2000 Report.

Delores C. S. James

Bibliography

World Health Organization (1948). Official Records of the World Health Organization, No 2: Proceedings and Final Acts of the International Health Conference Held in New York from 19 June to 22 July 1946. New York: United Nations, WHO Interim Commission.

Internet Resource

World Health Organization (1986). Ottawa Charter for Health Promotion. Available from <http://www.who.int/hpr>

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Health

320. Health

  1. agate symbolizes health; supposed to relieve snake and scorpion bites. [Class. and Medieval Legend: Leach, 27]
  2. Asclepius cup symbolizes well-being. [Gk. Myth.: Jobes, 397]
  3. Carna goddess of physical fitness. [Rom. Myth.: Leach, 192]
  4. Damia goddess of health. [Gk. Myth.: Jobes, 409]
  5. Hygeia goddess of health; daughter and personification of Asclepius. [Gk. Myth.: Kravitz, 123]
  6. Hygeias cup symbol of fertility and fitness. [Gk. Myth.: Jobes, 396397]

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health

health / hel[unvoicedth]/ • n. the state of being free from illness or injury: he was restored to health | [as adj.] a health risk. ∎  a person's mental or physical condition: bad health forced him to retire. ∎ fig. soundness, esp. financial or moral: a standard for measuring the financial health of a company. ∎  used to express friendly feelings toward one's companions before drinking.

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health

health soundness of body, mind, or spirit OE.; toast drunk to a person's welfare XVI. OE. hǣlð = OHG. heilida :- WGmc. *χailiþa, f. Gmc. *χailaz WHOLE; see -TH1.
Hence healthful salubrious XIV; having good health XVI (superseded in this sense by healthy XVI).

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health

healthhealth, stealth, wealth •commonwealth •filth, tilth •coolth

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Health

Chapter 6
Health

The demographic profiles of non-Hispanic African-Americans, Hispanics, Asian-Americans, Pacific Islanders, Native Americans, and Alaska Natives differ considerably from those of the nonminority population. Because a high percentage of minorities live in urban areas, they are exposed to a greater number of environmental hazards, including pollution, traffic hazards, substandard and/or overcrowded housing, and crime. Occupational risks are also greater for minorities because a greater percentage of them are employed in potentially dangerous jobs. Poverty, which is experienced disproportionately by African-Americans, Hispanics, and Native Americans and Alaska Natives, leads to poor nutrition, poor housing conditions, and poor access to health care. In addition, the amount of stress involved in facing daily discrimination and changing cultural environments as well as the lack of resources for solving stressful situations can play a critical role in the mental health of minority groups.

As a whole, Hispanics enjoy better health on a variety of measures than do non-Hispanic whites, despite Hispanics' disadvantaged position, higher poverty rates, lower educational attainment, and the obstacles to health care that they encounter. This is most likely due in part to the fact that Hispanics in the United States are younger than the non-Hispanic white population. More than a third (34.4%) of Hispanics were under the age of eighteen in 2002, compared with 22.8% of non-Hispanic whites. Conversely, only 5.1% of Hispanics were age sixty-five or older, compared with 14.4% of non-Hispanic whites. (See Figure 6.1.) In The Hispanic Population in the United States: March 2002 (June 2003, http://www.census.gov/prod/2003pubs/p20-545.pdf), Roberto R. Ramirez and G. Patricia de la Cruz explain that this age differential is partly due to the higher fertility rate of Hispanics and partly to their recent immigration status—younger people tend to immigrate; in 2002 four out of ten Hispanics in the United States were foreign born.

HEALTH CARE

Quality of Care

The 2004 National Healthcare Disparities Report (December 2004, http://www.qualitytools.ahrq.gov/disparitiesreport/2004/documents/nhdr2004.pdf), which is published by the U.S. Department of Health and Human Services, defines quality health care as "doing the right thing, at the right time, in the right way, for the right people—and having the best possible results." Quality health care is defined as care that is effective, safe, and timely, as well as equitable—meaning that the care does not vary in quality because of personal characteristics such as race or ethnicity.

The report focused on forty-six measures of effectiveness of health care and found that minorities consistently received a poorer quality of care than non-Hispanic whites in 2001. In fact, that difference in quality of care had actually worsened for African-Americans, Asian-Americans, and Native Americans and Alaska Natives since the previous year. African-Americans received poorer quality of care than whites for about 63% of the quality measures, Native Americans and Alaska Natives for about 32% of quality measures, and Asian-Americans for about 12% of the quality measures. (See Figure 6.2.) Hispanics received lower quality of care than non-Hispanic whites for about 50% of the quality measures.

Access to Care

The 2004 National Healthcare Disparities Report also measures access to health care, finding that minorities, particularly those of low socioeconomic status, face barriers to access health care that make receiving basic health services a struggle. Access is measured in several ways, including ability to get into the health care system, to get care within the health care system, and to find providers to meet their needs.

The report finds that in 2001 Native Americans and Alaska Natives had worse access to care than did whites for about half of access measures, African-Americans for about 34% of access measures, and Asian-Americans for about 31% of access measures. (See Figure 6.2.) Hispanics had worse access to care than non-Hispanic whites for a staggering 88% of access measures. (See Figure 6.3.) Part of these differences in access to care for minority groups had to do with socioeconomics; people below the poverty level had worse access to care than did high-income people (family incomes above 400% of the poverty level) for about 80% of access measures.

HEALTH INSURANCE

Lack of health insurance is one formidable barrier to receiving health care. The number of uninsured Americans rose to its highest level ever in 2004, when 45.8 million people were uninsured. Lack of insurance coverage is a significant barrier to getting basic health care services. The 2004 National Healthcare Disparities Report emphasizes that uninsured people are more likely to die early and to have a poor health status because it is more difficult for the uninsured to get health care and therefore they are diagnosed at later disease stages.

Between 2002 and 2004 members of minority groups were much less likely to carry health insurance coverage than were their white, non-Hispanic counterparts. On average during that period 32.6% of Hispanics, 29% of Native Americans and Alaska Natives, 21.8% of Native Hawaiians and Other Pacific Islanders, 19.8% of African-Americans, and 18% of Asian-Americans lacked coverage, compared with only 11% of non-Hispanic whites. (See Table 6.1.)

Those minorities who do have health insurance are more likely than non-Hispanic whites to be covered by government programs. In 2003 members of all minority groups except Asian-Americans were more likely to be covered by Medicaid (the federally funded health care program for low-income people) than were non-Hispanic whites. In that year Medicaid covered 8% of non-Hispanic whites and Asian-Americans. However, Medicaid covered 23.4% of non-Hispanic African-Americans, 21.8% of Hispanics, and 18.5% of Native Americans and Alaska Natives. Among Hispanics, Puerto Ricans were most likely and Cubans were least likely to be covered by Medicaid. The large proportion of minorities on Medicaid is in part explained by eligibility requirements; only poor and low-income people qualify, and members of these groups are disproportionately poor. (See Table 6.2.)

Nearly all people age sixty-five and older are covered by health insurance due largely to Medicare (the government health insurance program for senior citizens). However, a much higher proportion of minorities are additionally covered by Medicaid, while non-Hispanic whites are covered by private insurance. In 2003, 65.7% of non-Hispanic whites age sixty-five and over were covered by private health insurance; in contrast, only 40.2% of Asian-Americans, 37.6% of African-Americans, 37.3% of Native Americans and Alaska Natives, and 24% of Hispanics of the same age were covered by private insurance. (See Table 6.3.)

DOCTOR VISITS

Another measure of a group's access to care is the number of doctor visits. Since the 1980s, as more outpatient clinics and other outreach health facilities have opened, Americans have had increased opportunities to seek medical help; however, in 2003 members of minority groups were more likely than non-Hispanic whites to have made no visits to a doctor's office or emergency room in the previous twelve months. In that year, 25.3% of Hispanics, 23.3% of Native Americans and Alaska Natives, 22.6% of Asian-Americans, and 14.6% of African-Americans made no visits, compared with 13.5% of non-Hispanic whites who made no visits. (See Table 6.4.) In part, this can be explained by the disproportionate number of minorities who are poor or low income; these groups were more likely than nonpoor people to make no visits to a doctor's office or an emergency room in 2003.

INDIAN HEALTH SERVICE

Federal funding for Native American health care is provided through the Indian Health Service (IHS), which is "charged with raising Indians' health status to the highest possible level" (April 1993, http://archive.gao.gov/t2pbat6/149156.pdf). Delivery of health care to Native Americans is complicated by the lack of services and the long distances that sometimes must be traveled to receive care. Alaska Natives are often able to get preventive medical care only by flying to a medical facility, and, while transportation costs are covered for emergency care, transportation costs are not provided for routine care. The 2004 National Healthcare Disparities Report reports that nationwide about 60% of Native Americans rely on the Indian Health Service to provide access to health care.

Many Native American tribes have invested some of the money earned from their casinos to improve health services. The Sandia Pueblo in New Mexico, for example, now has a multimillion-dollar medical complex. This saves the residents the long drives to distant clinics that provide medical and dental care through the IHS. The center includes examination rooms, dental rooms, and state-of-the-art equipment. There is an adjacent wellness and education center that houses a gymnasium, a weight room, and aquatic therapy facilities.

PREGNANCY AND BIRTH

Prenatal Care

The importance of early prenatal care cannot be overemphasized, as doctors are now better able to detect, and often correct, potential problems early in pregnancy. While every pregnant woman should receive prenatal care, the National Center for Health Statistics (NCHS) believes the United States is capable of guaranteeing that more than 90% of pregnant women receive prenatal care during the first trimester of pregnancy.

In 2003, 84.1% of all women in the United States received prenatal care during their first trimester of pregnancy, but that percentage was significantly lower among some minority groups. Almost nine out of ten non-Hispanic white women (89%) and Asian and Pacific Islander women (85.4%) received prenatal care during their first trimester. However, only 77.5% of Hispanic women, 75.9% of African-American women, and 70.8% of Native American women did so. It is worthy of note, however, that despite the low rates of first-trimester prenatal care among Hispanic women in general, Cuban women had the highest rate of prenatal care of all racial/ethnic groups, at 92.1%. (See Table 6.5.)

Births and Fertility

Of the 4.1 million births in 2004, 2.3 million were to non-Hispanic white mothers, 944,993 to Hispanic mothers, 576,105 to African-American mothers, 229,352 to Asian and Pacific Islander mothers, and 43,931 to Native American mothers. However, the birth rate (live births per one thousand population in a specified group) was highest among Hispanics (22.9), followed by Asians and Pacific Islanders (16.8), African-Americans (15.1), and Native Americans (14); it was lowest for non-Hispanic whites, at 11.7. (See Table 6.6.)

The fertility rate refers to the number of live births per one thousand women ages fifteen to forty-four in a specified group. In 2004 Hispanic women had the highest fertility rate (97.7), followed by Asian and Pacific Islander women (67.2), African-American women (66.7), Native American women (58.9), and last by non-Hispanic white women (58.5). (See Table 6.6.) Although Hispanic women had the highest fertility rate, it varied among Hispanics from different countries of origin. According to Joyce A. Martin et al. in "Births: Final Data for 2003" (National Vital Statistics Reports, September 8, 2005, http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_02.pdf), in 2003 women of Mexican origin had the highest fertility rate (105.5), while Puerto Rican and Cuban women had the lowest (61.6 and 61.7, respectively).

Low Birth Weight and Infant Mortality

In "Explaining the 2001–02 Infant Mortality Increase: Data from the Linked Birth/Infant Death Data Set" (National Vital Statistics Reports, January 24, 2005, http://www.cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_12.pdf), Marian F. MacDorman et al. explain that moderately low birth weight is defined as being equal to 1,500 to 2,499 grams (3.3 to 5.5 pounds). Very low birth weight is less than 1,500 grams. Low-birth-weight babies, as well as premature babies (born before thirty-seven weeks of gestation), often suffer serious health problems and encounter developmental problems later in life. In 2002 the infant mortality rate for low-birth-weight infants was twenty-five times that for infants born weighting 2,500 grams or more.

The percentage of babies born with low birth weights increased between 1990 and 2003. According to the Centers for Disease Control and Prevention (CDC), in 1990, 7% of babies born weighed less than 2,500 grams compared with 7.9% of babies born in 2003. In 2003 African-Americans were almost twice as likely as non-Hispanic whites to have low-birth-weight babies. In that year, 13.4% of African-American babies were born with low birth weights, while 7.8% of Asian and Pacific Islander babies, 7.4% of Native American or Alaska Native babies, 7% of non-Hispanic white babies, and 6.7% of Hispanic babies were born with low birth weights. (See Table 6.7.)

The infant mortality rate (rate of deaths before one year of age) increased in 2002 for the first time in more than forty years, from 6.8 infant deaths per one thousand live births in 2001 to seven infant deaths per one thousand live births in 2002. This increase was due primarily to an increase in the number of births of very low-birth-weight babies. In 2002 non-Hispanic African-Americans suffered the highest rate of infant mortality, with 13.9 deaths per one thousand live births. That rate was more than double the rate of 5.8 deaths per one thousand live births for non-Hispanic whites. Native Americans and Alaska Natives also had a relatively high rate of infant deaths, at 8.6 per one thousand live births. Hispanic women (5.6 deaths per one thousand live births) and Asian and Pacific Islander women (4.8 deaths per one thousand live births) had the lowest infant mortality rates of any racial or ethnic group. (See Table 6.8.)

TABLE 6.1
Health insurance coverage of people by race and Hispanic origin using 2- and 3-year averages, 2002–04
[Numbers in thousands]
Racea and Hispanic origin People without health insurance coverage Change in coverage (2003–2004 average less 2002–2003 average) b
3-year average 2002–2004 2-year average
2002–2003 2003–2004 Uninsured Insured
Estimate Estimate Estimate Estimate Estimate
aFederal surveys now give respondents the option of reporting more than one race. Therefore, two basic ways of defining a race group are possible. A group such as Asian may be defined as those who reported Asian and no other race (the race-alone or single-race concept) or as those who reported Asian regardless of whether they also reported another race (the race-alone-or-in-combination concept). This table shows data using the first approach (race alone). The use of the single-race population does not imply that it is the preferred method of presenting or analyzing data. The About 2.6 percent of people reported more than one race in Census 2000.
bDetails may not sum to totals because of rounding.
source: Carmen DeNavas-Walt, Bernadette D. Proctor, and Cheryl Hill Lee, "Table 8. Health Insurance Coverage of People by Race and Hispanic Origin Using 2- and 3-Year Averages: 2002 to 2004," in Income, Poverty, and Health Insurance Coverage in the United States: 2004, Current Population Reports P60-229, U.S. Census Bureau, August 2005, http://www.census.gov/prod/2005pubs/p60-229.pdf (accessed January 23, 2006)
Percentage
All races15.515.415.70.2−0.2
White14.614.414.70.3−0.3
    White, not Hispanic1110.911.20.3−0.3
Black19.819.919.6−0.30.3
American Indian and Alaska Native2928.329.10.8−0.8
Asian1818.617.8−0.80.8
Native Hawaiian and Other Pacific Islander21.820.721.30.6−0.6
Hispanic origin (any race)32.632.632.70.2−0.2
Number
All races44,78544,26745,3911,1231,488
White33,82633,34534,3851,041593
    White, not Hispanic21,44921,18221,782600−160
Black7,1657,1547,133221*391
American Indian and Alaska Native66464166725−5
Asian2,1442,1802,149−31407
Native Hawaiian and other Pacific Islander151154137−17−75
Hispanic origin (any race)13,22412,99613,458461766

According to the "Pew Hispanic Center Fact Sheet" (June 2002, http://pewhispanic.org/files/factsheets/1.pdf), the Pew Hispanic Center finds that the connection between low income and educational attainment and high infant mortality seems to be more complicated than previously thought. Hispanics, who suffer higher poverty rates and lower educational attainment than do non-Hispanic whites, have a consistently lower infant mortality rate. Researchers speculate that greater social support, less high-risk behavior, and dietary factors may explain the differences. However, as Hispanic immigrants begin to adopt the lifestyle of the American mainstream, the health of that population will decline and the infant mortality rates will rise.

Other research shows that even professional, middle-class, educated African-American women have a higher risk of having low-birth-weight babies. According to Ziba Kashef in "Persistent Peril: Why African American Babies Have the Highest Infant Mortality Rate in the Developed World" (RaceWire, February 2003, http://www.arc.org/racewire/030210z_kashef.html), "researchers have found that even when they control for such varied factors as poverty, housing, employment, medical risk, abuse, social support and so on, 90 percent of the differences in birth weight between black and white moms remains unaccounted for." As a result, some experts have begun to look at factors such as the health of the mother's mother as well as chronic emotional stress resulting from living in a racist society to explain the poorer birth outcomes of African-American mothers.

TABLE 6.2
Medicaid coverage among persons under 65 years of age, by race/ethnicity and age and percent of poverty level, selected years, 1984–2003
[Data are based on household interviews of a sample of the civilian noninstitutionalized population]
Characteristic 1984 1989 1995 1997 a1998 1999 2000 2001 2002 2003
*Estimates are considered unreliable.
Notes: "—" = Data not available. Medicaid includes other public assistance through 1996. Starting in 1997 includes state-sponsored health plans. Starting in 1999 includes State Children's Health Insurance Program (SCHIP). In 2003, 9.4 percent of persons under 65 years of age were covered by Medicaid, 1.2 percent by state-sponsored health plans, and 1.7 percent by SCHIP
aIn 1997 the National Health Interview Survey (NHIS) was redesigned, including changes to the questions on health insurance coverage
bIncludes all other races not shown separately and, in 1984 and 1989, unknown poverty level.
cThe race groups, white, black, American Indian and Alaska Native, Asian, Native Hawaiian and other Pacific Islander, and 2 or more races, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Starting with data year 1999 race-specific estimates are tabulated according to 1997 Standards for Federal Data on Race and Ethnicity and are not strictly comparable with estimates for earlier years. The five single race categories plus multiple race categories shown in the table conform to 1997 standards Starting with data year 1999, race-specific estimates are for persons who reported only one racial group; the category "2 or more races" includes persons who reported more than one racial group. Prior to data year 1999, data were tabulated according to 1977 standards with four racial groups and the category "Asian only" included Native Hawaiian and other Pacific Islander. Estimates for single race categories prior to 1999 included persons who reported one race or, if they reported more than one race, identified one race as best representing their race.
source: Adapted from "Table 133. Medicaid Coverage among Persons under 65 Years of Age, according to Selected Characteristics: United States, Selected Years 1984–2003," in Health, United States, 2005, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, 2005, http://www.cdc.gov/nchs/data/hus/hus05.pdf (accessed January 25, 2006)
Number in millions
   Total b14.0 15.4 26.6 22.9 21.1 21.9 23.2 25.5 29.4 30.9
Percent of population
   Total b6.8 7.2 11.5 9.7 8.9 9.1 9.5 10.4 11.8 12.3
Race c
White only4.65.18.97.46.76.97.18.09.310.4
Black or African American only20.519.028.522.421.220.121.222.123.223.7
American Indian and Alaska Native only28.229.719.019.615.221.415.116.221.118.5
Asian only8.78.810.59.66.77.97.58.49.88.0
Native Hawaiian and other Pacific Islander only*****
2 or more races19.719.117.521.623.5
Hispanic origin and race c
Hispanic or Latino13.313.521.917.615.515.715.517.520.821.8
    Mexican12.212.421.617.214.314.514.016.620.221.7
    Puerto Rican31.527.333.431.026.128.629.430.329.031.0
    Cuban4.87.713.47.38.97.69.211.114.913.8
    Other Hispanic or Latino7.911.118.215.315.014.714.515.619.619.3
Not Hispanic or Latino6.26.610.28.78.08.28.59.210.310.6
    White only3.74.27.16.15.65.86.16.77.78.0
    Black or African American only20.719.028.122.121.020.121.022.023.223.4

DISEASES AND MINORITY POPULATIONS

Cancer

Cancer is the uncontrolled multiplication and spread of abnormal cells and can lead to death if unchecked. Cancer incidence varies according to racial and ethnic background. Such risk factors as occupation, use of tobacco and alcohol, sexual and reproductive behaviors, and nutritional and dietary habits influence the development of cancer. Cancer screening, treatment, and mortality rates also vary by race and ethnicity.

African-Americans have both the highest cancer incidence and the highest cancer mortality rates of all racial and ethnic groups, while the cancer incidence and mortality rates of other minority groups are relatively low. The Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute (NCI) is the most authoritative source of information on cancer incidence, mortality, and survival in the United States. According to SEER Cancer Statistics Review, 1975–2002 (November 2004, http://seer.cancer.gov/csr/1975_2002/), the incidence rates of all cancers between 1992 and 2002 were 526.7 per one hundred thousand African-Americans, 483.5 per one hundred thousand whites, 354.6 per one hundred thousand Hispanics, 339.7 per one hundred thousand Asians and Pacific Islanders, and 251.9 per one hundred thousand Native Americans and Alaska Natives. (See Table 6.9.) The mortality rates of all cancers between 1992 and 2002 were 259.3 per one hundred thousand African-Americans, 200.8 per one hundred thousand whites, 137.4 per one hundred thousand Hispanics, 135.3 per one hundred thousand Native Americans and Alaska Natives, and 125.1 per one hundred thousand Asians and Pacific Islanders. (See Table 6.10.)

The SEER Cancer Statistics Review, 1975–2002 states that more whites survived five years after diagnosis of invasive cancer than did African-Americans. More than two-thirds (66.4%) of whites survived five years, compared with only 56% of African-Americans. Much of this difference in survival can be attributed to later diagnosis of cancer in African-Americans due to lower screening rates and less access to health care. Among the most diagnosed cancers for all groups in the United States are breast cancer, prostate cancer, lung and bronchus cancer, and colon and rectum cancer.

TABLE 6.3
Health insurance coverage for persons 65 years of age and over, according to type of coverage and selected characteristics, selected years, 1989–2003
[Data are based on household interviews of a sample of the civilian noninstitutionalized population]
Characteristic Private insurance aPrivate insurance obtained through workplace a,b
1989 1995 2000 2001 2002 2003 1989 1995 2000 2001 2002 2003
Number in millions
   Total c22.4 23.5 21.2 21.3 20.6 21.5 11.2 12.4 12.0 12.2 11.8 11.9
Percent of population
   Total c76.5 74.6 63.4 63.1 60.9 62.7 38.4 39.5 35.9 36.2 34.9 34.8
Age
65-74 years78.275.163.163.460.962.343.743.339.639.838.038.2
75 years and over73.973.963.962.760.863.130.234.131.432.031.431.0
    75-84 years75.975.764.964.261.764.032.036.033.233.433.132.5
    85 years and over65.567.359.857.457.759.822.827.324.826.825.426.2
Sex
Male77.576.464.764.262.264.143.544.240.440.639.238.6
Female75.873.362.562.359.961.634.836.232.633.031.832.0
Race d
White only80.178.367.266.764.365.739.941.037.437.636.035.7
Black or African American only43.041.836.138.336.537.624.826.525.728.527.228.3
American Indian and Alaska Native only46.839.9*32.6*37.321.329.4
Asian only48.445.842.941.340.740.230.227.025.023.828.025.9
Native Hawaiian and other Pacific Islander only
2 or more races65.548.555.153.049.731.235.231.7
Hispanic origin and race d
Hispanic or Latino44.840.924.625.323.824.024.520.316.417.617.317.6
    Mexican36.433.321.725.822.325.722.217.813.818.016.819.5
Not Hispanic or Latino77.676.365.565.263.165.138.940.536.937.335.935.9
    White only81.480.469.168.866.468.640.442.238.338.637.037.0
    Black or African American only43.041.536.138.336.637.624.826.125.728.627.228.1
Percent of poverty level e
Below 100 percent46.340.334.132.830.733.211.513.912.715.212.712.9
100-149 percent67.567.647.048.346.947.222.326.718.922.619.816.8
150-199 percent81.175.961.861.858.761.839.538.829.228.828.626.9
200 percent or more86.685.772.871.469.771.152.350.645.544.143.444.0

BREAST CANCER

While fewer African-American women were diagnosed with breast cancer (120.2 per one hundred thousand) than were white women (138.3 per one hundred thousand) between 1992 and 2002, a higher proportion of African-American women died of the disease (36.2 per one hundred thousand) than did white women (twenty-eight per one hundred thousand). (See Table 6.9 and Table 6.10.) For years experts assumed that the difference in mortality rates was due to poor health care and late treatment for African-American women. However, Susan-LoveMD.org reports in "Study Finds Breast Tumors More Aggressive in African-American Women Than in White Women" (August 26, 2004, http://www.susanlovemd.com/community/flashes/hotflash040826_1.htm) that African-American women may be more susceptible to a more deadly form of the cancer. Tumors from African-American women were found to have more actively dividing cells than tumors from white women. The tumor cells in African-American women also lacked hormone receptors, another indicator of a poor prognosis. After peaking in the early 1990s, the death rate from breast cancer for African-American women had shown some improvement by 2002. (See Figure 6.4.)

Hispanics, Asians and Pacific Islanders, and Native Americans and Alaska Natives are less likely to be diagnosed with breast cancer or to die from breast cancer than either whites or African-Americans. The incidence rates of breast cancer between 1992 and 2002 were 92.8 per one hundred thousand Asians and Pacific Islanders, 88.2 per one hundred thousand Hispanics, and 60.7 per one hundred thousand Native Americans and Alaska Natives. (See Table 6.9.) The mortality rates of breast cancer were lowest for Asian and Pacific Islander women, at 12.9 per one hundred thousand, despite their higher incidence rates. The mortality rate for Hispanic women was highest of the three groups, at 17.7 per one hundred thousand women. (See Table 6.10.)

TABLE 6.3
Health insurance coverage for persons 65 years of age and over, according to type of coverage and selected characteristics, selected years, 1989–2003 [continued]
[Data are based on household interviews of a sample of the civilian noninstitutionalized population]
Characteristic Medicare health maintenance organization a,fMedicaid a,g
1989 1995 2000 2001 2002 2003 1989 1995 2000 2001 2002 2003
Notes: "—" = Data not available. In 1997 the National Health Interview Survey (NHIS) was redesigned, including changes to the questions on health insurance coverage. Percents do not add to 100 because (1) elderly persons with more than one type of insurance in addition to Medicare appear in more than one column, (2) elderly persons with Medicare fee-for-service only are not shown, and (3) the percent of elderly persons without health insurance (1.1 percent in 2003) is not shown.
*Estimates are considered unreliable.
aAlmost all persons 65 years of age and over are also covered by Medicare.
bPrivate insurance originally obtained through a present or former employer or union. Starting in 1997, also includes private insurance obtained through workplace, self-employed, or professional association.
cIncludes all other races not shown separately and, in 1984 and 1989, unknown poverty level.
dThe race groups, white, black, American Indian and Alaska Native, Asian, Native Hawaiian and other Pacific Islander, and 2 or more races, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Starting with data year 1999, race-specific estimates are tabulated according to 1997 Standards for Federal Data on Race and Ethnicity and are not strictly comparable with estimates for earlier years. The five single race categories plus multiple race categories shown in the table conform to 1997 standards Starting with data year 1999, race-specific estimates are for persons who reported only one racial group; the category "2 or more races" includes persons who reported more than one racial group. Prior to data year 1999, data were tabulated according to 1977 standards with four racial groups and the category "Asian only" included Native Hawaiian and other Pacific Islander. Estimates for single race categories prior to 1999 included persons who reported one race or, if they reported more than one race, identified one race as best representing their race.
ePoverty status was unknown for 15-18 percent of persons 65 years of age and over in 1984 and 1989. Missing family income data were imputed for 22-25 percent of persons 65 years of age and over in 1994–96, 36 percent in 1997, 41 percent in 1998, and 44-17 percent in 1999–2003.
fPersons reporting Medicare coverage are considered to have health maintenance organization (HMO) coverage if they responded yes when asked if they were under a Medicare managed care arrangement such as an HMO.
gIncludes public assistance through 1996. Starting with data year 1997 includes state-sponsored health plans. In 2003 the percent of the population 65 years of age and over covered by Medicaid was 7.3 percent, and 0.6 percent were covered by state-sponsored health plans.
source: Adapted from "Table 135. Health Insurance Coverage for Persons 65 Years of Age and Over, according to Type of Coverage and Selected Characteristics: United States, Selected Years, 1989–2003," in Health, United States, 2005, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, 2005, http://www.cdc.gov/nchs/data/hus/hus05.pdf (accessed January 25, 2006)
Number in millions
   Total c5.1 4.3 4.0 3.4 2.0 3.0 2.5 2.7 2.7 2.7
Percent of population
   Total c15.2 12.9 11.8 10.0 7.0 9.4 7.5 8.0 7.8 8.0
Age Percent of population
65-74 years15.712.711.79.56.38.47.67.67.98.0
75 years and over14.513.111.910.68.210.97.48.47.77.9
    75-84 years15.413.412.610.97.99.97.17.97.87.6
    85 years and over11.011.99.29.79.714.38.410.17.39.1
Sex
Male15.512.412.39.94.95.75.45.95.65.7
Female14.913.211.410.28.512.19.09.59.59.6
Race d
White only15.112.911.610.05.57.25.56.16.16.2
Black or African American only14.611.410.69.420.527.519.419.919.519.2
American Indian and Alaska Native only****30.9*35.4**32.7
Asian only16.713.418.615.221.333.621.022.920.028.5
Native Hawaiian and other Pacific Islander only********
2 or more races30.416.515.2**19.1*15.5
Hispanic origin and race d
Hispanic or Latino24.719.921.818.925.631.128.429.027.927.3
    Mexican23.718.219.014.527.431.626.625.723.625.7
Not Hispanic or Latino14.612.511.29.56.48.36.36.86.66.8
    White only14.512.511.19.34.85.94.64.95.04.8
    Black or African American only14.511.410.59.520.427.619.419.819.418.8
Percent of poverty level e
Below 100 percent15.19.19.19.428.136.228.131.029.531.8
100-149 percent16.412.811.810.79.012.813.715.012.813.3
150-199 percent15.714.112.811.74.75.85.46.86.66.4
200 percent or more14.813.312.09.72.22.22.83.03.13.1

PROSTATE CANCER

African-American men have a particularly high incidence of and mortality rate for prostate cancer. Between 1992 and 2002 the prostate cancer incidence rate among African-American men was 283.8 cases per one hundred thousand population, compared with a rate of only 175.5 cases per one hundred thousand population among whites. (See Table 6.9.) African-American men averaged 73.7 deaths from prostate cancer per one hundred thousand population during those same years, compared with 31.2 deaths per one hundred thousand white men. (See Table 6.10.) Even though the incidence rate and the mortality rate for prostate cancer decreased for both groups between the early 1990s and 2002, the incidence and mortality rates for African-American men remained higher than for all other race and ethnic groups. (See Figure 6.5.)

TABLE 6.4
Health care visits to doctor's offices, emergency departments, and home visits within the past 12 months, according to selected characteristics, selected years, 1997–2003
[Data are based on household interviews of a sample of the civilian noninstitutionalized population]
Characteristic Number of health care visits a
None 1-3 visits 4-9 visits 10 or more visits
1997 2002 2003 1997 2002 2003 1997 2002 2003 1997 2002 2003
Percent distribution
All personsb, c16.515.915.846.245.545.823.625.224.813.713.413.6
Racec, d
White only16.015.615.746.145.145.623.925.425.114.013.813.6
Black or African American only16.815.314.746.145.845.823.226.025.213.913.014.3
American Indian and Alaska Native only17.118.123.338.043.741.424.221.720.620.716.614.7
Asian only22.821.222.649.149.747.819.720.320.78.38.88.9
Native Hawaiian and other Pacific Islander only*******
2 or more races13.511.143.744.927.323.015.421.0
Hispanic origin and racec, d
Hispanic or Latino24.925.725.342.341.542.920.321.120.312.511.711.5
    Mexican28.928.827.840.840.542.518.519.318.811.811.511.0
Not Hispanic or Latino15.414.514.146.746.046.324.025.825.613.913.714.0
    White only14.714.013.546.645.846.224.426.126.114.314.214.2
    Black or African American only16.915.314.646.145.745.923.126.025.313.813.114.2
Respondent-assessed health statusc
Fair or poor7.810.18.723.322.223.229.029.428.839.938.339.3
Good to excellent17.216.616.448.447.748.123.324.924.511.110.810.9
Poverty statusc, e
Poor20.619.920.937.838.337.822.723.923.718.917.917.6
Near poor20.120.019.843.341.241.521.723.823.614.915.015.1
Nonpoor14.514.213.748.747.648.424.225.725.412.612.412.6
Hispanic origin and race and poverty statusc, d, e
Hispanic or Latino:
    Poor30.230.029.934.835.437.019.918.918.515.015.714.6
    Near poor28.730.228.639.737.840.220.419.920.611.212.210.5
    Nonpoor18.921.120.748.846.847.720.422.321.211.99.810.3
Not Hispanic or Latino:
    White only:
        Poor17.016.117.038.338.437.523.925.625.920.919.919.5
        Near poor17.316.716.644.141.341.022.225.024.916.317.017.4
        Nonpoor13.813.312.548.247.348.124.926.426.313.113.113.1
    Black or African American only:
        Poor17.417.315.738.539.738.123.425.926.520.717.119.6
        Near poor18.815.615.443.743.444.222.926.925.914.514.114.5
        Nonpoor15.614.413.751.749.150.622.725.324.310.011.111.4

Hispanics, Asians and Pacific Islanders, and Native Americans and Alaska Natives have both lower rates of prostate cancer incidence and lower rates of prostate cancer mortality than do African-Americans or whites. (See Figure 6.5.) The incidence rates of prostate cancer between 1992 and 2002 were 143.1 per one hundred thousand Hispanics, 104.6 per one hundred thousand Asians and Pacific Islanders, and 63.4 per one hundred thousand Native Americans and Alaska Natives. (See Table 6.9.) The mortality rates of prostate cancer were lowest for Asian and Pacific Islander males, at 14.1 per one hundred thousand, despite their higher incidence rates. The mortality rate for Hispanic males was highest of the three groups, at 24.7 per one hundred thousand. (See Table 6.10.)

LUNG AND BRONCHUS CANCER

According to the SEER Cancer Statistics Review, 1975–2002, lung cancer is the deadliest cancer for whites, Asians and Pacific Islanders, Native Americans and Alaska Natives, and Hispanics, and the second-deadliest cancer for African-Americans; the five-year survival rate for all races was only 15.3% of those diagnosed between 1995 and 2001. African-Americans have a particularly high incidence of lung cancer and mortality rate compared with other groups. Between 1992 and 2002 the lung cancer incidence rate among African-Americans was 81.6 cases per one hundred thousand population, compared with a rate of 63.7 cases per one hundred thousand whites, 42.8 cases per one hundred thousand Asians and Pacific Islanders, 36.3 cases per one hundred thousand Native Americans and Alaska Natives, and 33.4 per one hundred thousand Hispanics. (See Table 6.9.) Both the incidence rate and the mortality rate for lung cancer decreased between the early 1990s and 2002, especially for African-Americans; however, the incidence and mortality rates for African-Americans remained substantially higher than for all other race and ethnic groups. (See Figure 6.6.)

TABLE 6.4
Health care visits to doctor's offices, emergency departments, and home visits within the past 12 months, according to selected characteristics, selected years, 1997–2003 [continued]
[Data are based on household interviews of a sample of the civilian noninstitutionalized population]
Characteristic Number of health care visitsa
None 1-3 visits 4-9 visits 10 or more visits
1997 2002 2003 1997 2002 2003 1997 2002 2003 1997 2002 2003
Notes: "—" = Data not available. In 1997 the National Health Interview Survey (NHIS) questionnaire was redesigned
*Estimates are considered unreliable.
aThis table presents a summary measure of health care visits to doctor's offices, emergency departments, and home visits during a 12-month period.
bIncludes all other races not shown separately and unknown health insurance status.
cEstimates are age adjusted to the year 2000 standard population using six age groups: Under 18 years, 18-44 years, 45-54 years, 55-64 years, 65-74 years, and 75 years and over.
dThe race groups, white, black, American Indian and Alaska Native, Asian, Native Hawaiian and other Pacific Islander, and 2 or more races, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Starting with data year 1999 race-specific estimates are tabulated according to 1997 Standards for Federal Data on Race and Ethnicity and are not strictly comparable with estimates for earlier years. The five single race categories plus multiple race categories shown in the table conform to 1997 standards. Starting with data year 1999, race-specific estimates are for persons who reported only one racial group; the category "2 or more races" includes persons who reported more than one racial group. Prior to data year 1999, data were tabulated according to 1977 standards with four racial groups and the category "Asian only" included Native Hawaiian and other Pacific Islander. Estimates for single race categories prior to 1999 included persons who reported one race or, if they reported more than one race, identified one race as best representing their race.
ePoor persons are defined as below the poverty threshold. Near poor persons have incomes of 100 percent to less than 200 percent of poverty threshold. Nonpoor persons have incomes of 200 percent or greater than the poverty threshold. Missing family income data were imputed for 25-29 percent of persons in 1997–98 and 32-35 percent in 1999–2003.
fEstimates for persons under 65 years of age are age adjusted to the year 2000 standard using four age groups: Under 18 years, 18-44 years, 45-54 years, and 55-64 years of age. Estimates for persons 65 years of age and over are age adjusted to the year 2000 standard using two age groups: 65-74 years and 75 years and over.
gHealth insurance categories are mutually exclusive. Persons who reported both Medicaid and private coverage are classified as having private coverage. Starting in 1997 Medicaid includes state-sponsored health plans and State Children's Health Insurance Program (SCHIP). In addition to private and Medicaid the category "insured" also includes military plans, other government-sponsored health plans, and Medicare, not shown separately. Persons 65 years of age and over who reported Medicare HMO (health maintenance organization) and some other type of health insurance coverage are classified as having Medicare HMO. For persons 65 years of age and over the category "private" includes private and Medicare coverage.
source: Adapted from "Table 75. Health Care Visits to Doctor's Offices, Emergency Departments, and Home Visits within the Past 12 Months, according to Selected Characteristics: United States, Selected Years, 1997–2003," in Health, United States, 2005, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, 2005, http://www.cdc.gov/nchs/data/hus/hus05.pdf (accessed January 25, 2006)
Health insurance statusf, g
Under 65 years of age:
Insured14.313.312.849.048.749.123.625.125.213.112.912.9
    Private14.713.613.250.650.551.123.124.824.611.611.111.1
    Medicaid9.89.99.935.534.935.226.527.428.128.227.726.8
Uninsured33.736.338.142.842.142.415.314.713.48.26.96.1
65 years of age and over:
Medicare HMO8.97.75.435.830.930.633.140.938.922.320.525.2
Private7.36.14.835.932.033.534.038.135.922.723.825.8
Medicaid9.39.34.919.215.821.127.934.229.743.740.844.3
Medicare fee-for-service only15.514.411.634.033.428.728.130.735.322.421.424.5

COLON AND RECTUM CANCER

Colon and rectum cancer is the fourth most frequently diagnosed cancer in the United States; it is also the fourth deadliest. African-Americans are diagnosed more frequently than other groups. Between 1992 and 2002 African-Americans had an incidence of 62.6 cases per one hundred thousand population, compared with a rate of 53.6 per one hundred thousand whites, forty-seven per one hundred thousand Asians and Pacific Islanders, 38.9 per one hundred thousand Hispanics, and thirty-six per one hundred thousand Native Americans and Alaska Natives. (See Table 6.9.) African-Americans also had the highest mortality rate from colon and rectum cancer, at 28.6 deaths per one hundred thousand, compared with 21.1 deaths per one hundred thousand whites, 14.2 deaths per one hundred thousand Hispanics, 13.8 deaths per one hundred thousand Native Americans and Alaska Natives, and 13.5 deaths per one hundred thousand Asians and Pacific Islanders. (See Table 6.10.) Furthermore, while both the incidence rate of and the mortality rate from colon and rectum cancer steadily decreased for whites between the mid-1980s and 2002, the incidence and mortality rates for African-Americans remained static. (See Figure 6.7.)

Heart Disease and Stroke

Heart disease includes coronary and hypertensive heart diseases and heart failure. According to the 2004National Healthcare Disparities Report, about 13.2 million Americans had coronary heart disease, 1.2 million heart attacks occurred each year, and about five million Americans had heart failure annually.

TABLE 6.5
Prenatal care for live births, according to detailed race and Hispanic origin of mother, 1970–2003
[Data are based on birth certificates]
Prenatal care, race, and Hispanic origin of mother 197019751980198519901995199719992000200120022003
Notes: "—" = Data not available. Data for 2003 exclude Pennsylvania and Washington that implemented the 2003 revision to the U.S. Standard Certificate of Live Birth. Prenatal care data based on the 2003 revision are not comparable with data based on the 1989 revision to the U.S. Standard Certificate of Live Birth. Data for 1970 and 1975 exclude births that occurred in states not reporting prenatal care. The race groups, white, black, American Indian or Alaska Native, and Asian or Pacific Islander, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Interpretation of trend data should take into consideration expansion of reporting areas and immigration. Data for additional years are available. Some data for 1980–88 were revised and differ from previous editions of Health, United States.
aExcludes live births for whom trimester when prenatal care began is unknown.
bFor 2003, data are not shown for Asian or Pacific Islander subgroups during the transition from single race to multiple race reporting.
cPrior to 1993, data from states lacking an Hispanic-origin item on the birth certificate were excluded. Data for non-Hispanic white and non-Hispanic black women for years prior to 1989 are not nationally representative and are provided for comparison with Hispanic data.
source: "Table 7. Prenatal Care for Live Births, according to Detailed Race and Hispanic Origin of Mother: United States, Selected Years, 1970–2003," in Health, United States, 2005, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, 2005, http://www.cdc.gov/nchs/data/hus/hus05.pdf (accessed January 25, 2006)
Prenaatal care began during 1st trimester Percent of live births a
All races68.072.476.376.275.881.382.583.283.283.483.784.1
White72.375.879.279.379.283.684.785.185.085.285.485.7
Black or African American44.255.562.461.560.670.472.374.174.374.575.275.9
American Indian or Alaska Native38.255.857.557.966.768.169.569.369.369.870.8
Asian or Pacific Islanderb73.774.175.179.982.183.784.084.084.885.4
    Chinese71.876.782.682.081.385.787.488.587.687.087.2
    Japanese78.182.786.184.787.089.789.390.791.090.190.5
    Filipino60.670.677.376.577.180.983.384.284.985.085.4
    Hawaiian68.867.765.875.978.079.679.979.178.1
    Other Asian or Pacific Islander67.469.971.977.079.781.882.582.783.9
Hispanic or Latinoc60.261.260.270.873.774.474.475.776.777.5
    Mexican59.660.057.869.172.173.172.974.675.776.5
    Puerto Rican55.158.363.574.076.577.778.579.179.981.2
    Cuban82.782.584.889.290.491.491.791.892.092.1
    Central and South American58.860.661.573.276.977.677.677.478.779.2
    Other and unknown Hispanic or Latino66.465.866.474.376.074.875.877.376.777.0
Not Hispanic or Latino:c
    White81.281.483.387.187.988.488.588.588.689.0
    Black or African American60.860.260.770.472.374.174.374.575.275.9
Prenatal care began during 3rd trimester or no prenatal care
All races7.96.05.15.76.14.23.93.83.93.73.63.5
White6.35.04.34.84.93.53.23.23.33.23.13.0
Black or African American16.610.58.910.211.37.67.36.66.76.56.26.0
American Indian or Alaska Native28.922.415.212.912.99.58.68.28.68.28.07.6
Asian or Pacific Islanderb6.56.55.84.33.83.53.33.43.13.1
    Chinese6.54.43.74.43.43.02.42.02.22.42.1
    Japanese4.12.72.13.12.92.32.72.11.82.02.1
    Filipino7.24.14.04.84.54.13.32.83.03.02.8
    Hawaiian6.77.48.75.15.44.04.24.84.7
    Other Asian or Pacific Islander9.38.27.15.04.44.13.83.83.5
Hispanic or Latinoc12.012.412.07.46.26.36.35.95.55.3
    Mexican11.812.913.28.16.76.76.96.25.85.6
    Puerto Rican16.215.510.65.55.45.04.54.64.13.7
    Cuban3.93.72.82.11.51.41.41.31.31.3
    Central and South American13.112.510.96.15.05.25.45.74.94.7
    Other and unknown Hispanic or Latino9.29.48.56.05.36.35.95.45.35.4
Not Hispanic or Latino:c
    White3.54.03.42.52.42.32.32.22.22.1
    Black or African American9.710.911.27.67.36.66.76.56.26.0

Rates of heart disease vary considerably by race, with higher rates for African-Americans. Along with age, sex, and race, heredity is one of the risk factors for heart disease that cannot be changed. However, due to their higher rates of incidence of heart disease and stroke, African-Americans are encouraged to control other risk factors, including use of tobacco and alcohol, blood pressure and cholesterol levels, physical activity, weight, and stress.

HYPERTENSION

According to the American Heart Association in Heart Disease and Stroke Statistics: 2006 Update (2006, http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.105.171600v1), the prevalence of hypertension, or high blood pressure, in both African-American men and women is significantly higher than in white men and women, while prevalence of high blood pressure among Mexican Americans of both sexes is comparable to that in the non-Hispanic white community. Compared with whites, African-Americans develop high blood pressure earlier in life and their average blood pressure is much higher. As a result, African-Americans have a 1.3 times greater rate of nonfatal stroke, a 1.8 times greater rate of fatal stroke, and a 1.5 times greater rate of death from heart disease than do whites. Native American and Alaska Native adults are also more likely (29.7%) than white adults (22.8%) or Asian-American adults (19.3%) to ever have been told they had high blood pressure.

TABLE 6.6
Total births and percentage of births with selected demographic characteristics, by race and Hispanic origin of mother, 2003–04
[Data for 2004 are based on a continuous file of records received from the states. Figures for 2004 are based on weighted data rounded to the nearest individual. Birth rates are live births per 1,000 population in specified group. Fertility rates are live births per 1,000 women aged 15-44 years in specified group. Total fertility rates are sums of birth rates for 5-year age groups in specified group multiplied by 5.]
Race and Hispanic origin of mother Number Birth rate Fertility rate Total fertility rate Percent of births to unmarried mothers
2004 2003 2004 2003 2004 2003 2004 2003 2004 2003
aIncludes data for women of unknown Hispanic origin.
bRace and Hispanic origin are reported separately on the birth certificate.
cData for persons of Hispanic origin are included in the data for each race group according to the mother's reported race.
dIncludes births to Aleuts and Eskimos.
eIncludes all persons of Hispanic origin of any race.
source: "Table A. Total Births and Percentage of Births with Selected Demographic Characteristics, by Race and Hispanic Origin of Mother: United States, Final 2003 and Preliminary 2004," in "Births: Preliminary Data for 2004," National Vital Statistics Reports, vol. 54, no. 8, December 29, 2005, http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_08.pdf (accessed January 26, 2006)
All races and originsa4,115,5904,089,95014.014.166.366.12,048.52,042.535.734.6
Non-Hispanic whiteb2,304,1812,321,90411.711.858.558.51,852.51,856.524.523.6
Non-Hispanic blackb576,105576,03315.115.966.767.12,010.52,027.569.268.5
American Indian totalb, c, d43,93143,05214.013.858.958.41,735.01,731.562.361.3
Asian or Pacific Islander totalb, c229,352221,20316.816.867.266.31,900.51,873.015.515.0
Hispanice944,993912,32922.922.997.796.92,820.52,785.546.445.0

Researchers are not yet sure why African-Americans have a greater tendency toward high blood pressure, but a possible genetic predisposition toward high blood pressure in African-Americans may stem from a strong tendency to retain salt in their bodies. Scientists hypothesize that this developed as an adaptation to living in a very hot climate where excessive salt loss could result in death.

DEATHS FROM HEART DISEASE

According to the NCHS in Health, United States, 2005 (2005, http://www.cdc.gov/nchs/data/hus/hus05.pdf), the death rate from heart disease was higher for males among all racial and ethnic groups, but it declined between 1990 and 2002 for all groups. African-American males had the highest death rate from heart disease in 2002, at 371 deaths per one hundred thousand people, down from 485.4 in 1990. Hispanic males (219.8), Native American and Alaska Native males (201.2), and Asian and Pacific Islander males (169.8) all had lower death rates from heart disease than did non-Hispanic white males.

Health, United States, 2005 reports that females die of heart disease at high rates as well, although not at the rate that males do. In 2002 African-American females had the highest death rate for heart disease of all racial and ethnic groups, at 263.2 per one hundred thousand people, followed by non-Hispanic white females (193.7), Hispanic females (149.7), Native American and Alaska Native females (123.6), and Asian and Pacific Islander females (108.1). Death rates for all groups from heart disease had declined since 1990.

Alzheimer's Disease

Alzheimer's disease is a progressive brain disorder that gradually destroys a person's memory and ability to reason, communicate, and carry out daily activities. As it progresses, it also tends to affect personality and behavior and may result in anxiety, paranoia, and delusions or hallucinations. The disease can last from three to twenty years and eventually the loss of brain function will cause death. While the underlying causes of Alzheimer's disease remain unclear, some research indicates that minorities, particularly African-Americans, are at a greater risk of developing the disease.

The results of the study "APOE-ε4 Allele and the Risk of Alzheimer Disease among African-Americans, Whites, and Hispanics," conducted between 1991 and 1996 by Columbia University, were published in the Journal of the American Medical Association (March 1998). The findings indicate that African-Americans and Hispanics might be at greater risk for Alzheimer's disease than whites. In 1992 scientists first discovered that people with the apolipoprotein E gene, or APOE-ε4 (approximately 25% of the total population), have a greater risk for developing the disease. However, the Columbia University research shows that the increased risk associated with the APOE-ε4 gene applies only to whites. The study shows that African-Americans and a group of Hispanic Americans, mainly from the Caribbean, who do not have the gene, are still at a greater risk for Alzheimer's disease than whites.

TABLE 6.7
Low-birth-weight live births, according to mother's detailed race, Hispanic origin, and smoking status, 1970–2003
[Data are based on birth certificates]
Birthweight, race, Hispanic origin of mother, and smoking status of mother 1970 1975 1980 1985 1990 1995 1998 1999 2000 2001 2002 2003
Notes: "—" = Data not available. The race groups, white, black, American Indian or Alaska Native, and Asian or Pacific Islander, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Interpretation of trend data should take into consideration expansion of reporting areas and immigration. Data for additional years are available.
aExcludes live births with unknown birthweight. Percent based on live births with known birthweight.
bFor 2003, data are not shown for Asian or Pacific Islander subgroups during the transition from single race to multiple race reporting.
cPrior to 1993, data from states lacking an Hispanic-origin item on the birth certificate were excluded. Data for non-Hispanic white and non-Hispanic black women for years prior to 1989 are not nationally representative and are provided for comparison with Hispanic data.
dPercent based on live births with known smoking status of mother and known birthweight. Data from states that did not require the reporting of mother's tobacco use during pregnancy on the birth certificate are not included. Reporting area for tobacco use increased from 43 states and the District of Columbia (DC) in 1989 to 49 states and DC in 2000–02. In 2003 California did not require reporting of tobacco use during pregnancy. Data for 2003 also exclude Pennsylvania and Washington that implemented the 2003 revision to the U.S. Standard Certificate of Live Birth. Tobacco use data based on the 2003 revision are not comparable with data based on the 1989 revision to the U.S. Standard Certificate of Live Birth.
source: "Table 13. Low-Birthweight Live Births, according to Mother's Detailed Race, Hispanic Origin, and Smoking Status: United States, Selected Years, 1970–2003," in Health, United States, 2005, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, 2005, http://www.cdc.gov/nchs/data/hus/hus05.pdf (accessed January 25, 2006)
Low birthweight (less than 2,500 grams) Percent of live births a
All races7.937.386.846.756.977.327.577.627.577.687.827.93
White6.856.275.725.655.706.226.526.576.556.686.806.94
Black or African American13.9013.1912.6912.6513.2513.1313.0513.1112.9912.9513.2913.37
American Indian or Alaska Native7.976.416.445.866.116.616.817.156.767.337.237.37
Asian or Pacific Islanderb6.686.166.456.907.427.457.317.517.787.78
    Chinese6.675.295.214.984.695.295.345.195.105.335.52
    Japanese9.037.476.606.216.167.267.507.957.147.287.57
    Filipino10.028.087.406.957.307.838.238.308.468.668.61
    Hawaiian7.236.497.246.847.157.696.767.918.14
    Other Asian or Pacific Islander6.836.196.657.057.767.767.677.768.16
Hispanic or Latinoc6.126.166.066.296.446.386.416.476.556.69
    Mexican5.625.775.555.815.975.946.016.086.166.28
    Puerto Rican8.958.698.999.419.689.309.309.349.6810.01
    Cuban5.626.025.676.506.506.806.496.496.507.04
    Central and South American5.765.685.846.206.476.386.346.496.536.70
    Other and unknown Hispanic or Latino6.966.836.877.557.597.637.847.967.878.01
Not Hispanic or Latino:c
    White5.695.615.616.206.556.646.606.766.917.04
    Black or African American12.7112.6213.3213.2113.1713.2313.1313.0713.3913.55
Cigarette smokerd11.2512.1812.0112.0611.8811.9012.1512.40
Nonsmokerd6.146.797.187.217.197.327.487.66
Very low birthweight (less than 1,500 grams)
All races1.171.161.151.211.271.351.451.451.431.441.461.45
White0.950.920.900.940.951.061.151.151.141.161.171.17
Black or African American2.402.402.482.712.922.973.083.143.073.043.133.07
American Indian or Alaska Native0.980.950.921.011.011.101.241.261.161.261.281.30
Asian or Pacific Islanderb0.920.850.870.911.101.081.051.031.121.09
    Chinese0.800.520.660.570.510.670.750.680.770.690.74
    Japanese1.480.890.940.840.730.870.840.860.750.710.97
    Filipino1.080.930.990.861.051.131.351.411.381.231.31
    Hawaiian1.051.030.970.941.531.411.391.501.55
    Other Asian or Pacific Islander0.960.910.920.911.121.091.041.061.17
Hispanic or Latinoc0.981.011.031.111.151.141.141.141.171.16
    Mexican0.920.970.921.011.021.041.031.051.061.06
    Puerto Rican1.291.301.621.791.861.861.931.851.962.01
    Cuban1.021.181.201.191.331.491.211.271.151.37
    Central and South American0.991.011.051.131.231.151.201.191.201.17
    Other and unknown Hispanic or Latino1.010.961.091.281.381.321.421.271.441.28
Not Hispanic or Latino:c
    White0.870.910.931.041.151.151.141.171.171.18
    Black or African American12.7112.622.932.983.113.183.103.083.153.12
Cigarette smokerd1.731.851.871.911.911.881.881.92
Nonsmokerd1.181.311.441.431.401.421.451.44
TABLE 6.8
Number of infant deaths and infant mortality rates, by age at death and by race and Hispanic origin of mother, 2001–02
Infant deaths Neonatal* deaths Postneonatal deaths
Total Early Late
2002 2001 2002 2001 2002 2001 2002 2001
*Neonatal is less than 28 days of age, early neonatal is less than 7 days, late neonatal is 7-27 days, and postneonatal is 28 days through 11 months.
source: "Table A. Number of Infant Deaths and Infant Mortality Rates, by Age at Death and by Race and Hispanic Origin of Mother: United States, 2001–02 Linked Files," in "Explaining the 2001–02 Infant Mortality Increase: Data from the Linked Birth/Infant Death Data Set," National Vital Statistics Reports, vol. 53, no. 12, January 24, 2005, http://www.cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_12.pdf (accessed January 25, 2006)
Rate per 1,000 live births
    Total 7.0 6.8 4.7 4.5 3.7 3.6 0.9 0.9 2.3 2.3
White5.85.73.93.83.13.00.80.81.91.9
Black13.813.39.38.97.67.31.71.64.54.4
American Indian8.69.74.64.23.23.11.41.14.05.4
Asian or Pacific Islander4.84.73.43.12.72.50.70.61.41.6
Hispanic5.65.43.83.63.02.90.80.81.81.8
Non-Hispanic white5.85.73.93.83.03.00.80.81.91.9
Non-Hispanic black13.913.59.39.07.67.41.81.64.64.5
Number
    Total 27,970 27,523 18,791 18,275 15,020 14,622 3,771 3,653 9,179 9,248
White18,39518,08712,35212,0789,8049,5712,5482,5066,0446,009
Black8,2018,0845,5335,3964,5064,4251,0279712,6682,688
American Indian3664041951761371295847171228
Asian or Pacific Islander1,006947710624573496138128296323
Hispanic4,9274,6303,3603,1052,6732,4396876661,5671,526
Non-Hispanic white13,32713,3008,8538,8177,0026,9791,8511,8394,4744,483
Non-Hispanic black8,0317,9385,3995,2934,3864,3371,0149562,6322,645

The researchers surveyed 1,079 elderly men and women and found that African-Americans who lacked the APOE-ε4 gene were four times more likely than whites to get Alzheimer's disease. Since the APOE-ε4 could not account for the increased cases in African-Americans and Hispanics, researchers now believe that there are other genetic or environmental factors affecting minorities that increase their risk of developing Alzheimer's disease. None of the subjects of the study had the disease when the study began, but 221 developed it by the time the study ended.

The Alzheimer's Association emphasizes in African-Americans and Alzheimer's Disease: The Silent Epidemic (2003, http://www.alz.org/Media/newsreleases/2003/AA_ALZ.pdf) that the prevalence of Alzheimer's disease among African-Americans is estimated to be 14% to 100% higher than among whites. Since the turn of the twenty-first century, discoveries of risk factors for Alzheimer's disease—hypertension and high cholesterol—have begun to provide some explanation for this increased risk, as these risk factors are disproportionately present in the African-American community. The report stresses the importance of getting effective medical therapies for vascular disease and its risk factors, as these drugs could potentially protect against Alzheimer's disease as well.

Diabetes

Diabetes is a chronic disease in which the body does not produce or use insulin properly, leading to cells being starved for sugar and often resulting in damage to the heart, kidneys, and eyes. Diabetes is the fifth-deadliest disease in the United States; in fact, the death rate due to diabetes is on the rise at the same time that the death rates due to other diseases like cancer and heart disease have declined. In "Age-Adjusted Prevalence of Diagnosed Diabetes per 100 Population, by Race/Ethnicity and Sex, United States, 1980–2004" (October 6, 2005, http://www.cdc.gov/diabetes/statistics/prev/national/tableraceethsex.htm), the CDC reports that in 2004, 7.6% of African-American males and 7.8% of African-American females had been diagnosed with diabetes, 7% of Hispanic males and 6.8% of Hispanic females had diabetes, while only 5.1% of non-Hispanic white males and 4.3% of white females had diabetes.

Diabetes is a dangerous disease because it can cause many different complications, including heart disease, kidney failure, and loss of circulation in the extremities. The lack of circulation in the lower limbs can lead to infection of small wounds and gangrene, which eventually requires leg amputation. Diabetes requires effective management of hemoglobin A1c and lipids, as well as regular examination of eyes and feet and yearly influenza immunizations. However, the rates of receiving all five diabetic management services vary by race and ethnic group. Non-Hispanic whites were much more likely than either African-Americans or Hispanics to receive the recommended services. (See Figure 6.8.)

TABLE 6.9
Cancer incidence rates and trends for the top 15 cancer sites, by race/ethnicity, 1992–2002
Both sexes
Note: "—" = statistic not shown. Rate based on less than 25 cases for the time interval. Trend based on less than 10 cases for at least one year within the time interval.
aThe APC is the annual percent change over the time interval.
bIncidence data are from the 13 SEER (Surveillance, Epidemiology, and End Results) areas (San Francisco, Connecticut, Detroit, Hawaii, Iowa, New Mexico, Seattle, Utah, Atlanta, San Jose-Monterey, Los Angeles, Alaska Native Registry and rural Georgia).
cHispanic is not mutually exclusive from whites, blacks, Asian Pacific Islanders, and American Indians/Alaska Natives. Incidence data for Hispanics does not include cases from Detroit, Hawaii, Alaska Native Registry and rural Georgia.
dThe APC is significantly different from zero.
eIBD = Intrahepatic bile duct. NOS = Not otherwise specified.
source: "Table I-19. Age-Adjusted Rates and Trends for the Top 15 Cancer Sites by Race/Ethnicity: SEER Cancer Incidence, 1992–2002," in SEER Cancer Statistics Review, 1975–2002, National Cancer Institute, 2005, http://seer.cancer.gov/csr/1975_2002/results_merged/topic_race_ethnicity.pdf (accessed January 25, 2006)
All races White Black
Rate APC aRate APC aRate APC a
All sites475.4−0.6dAll sites483.5−0.4dAll sites526.7−1.0d
Prostate180.1−2.0dProstate175.5−2.1dProstate283.8−1.9d
Breast (females)132.4 0.4Breast (females)138.3 0.5Breast (females)120.2−0.2
Lung and bronchus63.2−1.3dLung and bronchus63.7−1.1dLung and bronchus81.6−1.4d
Colon and rectum53.9−0.8dColon and rectum53.6−0.9dColon and rectum62.6−0.3
Corpus and uterus, NOSe24.4−0.2Corpus and uterus, NOSe25.9−0.3Corpus and uterus, NOSe18.4 1.8d
Urinary bladder20.3−0.2Urinary bladder22.3 0.0Pancreas16.0−1.9d
Non-Hodgkin lymphoma19.2 0.1Non-Hodgkin lymphoma20.2 0.1Non-Hodgkin lymphoma14.4 0.3
Melanoma of the skin16.2 2.4dMelanoma of the skin19.2 2.9dStomach13.7−1.5d
Ovary14.2−0.9dOvary15.1−0.8dKidney and renal pelvis13.1 2.3d
Leukemia12.5−0.9dLeukemia13.2−0.8dOral cavity and pharynx12.6−2.8d
Pancreas11.1−0.3Kidney and renal pelvis11.4 1.7dCervix uteri12.6−3.8d
Kidney and renal pelvis11.1 1.5dOral cavity and pharynx11.0−1.2dUrinary bladder12.5 0.2
Oral cavity and pharynx11.0−1.5dPancreas10.9 0.0Myeloma11.5−1.3d
Cervix uteri9.7−2.8dCervix uteri9.3−2.2dOvary10.3−1.6d
Stomach9.1−1.5dStomach7.8−1.6dLeukemia10.0−1.4
Asian/Pacific Islander American Indian/Alaska Native Hispanic c
Rate APC aRate APC aRate APC a
All sites339.7−0.6dAll sites251.9−2.7dAll sites354.6−0.4d
Prostate104.6−1.7dProstate63.4−6.8dProstate143.1−0.7
Breast (females)92.8 1.5dBreast (females)60.7−3.5dBreast (females)88.2 0.6
Colon and rectum47.0−0.3Lung and bronchus36.3−4.2dColon and rectum38.9−0.1
Lung and bronchus42.8−1.1dColon and rectum36.0−1.8Lung and bronchus33.4−1.8d
Stomach17.4−3.3dKidney and renal pelvis11.3−4.4dCervix uteri17.3−3.3d
Corpus and uterus, NOSe17.0 1.6dStomach10.8 2.6Corpus and uterus, NOSe16.6 0.7
Liver & IBDe13.8 0.6Corpus and uterus, NOSe10.1Non-Hodgkin lymphoma16.1−0.4
Non-Hodgkin lymphoma13.7 0.6Ovary8.9Stomach13.5−1.7d
Cervix uteri10.5−4.9dNon-Hodgkin lymphoma8.2 1.8Ovary11.9 0.2
Ovary10.4 0.3Pancreas7.5Urinary bladder10.8−0.1
Urinary bladder9.7 0.1Oral cavity and pharynx7.2−6.7dKidney and renal pelvis10.8 2.4d
Pancreas9.3−0.5Liver&IBDe7.1−2.7Pancreas10.0−0.2
Oral cavity and pharynx8.9−1.1Cervix uteri6.6−6.9dLeukemia9.5−0.7
Thyroid8.0 1.9dLeukemia4.9 2.4Liver & IBDe8.9 3.4d
Leukemia7.8−1.3dUrinary bladder4.8Oral cavity and pharynx6.7−2.1d
TABLE 6.10
Cancer mortality rates and trends for the top 15 cancer sites, by race/ethnicity, 1992–2002
Both sexes
Note: Mortality data are analyzed from a public use file provided by the National Center for Health Statistics (NCHS).
aThe APC is the annual percent change over the time interval.
bHispanic is not mutually exclusive from whites, blacks, Asian Pacific Islanders, and American Indians/Alaska Natives. Mortality data for Hispanics does not include cases from Connecticut, Maine, Maryland, Minnesota, New Hampshire, New York, North Dakota, Oklahoma and Vermont.
cThe APC is significantly different from zero.
dIBD = Intrahepatic bile duct. ONS = Other nervous system. NOS = Not otherwise specified.
source: "Table I-22. Age-Adjusted Rates and Trends for the Top 15 Cancer Sites by Race/Ethnicity: US Mortality, 1992–2002," in SEER Cancer Statistics Review, 1975–2002, National Cancer Institute, 2005, http://seer.cancer.gov/csr/1975_2002/results_merged/topic_race_ethnicity.pdf (accessed January 25, 2006)
All races White Black
Rate APC aRate APC aRate APC a
All sites204.0−1.0cAll sites200.8−0.9cAll sites259.3−1.5c
Lung and bronchus57.1−0.8cLung and bronchus56.9−0.7cProstate73.7−2.5c
Prostate33.9−3.6cProstate31.2−3.7cLung and bronchus66.9−1.5c
Breast (females)28.5−2.4cBreast (females)28.0−2.5cBreast (females)36.2−1.2c
Colon and rectum21.6−1.8cColon and rectum21.1−1.9cColon and rectum28.6−0.8c
Pancreas10.6−0.1Pancreas10.3−0.1Pancreas14.4−1.1c
Ovary9.0−0.5cOvary9.3−0.4Stomach9.6−2.6c
Non-Hodgkin lymphoma8.4−0.8Non-Hodgkin lymphoma8.7−0.8Ovary7.6−0.8c
Leukemia7.7−0.6cLeukemia7.9−0.5cMyeloma7.5−0.8c
Stomach4.9−3.0cBrain and ONSd5.0−0.8cEsophagus7.3−4.1c
Brain and ONSd4.7−0.9cUrinary bladder4.5−0.1Corpus and uterus, NOSd7.0−0.2
Liver & IBDd4.4 1.9cStomach4.4−3.2cLeukemia7.0−1.0c
Urinary bladder4.4−0.3cKidney and renal pelvis4.3−0.1Cervix uteri6.2−4.9c
Esophagus4.3−0.6cLiver & IBDd4.1 2.0cLiver & IBDd6.0 1.3c
Kidney and renal pelvis4.2−0.1Esophagus4.1 1.6cNon-Hodgkin lymphoma5.7−0.5
Corpus and uterus, NOSd4.1−0.1Corpus and uterus, NOSd3.9−0.2Oral cavity and pharynx4.7−4.3c
Asian/Pacific Islander American Indian/Alaska Native Hispanic b
Rate APC aRate APC aRate APC a
All sites125.1−1.7cAll sites135.3−0.7All sites137.4−0.6c
Lung and bronchus28.6−1.5cLung and bronchus36.3−0.9Lung and bronchus25.5−0.9c
Prostate14.1−5.2cProstate21.5−4.5cProstate24.7−2.4c
Colon and rectum13.5−1.9cBreast (females)14.4−1.5Breast (females)17.7−1.9c
Breast (females)12.9−0.6Colon and rectum13.8 0.7Colon and rectum14.2−0.2
Liver & IBDd10.8−0.7Pancreas6.2 0.4Pancreas8.4−0.1
Stomach9.7−3.9cLiver & IBDd5.6 2.2Stomach7.4−1.8c
Pancreas7.5−0.6Stomach5.5−1.1Liver & IBDd7.2 2.0c
Non-Hodgkin lymphoma5.2−1.7cOvary5.1−0.4Non-Hodgkin lymphoma6.5−0.6
Ovary4.8 0.0Kidney and renal pelvis4.9 0.6Ovary6.2−0.6
Leukemia4.3−1.4Non-Hodgkin lymphoma4.4 2.1Leukemia5.3−0.1
Cervix uteri2.9−3.3cLeukemia4.1−1.8Cervix uteri3.8−3.0c
Oral cavity and pharynx2.5−2.4cCervix uteri3.2−4.7cKidney and renal pelvis3.8 0.4
Corpus and uterus, NOSd2.2 1.4Myeloma2.9−0.5Corpus and uterus, NOSd3.2 0.6
Esophagus2.1−3.3cEsophagus2.7 2.6cMyeloma3.2 1.4
Brain and ONSd1.9 0.1Corpus and uterus, NOSd2.6 0.3Brain and ONSd2.9 0.6

AIDS

Acquired immune deficiency syndrome (AIDS) is caused by a virus that affects the body's immune system, making it difficult to fight invasions from infection or other foreign substances. As a result, people infected with the AIDS virus are subject to a number of opportunistic infections, primarily Pneumocystis carinii pneumonia and aposi's sarcoma, a form of skin cancer. AIDS, which is caused by the human immunodeficiency virus (HIV), is not transmitted casually, but only through the transfer of bodily fluids such as blood and semen. The CDC reports only four methods of transmission: contaminated blood, sexual transmission, contaminated syringes from intravenous drug use, and perinatal (around the time of birth) transmission from a mother to her child or through breast milk.

Minorities have been especially hard hit by the AIDS epidemic. The CDC notes that of the estimated 462,792 people living with AIDS in 2004, 220,028 (47.5%) were African-Americans, 157,172 (34%) were non-Hispanic whites, and 78,039 (16.9%) were Hispanics. Asians and Pacific Islanders and Native Americans and Alaska Natives were the least likely groups to be living with HIV/AIDS, at less than 1% (2,765 and 1,996, respectively) each. (See Table 6.11.).

Far more AIDS cases have been diagnosed among African-American children than among children of other racial or ethnic backgrounds. Through 2004, 5,590 cases among African-American children, 2,128 among Hispanic children, and 1,612 among white, non-Hispanic children had been diagnosed. Only fifty-three cases had been diagnosed among Asian and Pacific Islander children, and only thirty-four had been diagnosed among Native American and Alaska Native children. However, the rate of diagnosis among African-American children dropped the most between 2000 and 2004, from ninety-three cases in 2000 to twenty-nine in 2004%#x2014;a decrease of 68.8%. (See Table 6.12.) Cases among Hispanic children had fallen from eighteen in 2000 to eight in 2004, a decrease of 55.6%, while cases among white, non-Hispanic children had fallen from eleven in 2000 to seven in 2004, a decrease of 36.4%.

Methods of transmission of HIV differ considerably by race. White men with AIDS had overwhelmingly contracted the disease through homosexual contact; 73% had done so, with the next-highest transmission method for this group being intravenous drug use, at 9%. Most Asian and Pacific Islander men with AIDS (69%) and Native American and Alaska Native men with AIDS (55%) also contracted the disease through homosexual contact. While the majority of African-American men with AIDS (37%) and Hispanic men with AIDS (43%) acquired the disease through homosexual activity, a significant proportion of African-American men (31%) and Hispanic men (32%) with AIDS contracted the disease through intravenous drug use. In addition, a sizeable portion of African-American men with AIDS had contracted the disease through heterosexual contact (10%). (See Table 6.13.)

Most women who had contracted AIDS through December 2004 had done so through heterosexual contact or intravenous drug use. White women were about equally likely to contract AIDS through heterosexual contact (41%) or intravenous drug use (40%) as were Native Americans and Alaska Natives, 41% of whom contracted the disease through heterosexual contact and 43% of whom contracted the disease through intravenous drug use. African-American women were slightly more likely to contract the disease through heterosexual contact (42%) than they were through intravenous drug use (36%). Hispanic women were also slightly more likely to contract AIDS through heterosexual contact (49%) rather than through intravenous drug use (37%). Asian and Pacific Islander women were much more likely to contract AIDS through heterosexual contact (52%) than they were through intravenous drug use (12%). (See Table 6.14.)

Not only are African-Americans extremely over-represented in new diagnoses each year but they also suffer from disparities in care for HIV and AIDS. The 2004 National Healthcare Disparities Report documents that racial and ethnic differences have been shown in the receipt of antiretroviral therapy (to prevent HIV-infected people from developing AIDS) and therapy to prevent Pneumocystis carinii pneumonia.

Sickle-Cell Anemia in African-Americans

Sickle-cell anemia, a hereditary disease that primarily strikes African-American people in the United States, is a blood disorder in which defective hemoglobin causes red blood cells to become sickle shaped, rather than round. This can create blockages in small arteries and can result in many problems, including chronic anemia, episodes of intense pain, strokes, and death. Scientists believe the genetic trait arose randomly in Africa and survived as a defense against malaria. The disease can be inherited only when both parents have the sickle-cell trait and the child inherits the defective gene from both parents. One of every twelve African-Americans is a carrier for sickle-cell anemia, and about one of every five hundred African-American infants is born with it. According to the National Institutes of Health (NIH), many non-African-Americans with ancestors from malaria regions—parts of Greece, Italy, the Near East, and India—also have the disease. However, of the seventy-two thousand Americans the NIH estimated had sickle-cell anemia in 2002, most were of African descent. About one thousand babies are born each year in the United States with the disease.

BEHAVIORS THAT THREATEN HEALTH

Cigarette Smoking

Nicotine is the drug in tobacco that causes addiction; cigarette smoking is the most popular method of taking nicotine in the United States. Tobacco use is the leading cause of preventable death in the United States. Smoking during pregnancy causes an increased risk of stillborn, premature birth, and low birth weight. The tar in cigarettes increases the user's risk of lung cancer, emphysema, and other bronchial diseases, while the carbon monoxide in the smoke increases the chance of cardiovascular diseases.

In 2004 Native Americans and Alaska Natives were more likely to smoke than any other group: 33.8% reported smoking in the past month, 41.5% in the past year, and 83.1% had smoked at some point in their lifetime. Non-Hispanic whites were the next most likely to smoke. African-Americans were slightly more likely than Hispanics to smoke: 27.3% had smoked in the past month, compared with 23.3% of Hispanics; 31.6% had smoked in the past year, compared with 29.8% of Hispanics; and 62.1% had smoked in their lifetime, compared with 55.8% of Hispanics. Asian-Americans were least likely to smoke; only 11.7% reported smoking in the past month, 15.9% in the past year, and 44.9% in their lifetime. (See Table 6.15.)

Cigarette smoking is most likely among those ages eighteen to twenty-five, regardless of race or ethnic group. Among this age group, whites are overwhelmingly more likely to smoke than their African-American or Hispanic counterparts. In 2004, 45.1% of eighteen- to twenty-five-year-old whites smoked, compared with 31.7% of Hispanics and 28.8% of African-Americans. However, the race and ethnic difference leveled off among smokers age twenty-six and older. In 2004, 25.7% of African-Americans in this age group smoked, as did 25% of whites and 20.9% of Hispanics. (See Figure 6.9.)

Diet and Nutrition

One reason that Asians and Pacific Islanders enjoy better health than other racial and ethnic groups is their diet. The typical Asian and Pacific Islander diet is low in fat and cholesterol. The staple food for many Asian-Americans is rice. Consumption of vegetables is relatively high; pork and fish are also commonly eaten. Dairy products are used less frequently. The traditional sources of calcium are soybean curd, sardines, and green, leafy vegetables, all healthy sources of nutrients.

The Healthy Eating Index is computed periodically by the U.S. Department of Agriculture, and its most recent publication is the Report Card on the Diet Quality of African Americans (July 1998, http://www.usda.gov/cnpp/ INSIGHT6c.PDF). This report finds that of various population subgroups, African-Americans have particularly poor diets. Between 1994 and 1996, the period of the study, 28% of African-Americans had poor diets, compared with 16% of whites. Fewer than 50% of African-Americans met the dietary recommendations for consumption of grains, vegetables, fruits, milk, meat, total fat, saturated fat, or sodium.

Native American diets have been negatively affected by the introduction of nonnative foods. Although there are considerable tribal variations in diet, studies show that the less Native Americans eat of their traditional foods, the greater their levels of obesity and adult-onset diabetes. High carbohydrate, sodium, and saturated fat contents can characterize most current Native American diets. Also, Native American diets are relatively low in meat and dairy products. Factors contributing to these eating habits include food availability, preference for nonnative food, and place of residence.

Drug Abuse

ALCOHOL

Alcohol depresses the central nervous system. Consumption of small amounts of alcohol can actually have a beneficial affect on the body. However, when consumed in larger amounts, alcohol impairs judgment and increases reaction time, can interfere with prescription and nonprescription medications in adverse ways, and can cause serious damage to developing fetuses. Chronic health consequences of excessive drinking include increased risk of liver cirrhosis, pancreatitis, certain types of cancer, high blood pressure, and psychological disorders. Addiction to alcohol is a chronic disease that is often progressive and sometimes fatal.

In 2004 Asian-Americans, Native Americans and Alaska Natives, Hispanics, and African-Americans were all less likely to report having used alcohol in the past month than were non-Hispanic whites. The rate of binge alcohol use, defined as five or more drinks on one occasion in at least one day in the previous month, was lowest among Asian-Americans (13%) and African-Americans (18%), while Hispanics (24%) and Native Americans and Alaska Natives (25%) had rates comparable to that of whites (23%). (See Figure 6.10.)

TABLE 6.11
Estimated numbers of persons living with HIV/AIDS, by year and selected characteristics, 2001–04
2001 2002 2003 2004
Note: These numbers do not represent reported case counts. Rather, these numbers are point estimates, which result from adjustments of reported case counts. The reported case counts are adjusted for reporting delays and for redistribution of cases in persons initially reported without an identified risk factor. The estimates do not include adjustment for incomplete reporting.
Data include persons with a diagnosis of HIV infection. This includes persons with a diagnosis of HIV only, a diagnosis of HIV infection and a later AIDS diagnosis, and concurrent diagnoses of HIV infection and AIDS.
Since 2000, the following 35 areas have had laws or regulations requiring confidential name-based HIV infection reporting: Alabama Alaska, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, Wyoming, Guam and the U.S. Virgin Islands. Since July 1997, Florida has had confidential name-based HIV infection reporting only for new diagnoses.
aIncludes hemophilia, blood transfusion, perinatal, and risk factor not reported or not identified.
bIncludes hemophilia, blood transfusion, and risk factor not reported or not identified.
cIncludes persons of unknown race or multiple races and persons of unknown sex. Because column totals were calculated independently of the values for the subpopulations, the values in each column may not sum to the column total.
source: "Table 8. Estimated Numbers of Persons Living with HIV/AIDS, by Year and Selected Characteristics, 2001–2004—35 Areas with Confidential Name-Based HIV Infection Reporting," in HIV/AIDS Surveillance Report, 2004, vol. 16, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2004report/default.htm (accessed January 26, 2006)
Age as of end of year (years)
<134,8384,5984,1873,713
13-148309501,1231,239
15-192,7452,9683,3013,683
20-2411,50012,03312,58213,371
25-2925,33425,76826,53827,836
30-3452,67251,89650,41649,133
35-3982,53983,13381,89180,086
40-4479,32586,42293,41499,742
45-4959,00865,87972,49879,728
50-5434,92940,48845,93252,658
55-5916,27119,55023,28627,571
60-647,7819,49711,09813,170
≥656,6747,8169,09910,861
Race/ethnicity
White, not Hispanic133,475141,120148,459157,172
Black, not Hispanic181,964195,147206,936220,028
Hispanic63,10568,25272,96778,039
Asian/Pacific Islander1,7962,0842,4152,765
American Indian/Alaska Native1,5871,7281,8651,996
Transmission category
    Male adult or adolescent
    Male-to-male sexual contact159,937172,502184,778199,085
    Injection drug use57,28758,95960,11361,799
    Male-to-male sexual contact and injection drug use21,64322,20122,68823,337
    Heterosexual contact34,38637,98641,29144,655
    Othera3,4453,5243,6023,702
    Subtotal276,698295,172312,472332,578
    Female adult or adolescent
    Injection drug use30,97732,00332,74233,621
    Heterosexual contact68,17374,92581,00787,262
    Othera2,0772,2362,3832,523
    Subtotal101,227109,164116,133123,405
    Child (<13 yrs at diagnosis)
    Perinatal5,8105,9546,0576,100
    Otherb706703698704
    Subtotal6,5156,6576,7556,804
    Totalc 384,446 410,998 435,364 462,792

ILLICIT DRUG USE

According to the CDC, illicit drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens (including LSD and PCP), inhalants, or any prescription-type psychotherapeutic drug used nonmedically. Illicit drug use is a particular problem in the Native American and Alaska Native community, where rates of use in the past month, past year, and lifetime use were highest. In 2004 the rate of illicit drug use in the past month was highest for Native Americans and Alaska Natives (12.3%) and lowest for Asian-Americans (3.1%). African-Americans (8.7%), non-Hispanic whites (8.1%), and Hispanics (7.2%) reported similar rates of illicit drug use in the past month. (See Table 6.16.)

TABLE 6.12
Estimated numbers of AIDS cases in children less than 13 years of age, by year of diagnosis and transmission category, 2000–04
Year of diagnosis Cumulative through 2004a
2000 2001 2002 2003 2004
Note: These numbers do not represent reported case counts. Rather, these numbers are point estimates, which result from adjustments of reported case counts. The reported case counts are adjusted for reporting delays and for redistribution of cases in persons initially reported without an identified risk factor. The estimates do not include adjustment for incomplete reporting.
aIncludes children with a diagnosis of AIDS, from the beginning of the epidemic through 2004.
bIncludes children of unknown race or multiple races. Cumulative total includes 24 children of unknown race or multiple races. Because column totals were calculated independently of the values for the subpopulations, the values in each column may not sum to the column total.
source: "Table 4. Estimated Numbers of AIDS Cases in Children <13 Years of Age, by Year of Diagnosis and Transmission Category, 2000–2004—United States," in HIV/AIDS Surveillance Report, 2004, vol. 16, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2004report/default.htm (accessed January 26, 2006)
Race/ethnicity
White, not Hispanic1113141271,612
Black, not Hispanic93797143295,590
Hispanic1822211282,128
Asian/Pacific Islander2110153
American Indian/Alaska Native0011134
Transmission category
Hemophilia/coagulation disorder00000230
Mother with the following risk factor for, or documented, HIV infection12211310568478,779
    Injection drug use23149953,338
    Sex with injection drug user1574721,524
    Sex with bisexual male33302201
    Sex with person with hemophilia0100037
    Sex with HIV-infected transfusion recipient0000027
    Sex with HIV-infected person, risk factor not specified35363820181,515
    Receipt of blood transfusion, blood components, or tissue21210152
    Has HIV infection, risk factor not specified45494831191,984
Receipt of blood transfusion, blood components, or tissue10200389
Other/risk factor not reported or identified1311045
    Totalb 124 115 109 69 48 9,443

LIFE EXPECTANCY AND DEATH

Life Expectancy

Women tend to live longer than men, and whites are likely to live longer than African-Americans. When comparing the life expectancies of African-American and white babies, African-American males born in 2003 had the shortest life expectancy of sixty-nine years, while white females had the longest life expectancy of 80.5 years. African-American females had a life expectancy of 76.1 years, and white males had a life expectancy of 75.3 years. (See Table 6.17.) According to Health, United States, 2005, the life expectancy of all groups at birth had risen dramatically since 1900, especially for African-Americans.

Age-adjusted death rates are measured per one hundred thousand in a specified population group. In 2003 African-Americans died at a higher rate than white Americans, with a death rate of 1,319.1 for African-American males and 885.6 for African-American females, compared with a death rate of 973.9 for white males and 693.1 for white females. (See Table 6.17.)

Leading Causes of Death

In 2003 heart disease was the leading cause of death among Americans, with 232.3 deaths per one hundred thousand of the population that year. Cancers (malignant neoplasms) were the second-leading cause of death, with 190.1 deaths per one hundred thousand population, followed by cerebrovascular diseases, which caused 53.5 deaths per one hundred thousand population. Chronic lower respiratory diseases and accidents rounded out the top five leading causes of death that year. (See Table 6.18.)

In 2002 heart disease was the leading cause of death among every racial or ethnic group except for Asians and Pacific Islanders, who died more often from malignant neoplasms. That year, 77,621 (26.8%) African-Americans, 27,887 (23.8%) Hispanics, and 9,983 (26%) Asians and Pacific Islanders died of heart disease. Cancer was the second-leading cause of death among African-Americans, and stroke was the third-leading cause. (See Table 6.19.)

The Health, United States, 2005 reports that in 2002 unintentional injuries, including automobile accidents, were particularly high in the Native American community, causing 1,488 deaths, as well as in the Hispanic community, causing 10,106 deaths. Native American males had a particularly high rate of motor vehicle deaths—thirty-nine per one hundred thousand, compared with the overall rate of 15.7 per one hundred thousand population. Suicide was the eighth-leading cause of death for both Native Americans and Asians and Pacific Islanders. Homicide ranked tenth among Native Americans, seventh among Hispanics, and sixth among African-Americans. (See Table 6.19.)

TABLE 6.13
Male adult/adolescent AIDS cases by exposure category and race/ethnicity, reported through 2004
aIncludes persons with a diagnosis of AIDS, reported from the beginning of the epidemic through 2004. Cumulative total includes 1,701 males of unknown race or multiple races.
bTotal includes 133 males of unknown race or multiple races.
source: "Table 19. Reported AIDS Cases for Male Adults and Adolescents, by Transmission Category and Race/Ethnicity, Cumulative through 2004—United States," in HIV/AIDS Surveillance Report, 2004, vol. 16, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2004report/default.htm (accessed January 26, 2006)
Transmission category White, not Hispanic Black, not Hispanic Hispanc
2004 Cumulative through 2004a 2004 Cumulative through 2004a 2004 Cumulative through 2004a
No. %No. %No. %No. %No. %No. %
Male-to-male sexual contact7,36966242,529734,6713494,831373,2004558,98143
Injection drug use933830,63292,2891780,347311,2951844,01232
Male-to-male sexual contact and injection drug use760729,2209573420,212830549,8387
Hemophilia/coagulation disorder4303,931117059801004540
Heterosexual contact41647,13022,1151526,09610782119,5627
    Sex with injection drug user7612,198123926,487311022,2472
    Sex with person with hemophilia103602030010110
    Sex with HIV-infected transfusion recipient7017801402090701150
    Sex with HIV-infected person, risk factor not specified33234,71811,8601319,370766497,1895
Receipt of blood transfusion, blood components, or tissue2603,18214101,19701906400
Other/risk factor not reported or identified1,6101414,98054,1273035,801141,4792113,07310
    Total 11,157 100 331,604 100 13,833 100 259,082 100 7,090 100 136,560 100
Transmission category Asian/Pacific Islander American Indian/Alaska Native Total
2004 Cumulative through 2004a 2004 Cumulative through 2004a 2004 Cumulative through 2004a
No. %No. %No. %No. %No. %No. %
Male-to-male sexual contact228584,1446970471,3025515,60748402,72255
Injection drug use13328852215369164,56414155,87221
Male-to-male sexual contact and injection drug use16424442316402171,696560,0388
Hemophilia/coagulation disorder10671003117105,0961
Heterosexual contact328326514910343,3731043,3476
    Sex with injection drug user2157164331435111,0481
    Sex with person with hemophilia0010000040780
    Sex with HIV-infected transfusion recipient008000302905170
    Sex with HIV-infected person, risk factor not specified3082604856732,905931,7044
Receipt of blood transfusion, blood components, or tissue31118211909005,1631
Other/risk factor not reported or identified1022681014181214067,3552265,0629
    Total 395 100 5,997 100 148 100 2,356 100 32,756 100 737,300 100

HOMICIDE

Health, United States, 2005 states that homicides are disproportionately high in the non-Hispanic African-American population, and the high homicide rate among African-Americans might be one of the reasons African-American men in their twenties and thirties have a higher death rate than men that age in other ethnic and racial groups. In 2002 there were 83.1 deaths per one hundred thousand African-American men between the ages of fifteen and twenty-four, and 82.2 deaths per one hundred thousand African-American men between the ages of twenty-five and thirty-four. In comparison, there were 5.2 deaths per one hundred thousand white, non-Hispanic men ages fifteen to twenty-four, and 5.3 deaths per one hundred thousand white, non-Hispanic men ages twenty-five to thirty-five.

According to Health, United States, 2005, in 2002 Hispanics, like African-Americans, had a higher homi-cide rate than most other groups, particularly among youth. The death rate for Hispanic men ages fifteen to twenty-four years was 29.6 per one hundred thousand; for Hispanic men ages twenty-five to thirty-four it was 19.8 per one hundred thousand. However, between 1990 and 2002 the homicide death rate among all Hispanic men dropped from 27.4 to 11.6, a hopeful sign for the future.

TABLE 6.14
Female adult/adolescent AIDS cases by exposure category and race/ethnicity, reported through 2004
aIncludes persons with a diagnosis of AIDS, reported from the beginning of the epidemic through 2004. Cumulative total includes 481 females of unknown race or multiple races.
bTotal includes 56 females of unknown race or multiple races.
source: "Table 21. Reported AIDS Cases for Female Adults and Adolescents, by Transmission Category and Race/Ethnicity, Cumulative through 2004—United States," in HIV/AIDS Surveillance Report, 2004, vol. 16, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2004report/default.htm (accessed January 26, 2006)
Transmission category White, not Hispanic Black, not Hispanic Hispanic
2004 Cumulative through 2004a 2004 Cumulative through 2004a 2004 Cumulative through 2004a
No. %No. %No. %No. %No. %No. %
Injection drug use6043113,985401,2681736,710364452111,97937
Hemophilia/coagulation disorder201170130139040630
Heterosexual contact7964014,324413,3554443,319421,0214915,93749
    Sex with injection drug user192105,36315478612,8431318696,11519
    Sex with bisexual male5031,714515822,05323627282
    Sex with person with hemophilia70318160110020440
    Sex with HIV-infected transfusion recipient5033112002520701180
    Sex with HIV-infected person, risk factor not specified542276,598192,6933528,06127790388,93227
Receipt of blood transfusion, blood components, or tissue2211,85856611,51611716102
Other/risk factor not reported or identified548284,393132,8843820,42320597294,21213
    Total 1,972 100 34,677 100 7,586 100 102,107 100 2,084 100 32,801 100
Transmission category Asian/Pacific Islander American Indian/Alaska Native Total
2004 Cumulative through 2004a 2004 Cumulative through 2004a 2004b Cumulative through 2004a
No. %No. %No. %No. %No. %No. %
Injection drug use77115122134256432,3552063,18137
Hemophilia/coagulation disorder117112312103310
Heterosexual contact4747489523048246415,2784574,54043
    Sex with injection drug user77108117119215871724,56814
    Sex with bisexual male338093529525124,6173
    Sex with person with hemophilia004000201504780
    Sex with HIV-infected transfusion recipient2222223513707330
    Sex with HIV-infected person, risk factor not specified3535275291829118204,1043544,14426
Receipt of blood transfusion, blood components, or tissue1194100014210614,1112
Other/risk factor not reported or identified434323525101678134,0993529,44017
    Total 99 100 940 100 62 100 597 100 11,859 100 171,603 100

HIV AND AIDS

The difference in the HIV/AIDS death rate among the racial and ethnic groups is staggering, with a much higher rate among African-Americans than any other group of Americans. In 2004, 7,978 African-Americans died from AIDS, compared with 4,316 whites, 3,228 Hispanics, ninety-one Native Americans, and eighty-two Asians and Pacific Islanders. (See Table 6.20.) Health, United States, 2005 reports that the HIV/ AIDS death rate for African-American males in 2002 was 33.3 per one hundred thousand, compared with 9.1 per one hundred thousand Hispanic males, 3.4 per one hundred thousand Native American males, and 1.5 per one hundred thousand Asian and Pacific Islander males. The death rate for African-American females was also very high in that year, at 13.4 per one hundred thousand, compared with 2.6 per one hundred thousand Hispanic females and 0.6 per one hundred thousand non-Hispanic white females.

TABLE 6.15
Tobacco product use, by demographic characteristics, 2003 and 2004
Demographic characteristic Time period
Lifetime Past year Past month
2003 2004 2003 2004 2003 2004
Note: Tobacco products include cigarettes, smokeless tobacco (i.e., chewing tobacco or snuff), cigars, or pipe tobacco. Tobacco product use in the past year excludes past year pipe tobacco use, but includes past month pipe tobacco use
aDifference between estimate and 2004 estimate is statistically significant at the 0.05 level
bDifference between estimate and 2004 estimate is statistically significant at the 0.01 level
cLow precision; no estimate reported.
source: "Table 2.26B. Tobacco Product Use in Lifetime, Past Year, and Past Month among Persons Aged 12 or Older, by Demographic Characteristics: Percentages, 2003 and 2004," in Results from the 2004 National Survey on Drug Use and Health: National Findings, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2005, http://www.drugabusestatistics.samhsa.gov/NSDUH.htm#NSDUHinfo (accessed January 26, 2006)
   Total 72.7b 71.4 35.1 34.5 29.8 29.2
Age
12-1734.5b32.722.522.114.414.4
18-2574.8a73.553.854.344.844.6
26 or older77.6a76.433.532.829.328.5
Gender
Male79.879.342.442.335.935.7
Female66.1b64.028.227.224.023.1
Hispanic origin and race
Not Hispanic or Latino74.673.835.935.230.630.1
    White78.177.337.036.831.631.4
    Black or African American63.362.134.031.630.027.3
    American Indian or Alaska Native79.483.148.441.541.833.8
    Native Hawaiian or other Pacific Islander60.6c42.0c37.0c
    Asian45.344.918.315.913.811.7
    Two or more races76.879.140.246.634.441.3
Hispanic or Latino59.9b55.829.829.823.723.3
TABLE 6.16
Illicit drug use, by demographic characteristics, 2003–04
Demographic characteristic Time period
Lifetime Past year Past month
2003 2004 2003 2004 2003 2004
Note: Illicit drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used nonmedically.
aDifference between estimate and 2004 estimate is statistically significant at the 0.05 level
bLow precision; no estimate reported.
source: "Table 1.28B. Illicit Drug Use in Lifetime, Past Year, and Past Month among Persons Aged 12 or Older, by Demographic Characteristics: Percentages, 2003 and 2004," in Results from the 2004 National Survey on Drug Use and Health: National Findings, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2005, http://www.drugabusestatistics.samhsa.gov/NSDUH.htm#NSDUHinfo (accessed January 26, 2006)
   Total 46.4 45.8 14.7 14.5 8.2 7.9
Age
12-1730.530.021.821.011.210.6
18-2560.559.234.633.920.319.4
26 or older46.145.610.310.25.65.5
Gender
Male51.250.717.216.910.09.9
Female41.941.112.412.26.56.1
Hispanic origin and race
Not Hispanic or Latino47.747.314.714.78.28.0
    White49.249.114.915.08.38.1
    Black or African American44.643.315.414.68.78.7
    American Indian or Alaska Native62.458.418.926.212.112.3
    Native Hawaiian or other Pacific Islander51.0b18.5b11.1b
    Asian25.624.3 7.16.93.83.1
    Two or more races60.154.920.121.012.013.3
Hispanic or Latino37.035.414.7a12.98.07.2
TABLE 6.17
Deaths, age-adjusted death rates, and life expectancy at birth, by race and sex, 2002–03
Measure and sex All races a,bWhite bBlack b
2003 2002 2003 2002 2003 2002
aIncludes races other than white and black.
bCalifornia, Hawaii, Idaho, Maine, Montana, New York, and Wisconsin reported multiple-race data in 2003. The multiple-race data for these states were bridged to the single-race categories of the 1977 Office of Management and Budget (OMB) standards for comparability with other states.
cAge-adjusted death rates are per 100,000 U.S. standard population, based on the year 2000 standard.
dLife expectancy at birth stated in years.
source: Adapted from "Table 1. Deaths, Age-Adjusted Death Rates, and Life Expectancy at Birth, by Race and Sex; Maternal and Infant Deaths and Mortality Rates, by Race: United States, 2002 and 2003," in Deaths: Final Data for 2003, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, January 19, 2006, http://www.cdc.gov/nchs/products/pubs/pubd/hestats/finaldeaths03/finaldeaths03.htm (accessed January 25, 2006)
All deaths 2,448,2882,443,3872,103,7142,102,589291,300290,051
Age-adjusted death ratec832.7845.3817.0829.01,065.91,083.3
    Male994.31,013.7973.9992.91,319.11,341.4
    Female706.2715.2693.1701.3885.6901.8
Life expectancy at birthd77.577.378.077.772.772.3
    Male74.874.575.375.169.068.8
    Female80.179.980.580.376.175.6
TABLE 6.18
Deaths, by race and sex for the 15 leading casuse of death, 2003
[Death rates on an annual basis per 100,000 population: age-adjusted rates per 100,000 U.S. standard population]
Ranka Cause of death (based on the Tenth Revision International Classification of Diseases, 1992) Number Percent of total deaths 2003 crude death rate Age-adjusted death rate
2003 Percent change Ratio
2002 to 2003 Male to female Black to white Hispanic to Non-Hispanic white
aRank based on number of deaths.
bCategory not applicable.
source: "Table 2. Percentage of Total Deaths, Death Rates, Age-Adjusted Death Rates for 2003, Percentage Change in Age-Adjusted Death Rates from 2002 to 2003 and Ratio of Age-Adjusted Death Rates by Race and Sex for the 15 Leading Causes of Death for the Total Population in 2003: United States," in Deaths: Final Data for 2003, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, January 19, 2006, ttp://www.cdc.gov/nchs/products/pubs/pubd/hestats/finaldeaths03/finaldeaths03.htm (accessed January 25, 2006)
bAll causes2,448,288100.0841.9832.7−1.51.41.30.8
1Diseases of heart (100-109,111,113,120-151)685,08928.0235.6232.3−3.51.51.30.8
2Malignant neoplasms (C00-C97)556,90222.7191.5190.1−1.81.51.20.7
3Cerebrovascular diseases (I60-I69)157,6896.454.253.5−4.81.01.50.8
4Chronic lower respiratory diseases (J40-J47)126,3825.243.543.3−0.51.40.70.4
5Accidents (unintentional injuries) (V01-X59,Y85-Y86)109,2774.537.637.31.12.21.00.8
6Diabetes mellitus (E10-E14)74,2193.025.525.3−0.41.32.11.6
7Influenza and pneumonia (J10-J18)65,1632.722.422.0−2.71.41.10.8
8Alzheimer's disease (G30)63,4572.621.821.45.90.80.80.6
9Nephritis, nephrotic syndrome and nephrosis (N00-N07,N17-N19,N25-N27)42,4531.714.614.41.41.42.31.0
10Septicemia (A40-A41)34,0691.411.711.6−0.91.22.30.8
11Intentional self-harm (suicide) (U03,X60-X84,Y87.0)31,4841.310.810.8−0.94.30.40.4
12Chronic liver disease and cirrhosis (K70.K73-K74)27,5031.19.59.3−1.12.20.91.6
13Essential (primary) hypertension and hypertensive renal disease (110,112)21,9400.97.57.45.71.02.81.0
14Parkinson's disease (G20-G21)17,9970.76.26.25.12.20.40.5
15Assault (homicide) (U01-U02,X85-Y09,Y87.1)17,7320.76.16.0−1.63.65.72.9
bAll other causes (residual)416,93217.0143.4bbbbb
TABLE 6.19
Leading causes of death and numbers of deaths, by race and Hispanic origin, 1980 and 2002
[Data are based on death certificates]
Sex, race, Hispanic origin, and rank order 1980 2002
Cause of death Deaths Cause of death Deaths
All persons
All causes1,989,841All causes2,443,387
 1Diseases of heart761,085Diseases of heart696,947
 2Malignant neoplasms416,509Malignant neoplasms557,271
 3Cerebrovascular diseases170,225Cerebrovascular diseases162,672
 4Unintentional injuries105,718Chronic lower respiratory diseases124,816
 5Chronic obstructive pulmonary diseases56,050Unintentional injuries106,742
 6Pneumonia and influenza54,619Diabetes mellitus73,249
 7Diabetes mellitus34,851Influenza and pneumonia65,681
 8Chronic liver disease and cirrhosis30,583Alzheimers disease58,866
 9Atherosclerosis29,449Nephritis, nephrotic syndrome and nephrosis40,974
10Suicide26,869Septicemia33,865
Black or African American
All causes233,135All causes290,051
 1Diseases of heart72,956Diseases of heart77,621
 2Malignant neoplasms45,037Malignant neoplasms62,617
 3Cerebrovascular diseases20,135Cerebrovascular diseases18,856
 4Unintentional injuries13,480Diabetes mellitus12,687
 5Homicide10,172Unintentional injuries12,513
 6Certain conditions originating in the perinatal period6,961Homicide8,287
 7Pneumonia and influenza5,648Human immunodeficiency virus (HIV) disease7,835
 8Diabetes mellitus5,544Chronic lower respiratory diseases7,831
 9Chronic liver disease and cirrhosis4,790Nephritis, nephrotic syndrome and nephrosis7,488
10Nephritis, nephrotic syndrome, and nephrosis3,416Septicemia6,137
American Indian or Alaska Native
All causes6,923All causes12,415
 1Diseases of heart1,494Diseases of heart2,467
 2Unintentional injuries1,290Malignant neoplasms2,175
 3Malignant neoplasms770Unintentional injuries1,488
 4Chronic liver disease and cirrhosis410Diabetes mellitus744
 5Cerebrovascular diseases322Cerebrovascular diseases567
 6Pneumonia and influenza257Chronic liver disease and cirrhosis547
 7Homicide217Chronic lower respiratory diseases452
 8Diabetes mellitus210Suicide324
 9Certain conditions originating in the perinatal period199Influenza and pneumonia293
10Suicide181Homicide267
Asian or Pacific Islander
All causes11,071All causes38,332
 1Diseases of heart3,265Malignant neoplasms9,998
 2Malignant neoplasms2,522Diseases of heart9,983
 3Cerebrovascular diseases1,028Cerebrovascular diseases3,530
 4Unintentional injuries810Unintentional injuries1,875
 5Pneumonia and influenza342Diabetes mellitus1,359
 6Suicide249Influenza and pneumonia1,171
 7Certain conditions originating in the perinatal period246Chronic lower respiratory diseases1,138
 8Diabetes mellitus227Suicide661
 9Homicide211Nephritis, nephrotic syndrome and nephrosis649
10Chronic obstructive pulmonary diseases207Septicemia423
TABLE 6.19
Leading causes of death and numbers of deaths, by race and Hispanic origin, 1980 and 2002 [continued]
[Data are based on death certificates]
Sex, race, Hispanic origin, and rank order 1980 2002
Cause of deathDeathsCause of deathDeaths
Note: "…" = Category not applicable.
"—" = Data not available.
source: Adapted from Table 31. Leading Causes of Death and Numbers of Deaths, according to Sex, Race, and Hispanic Origin: United States, 1980 and 2002, in Health, United States, 2005, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, 2005, http://www.cdc.gov/nchs/data/hus/hus05.pdf (accessed January 25, 2006)
Hispanic or Latino
All causes117,135
 1Diseases of heart27,887
 2Malignant neoplasms23,141
 3Unintentional injuries10,106
 4Cerebrovascular diseases6,451
 5Diabetes mellitus5,912
 6Chronic liver disease and cirrhosis3,409
 7Homicide3,129
 8Chronic lower respiratory diseases3,058
 9Influenza and pneumonia2,824
10Certain conditions originating in the perinatal period2,402
TABLE 6.20
Estimated numbers of deaths of persons with AIDS, by year of death and selected characteristics, 2000–04
Year of death Cumulative through 2004a
2000 2001 2002 2003 2004
Note: These numbers do not represent reported case counts. Rather, these numbers are point estimates, which result from adjustments of reported case counts. The reported case counts are adjusted for reporting delays and for redistribution of cases in persons initially reported without an identified risk factor. The estimates do not include adjustment for incomplete reporting.
aIncludes persons who died with AIDS, from the beginning of the epidemic through 2004.
bIncludes hemophilia, blood transfusion, perinatal, and risk factor not reported or not identified.
cIncludes hemophilia, blood transfusion, and risk factor not reported or not identified.
dIncludes persons of unknown race or multiple races and persons of unknown sex. Cumulative total includes 836 persons of unknown race or multiple races. Because column totals were calculated independently of the values for the subpopulations, the values in each column may not sum to the column total.
source: Table 7. Estimated Numbers of Deaths of Persons with AIDS, by Year of Death and Selected Characteristics, 20002004United States, in HIV/AIDS Surveillance Report, 2004, vol. 16, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2004report/default.htm (accessed January 26, 2006)
Age at death (years)
<1352463228185,094
13-148411716266
15-1941443943321,055
20-241672151671751848,808
25-2971063559556950544,516
30-341,9931,7441,5551,3731,15796,357
35-393,3463,2923,1082,9692,404116,206
40-443,5233,8353,7263,8003,378100,633
45-493,0813,1213,3643,4323,01667,842
50-541,9662,1522,3962,5242,31439,936
55-591,0071,1411,2281,4031,34322,452
60-6459365562172670112,946
>6565272870280173013,004
Race/ethnicity
White, not Hispanic5,3255,1945,2105,0914,316229,220
Black, not Hispanic8,6059,0118,9748,9507,978201,045
Hispanic3,0253,1953,1173,5373,22893,163
Asian/Pacific Islander951009181823,272
American Indian/Alaska Native66818473911,578
Transmission category
    Male adult or adolescent
    Male-to-male sexual contact5,9556,0686,0165,9905,450256,053
    Injection drug use4,0704,0744,0624,1163,308109,070
    Male-to-male sexual contact and injection drug use1,3241,3661,3231,3221,18039,467
    Heterosexual contact1,3891,5281,5131,6341,54824,268
    Otherb1951661671601139,843
    Subtotal12,93313,20213,08013,22211,599438,701
Female adult or adolescent
    Injection drug use1,8921,9071,9771,9891,74441,178
    Heterosexual contact2,1502,3422,3312,4702,32739,576
    Otherb879191101674,142
    Subtotal4,1294,3404,4004,5604,13884,897
Child (<13 yrs at diagnosis)
    Perinatal72665961574,982
    Otherc53664
    Subtotal77696567615,515
Region of residence
Northeast5,2005,1305,2135,6544,019169,693
Midwest1,6221,6461,6231,1991,23450,333
South7,0787,3867,3617,8397,192181,690
West2,5672,6832,5852,4282,540108,183
U.S. dependencies, possessions, and associated nations67276676373081419,214
    Totald 17,139 17,611 17,544 17,849 15,798 529,113

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Health

Health

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Medical Education. In addition to the traditional long apprenticeships (lasting a minimum of three years) of West African secret guilds or societies of medicine men and women and diviner/priests, medical education became available through the Islamic universities in Timbuktu and Djenné. As early as the eleventh century C.E., the Islamic scientist and philosopher Ibn Sina (also known as Avicenna) wrote his Qanun fi at-tibb (Canon of Medicine) in Arabic. It was destined to become the most famous medical book in the known world. Ibn Sina compiled earlier Greek and other cultures’ medical and surgical treatises along with his own medical observations, theories, and discoveries. This work became available in the Islamic universities and their related health centers located at Timbuktu and Djenné.

[This text has been suppressed due to author restrictions]

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Doctor-Patient Relationship. Scholars can extrapolate from more-recent information about the interaction of doctor and patient in traditional West African medicine. As medical practitioners have discovered and reported in the late twentieth century, the trust and belief of the patient are imperative for an optimal result. With close, attentive observation of the patient and a thorough knowledge of his or her physical, mental, and emotional environment, the medical professional has a significant advantage as he or she works to benefit the person seeking good health. Similarly, the West African medicine man or woman living in the same village as the patient during the period 500-1590 knew more of the medical, mental, communal, and spiritual circumstances of the individual and was, therefore, able to help the person heal from within as well as from without. Both physical and psychological methods were employed by the medicine man or woman. In addition to pharmacology, the dance, which helped the individual and the community “draw down the spirit” and which put the community’s focus on the person’s recovery, became a powerful tool for healing.

Braces and Bones. Around 1217 braces were made for the legs of the seven-year-old prince Sundiata, who had had a walking disability since birth. The braces, plus an iron rod, helped him walk upright rather than on all fours (his determination reflected the drive that later helped him become the first king of Mali). The braces may have been made from the bones of an animal, from branches softened with plant fiber and tied around the limbs, or from iron. Oral tradition maintains that Sundiata bent a large rod of iron when he first stood up. As for the setting of bones and the reducing of fractures, substantial archaeological evidence, in the form of bones from burial places, is available to show that those procedures were commonly practiced in early West Africa.

Surgery and Cautery. Surgical equipment that allowed delicate operations like cataract removal, mentioned as occurring at Djenné, could have been manufactured by West African smiths if they were able to produce fine enough and hard enough metal, such as carbon steel. Since there is no irrefutable evidence of carbon steel production in West Africa between 500 and 1590, it is likely they imported steel from kingdoms to the east or from the Egyptians through the North African trade. During this period the Arabic chronicler al-Bakri commented indirectly on the infibulation surgical procedure. Infibulation was the sewing of a female’s labia to make a narrower opening, though there was also a procedure that could apply to males. In his comments on the inhabitants of the town of Audaghost, al-Bakri wrote of slave girls with “sexual organs so narrow that one of them may be enjoyed as though she were a virgin indefinitely.” However, surgery, when it occurred, was often an emergency effort. Cautery, too, was for extreme treatment. For example, a man who had not heeded warnings about handling poisonous snakes was bitten while on caravan with Arab traveler and author Ibn Battuta. To help him, the Masufa guides cauterized the finger where the snake bite occurred, in hopes of reducing the pain from the venom. When that failed, the injured man killed a camel so he could put his hand in the water of its stomach; that procedure also failed, and the finger had to be amputated.

Environment and Disease. The tropical areas of Africa are perhaps the most fertile places for diseases carried by insects and parasites, especially if there is much standing rainwater or condensate. Malaria, yellow fever, schistosomiasis

[Image not available for copyright reasons]

(bilharzia or blood fluke), yaws, dengue, West Nile virus, onchocerciasis (river blindness), internal parasites, and trypanosomiasis (sleeping sickness) are common to a hot or hot-and-humid region where such insects as the anopheles mosquito, tsetse fly, and black fly can flourish and where frost never comes to keep the disease-carrying insect populations in check (with the exception of the high mountains). In that regard it is heartening to see al-Bakri’s comment on the western city of Sijilmasa in the mid eleventh century: “There are no flies and none of its inhabitants falls ill with leprosy (judham). When anyone suffering from this complaint enters the town his illness does not develop further.” However, al-Bakri also reported that some kings in that area wore clothes made from a flax-like, fireproof material that also was used for ropes for animals (tamatghast, or asbestos). Its use was certain to have affected people’s respiratory health, though certainly so slowly that no connection was made between the two. Although lice did not flourish in the tropical region of West Africa, thus saving people there from the risk of exposure to bubonic plague, Ibn Battuta wrote that body lice did exist in what he called “the wilderness” between Taghaza in the desert and the Sudan (probably the northern part of the Sahel). The cure was to have containers of mercury attached to the body by a neck cord—a potentially dangerous solution, considering the toxicity of mercury. As for the role of animals in the health of West Africans, people on caravan would, when they ran out of water, kill a camel and drink the water stored in its belly.

Disease Resistance. Because of the tsetse flies in the rain forests and the sleeping sickness they carried, which killed animals as well as people, it was not possible for forest dwellers to keep the large range of domesticated animals that were popular on the savanna. However, there were exceptions in the form of certain resistant cows and a small variety of goat. Similarly, over a period of 1,500 years before 500, people whose ancestors had lived in the forest evolved the sickle cell trait in their blood, which made a person immune to malaria and, when present in only one parent, was not fatal, as it was when inherited from both parents.

Contact with Outsiders. Because Africa from latitude twenty degrees north to twenty degrees south has always had some of the widest ranges of diseases in the world, and because these are especially virulent for outsiders, the region enjoyed relative isolation for thousands of years. Indeed, the coast of West Africa south of Cape Vert (present-day Senegal) was called by Europeans “the white man’s grave” because the Europeans’ immune systems had no resistance to the diseases of the tropical and subtropical environment. By the time Europeans began arriving and trading in the fifteenth century, many West Africans’ natural immune systems had already been weakened by the rise of cities and the density of human habitation there. Smallpox was carried into Africa by Europeans. Because it was an unknown factor to which they had no immunity, it devastated the people on the southwestern coast of West Africa.

Pharmacology. Observation and secret testing of local materials from plants, animals, and other sources led to a huge materia medica committed to memory and used by astute West African physician-priests who had carefully learned the knowledge from older doctors. Among biologicals occurring naturally in the rich resources of the rain forest and savanna one could find kaolin clay for diarrhea. For treatment of malaria, the most frequently experienced disease of the period 500-1590, West African doctors used parts of certain plants of the Rubiacea and Apocynacea families, plus steam inhalation of neem oil, lemongrass, pawpaw, or mango. For fever and jaundice they used Morinda lucida (methylanthraquinones) found from Burkina Faso eastward. Soapberry or Balanites aegyptiaca (desert date) was useful in every part: the bark for schistosomiasis; the root and fruit for treatment of parasitic worms, poison arrows, malaria, and herpes. To quote a Bornu saying: “A bito (soapberry) tree and a milk cow are just the same.” The much-requested kola nut was the source of a stimulant popular with West Africans and their trading partners; the trade in kola nuts northward and northeast certainly helped feed the European craving for a bright, energetic feeling. The kola nut also provided a slight diuretic effect. For diabetes the Africans used the Madagascar periwinkle; for heart and blood-pressure conditions, Strophanthus and Rauwolfia (similar to reserpine but with fewer side effects). The leaves of the latter plant were also used in treating smallpox. In 1415, Anselm d’Isalguier returned to France from Africa. He brought with him his wife, who was a Songhai princess, as well as an African servant who was also a doctor. The physician subsequently provided medical assistance to King Charles VI, astonishing and upsetting the French medical community whose medicine was not effective for his mental condition.

Immunization. West Africans also made advances in immunization. In the earliest known attempt to vaccinate against malaria, a heated iron poker with a bit of infectious material on the tip was used to make a small hole in the skin of a person. There are also reports of this procedure being done with a Thom to inoculate people against smallpox. Oral traditions identify this latter procedure as occurring centuries before vaccination for smallpox in Western medicine.

Poisons. West Africans amassed a substantial collection of special knowledge on poisons used in warfare and hunting and their antidotes. Plants for poison included Euphorbia hirta, Strophantus hispidus, Bridelia ferruguinea and Erythrophlem guinese. Poison-tipped iron arrows were reportedly used by Malians hunting wild buffalo. Around 1337 C.E. Syrian scholar al-Umari noted that the poisonous gall bladder of a slain Niger River crocodile, for which there was no known antidote, was taken to the king’s storehouse of valuables.

Sources

Bala Achi, “Biologically-based Warfare in Pre-Colonial Nigeria,” in Science and Technology in African History with Case Studies from Nigeria, Sierra Leone, Zimbabwe, and Zambia, edited by Gloria Thomas-Emeagwali (Lewiston, N.Y.: Edwin Mellen Press, 1992), pp. 23-31.

Al-Bakri, “The Book of Routes and Realms” / “Kitab al-masalik wa-1-mamalik,” in Corpus of Early Arabic Sources for West African History, translated by J. F. P. Hopkins, edited by Nehemia Levtzion and Hopkins (Cambridge & , New York: Cambridge University Press, 1981), pp. 62-87.

Graham Connah, African CivilizationsPrecolonial Cities and States in Tropical Africa: An Archaeological Perspective (Cambridge & New York: Cambridge University Press, 1987).

Charles S. Finch, “The African Background of Medical Science,” mBlacks in Science: Ancient and Modern, edited by Ivan Van Sertima (New Brunswick, N.J.: Transaction, 1983), pp. 140-156.

Ibn Battuta, “Journey” / “Tuhfat al-nuzzar fi ghara’ib al-amsar wa-‘aja’ ib al-asfar” or “Rigla,” in Corpus of Early Arabic Sources for West African History, pp. 279-304.

Maurice M. Iwu, Handbook of African Medicinal Plants (Boca Raton, Fla.: CRC, 1993).

Leo Africanus, The History and Description of Africa, and of the Notable Things Therein Contained, 3 volumes, edited by Robert Brown (London: Printed for the Hakluyt Society, 1896).

Patricia McKissack and Fredrick McKissack, The Royal Kingdoms of Ghana, Mali, and Songbay: Life in Medieval Africa (New York: Holt, 1994).

K. David Patterson and Gerald W. Hartwig, “The Disease Factor: An Introductory Overview,” in Disease in African History: An Introductory Survey and Case Studies, edited by Hartwig and Patterson (Durham, N.C.: Duke University Press, 1978), pp. 3-24.

PBS, “Islam: Empire of Faith, Medicine” (1 December 2002) <http://www.pbs.org/empires/islam/innomedicine.html>.

Renee L. Pennington, “Disease as a Factor in African History,” in Encyclopedia of Precolonial Africa: Archaeology, History, Languages, Cultures, and Environments, edited by Joseph O. Vogel and Jean Vogel (Walnut Creek, Cal.: AltaMira, 1997), pp. 45-48.

Al-Umari, “Pathways of Vision in the Realms of the Metropolises”/“Masalik al-Absar,” in Corpus of Early Arabic Sources for West African History, pp. 252-276.

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Health

Health

Health: An Overview...37

    Jamie Warren

Life Expectancy and Mortality Rates...39

    Kelly M. Ray

Childbirth and Midwifery...42

    Nelson Rhodes

Elder Care...43

    Yvonne Sims

Hygiene...45

    Tanya M. Mears

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Health

Health

Health is a profoundly cultural concept. Prior to the seventeenth century, the Western world understood health in ways that mingled religious and medical perspectives. Religious explanations of disease (e.g., sin or spirit possession) as well as corresponding schemas for therapeutic intervention (e.g., confession or exorcism) have historically influenced Western attitudes toward health. However, the Scientific Revolution of the seventeenth and eighteenth centuries challenged these religious conceptions of health and disease. Scientific medicine focused solely on the material causes of disease, hoping to understand health without the interference of philosophical or religious ideas. This, of course, was itself a culturally conditioned attempt to understand health. It rested on faith in the rationalistic assumptions of the Enlightenment era, which confidently proclaimed scientific rationality to be the sole avenue toward meaningful knowledge. It should not be surprising that many Americans do not share this unreserved faith in materialistic science to understand all the complexities of human nature. Indeed, most Americans envision their lives as in some way participating in a sacred reality. And for this reason religious attitudes continue to influence many Americans' understanding of both physical and mental health.

The major religious traditions found in the contemporary United States have long histories of addressing matters of health and medicine. From biblical times to the present, rabbis, priests, and ministers have been concerned with issues related to the health of the body as well as the health of the mind and soul. The religious values taught by institutional religion influence the majority of Americans' attitudes toward sickness, sexuality, and lifestyle, including their attitudes toward such issues as birth control, abortion, and euthanasia. The biblical accounts of Jesus performing healing miracles supports ongoing belief in various forms of "faith healing" such as those that form the nucleus of the charismatic movement within Roman Catholicism or numerous Protestant pentecostal denominations. It should also be noted that church-supported hospitals can be found throughout the United States and that virtually every denomination has ordained clergy whose duties include pastoral care activities intended to heal, sustain, and guide individuals throughout the course of their lives.

Two religious denominations indigenous to American religious history warrant special attention for their persistent interest in the connection between spirituality and health. The Church of Christ, Scientist was founded by Mary Baker Eddy in 1879 with the principal task of demonstrating that health is a spiritual rather than a physical reality. Christian Science has profound faith that God has created all that is, and all that God creates is good. From this theological postulate it follows that sickness, pain, or evil are not creations of God and therefore do not exist in any real sense. These negative conditions are instead only the delusional appearance created by an erring, mortal mind. Because disease is considered to be rooted in a false conception, healing only requires that we replace spiritual ignorance with spiritual understanding. A second denomination that emphasizes the relationship between religion and health is the Seventh-Day Adventist Church. The church's founder, Ellen Gould White, received numerous visions and revelations in which she learned that healthful living is a moral and religious obligation. Declaring that "it is as truly a sin to violate the laws of our being as it is to break the Ten Commandments," Ellen White made concern with healthful living an essential element of preparing ourselves for the Second Coming of Christ. While interest in faith healing is part of the Seventh-Day Adventist heritage, more characteristic of the denomination is its concern with healthful diet. Strongly discouraging drinking, smoking, and meat-eating, Seventh-Day Adventists also support hospitals throughout the world in their efforts to make health reform an essential element of evangelical piety.

Some of the most interesting attempts to connect spirituality and health over the past few decades have occurred outside of established religious traditions in systems variously referred to as alternative medicine, holistic therapies, or New Age healing. Included among these health systems are chiropractic medicine, homeopathy, positive-thinking regimens, acupuncture, iridology, t'ai chi, yoga, Ayurvedic medicine, massage therapies, crystal healing, and various twelve-step recovery programs. Although their specific philosophies and practices differ, they are all concerned with healing the whole person and awakening our spiritual sensibilities. Taken together, these healing groups constitute an impressive expression of unchurched American spirituality. Most of these alternative healing systems draw a great deal of their vocabulary from Eastern religions and Western metaphysical philosophies. These belief systems envision humans as existing on many levels (or dimensions), including the physical, mental, and spiritual or astral levels. The healing techniques that these groups utilize seek to restore harmony and interconnection between and among these levels of selfhood. Such inner harmony is said to allow persons to become inwardly receptive to the "inflow" of healing energies that emanate from the spiritual or astral plane and restore health to the physical and mental dimensions of our lives.

According to the New England Journal of Medicine, those who become interested in these nontraditional conceptions of health are typically white, between ages twenty-five and fifty, and above average in education and income. Moreover, relatively few suffer from acute illness or refuse to consult medical doctors. What they most have in common is their interest in understanding health in ways that place them outside the intellectual boundaries of either scientific or religious orthodoxy—that is, adherents of these groups have found scientific materialism too confining. Scientific rationality has failed to provide them with an outlook on life that might disclose the ultimate meaning or significance of our lives. Biblical religion also strikes them as an inadequate guide to life. Most of those attracted to alternative healing philosophies are self-styled progressive thinkers and find scriptural religion too narrow and dogmatic. Holistic and New Age medical systems, on the other hand, invite people to explore the intimate correspondences and interconnections among the physical, mental, and spiritual levels of human existence.

There have been some theoretical developments within medical science that have made new connections between health and spirituality. Research in psychosomatic medicine has made it clear that it is not possible to make a complete separation between a patient's mind and body. Our personalities, inclusive of our beliefs and general world outlook, have a great deal to do with our overall health. Studies now indicate that religious belief is positively correlated with resistance to heart disease, stroke, and cancer. Continued research in the relationship between spirituality and health may well point the way to a reintegration of science and religion.

Psychotherapists have also given increased attention to the positive effects of religion on mental health. For many decades it was assumed that religion promoted superstition, dependency, and overall psychological weakness. Yet in recent decades studies have shown that religious belief is positively correlated with resistance to depression and suicide, avoidance of anxiety, and positive outcomes in substance abuse programs. Many psychotherapists have gone further and suggested that health should be understood as something more than the absence of disease. Full health, it is argued, should be considered as the capacity to sustain a lifestyle that is spiritual in the broadest sense of the term (i.e., including the abilities for creativity, self-renewal, empathy for others, spontaneity, and the subjective sense of fulfillment). This concern with understanding the nature of full psychological health accounts for the recent popularity of the psychological theories of Carl Jung. Jung proposed that the mind is by no means machinelike or wholly at the mercy of the outer environment. In his view, the mind is purposeful, spontaneously pushing toward wholeness and growth. Many Americans have found in Jung's work a "psychotherapeutic spirituality" that, while not religious in a traditional sense, is overtly spiritual in its emphasis on humanity's capacity for self-transformation. Many other psychological writers, such as Rollo May, Fritz Perls, Abraham Maslow, Carl Rogers, M. Scott Peck, and Thomas Moore, have also attracted sizable reading audiences who yearn for new understandings of the "further reaches" of human nature.

It appears that although Western science has attempted to separate considerations of the body from those of the human spirit, most Americans continue to view them as integrally related. The healing ministries of America's churches, alternative medicine, humanistic psychotherapy, and even recent research within scientific medicine are all evidence that American culture continues to support belief in the positive effect of religion on both mental and physical health.


See alsoAbortion; Alternative Medicine; Birth Control; Christian Science; Euthanasiaand Assisted Suicide; Healing; Holistic Health; New Age Spirituality; Psychotherapy; Quantum Healing; Seventh-Day Adventism; Twelve-Step Programs.

Bibliography

Bregman, Lucy. "Psychotherapies." In Spirituality andthe Secular Quest, edited by Peter Van Ness. 1996.

Fuller, Robert C. Alternative Medicine and American Religious Life. 1989.

Koenig, Harold. Is Religion Good for Your Health? TheEffects of Religion on Physical and Mental Health. 1997.

Numbers, Ronald, and Darrel Amundsen, eds. Caringand Curing: Health and Medicine in the Western Religious Traditions. 1986.

Schumaker, John, ed. Religion and Mental Health. 1992.

Robert C. Fuller

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Health

CHAPTER 6
HEALTH

Minority groups face particular health-care challenges in addition to those of the general population. The Office of Minority Health was created in 1985 to advocate culturally and linguistically competent services and prevention efforts for minority communities. Among their main areas of concern:

  • Infant mortality (death) rates for African-Americans and Native Americans/Alaska Natives are significantly higher than they are for whites.
  • African-American men under age sixty-five develop prostate cancer at a rate nearly twice that of white Americans.
  • Asians and Pacific Islanders (APIs) have the highest rates of tuberculosis.
  • Hispanics have two to three times the rate of stomach cancer.
  • Native Americans/Alaska Natives suffer from diabetes at nearly three times the average rate, while African-Americans suffer 70 percent higher rates than whites.
  • More than 75 percent of AIDS cases among women and children occur among racial or ethnic minorities.

SOCIAL CHARACTERISTICS OF MINORITY POPULATIONS THAT AFFECT HEALTH

The demographic profiles of non-Hispanic African-Americans, Hispanics, Asians, Pacific Islanders, Native Americans, and Alaska Natives differ considerably from those of the nonminority population. Because a high percentage of minorities live in urban areas, they are exposed to a greater number of environmental hazards, including pollution, traffic hazards, substandard and/or overcrowded housing, and crime. Occupational risks are also greater for minorities because a greater percentage of them are employed in potentially dangerous jobs. In addition, the amount of stress in changing cultural environments and the lack of resources for solving stressful situations can play a critical role in the mental health of minority groups.

Differences exist within each minority group concerning the number and status of native-born versus foreign-born persons, age at time of immigration, and how fully group members have assimilated into American society. Moreover, dietary patterns are different among the various minority groups and vary according to how thoroughly minorities have adopted nonminority eating patterns.

SELF-ASSESSMENT OF HEALTH

In addition to indicating physical and mental illnesses, the way people feel often reflects their attitudes toward themselves and society. In 2001, 15.5 percent of non-Hispanic African-Americans reported their health as fair or poor, compared to 7.9 percent of non-Hispanic white individuals. Approximately 14.5 percent of Native Americans and Alaska Natives reported their health as fair or poor, as did 8.1 percent of Asians. Approximately 12.7 percent of Hispanics reported their health as fair or poor, and 12.5 percent of Mexican-origin Hispanics reported their health as fair or poor. (See Table 6.1.)

PREGNANCY AND BIRTH

The importance of early prenatal care cannot be overemphasized, as doctors are now better able to detect, and often correct, potential problems early in pregnancy. While every pregnant woman should receive prenatal care, the National Center for Health Statistics believes the United States is capable of guaranteeing that more than 90 percent of pregnant women receive prenatal care during the first trimester of pregnancy.

In 2001, 83.4 percent of all women in the United States received prenatal care during their first trimester of pregnancy, but that percentage was significantly lower among some minority groups. While 88.5 percent of non-Hispanic white women received prenatal care during

Characteristic 1991 1995 19971 19981 19991 20001 20011
Percent of persons with fair or poor health
Total2,3 10.4 10.6 9.2 9.1 8.9 9.0 9.2
Age
Under 18 years2.62.62.11.81.61.71.8
Under 6 years2.72.71.91.51.41.51.6
6–17 years2.62.52.11.91.81.81.9
18–44 years6.16.65.35.35.15.15.4
18–24 years4.84.53.43.23.43.23.3
25–44 years6.47.25.95.95.65.76.0
45–54 years13.413.411.711.611.511.911.7
55–64 years20.721.418.218.018.517.919.2
65 years and over29.028.326.726.726.127.026.6
65–74 years26.025.623.123.922.722.623.0
75 years and over33.632.231.530.430.232.230.8
Sex2
Male10.010.18.88.88.68.89.0
Female10.811.19.79.49.29.39.5
Race2,4
White only9.69.78.38.28.08.28.2
Black or African American only16.817.215.815.714.614.615.4
American Indian and Alaska Native only18.318.717.317.614.717.214.5
Asian only7.89.37.87.18.67.48.1
Native Hawaiian and Other Pacific Islander only- - -- - -- - -- - -***
2 or more races- - -- - -- - -- - -12.916.413.8
Black or African American; White- - -- - -- - -- - -*20.514.6*10.1
American Indian and Alaska Native; White- - -- - -- - -- - -14.518.815.0
Hispanic origin and race2,4
Hispanic or Latino15.615.113.013.111.912.912.7
Mexican17.016.713.113.512.312.912.5
Not Hispanic or Latino##8.98.88.68.78.9
White only9.19.18.07.87.77.97.9
Black or African American only16.817.315.815.814.614.615.5
Poverty status2,5
Poor22.823.721.422.221.720.921.0
Near poor14.715.514.615.614.915.315.5
Nonpoor6.86.76.15.76.16.36.2
Hispanic origin and race and poverty status2,4,5
Hispanic or Latino:
Poor23.622.719.821.718.919.118.8
Near poor18.016.914.015.314.216.515.2
Nonpoor9.38.78.87.98.28.49.2
Not Hispanic or Latino:
White only:
Poor21.922.820.621.320.520.119.4
Near poor14.014.814.115.314.514.714.6
Nonpoor6.46.25.75.35.75.85.8
Black or African American only:
Poor25.827.725.626.327.225.326.5
Near poor17.019.319.519.318.219.420.9
Nonpoor10.99.99.69.08.69.69.3
Geographic region2
Northeast8.39.18.07.97.57.67.4
Midwest9.19.78.18.08.08.08.8
South13.112.310.810.910.510.710.8
West9.710.18.88.48.78.88.6

their first trimester, only 74.5 percent of African-American women did so. Asian and Pacific Islander (API) women were likely to get prenatal care early in their pregnancies, as 84 percent received care in their first trimester in 2001. Only 75.7 percent of Hispanic women and 69.3 percent of Native American women, however, did so. (See Table 6.2.)

Births and Fertility

Of the 4.1 million births in 2000, 2.4 million were white, 604,346 were African-American, and 815,868 were Hispanic. However, despite a higher number of white births compared to African-American and Hispanic births, the fertility rate—the number of live births per 1,000 women ages fifteen to forty-four in a specified

Characteristic 1991 1995 19971 19981 19991 20001 20011
Location of residence2 Percent of persons with fair or poor health
Within MSA69.910.18.78.58.38.58.7
Outside MSA611.912.611.111.411.111.111.0
* Estimates are considered unreliable. Data preceded by an asterisk have a relative standard error (RSE) of 20–30 percent. Data not shown have a RSE of greater than 30 percent.
- - - Data not available.
#Estimates calculated upon request.
1Data starting in 1997 are not strictly comparable with data for earlier years due to the 1997 questionnaire redesign.
2Estimates are age adjusted to the year 2000 standard population using six age groups: Under 18 years, 18–44 years, 45–54 years, 55–64 years, 65–74 years, and 75 years and over.
3Includes all other races not shown separately and unknown poverty status.
4The race groups, white, black, American Indian and Alaska Native (AI/AN), Asian, Native Hawaiian and Other Pacific Islander, and 2 or more races, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Starting with data year 1999 race-specific estimates are tabulated according to 1997 Standards for Federal data on Race and Ethnicity and are not strictly comparable with estimates for earlier years. The five single race categories plus multiple race categories shown in the table conform to 1997 Standards. The 1999 race-specific estimates are for persons who reported only one racial group; the category "2 or more races" includes persons who reported more than one racial group. Prior to data year 1999, data were tabulated according to 1977 Standards with four racial groups and the category "Asian only" included Native Hawaiian and Other Pacific Islander. Estimates for single race categories prior to 1999 included persons who reported one race or, if they reported more than one race, identified one race as best representing their race. The effect of the 1997 Standard on the 1999 estimates can be seen by comparing 1999 data tabulated according to the two Standards: Age-adjusted estimates based on the 1977 Standards of the percent of persons in fair or poor health are: identical for the white and black groups; 0.1 percentage points lower for the Asian and Pacific Islander group; and 0.8 percentage points higher for the AI/AN group than estimates based on the 1997 Standards.
6Poor persons are defined as below the poverty threshold. Near poor persons have incomes of 100 percent to less than 200 percent of the poverty threshold. Nonpoor persons have incomes of 200 percent or greater than the poverty threshold. Missing family income data were imputed for 16–18 percent of persons in 1991 and 1995.
Poverty status was unknown for 20 percent of persons in the sample in 1997, 25 percent in 1998, 28 percent in 1999, 27 percent in 2000, and 29 percent in 2001.
6MSA is metropolitan statistical area.
source: "Table 57. Respondent-Assessed Health Status According to Selected Characteristics: United States, Selected Years 1991–2001," in Health, United States, 2003, Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, 2003 [Online] http://www.cdc.gov/nchs/data/hus/hus03.pdf [accessed March 11, 2004]
Non-Hispanic
Year All races1 White Black American Indian2 Asian or Pacific Islander2 Hispanic3
200183.488.574.569.384.075.7
200083.288.574.369.384.074.4
199983.288.474.169.583.774.4
199882.887.973.368.883.174.3
199782.587.972.368.182.173.7
199681.987.471.567.781.272.2
199581.387.170.466.779.970.8
199480.286.568.365.279.768.9
199378.985.666.163.477.666.6
199277.784.964.062.176.664.2
199176.283.761.959.975.361.0
199075.883.360.757.975.160.2
198975.582.759.957.974.859.5
198576.2- - -- - -57.574.1- - -
198076.3- - -- - -55.873.7- - -
- - - Data not available.
1Includes races other than white and black and origin not stated.
2Includes persons of Hispanic and non-Hispanic origin.
3Includes all persons of Hispanic origin of any race.
source: Joyce A. Martin, Brady E. Hamilton, Stephanie J. Ventura, Fay Menacker, Melissa M. Park, and Paul D. Sutton, "Table D. First Trimester Prenatal Care by Race and Hispanic Origin of Mother, 1980, 1985, 1990–2001," in "Births: Final Data for 2001," National Vital Statistics Reports, vol. 51, no. 2, December 18, 2002 [Online] http://www.cdc.gov/nchs/data/nvsr/nvsr51/nvsr51_02.pdf [accessed March 11, 2004]

group—for Hispanics and African-Americans was higher than that of white Americans. The fertility rate for non-Hispanic white Americans was 58.5 in 2000, compared to 73.7 for non-Hispanic African-Americans and 105.9 for Hispanics. (See Table 1.4 in Chapter 1.)

Low Birth Weight and Infant Mortality

Moderately low birth weight is defined as being equal to 1,500 to 2,499 grams (3.3 to 5.5 pounds). Very low birth weight is less than 1,500 grams. Low-birth-weight babies, as well as premature babies (born before thirty-seven weeks of gestation), often suffer serious health problems and encounter development problems later in life. In 2001 African-Americans were more likely to have low-birth-weight babies than other racial and ethnic groups. In that year, 13.1 percent of non-Hispanic African-American babies were born with low birth weights, followed by 9.3 percent of Puerto Rican–origin Hispanics and 8.7 percent of Filipinos. Chinese women, at 5.3 percent, were least likely to give birth to low-birth-weight babies. (See Table 6.3.)

The percentage of babies born with low birth weights has increased over the past two decades. While the percentage of non-Hispanic African-American low-birth-weight births declined slightly from 13.3 percent in 1990 to 13.1 percent in 2001, it is still higher than the 12.7 percent registered in 1980. The percentage of low-birth-weight births among white non-Hispanics, Hispanics, Native Americans and Alaska Natives, and APIs has increased since 1980. Approximately 5.7 percent of non-Hispanic white women gave birth to low-birth-weight babies in 1980, compared to 6.7 percent in 2001. Among Hispanics, 6.1 percent of babies born in 1980 had low birth weights, compared to 6.5 percent in 2001. Among Native Americans and Alaska

Birthweight, race, Hispanic origin of mother, and smoking status of mother 1970 1975 1980 1985 1990 1995 1996 1997 1998 1999 2000 2001
Low birthweight
(less than 2,500 grams)
Percent of live births1
All races7.937.386.846.756.977.327.397.517.577.627.577.68
White6.856.275.725.655.706.226.346.466.526.576.556.68
Black or African American13.9013.1912.6912.6513.2513.1313.0113.0113.0513.1112.9912.95
American Indian or Alaska Native7.976.416.445.866.116.616.496.756.817.156.767.33
Asian or Pacific Islander- - -- - -6.686.166.456.907.077.237.427.457.317.51
Chinese6.675.295.214.984.695.295.035.065.345.195.105.33
Japanese9.037.476.606.216.167.267.276.827.507.957.147.28
Filipino10.028.087.406.957.307.837.928.338.238.308.468.66
Hawaiian- - -- - -7.236.497.246.846.777.207.157.696.767.91
Other Asian or Pacific Islander- - -- - -6.836.196.657.057.427.547.767.767.677.76
Hispanic or Latino2- - -- - -6.126.166.066.296.286.426.446.386.416.47
Mexican- - -- - -5.625.775.555.815.865.975.975.946.016.08
Puerto Rican- - -- - -8.958.698.999.419.249.399.689.309.309.34
Cuban- - -- - -5.626.025.676.506.466.786.506.806.496.49
Central and South American- - -- - -5.765.685.846.206.036.266.476.386.346.49
Other and unknown Hispanic or Latino- - -- - -6.966.836.877.557.687.937.597.637.847.96
Not Hispanic or Latino2
White- - -- - -5.675.605.616.206.366.476.556.646.606.76
Black or African American- - -- - -12.7112.6113.3213.2113.1213.1113.1713.2313.1313.07
Cigarette smoker3- - -- - -- - -- - -11.2512.1812.1312.0612.0112.0611.8811.90
Nonsmoker3- - -- - -- - -- - -6.146.796.917.077.187.217.197.32
Very low birthweight (less than 1,500 grams)
All races1.171.161.151.211.271.351.371.421.451.451.431.44
White0.950.920.900.940.951.061.091.131.151.151.141.16
Black or African American2.402.402.482.712.922.972.993.043.083.143.073.04
American Indian or Alaska Native0.980.950.921.011.011.101.211.191.241.261.161.26
Asian or Pacific Islander- - -- - -0.920.850.870.910.991.051.101.081.051.03
Chinese0.800.520.660.570.510.670.640.740.750.680.770.69
Japanese1.480.890.940.840.730.870.810.780.840.860.750.71
Filipino1.080.930.990.861.051.131.201.291.351.411.381.23
Hawaiian- - -- - -1.051.030.970.940.971.411.531.411.391.50
Other Asian or Pacific Islander- - -- - -0.960.910.920.911.041.071.121.091.041.06
Hispanic or Latino2- - -- - -0.981.011.031.111.121.131.151.141.141.14
Mexican- - -- - -0.920.970.921.011.011.021.021.041.031.05
Puerto Rican- - -- - -1.291.301.621.791.701.851.861.861.931.85
Cuban- - -- - -1.021.181.201.191.351.361.331.491.211.27
Central and South American- - -- - -0.991.011.051.131.141.171.231.151.201.19
Other and unknown Hispanic or Latino- - -- - -1.010.961.091.281.481.351.381.321.421.27
Not Hispanic or Latino2
White- - -- - -0.860.900.931.041.081.121.151.151.141.17
Black or African American- - -- - -2.462.662.932.983.023.053.113.183.103.08
Cigarette smoker3- - -- - -- - -- - -1.731.851.851.831.871.911.911.88
Nonsmoker3- - -- - -- - -- - -1.181.311.351.401.441.431.401.42
- - - Data not available.
1Excludes live births with unknown birthweight. Percent based on live births with known birthweight.
2Prior to 1993, data from states lacking an Hispanic-origin item on the birth certificate were excluded.
3Percent based on live births with known smoking status of mother and known birthweight. Data from states that did not require the reporting of mother's tobacco use during pregnancy on the birth certificate are not included. Reporting area for tobacco use increased from 43 states and the District of Columbia (DC) in 1989 to 49 states and DC in 2000–01.
Notes: The race groups, white, black, American Indian or Alaska Native, and Asian or Pacific Islander, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Interpretation of trend data should take into consideration expansion of reporting areas and immigration.
source: "Table 12. Low-Birthweight Live Births, According to Mother's Detailed Race, Hispanic Origin, and Smoking Status: United Sates, Selected Years 1970–2001," in Health, United States, 2003, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, 2003 [Online] http://www.cdc.gov/nchs/data/hus/tables/2003/03hus012.pdf [accessed May 14, 2004]

Natives, 6.4 percent of babies born in 1980 had low birth weights, compared to 7.3 percent in 2001. Approximately 6.7 percent of APIs had low-birth-weight babies in 1980, compared to 7.5 percent in 2001. (See Table 6.3.)

The infant mortality rate (rate of deaths before one year of age) has declined for most races and ethnic groups. In 2001 non-Hispanic African-Americans suffered the highest rate of infant mortality, with 13.5 deaths per 1,000 live births. That rate was more than double the rate for non-Hispanic whites, which was 5.7 deaths per 1,000 live births. Hispanic women had 5.4 deaths per 1,000 live births, while Native Americans and Alaska Natives had 9.7 deaths (a substantial increase over 8.3 percent in 2000) and APIs had 4.7 deaths per 1,000 live births. (See Table 6.4.)

Race and Hispanic origin of mother 19831 19851 19901 19952 19982 19992 20002 20012
Infant3 deaths per 1,000 live births
All mothers10.910.48.97.67.27.06.96.8
White9.38.97.36.36.05.85.75.7
Black or African American19.218.616.914.613.814.013.513.3
American Indian or Alaska Native15.213.113.19.09.39.38.39.7
Asian or Pacific Islander8.37.86.65.35.54.84.94.7
Chinese9.55.84.33.84.02.93.53.2
Japanese*5.6*6.0*5.5*5.3*3.4*3.5*4.5*4.0
Filipino8.47.76.05.66.25.85.75.5
Hawaiian11.2*9.9*8.0*6.59.9*7.09.0*7.3
Other Asian or Pacific Islander8.18.57.45.55.75.14.84.8
Hispanic or Latino4,59.58.87.56.35.85.75.65.4
Mexican9.18.57.26.05.65.55.45.2
Puerto Rican12.911.29.98.97.88.38.28.5
Cuban7.58.57.25.3*3.74.64.64.2
Central and South American8.58.06.85.55.34.74.65.0
Other and unknown Hispanic or Latino10.69.58.07.46.57.26.96.0
Not Hispanic or Latino:
White59.28.67.26.36.05.85.75.7
Black or African American519.118.316.914.713.914.113.613.5
*Estimates are considered unreliable. Rates preceded by an asterisk are based on fewer than 50 events. Rates not shown are based on fewer than 20 events.
1Rates based on unweighted birth cohort data.
2Rates based on a period file using weighted data.
3Infant (under 1 year of age)
4Persons of Hispanic origin may be of any race.
5Prior to 1995, data shown only for states with an Hispanic-origin item on their birth certificates.
Notes: The race groups white, black, American Indian or Alaska Native, and Asian or Pacific Islander include persons of Hispanic and non-Hispanic origin. National linked files do not exist for 1992–94.
source: "Table 19. Infant, Neonatal, and Postneonatal Mortality Rates, According to Detailed Race and Hispanic Origin of Mother: United States, Selected Years 1983–2001," in Health, United States, 2003, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, 2003 [Online] http://www.cdc.gov/nchs/data/hus/tables/2003/03hus019.pdf [accessed May 14, 2004]

DOCTOR AND DENTIST VISITS

Since the 1980s, as more outpatient clinics and other out-reach health facilities have opened, most Americans have had increased opportunities to seek medical help. The National Center for Health Statistics (NCHS) reported that in 2001 minorities were more likely than whites to have made no health-care visits to a doctor's office or an emergency department during the past twelve months. While 14.3 percent of non-Hispanic whites made no visits to a doctor's office or an emergency department, 16.4 percent of non-Hispanic African-Americans made no such visits. Among Hispanics, 27 percent of the population made no health-care visits to a doctor's office in 2001. Approximately 31.4 percent of Mexican-origin Hispanics made no visits to a doctor's office in 2001. Native Americans/Alaska Natives and APIs were also more likely than non-Hispanic whites to refrain from seeing a doctor. Approximately 21.4 percent of Native Americans and Alaska Natives made no visits to a doctor's office in 2001, compared to 20.8 percent of Asians. (See Table 6.5.)

Among non-Hispanic whites between the ages of eighteen and sixty-four, 68.7 percent reported in 2001 that they had visited a dentist within the past year. Only 57.1 percent of non-Hispanic African-Americans had been to a dentist in the past year, as had only 49.2 percent of Hispanics. Among Native Americans and Alaska Natives, 47.7 percent of people between the ages of eighteen and sixty-four had visited a dentist; among Asians, 64.3 percent had visited a dentist. (See Table 6.6)

HEALTH INSURANCE

According to the NCHS, in 2001, 19.2 percent of non-Hispanic African-Americans under the age of sixty-five had no private health insurance coverage, compared to 11.9 percent of their non-Hispanic white counterparts. More than a third (34.8 percent) of all Hispanics had no insurance, while 17.1 percent of Asians failed to have health insurance. (See Table 6.7.)

In 2001 Medicaid (the federally funded health-care program for low-income people) covered 7 percent of non-Hispanic whites, 20.3 percent of non-Hispanic African-Americans, 15.5 percent of Native Americans/Alaska Natives, and 8.8 percent of Asians under age sixty-five in 2001. Approximately 16 percent of all Hispanics were covered by Medicaid, including 28.5 percent of all Puerto Ricans. (See Table 6.8.)

CIGARETTE SMOKING

In 2001 Native Americans and Alaska Natives were more likely to smoke than any other group, with 40.4 percent

Number of health care visits1
None 1–3 visits 4–9 visits 10 or more visits
Characteristic 1997 1999 2001 1997 1999 2001 1997 1999 2001 1997 1999 2001
Percent distribution
All persons2,316.517.516.546.245.845.823.623.324.413.713.413.3
Age
Under 18 years11.812.411.654.154.454.625.225.026.18.98.27.6
Under 6 years5.05.95.544.945.945.837.036.837.913.011.310.8
6–17 years15.315.514.658.758.558.919.319.420.56.86.76.1
18–44 years21.724.223.346.745.846.119.017.818.912.612.311.8
18–24 years22.024.825.446.846.144.720.017.819.511.211.410.5
25–44 years21.624.022.646.745.746.518.717.818.713.012.612.2
45–64 years16.916.915.642.942.442.924.725.025.715.515.715.9
45–54 years17.918.417.143.943.244.923.422.823.614.815.714.4
55–64 years15.314.713.341.341.139.626.728.428.916.715.818.2
65 years and over8.97.97.134.734.332.332.534.135.623.823.725.0
65–74 years9.88.68.136.936.935.831.633.233.521.621.322.6
75 years and over7.77.25.831.831.128.233.835.138.126.626.627.9
Sex3
Male21.323.121.347.145.546.520.620.621.611.010.810.7
Female11.812.011.945.446.145.126.525.927.116.315.915.9
Race3,4
White only16.016.915.946.145.745.723.923.824.814.013.613.5
Black or African American only16.818.416.446.146.246.423.221.924.013.913.513.2
American Indian and Alaska Native only17.120.6*21.438.034.336.424.227.825.420.717.216.9
Asian only22.823.120.849.147.348.319.719.422.38.310.28.6
Native Hawaiian and Other Pacific
Islander only- - -**- - -**- - -**- - -**
2 or more races- - -15.218.0- - -40.841.2- - -22.223.5- - -21.817.3
Hispanic origin and race3,4
Hispanic or Latino24.926.227.042.344.340.220.319.220.712.510.312.0
Mexican28.930.231.440.843.039.218.518.219.611.88.79.8
Not Hispanic or Latino15.416.215.046.746.046.524.023.925.013.913.913.5
White only14.715.514.346.646.046.424.424.525.414.314.113.9
Black or African American only16.918.416.446.146.246.423.121.924.013.813.513.1
Respondent-assessed health status3
Fair or poor7.89.89.023.325.922.129.024.327.739.940.141.3
Good to excellent17.218.117.348.447.748.023.323.224.311.111.010.5
Poverty status3,5
Poor20.321.521.737.139.237.222.721.323.419.918.017.7
Near poor19.922.220.442.841.641.421.821.522.915.514.715.3
Nonpoor14.014.914.048.047.047.425.025.025.813.013.112.8
Hispanic origin and race and poverty status3,4,5 Percent distribution
Hispanic or Latino:
Poor30.631.234.333.838.232.720.018.718.115.611.814.9
Near poor29.130.228.939.042.139.320.917.520.211.010.111.6
Nonpoor18.721.019.948.646.844.620.321.924.712.310.210.8
Not Hispanic or Latino:
White only:16.317.216.237.738.938.724.023.326.422.120.718.8
Poor17.119.817.143.740.841.322.323.324.117.016.117.6
Near poor13.214.013.147.646.947.525.725.526.113.413.613.3
Nonpoor
Black or African American only:
Poor17.818.017.337.439.938.123.323.124.021.519.020.5
Near poor18.919.918.143.044.044.923.420.523.414.715.613.6
Nonpoor15.616.314.650.548.247.423.323.726.610.611.811.4
Health insurance status6,7
Under 65 years of age:
Insured14.315.414.149.048.649.123.623.224.213.112.712.6
Private14.715.914.450.649.950.623.122.924.011.611.311.0
Medicaid9.810.710.435.535.635.426.526.026.328.227.627.8
Uninsured33.737.337.542.841.641.415.313.214.68.27.96.5

reported as smokers. Next came non-Hispanic whites with 27.4 percent, non-Hispanic African-Americans with 25.7 percent, Hispanics with 23.1 percent, and Asians with 16.2 percent. Among Asian subgroups, Vietnamese (26.5 percent) and Koreans (27.2 percent) had the largest number of smokers. Among Hispanics, 30.4 percent of

Number of health care visits1
None 1–3 visits 4–9 visits 10 or more visits
Characteristic 1997 1999 2001 1997 1999 2001 1997 1999 2001 1997 1999 2001
Percent distribution
65 years of age and over:
Medicare HMO8.95.75.035.834.230.033.134.641.122.325.523.9
Private7.36.75.535.934.934.634.034.935.222.723.524.8
Medicaid9.3*7.36.119.221.418.727.934.831.643.736.543.5
Medicare fee-for-service only15.514.014.134.035.830.528.131.034.222.419.221.2
Poverty status and health insurance status5,6,7
Under 65 years of age:
Poor:
Insured13.714.614.038.841.441.124.523.224.922.920.720.0
Uninsured36.739.843.238.839.334.614.912.615.39.58.36.9
Near poor:
Insured15.617.015.845.544.944.722.322.622.716.615.516.8
Uninsured34.538.035.341.840.240.915.613.416.68.18.47.2
Nonpoor:
class="textStyle7">Insured13.414.713.650.349.149.824.224.225.012.112.011.6
Uninsured29.132.931.945.443.746.017.014.615.58.48.86.6
Geographic region3
Northeast13.212.811.845.946.447.226.025.626.614.915.214.3
Midwest15.916.214.947.746.747.222.823.824.013.613.313.9
South17.218.917.746.145.545.223.322.524.413.513.212.8
West19.120.920.544.844.844.122.821.922.813.312.412.7
Location of residence3
Within MSA816.217.416.446.445.945.723.723.424.613.713.213.2
Outside MSA817.317.716.745.445.146.123.322.923.613.914.413.6
* Estimates are considered unreliable. Data not shown have a relative standard error (RSE) of greater than 30 percent. Data preceded by an asterisk have a RSE of 20–30 percent.
- - - Data not available.
1This table presents a summary measure of ambulatory and home health care visits during a 12-month period.
2Includes all other races not shown separately, unknown poverty status, and unknown health insurance status.
3Estimates are age adjusted to the year 2000 standard population using six age groups: Under 18 years, 18–44 years, 45–54 years, 55–64 years, 65–74 years, and 75 years and over.
4The race groups, white, black, American Indian and Alaska Native (AI/AN), Asian, Native Hawaiian and Other Pacific Islander, and 2 or more races, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Starting with data year 1999 race-specific estimates are tabulated according to 1997 Standards for Federal data on Race and Ethnicity and are not strictly comparable with estimates for earlier years. The five single race categories plus multiple race categories shown in the table conform to 1997 Standards. The 1999 race-specific estimates are for persons who reported only one racial group; the category "2 or more races" includes persons who reported more than one racial group. Prior to data year 1999, data were tabulated according to 1977 Standards with four racial groups and the category "Asian only" included Native Hawaiian and Other Pacific Islander. Estimates for single race categories prior to 1999 included persons who reported one race or, if they reported more than one race, identified one race as best representing their race. The effect of the 1997 Standard on the 1999 estimates can be seen by comparing 1999 data tabulated according to the two Standards: Age-adjusted estimates based on the 1977 Standard of the percent of persons with a specified number of health care contacts are: (no visits) identical for white and black persons; 0.1 percentage points higher for AI/AN persons; 0.4 percentage points lower for Asian and Pacific Islander persons; (1–3 visits) identical for white persons; 0.1 percentage points lower for black persons; 1.3 percentage points higher for AI/AN persons; 0.1 percentage points lower for Asian and Pacific Islander persons; (4–9 visits) identical for white persons; 0.2 percentage points higher for black persons; 2.2 percentage points lower for AI/AN persons; 0.4 percentage points higher for Asian and Pacific Islander persons; (10 or more visits) identical for white and black persons; 0.9 percentage points higher for AI/AN persons; and 0.1 percentage points higher for Asian and Pacific Islander persons than estimates based on the 1997 Standards.
5Poor persons are defined as below the poverty threshold. Near poor persons have incomes of 100 percent to less than 200 percent of poverty threshold. Nonpoor persons have incomes of 200 percent or greater than the poverty threshold. Poverty status was unknown for 20 percent of persons in the sample in 1997, 25 percent in 1998, 28 percent in 1999, 27 percent in 2000, and 28 percent in 2001.
6Estimates for persons under 65 years of age are age adjusted to the year 2000 standard using four age groups: Under 18 years, 18–44 years, 45–54 years, and 55–64 years of age. Estimates for persons 65 years of age and over are age adjusted to the year 2000 standard using two age groups: 65–74 years and 75 years and over.
7Health insurance categories are mutually exclusive. Persons who reported both Medicaid and private coverage are classified as having private coverage. Persons 65 years of age and over who reported Medicare HMO (health maintenance organization) and some other type of health insurance coverage are classified as having Medicare HMO. Starting in 1997 Medicaid includes state-sponsored health plans and State Children's Health Insurance Program (SCHIP). The category "insured" also includes military, other state, and Medicare coverage.
8MSA is metropolitan statistical area.
source: "Table 70. Health Care Visits to Doctor's Offices, Emergency Departments, and Home Visits within the Past 12 Months, According to Selected Characteristics: United States, Selected Years 1997–2001," in Health, United States, 2003, Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, 2003 [Online] http://www.cdc.gov/nchs/data/hus/hus03.pdf [accessed March 11, 2004]

Puerto Ricans smoked cigarettes, by far the highest rate for a Hispanic subgroup. (See Table 6.9.)

DRUG ABUSE AMONG MINORITY POPULATIONS

In 2001, 67.7 percent of non-Hispanic white Americans aged eighteen and over reported that they had consumed alcohol within the past month, compared to 51.5 percent of Native Americans/Alaska Natives, 49.8 percent of Hispanics, 46.5 percent of non-Hispanic African-Americans, and 44.7 percent of Asians. (See Table 6.10.) In terms of binge drinking, defined as five or more drinks on one occasion in at least one day in the previous month, Native Americans and Alaska Natives had the greatest percentage, with 34.6, followed by Hispanics with 32.2

2 years of age and over1 2–17 years of age 18–64 years of age 65 years of age and over2
Characteristic 1997 1999 2001 1997 1999 2001 1997 1999 2001 1997 1999 2001
Percent of persons with a dental visit in the past year3
Total4 64.9 65.2 65.6 72.7 72.6 73.3 64.1 64.6 64.6 54.8 55.0 56.3
Sex
Male62.662.562.672.372.372.760.460.460.255.454.756.1
Female67.267.868.573.072.873.967.768.568.954.455.256.5
Race5
White only66.567.267.474.074.574.965.766.666.656.856.858.5
Black or African American only56.556.256.968.867.668.057.055.857.235.439.737.5
American Indian and Alaska Native only51.556.253.966.858.272.949.955.247.7**50.6*50.7
Asian only61.863.664.969.969.674.460.363.164.353.953.253.4
Native Hawaiian and Other Pacific Islander only- - -**- - -**- - -**- - -**
2 or more races- - -58.656.3- - -73.069.3- - -57.857.1- - -*35.1*34.5
Black or African American; White- - -63.752.7- - -68.757.6- - -58.855.5- - -**
American Indian and Alaska Native; White- - -55.858.7- - -70.379.2- - -53.553.6- - -**39.0
Hispanic origin and race5
Hispanic or Latino52.952.351.261.059.360.550.850.649.247.844.042.6
Not Hispanic or Latino66.466.967.574.774.975.865.766.366.755.255.657.2
White only68.268.969.676.477.077.867.568.368.757.257.359.4
Black or African American only56.556.156.968.867.768.156.955.757.135.339.637.6
Poverty status6
Poor47.246.247.062.057.861.046.446.045.830.331.930.6
Near poor48.948.549.761.661.663.246.446.146.939.638.940.0
Nonpoor72.372.072.079.779.979.371.170.870.566.364.467.0
Hispanic origin and race and poverty status5,6
Hispanic or Latino:
Poor41.941.538.756.849.654.239.039.735.133.032.129.8
Near poor46.243.843.254.154.059.242.641.039.849.234.830.6
Nonpoor65.163.864.474.872.071.162.562.062.856.558.960.8
Not Hispanic or Latino:
White only:
Poor49.949.851.563.362.662.950.350.652.131.131.932.3
Near poor51.050.252.964.863.264.448.248.051.041.239.642.1
Nonpoor73.673.673.780.781.881.772.572.472.067.665.468.6
Black or African American only:
Poor46.744.945.166.761.063.244.542.142.926.233.525.2
Near poor44.947.647.360.166.364.244.745.244.923.630.933.4
Nonpoor65.464.264.175.572.772.466.264.765.448.951.546.1

percent, non-Hispanic whites with 32 percent, Asians with 23.2 percent, and non-Hispanic African-Americans with 20.5 percent. (See Table 6.10.)

Illicit Drug Use

According to the Centers for Disease Control and Prevention (CDC), illicit drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens (including LSD and PCP), inhalants, or any prescription-type psychotherapeutic drug used nonmedically. In 2001, 7.4 percent of non-Hispanic African-Americans over the age of twelve had used an illicit drug in the past month. Among non-Hispanic whites, the percentage was 7.2 percent, for Hispanics it was 6.4 percent, and Asians just 2.8 percent. On the other hand, 7.5 percent of Native Hawaiian and other Pacific Islanders and 9.9 percent of Native Americans and Alaska Natives reported use of an illicit drug. (See Table 6.11.)

MARIJUANA USE.

In 2001, 5.6 percent of non-Hispanic whites and non-Hispanic African-Americans over the age of twelve and 4.2 percent of Hispanics reported that they had smoked marijuana in the past month. Only 1.7 percent of Asians over the age of twelve said they had smoked marijuana in the past month. On the other extreme, 7.1 percent of Native Hawaiians and other Pacific Islanders and 8 percent of Native Americans and Alaska Natives reported marijuana use. (See Table 6.11.)

AIDS AND MINORITIES

Acquired immune deficiency syndrome (AIDS) is caused by a virus that affects the body's immune system, making it difficult to fight invasions from infection or other foreign substances. As a result, persons infected with the AIDS virus are subject to a number of opportunistic infections, primarily Pneumocystis carinii pneumonia and Kaposi's sarcoma, a form of skin cancer.

2 years of age and over1 2–17 years of age 18–64 years of age 65 years of age and over2
Characteristic 1997 1999 2001 1997 1999 2001 1997 1999 2001 1997 1999 2001
Geographic region Percent of persons with a dental visit in the past year3
Northeast69.670.972.277.578.579.669.671.572.255.554.359.6
Midwest68.368.168.476.476.87.467.467.668.057.654.355.0
South60.060.660.268.068.068.859.459.458.749.052.452.0
West64.964.765.771.569.970.762.963.364.461.961.962.6
Location of residence
Within MSA766.567.167.073.673.173.965.766.866.057.658.159.1
Outside MSA759.158.360.369.370.770.758.056.259.146.145.047.2
* Estimates are considered unreliable. Data preceded by an asterisk have a relative standard error (RSE) of 20–30 percent. Data not shown have a RSE greater than 30 percent.
- - - Data not available.
1Estimates are age adjusted to the year 2000 standard using six age groups: 2–17 years, 18–44 years, 45–54 years, 55–64 years, 65–74 years, and 75 years and over.
2Estimates for the elderly are the percent of persons 65 years of age and over with a dental visit in the past year. Data from the 1997–2001 National Health Interview Survey estimate that 28–30 percent of persons 65 years of age and over (elderly) were edentulous (having lost all their natural teeth). In 1997–2001 about 70 percent of elderly dentate persons compared with 17–20 percent of elderly edentate persons had a dental visit in the past year.
3Respondents were asked "About how long has it been since you last saw or talked to a dentist?"
4Includes all other races not shown separately and unknown poverty status.
5The race groups, white, black, American Indian and Alaska Native (AI/AN), Asian, Native Hawaiian and Other Pacific Islander, and 2 or more races, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Starting with data year 1999 race-specific estimates are tabulated according to 1997 Standards for Federal data on Race and Ethnicity and are not strictly comparable with estimates for earlier years. The five single race categories plus multiple race categories shown in the table conform to 1997 Standards. The 1999 race-specific estimates are for persons who reported only one racial group; the category "2 or more races" includes persons who reported more than one racial group. Prior to data year 1999, data were tabulated according to 1977 Standards with four racial groups and the category "Asian only" included Native Hawaiian and Other Pacific Islander. Estimates for single race categories prior to 1999 included persons who reported one race or, if they reported more than one race, identified one race as best representing their race. The effect of the 1997 Standard on the 1999 estimates can be seen by comparing 1999 data tabulated according to the two Standards: Age-adjusted estimates based on the 1977 Standard of the percent of persons with a recent dental visit are: 0.1 percentage points lower for white and black persons; identical for AI/AN persons; and 0.2 percentage points lower for Asian and Pacific Islander persons than estimates based on the 1997 Standards.
6Poor persons are defined as below the poverty threshold. Near poor persons have incomes of 100 percent to less than 200 percent of the poverty threshold. Nonpoor persons have incomes of 200 percent or greater than the poverty threshold. Poverty status was unknown for 20 percent of persons in the sample in 1997, 25 percent in 1998, 28 percent in 1999, 27 percent in 2000, and 28 percent in 2001.
7MSA is metropolitan statistical area.
source: "Table 78. Dental Visits in the Past Year According to Selected Characteristics: United States, Selected Years 1997–2001," in Health, United States, 2003, Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, 2003 [Online] http://www.cdc.gov/nchs/data/hus/hus03.pdf [accessed March 11, 2004]

AIDS, which is caused by the human immunodeficiency virus (HIV), is not transmitted casually, but only through the transfer of bodily fluids, such as blood and semen. The CDC reports only four methods of transmission: contaminated blood, sexual transmission, contaminated syringes from intravenous drug use, and perinatal (around the time of birth) transmission from a mother to her child or through breast milk.

Minorities have been especially hard hit by the AIDS epidemic. The CDC noted that, of the estimated 280,286 persons living with AIDS in 2002, nearly 50 percent (141,184) were non-Hispanic African-Americans. Approximately 38.3 percent (107,992) were non-Hispanic whites, and 10 percent (28,364) were Hispanics. Asians and Pacific Islanders (APIs) and Native Americans/Alaska Natives are the least likely groups to have AIDS, at less than 1 percent each. (See Table 6.12.)

More pediatric AIDS cases have been reported among non-Hispanic African-Americans and Hispanics than other groups. Through December 2001, 5,337 pediatric AIDS cases had been reported among non-Hispanic African-Americans, and 2,060 pediatric AIDS cases had been reported among Hispanics. In comparison, 1,579 cases had been reported among non-Hispanic whites, 54 cases had been reported among APIs, and 31 had been reported among Native Americans/Alaska Natives. (See Table 6.13.)

Although everyone can become infected with AIDS in the same ways, the proportions of the methods of transmission differ considerably by race. For non-Hispanic white men who contracted AIDS through December 2001, 74 percent did so from homosexual contact and 9 percent from intravenous drug use. While most non-Hispanic African-American men with AIDS (37 percent) and Hispanic men with AIDS (42 percent) acquired the disease through homosexual activity, a significant proportion of non-Hispanic African-American men (33 percent) and Hispanic men (34 percent) with AIDS contracted the disease through intravenous drug use. For API men with AIDS, most (71 percent) acquired the disease through sex with other men, while 5 percent reported being infected through intravenous drug use. Native American and Alaska Native men with AIDS cited the leading causes as sex with men (55 percent) and intravenous drug use (16 percent). (See Table 6.14.)

Characteristic 1984 1989 1995 1996 19971 1998 1999 2000 2001
Number in millions
Total2 29.8 33.4 37.1 38.6 41.0 39.2 38.5 40.5 39.2
Percent of population
Total, age adjusted2,314.315.315.916.517.416.516.116.816.2
Total, crude214.515.616.116.617.516.616.116.816.1
Age
Under 18 years13.914.713.413.214.012.711.912.411.0
Under 6 years14.915.111.811.712.511.511.011.79.7
6–17 years13.414.514.313.914.713.312.312.811.7
18–44 years17.118.420.421.122.421.421.022.021.7
18–24 years25.027.128.029.330.129.027.429.729.3
25–34 years16.218.321.122.423.822.222.122.722.3
35–44 years11.212.315.115.216.716.416.316.816.7
45–64 years9.610.510.912.112.412.212.212.712.3
45–54 years10.511.011.612.412.812.612.812.813.0
55–64 years8.710.09.911.611.811.411.412.511.0
Sex3
Male15.016.417.217.818.517.517.217.817.2
Female13.614.314.615.216.215.515.015.815.1
Race3,4
White only13.414.215.315.816.315.214.615.214.7
Black or African American only20.021.418.219.620.220.719.520.019.3
American Indian and Alaska Native only######38.338.233.4
Asian only18.018.518.219.019.318.116.417.317.1
Native Hawaiian and Other Pacific Islander only- - -- - -- - -- - -- - -- - -***
2 or more races- - -- - -- - -- - -- - -- - -16.818.418.6
Hispanic origin and race3,4
Hispanic or Latino29.132.431.532.434.334.033.935.434.8
Mexican33.238.836.237.539.240.038.039.939.0
Puerto Rican18.123.318.315.119.419.419.816.416.0
Cuban21.620.922.118.820.518.419.725.219.2
Other Hispanic or Latino27.525.229.730.532.931.130.832.733.1
Not Hispanic or Latino13.013.514.014.515.114.113.514.113.4
White only11.811.912.913.313.712.512.112.511.9
Black or African American only19.721.318.119.520.120.719.420.019.2
Age and percent of poverty level5
All ages:3
Below 100 percent34.735.831.734.534.434.634.434.233.3
100–149 percent27.031.331.733.336.136.535.836.532.4
150–199 percent17.421.824.024.325.926.727.727.326.4
200 percent or more5.86.88.68.68.88.07.78.78.4
Under 18 years:
Below 100 percent28.931.620.021.022.421.521.620.419.8
100–149 percent22.826.124.825.026.128.024.925.618.5
150–199 percent12.715.818.016.019.717.318.816.816.1
200 percent or more4.24.46.46.16.15.04.45.54.5
Geographic region
Northeast10.110.713.113.513.42.312.212.111.6
Midwest11.110.512.112.213.111.911.512.311.7
South17.419.419.220.020.720.019.820.420.0
West17.818.417.718.620.419.918.620.218.6

Approximately 41 percent of non-Hispanic white women who contracted AIDS through December 2001 did so via intravenous drug use, and 40 percent did so via heterosexual contact. Among non-Hispanic African-American women, 39 percent contracted the disease via drug use while 39 percent did so through heterosexual contact. Among Hispanic women, 38 percent contracted AIDS via intravenous drug use while 47 percent did so via heterosexual contact. Among API women, 49 percent contracted AIDS via heterosexual contact, while among Native Americans and Alaska Natives, 37 percent did so via heterosexual activity. (See Table 6.15.)

HEALTH OF AFRICAN-AMERICANS

Cancer

Cancer distribution among various population groups varies according to racial and ethnic background. Such risk factors as occupation, use of tobacco and alcohol, sexual and reproductive behaviors, and nutritional and dietary habits influence the development of cancer. In addition to

Characteristic 1984 1989 1995 1996 19971 1998 1999 2000 2001
Location of residence3 Percent of population3
Within MSA613.314.915.215.616.715.815.316.315.6
Outside MSA616.416.918.719.719.919.218.918.818.5
#Estimates calculated upon request.
* Estimates are considered unreliable. Data not shown have a relative standard error of greater than 30 percent.
- - - Data not available.
1In 1997 the National Health Interview Survey (NHIS) was redesigned, including changes to the questions on health insurance coverage.
2Includes all other races not shown separately and unknown poverty level.
3Estimates are for persons under 65 years of age and are age adjusted to the year 2000 standard using three age groups: under 18 years, 18–44 years, and 45–64 years.
4The race groups, white, black, American Indian and Alaska Native (AI/AN), Asian, Native Hawaiian and Other Pacific Islander, and 2 or more races, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Starting with data year 1999 race-specific estimates are tabulated according to 1997 Standards for Federal data on Race and Ethnicity and are not strictly comparable with estimates for earlier years. The five single race categories plus multiple race categories shown in the table conform to 1997 Standards. The 1999 and later race-specific estimates are for persons who reported only one racial group; the category "2 or more races" includes persons who reported more than one racial group. Prior to data year 1999, data were tabulated according to 1977 Standards with four racial groups and the category "Asian only" included Native Hawaiian and Other Pacific Islander. Estimates for single race categories prior to 1999 included persons who reported one race or, if they reported more than one race, identified one race as best representing their race. The effect of the 1997 Standard on the 1999 estimates can be seen by comparing 1999 data tabulated according to the two Standards: Age-adjusted estimates based on the 1977 Standards of the percent with no health insurance coverage are: 0.1 percentage points higher for the white group; identical for the black group; 0.1 percentage points lower for the Asian and Pacific Islander group; and 1.5 percentage points higher for the AI/AN group than estimates based on the 1997 Standards.
5Missing family income data were imputed for 15–17 percent of the sample under 65 years of age in 1994–96. Percent of poverty level was unknown for 19 percent of sample persons under 65 in 1997, 24 percent in 1998, 27 percent in 1999, and 26 percent in 2000 and 2001.
6MSA is metropolitan statistical area.
Note: Persons not covered by private insurance, Medicaid, State Children's Health Insurance Program (SCHIP), public assistance (through 1996), state-sponsored or other government-sponsored health plans (starting in 1997), Medicare, or military plans are included.
source: "Table 129. No Health Insurance Coverage among Persons under 65 Years of Age, According to Selected Characteristics: United States, Selected Years 1984–2001," in Health, United States, 2003, Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, 2003 [Online] http://www.cdc.gov/nchs/data/hus/hus03.pdf [accessed March 11, 2004]

early detection, socioeconomic status can be an important factor in receiving and surviving cancer treatment.

Cancer incidence and mortality rates are generally higher for African-Americans than for white Americans. The Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute (NCI) is the most authoritative source of information on cancer incidence, mortality, and survival in the United States. In SEER Cancer Statistics Review, 19752000 (Bethesda, MD, 2003), the NCI reported that the incidence rates between 1996 and 2000 were 521.7 per 100,000 African-Americans and 479.8 per 100,000 whites. The five-year survival rate for cancer in African-Americans diagnosed between 1992 and 1999 was about 53.3 percent, compared to 64.4 percent for whites. Much of this difference in survival can be attributed to later diagnosis in African-Americans. According to data compiled by the NCHS, types of cancer for which African-Americans have significantly higher incidence and mortality rates include stomach, esophagus, myeloma, pancreas, larynx, and prostate. The most fatal type of cancer for both male and female African-Americans is lung cancer.

BREAST CANCER.

According to Cancer Facts and Figures for African Americans 20032004, produced by the American Cancer Society, African-American women experience a slightly lower rate of breast cancer than their white counterparts, but they are more likely to die as a result of their cancer. According to figures released by the National Cancer Institute in 2002, the incidence rate for African-American women was 123.7 per 100,000 for the years 1995–1999, while white women experienced breast cancer at a rate of 140.9 per 100,000. However, deaths from breast cancer during the same period occurred at a rate of 37.1 per 100,000 among African-American women and 28.2 per 100,000 among white women. For years experts assumed that the difference was due to poor health care and late treatment for African-American women. Recent studies, however, indicate that African-American women may be more susceptible to a more deadly form of the cancer. Tumors from African-American women were found to have more actively dividing cells than tumors from white women. The tumor cells in African-American women also lacked hormone receptors, another indicator of a poor prognosis. After peaking in the early 1990s, the death rate from breast cancer for African-American women had shown improvement by 2001, at 34.4 per 100,000. (See Table 6.16.)

PROSTATE CANCER.

African-American men have a particularly high incidence and mortality rate of prostate cancer. Between 1995 and 1999, the prostate cancer incidence rate among African-American men was 266.8 cases per 100,000 population, compared to a rate of only 163.2 cases per 100,000 population among whites. The mortality rate for those same years among African-American men averaged 72.8 deaths from prostate cancer per 100,000 population, compared to 31.2 deaths per 100,000 for white men, according to the American Cancer Society.

Characteristic 1984 1989 1995 1996 19971 1998 1999 2000 2001
Number in millions
Total2 14.0 15.4 26.6 25.8 22.9 21.1 21.9 22.9 25.2
Percent of population
Total, age adjusted2,3 6.7 7.1 11.3 10.9 9.6 8.8 9.0 9.4 10.3
Total, crude2 6.8 7.2 11.5 11.1 9.7 8.9 9.1 9.5 10.4
Age
Under 18 years11.912.621.520.718.417.118.119.421.2
Under 6 years15.515.729.328.224.722.423.524.325.8
6–17 years10.110.917.416.915.214.515.517.019.0
18–44 years5.15.27.87.66.65.85.75.66.3
18–24 years6.46.810.49.78.88.08.18.18.4
25–34 years5.35.28.27.86.85.75.75.56.2
35–44 years3.54.05.96.25.24.64.34.35.1
45–64 years3.44.35.65.34.64.54.44.54.7
45–54 years3.23.85.14.94.04.13.94.24.4
55–64 years3.64.96.45.95.65.05.34.95.2
Sex3
Male5.25.69.28.98.17.57.78.08.9
Female8.08.613.312.811.010.110.410.811.6
Race3,4
White only4.65.18.88.77.56.76.97.28.1
Black or African American only18.917.826.023.020.519.618.719.420.4
American Indian and Alaska Native only######41.344.215.5
Asian only9.111.310.7*11.59.46.78.47.88.8
Native Hawaiian and Other Pacific Islander only- - -- - -- - -- - -- - -- - -***
2 or more races- - -- - -- - -- - -- - -- - -15.815.614.6
Hispanic origin and race3,4
Hispanic or Latino12.212.719.818.516.014.114.114.216.0
Mexican11.111.518.817.615.312.612.412.514.6
Puerto Rican28.626.931.131.328.924.527.027.628.5
Cuban4.87.813.8*13.18.2*9.18.39.712.2
Other Hispanic or Latino7.410.416.915.013.913.913.814.115.0
Not Hispanic or Latino6.26.610.29.78.78.08.28.69.3
White only3.74.27.17.06.25.76.06.37.0
Black or African American only19.117.825.622.720.319.418.719.320.3
Age and percent of poverty level5
All ages:3
Below 100 percent30.535.344.742.938.837.936.837.239.0
100–149 percent7.511.018.017.417.516.018.620.323.5
150–199 percent3.15.07.98.07.47.29.810.813.3
200 percent or more0.61.11.81.71.71.82.02.32.6
Under 18 years:
Below 100 percent43.147.866.065.259.758.759.960.964.3
100–149 percent9.012.327.226.630.225.933.537.141.4
150–199 percent4.46.113.112.212.212.818.021.526.5
200 percent or more0.81.63.32.82.93.23.74.75.3

In 2001, while the mortality rate from prostate cancer among African-American men was a full ten points lower than it was in 1995, at 66.1 deaths per 100,000 population, it remained significantly higher than for other racial and ethnic groups. (See Table 6.16.)

Heart Disease, Hypertension, and Stroke

Rates of heart disease vary considerably by race, with higher rates for African-Americans. Along with age and sex, race, as part of heredity, is one of the risk factors for heart disease that cannot be changed. However, due to their higher rates of incidence of heart disease and stroke, African-Americans are encouraged to control other risk factors, including use of tobacco and alcohol, blood pressure and cholesterol levels, physical activity, weight, and stress.

According to the American Heart Association, the prevalence of hypertension, or high blood pressure, in both African-American males and females is significantly higher than in white males and females. The Association reported that in 2001 approximately 41.6 percent of African-American males and 44.7 percent of African-American females suffered from high blood pressure. African-Americans develop high blood pressure at younger ages than whites do. Hypertension is also generally more severe in African-Americans than in whites and, as a result, African-Americans have greater rates of both nonfatal and fatal strokes. Geography also appears to play

Characteristic 1984 1989 1995 1996 19971 1998 1999 2000 2001
Geographic region3 Percent of population
Northeast8.56.811.711.511.29.810.110.510.8
Midwest7.27.510.38.78.27.57.37.99.0
South5.06.411.111.18.68.68.99.410.7
West6.98.212.412.411.49.710.310.210.6
Location of residence3
Within MSA67.17.011.110.49.58.58.48.89.8
Outside MSA65.97.812.012.79.99.811.511.912.4
# Estimates calculated upon request.
* Estimates are considered unreliable. Data preceded by an asterisk have a relative standard error of 20–30 percent. Data not shown have a relative standard error of greater than 30 percent.
- - - Data not available.
1In 1997 the National Health Interview Survey (NHIS) was redesigned, including changes to the questions on health insurance coverage.
2Includes all other races not shown separately and unknown poverty level.
3Estimates are for persons under 65 years of age and are age adjusted to the year 2000 standard using three age groups: under 18 years, 18–44 years, and 45–64 years.
4The race groups, white, black, American Indian and Alaska Native (AI/AN), Asian, Native Hawaiian and Other Pacific Islander, and 2 or more races, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Starting with data year 1999 race-specific estimates are tabulated according to 1997 Standards for Federal data on Race and Ethnicity and are not strictly comparable with estimates for earlier years. The five single race categories plus multiple race categories shown in the table conform to 1997 Standards. The 1999 and later race-specific estimates are for persons who reported only one racial group; the category "2 or more races" includes persons who reported more than one racial group. Prior to data year 1999, data were tabulated according to 1977 Standards with four racial groups and the category "Asian only" included Native Hawaiian and Other Pacific Islander. Estimates for single race categories prior to 1999 included persons who reported one race or, if they reported more than one race, identified one race as best representing their race. The effect of the 1997 Standard on the 1999 estimates can be seen by comparing 1999 data tabulated according to the two Standards: Age-adjusted estimates based on the 1977 Standards of the percent with Medicaid are: 0.1 percentage points higher for the white group; 0.8 percentage points higher for the Asian and Pacific Islander group and 0.8 percentage points higher for the AI/AN group than estimates based on the 1997 Standards.
5Missing family income data were imputed for 15–17 percent of the sample under 65 years of age in 1994–96. Percent of poverty level was unknown for 19 percent of sample persons under 65 in 1997, 24 percent in 1998, 27 percent in 1999, and 26 percent in 2000 and 2001.
6MSA is metropolitan statistical area. Note: Medicaid includes other public assistance through 1996. Starting in 1997 includes state-sponsored health plans. Starting in 1999 includes State Children's Health Insurance Program (SCHIP). In 2001, 7.9 percent were covered by Medicaid, 1.2 percent by state-sponsored health plans, and 1.2 percent by SCHIP.
source: "Table 128. Medicaid Coverage among Persons under 65 Years of Age, According to Selected Characteristics: United States, Selected Years, 1984–2001," in Health, United States, 2003, Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, 2003 [Online] http://www.cdc.gov/nchs/data/hus/hus03.pdf [accessed March 11, 2004]

a role, with African-Americans who live in the South experiencing greater prevalence of high blood pressure and stroke than those in other areas of the country. High blood pressure remains a leading cause of stroke for non-Hispanic African-Americans age twenty and older.

Researchers are not yet sure why African-Americans have a greater tendency toward high blood pressure, but a possible genetic predisposition toward high blood pressure in African-Americans may stem from a strong tendency to retain salt in their bodies. Scientists have hypothesized that this developed as an adaptation to living in a very hot climate where excessive salt loss could result in death.

Approximately 20 percent of African-Americans experience high serum cholesterol levels of greater than 240 mg/dl, which is about the same rate as other racial and ethnic groups in the United States. However, the American Heart Association warns that another 25 percent have total blood cholesterol levels over 200 mg/dl and are thus at risk of developing high cholesterol.

Sickle-Cell Anemia

Sickle-cell anemia, a hereditary disease that primarily strikes African-American people in the United States, is a blood disorder in which defective hemoglobin causes red blood cells to become sickle shaped, rather than round. This can create blockages in small arteries and can result in many problems, including chronic anemia, episodes of intense pain, strokes, and death. Scientists believe the genetic trait arose randomly in Africa and survived as a defense against malaria. The disease can be inherited only when both parents have the sickle-cell trait and the child inherits the defective gene from both parents. One of every twelve African-Americans is a carrier for sickle-cell anemia, and about one of every 500 African-American infants is born with it. According to the National Institutes of Health (NIH), many non-African-Americans with ancestors from malaria regions—parts of Greece, Italy, the Near East, and India—also have the disease. However, of the 72,000 Americans the NIH estimated had sickle-cell anemia in 2002 most were of African descent.

Alzheimer's Disease

The results of a study, "The APOE4 Allele and the Risk of Alzheimer Disease among African-Americans, Whites, and Hispanics," conducted between 1991 and 1996 by Columbia University, were published in the Journal of the American Medical Association (vol. 279, no. 10, March 1998). The findings indicated that African-Americans and Hispanics might be at greater risk for Alzheimer's disease than whites. In 1992 scientists first

Race/ethnicity Male % Female % Total %
Non-Hispanic
White29.125.927.4
Black30.122.225.7
American Indian/Alaska Native40.940.040.4
Hawaiian/Other Pacific Islander1
Asian224.19.116.2
Chinese19.35.912.3
Filipino6.914.8
Japanese18.319.0
Asian Indian20.03.012.6
Korean27.2
Vietnamese26.5
Hispanic229.217.323.1
Mexican29.815.622.8
Puerto Rican34.227.330.4
Central or South American26.316.921.3
Cuban21.117.519.2
Total 29.2 24.1 26.5
1Data unreliable.
2Includes respondents reporting racial/ethnic subgroups not shown and respondents reporting more than one subgroup.
source: Adapted from "Table 2. Percentage of Persons Aged >18 Years Reporting Cigarette Use during the Preceding Month, by Race/Ethnicity and Sex—National Survey on Drug Use and Health, United States, 1999–2001," in Prevalence of Cigarette Use among 14 Racial/Ethnic Populations—United States, 1999–2001, Morbidity and Mortality Weekly Report, vol. 53, no. 3, Centers for Disease Control and Prevention, Atlanta, GA, January 30, 2004 [Online] http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5303a2.htm [accessed March 11, 2004]

discovered that people with the apolipoprotein-E gene, or APOE4 (approximately 25 percent of the total population), are at greater risk for developing the disease. The Columbia University research, however, showed that the increased risk associated with the APOE4 gene applies only to whites. The study showed that African-Americans and a group of Hispanic Americans, mainly from the Caribbean, who do not have the gene, are still at greater risk for Alzheimer's disease than whites.

The researchers surveyed 1,079 elderly men and women and found that African-Americans who lacked the APOE4 gene were four times more likely than whites to get Alzheimer's disease. Since the APOE4 could not account for the increased cases in African-Americans and Hispanics, researchers now believe that there are other genetic or environmental factors affecting minorities that increase their risk of developing Alzheimer's disease. None of the subjects of the study had the disease when the study began, but 221 developed Alzheimer's by the time the study ended.

Diabetes

Another health problem in the African-American community is the high incidence of diabetes. Diabetes was the seventh-leading cause of death for African-American men in 2001 and the fourth-leading cause of death for African-American women in the same year. One of the reasons diabetes is such a dangerous disease is because it can cause many different complications, including heart disease, kidney failure, and loss of circulation in the extremities. Lack of circulation in the lower limbs can lead to infection of small wounds and gangrene eventually requiring leg amputation. According to the CDC, 11.4 percent of all non-Hispanic blacks age twenty years or older have diabetes, compared with 8.4 percent of non-Hispanic whites and 8.2 percent of all Hispanic Americans of similar age.

Life Expectancy

Women tend to live longer than men, and whites are likely to live longer than African-Americans. In 2001, when comparing the life expectancies at birth of African-Americans and whites, African-American men (68.6 years) had the shortest life expectancy, while white women (80.2 years) had the longest life expectancy. African-American females had a life expectancy of 75.5 years, and white men could expect to live approximately seventy-five years. (See Table 6.17.)

In 2001, as reported by the Centers for Disease Control, African-Americans died at a higher rate than white Americans, with an age-adjusted rate of 1,101.2 African-American deaths per 100,000 people, compared with 836.5 white deaths per 100,000. (See Table 6.16.) During the same year, the number of infants who died during the first year of life for African-Americans was 2.5 times greater than for the white population, and maternal mortality, the number of women who died during childbirth or from its complications, was 3.4 times greater for African-Americans than for white women. On the other hand, non-Hispanic African-American individuals are significantly less likely than non-Hispanic whites to die of suicide. In 2001 the African-American suicide rate, at 5.5 per 100,000 population, was half that of the non-Hispanic white population, which numbered 12.5 per 100,000. (See Table 6.16.)

Leading Causes of Death

Heart disease was the leading cause of death among non-Hispanic African-Americans in 2001, according to the National Center for Health Statistics. That year more than 25 percent of deaths of African-American males and 28.7 percent of deaths of African-American females were attributed to heart disease. Cancer was the second-leading cause of death among African-Americans, and stroke the third leading cause among African-American women, though men died more often from unintentional injuries.

HOMICIDE.

Homicides are disproportionately high in the non-Hispanic African-American population, and the

Both sexes Male Female
Characteristic 1997 2000 2001 1997 2000 2001 1997 2000 2001
Drinking status1 Percent distribution
18 years and over, age adjusted2
All100.0100.0100.0100.0100.0100.0100.0100.0100.0
Lifetime abstainer21.224.122.614.017.515.227.629.929.2
Former drinker15.714.414.916.214.916.015.314.214.0
Infrequent9.08.28.57.77.07.710.19.29.1
Regular6.76.36.48.57.88.35.25.04.8
Current drinker63.161.562.569.867.768.857.055.856.8
Infrequent15.014.712.811.711.19.218.118.216.2
Regular48.146.748.758.156.658.438.937.739.7
18 years and over, crude
All100.0100.0100.0100.0100.0100.0100.0100.0100.0
Lifetime abstainer21.124.022.514.017.515.227.730.129.3
Former drinker15.514.314.815.614.315.515.414.314.1
Infrequent8.98.18.47.56.87.510.19.39.2
Regular6.66.26.48.17.58.05.25.04.9
Current drinker63.461.762.770.568.269.357.055.656.6
Infrequent15.014.712.911.711.19.318.118.116.2
Regular48.446.948.858.857.258.938.837.539.5
Age Percent current drinkers among all persons
All persons:
18–44 years69.467.469.074.873.075.064.261.963.2
18–24 years62.259.463.666.764.069.657.754.957.7
25–44 years71.669.970.877.276.076.866.164.165.0
45–64 years63.362.062.570.868.167.856.256.357.5
45–54 years67.165.165.673.870.370.160.760.161.2
55–64 years57.357.257.665.864.664.249.450.651.6
65 years and over43.442.142.052.750.050.936.636.235.5
65–74 years48.646.945.856.752.655.242.042.238.2
75 years and over36.636.337.646.746.645.130.229.732.6
Race2,3
White only66.064.665.871.869.771.060.759.961.0
Black or African American only47.846.846.656.956.256.940.939.438.6
American Indian and Alaska Native only53.954.251.566.162.662.845.246.938.6
Asian only45.843.044.760.155.959.731.629.330.1
Native Hawaiian and Other Pacific Islander only- - -**- - -**- - -**
2 or more races- - -61.668.5- - -70.569.9- - -52.767.1
Hispanic origin and race2,3
Hispanic or Latino53.452.149.864.663.761.242.141.239.0
Mexican53.050.649.866.964.463.038.936.836.7
Not Hispanic or Latino64.152.149.870.263.761.258.741.239.0
White only67.566.067.772.770.472.062.961.963.7
Black or African American only47.846.846.557.156.457.040.739.338.4
Geographic region2
Northeast68.768.068.474.473.273.863.863.763.7
Midwest66.865.667.173.070.771.761.161.163.0
South56.254.355.563.962.163.249.247.148.5
West64.962.864.071.568.470.558.957.257.6
Location of residence2
Within MSA464.763.064.171.069.070.459.157.558.3
Outside MSA457.456.056.965.762.662.849.550.351.6
Level of alcohol consumption in past year for current drinkers5 Percent distribution of current drinkers
18 years and over, age adjusted2
All drinking levels100.0100.0100.0100.0100.0100.0100.0100.0100.0
Light69.670.668.859.560.459.181.082.079.6
Moderate22.522.223.431.832.032.612.011.513.0
Heavier7.97.17.98.77.78.37.06.57.3

high homicide rate among African-Americans might be one of the reasons African-American men in their twenties and thirties have a higher death rate than men that age in other ethnic and racial groups. In 2001 there were 267.2 deaths per 100,000 non-Hispanic African-American men between the ages of twenty-five and thirty-four. In comparison, there were 131.4 deaths per 100,000 in that age group among non-Hispanic white males, 182.2 deaths per 100,000 in that age group among Native American males, 61.2 per 100,000 among Asian and Pacific Islander males,

Both sexes Male Female
Characteristic 1997 2000 2001 1997 2000 2001 1997 2000 2001
18 years and over, crude Percent distribution of current drinkers
All drinking levels100.0100.0100.0100.0100.0100.0100.0100.0100.0
Light69.870.869.059.660.559.281.482.379.9
Moderate22.322.123.231.731.832.411.711.312.9
Heavier7.97.17.88.87.78.46.96.47.2
Number of days in the past year with 5 or more drinks
18 years and over, crude
All current drinkers100.0100.0100.0100.0100.0100.0100.0100.0100.0
No days65.968.267.654.756.957.278.680.679.0
At least 1 day34.131.832.445.343.142.821.419.421.0
1–11 days18.517.417.122.021.219.914.613.314.0
12 or more days15.614.415.323.421.922.86.86.17.0
Hispanic origin, race, and age3 Percent of persons with 5 or more drinks on at least one day among current drinkers
All persons:
18 years and over, age adjusted232.430.330.643.341.240.520.218.519.9
18 years and over, crude34.131.832.445.343.142.721.419.420.9
18–44 years42.440.441.454.652.352.228.727.029.2
18–24 years51.652.251.861.560.860.140.242.441.7
25–44 years40.037.138.352.849.949.725.722.825.7
45–64 years25.323.523.836.135.034.712.910.811.9
45–54 years28.525.526.440.137.938.015.312.014.0
55–64 years19.619.918.928.929.928.78.38.78.0
65 years and over11.29.18.217.814.813.14.43.43.1
65–74 years13.911.310.221.618.315.55.54.24.0
75 years and over6.75.85.311.09.59.1*2.5**
Race2,3
White only33.331.031.844.441.842.020.919.220.7
Black or African American only23.623.920.631.734.127.514.912.712.5
American Indian and Alaska Native only54.545.034.670.547.035.938.434.7*27.9
Asian only25.520.323.230.725.428.916.610.8*12.9
Native Hawaiian and Other Pacific Islander only- - -**- - -**- - -**
2 or more races- - -44.041.6- - -53.159.9- - -31.524.3
Hispanic origin and race2,3
Hispanic or Latino36.831.932.246.343.041.922.316.017.9
Mexican39.037.535.650.149.045.920.317.917.7
Not Hispanic or Latino31.931.932.242.743.041.920.016.017.9
White only33.231.232.044.542.142.221.019.721.3
Black or African American only23.423.820.531.733.827.414.412.712.5
Geographic region Percent of persons with 5 or more drinks on at least one day among current drinkers
Northeast31.328.930.043.139.741.418.918.118.8
Midwest33.833.333.644.744.744.421.621.522.4
South30.927.427.940.537.136.119.215.618.0
West33.432.031.744.643.141.420.818.820.1

and 115.5 per 100,000 among Hispanic males. (See Table 6.18.) The age-adjusted rate of deaths attributable to homicide ranges from 5.6 per 100,000 for non-Hispanic white males to 36.2 for black males. (See Table 6.19.)

HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE.

The difference in death rate from HIV disease among the racial and ethnic groups is staggering, with a much higher rate among African-Americans than any other group of Americans. In 2001, the death rate from HIV disease per 100,000 population among African-Americans was 22.8 compared with 6.2 deaths among Hispanics, 2.7 deaths among Native Americans/Alaska Natives, 2.1 deaths among non-Hispanic whites, and .07 deaths among APIs. (See Table 6.16.)

HISPANICS AND HEALTH

The U.S. Hispanic population faces significant obstacles to good health. For instance, in 2002 Hispanics made up 21.8 percent of the population living below the poverty level. (See Table 5.6 in Chapter 5.) Furthermore, Hispanic Americans are also over-represented in low-paying jobs in the manufacturing and construction industries, as well as farming and metal mining, all of which report a high number of work-related injuries. According to the study Occupational Hispanic Workers issued by the Bureau of Labor Statistics in 2002, between 1992 and 1999 more than 5,100 Hispanic workers lost their lives while on the job. The highest incidence of fatal injuries occurred in the construction, agriculture, retail, and service industries.

Both sexes Male Female
Characteristic 1997 2000 2001 1997 2000 2001 1997 2000 2001
Location of residence2
Within MSA431.630.030.142.440.439.919.818.519.1
Outside MSA434.831.332.845.743.142.221.218.522.5
*Estimates are considered unreliable. Data preceded by an asterisk have a relative standard error (RSE) of 20–30 percent. Data not shown have a RSE of greater than 30 percent.
- - - Data not available.
1Drinking status categories are based on self-reported responses to questions about alcohol consumption. Lifetime abstainers had fewer than 12 drinks in their lifetime. Former drinkers had at least 12 drinks in their lifetime and none in the past year. Former infrequent drinkers are former drinkers who had fewer than 12 drinks in any one year. Former regular drinkers are former drinkers who had at least 12 drinks in any one year. Current drinkers had 12 drinks in their lifetime and at least one drink in the past year. Current infrequent drinkers are current drinkers who had fewer than 12 drinks in the past year. Current regular drinkers are current drinkers who had at least 12 drinks in the past year.
2Estimates are age adjusted to the year 2000 standard population using four age groups: 18–24 years, 25–44 years, 45–64 years, and 65 years and over.
3The race groups, white, black, American Indian and Alaska Native (AI/AN), Asian, Native Hawaiian and Other Pacific Islander, and 2 or more races, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Starting with data year 1999 race-specific estimates are tabulated according to 1997 Standards for Federal data on Race and Ethnicity and are not strictly comparable with estimates for earlier years. The five single race categories plus multiple race categories shown in the table conform to 1997 Standards. The 1999 race-specific estimates are for persons who reported only one racial group; the category "2 or more races" includes persons who reported more than one racial group. Prior to data year 1999, data were tabulated according to 1977 Standards with four racial groups and the category "Asian only" included Native Hawaiian and Other Pacific Islander. Estimates for single race categories prior to 1999 included persons who reported one race or, if they reported more than one race, identified one race as best representing their race. The effect of the 1997 Standard on the 1999 estimates can be seen by comparing 1999 data tabulated according to the two Standards: Age-adjusted estimates based on the 1977 Standards of the percent of persons who are current drinkers are: identical for the white men; 0.3 percentage points higher for black men; 1.6 percentage points higher for AI/AN men; 0.2 percentage points lower for Asian and Pacific Islander men; identical for white women; 0.2 percentage points higher for black women; 1.8 percentage points lower for AI/AN women; and 2.4 percentage points higher for Asian and Pacific Islander women than estimates based on the 1997 Standards.
4MSA is metropolitan statistical area.
5Level of alcohol consumption categories are based on self-reported responses to questions about average alcohol consumption and defined as follows: light drinkers: 3 drinks or fewer per week; moderate drinkers: more than 3 drinks and up to 14 drinks per week for men and more than 3 drinks and up to 7 drinks per week for women; heavier drinkers: more than 14 drinks per week for men and more than 7 drinks per week for women. (Most drinking guidelines consider more than 7 drinks per week to be a heavier level of consumption for women. U.S. Department of Agriculture: Dietary Guidelines for Americans, 2000, 5th edition.)
source: "Table 65. Alcohol Consumption by Persons 18 Years of Age and over, According to Selected Characteristics: United States, Selected Years 1997–2001," in Health, United States, 2003, Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, 2003 [Online] http://www.cdc.gov/nchs/data/hus/hus03.pdf [accessed March 11, 2004]

Despite these difficulties, Hispanics exhibit good health as a group in a number of areas. For example, the Hispanic population has seen a decline in the proportion of people who have died of heart disease in recent years. In 2001 there were 192.2 deaths per 100,000 people from heart disease among Hispanics, down from 217.1 deaths per 100,000 people in 1990. Hispanics also had a lower proportion of lung cancer rates in 1998 than other races and ethnic groups. There were 23.8 lung cancer deaths per 100,000 people among Hispanics, compared to 62.5 deaths per 100,000 among Black or African-Americans, and 57.7 deaths per 100,000 among non-Hispanic white Americans. (See Table 6.16.)

Health Insurance

Having health insurance is commonly associated with employment, retirement, and income. Hispanics are less likely than any other population group to have medical insurance. In 2001, 34.8 percent of Hispanics had no medical health insurance, compared to 11.9 percent of non-Hispanic whites and 19.2 percent of non-Hispanic African-Americans. Among Hispanic subgroups, a higher percentage of Mexicans (39 percent) than Cubans (19.2 percent) and Puerto Ricans (16 percent) had no insurance. (See Table 6.7.)

Infant Mortality

Recent studies question the commonly assumed connection between lower levels of income and education and high infant mortality. Between 1998 and 2001 Hispanics had a consistently lower infant mortality rate than non-Hispanic whites. There were 5.4 deaths per 1,000 live births among Hispanics in 2001, compared to 5.7 deaths per 1,000 live births among non-Hispanic whites. The infant mortality rate was significantly higher among African-Americans and Native Americans/Alaska Natives. Among non-Hispanic African-Americans, there were 13.5 infant deaths per 1,000 live births, and among Native Americans/Alaska Natives, there were 9.7 deaths per 1,000 live births. (See Table 6.4.) Researchers have speculated that greater social support, less high-risk behavior, and dietary factors may explain the differences.

Cancer

In addition to lower fatalities from lung cancer, Hispanics are also less likely than other racial and ethnic groups to die from breast cancer. Among Hispanic women, in 2001 there were 16.3 breast cancer deaths per 100,000 people, compared to 34.4 deaths per 100,000 population among Black or African-Americans and 26 deaths among non-Hispanic whites per 100,000 population. That same year there were 23.5 prostate cancer-related deaths per 100,000 population among Hispanics, compared to 66.1 deaths per 100,000 population among Black or African-Americans and 26.7 deaths per 100,000 population among non-Hispanic whites. (See Table 6.16.)

Any illicit drug1 Marijuana Nonmedical use of any psychotherapeutic drug2
Age, sex, race, and Hispanic origin 1999 2000 2001 1999 2000 2001 1999 2000 2001
Percent of population
12 years and ove6.36.37.14.74.85.41.81.72.1
Age
12–13 years3.93.03.81.51.11.51.81.61.8
14–15 years9.89.810.96.96.97.63.43.03.5
16–17 years15.416.417.813.213.714.93.44.34.4
18–25 years16.415.918.814.213.616.03.73.64.8
26–34 years6.87.88.85.45.96.81.52.12.4
35 years and over3.43.33.52.22.32.41.31.01.3
Sex
Male8.17.78.76.56.27.01.91.82.2
Female4.65.05.53.13.53.81.71.72.0
Age and sex
12–17 years9.89.710.87.27.28.02.93.03.2
Male10.19.811.47.87.78.92.62.72.7
Female9.49.510.26.76.67.13.13.33.8
Hispanic origin and race3
Not Hispanic or Latino:
White only6.26.47.24.74.95.61.91.82.3
Black or African American only7.56.47.45.95.25.61.41.21.6
American Indian and Alaska Native only10.412.69.96.910.18.03.53.92.3
Native Hawaiian and Other Pacific Islander only*6.27.5*2.57.10.33.51.1
Asian only3.22.72.82.31.41.70.91.10.8
2 or more races10.314.812.68.512.59.62.72.35.3
Hispanic or Latino, any race6.15.36.44.23.64.21.71.71.9
Alcohol use Binge alcohol use4 Heavy alcohol use5
1999 2000 2001 1999 2000 2001 1999 2000 2001
Age Percent of population
12 years and over46.446.648.320.220.620.55.75.65.7
12–13 years4.44.64.41.82.01.90.20.20.2
14–15 years15.415.716.69.09.39.21.61.81.7
16–17 years29.629.130.819.320.320.85.46.05.7
18–25 years57.256.858.837.937.838.713.312.813.6
26–34 years57.458.359.929.330.330.17.57.67.8
35 years and over46.646.848.716.016.416.24.24.14.2
Sex
Male53.253.654.828.128.328.29.28.79.2
Female40.240.242.312.913.513.42.42.72.6
Age and sex
12–17 years16.516.417.310.110.410.62.42.62.5
Male16.716.217.211.311.211.23.03.23.1
Female16.316.517.38.99.69.91.82.01.9
Hispanic origin and race3
Not Hispanic or Latino:
White only50.350.752.721.121.221.56.26.26.4
Black or African American only34.333.735.116.317.716.83.64.04.1
American Indian and Alaska Native only33.935.135.020.026.221.85.87.27.1
Native Hawaiian and Other Pacific Islander only*****17.0** 4.0
Asian only30.728.031.910.811.610.12.51.41.5
2 or more races41.441.643.220.217.519.47.75.26.7
Hispanic or Latino, any race38.639.839.521.722.721.35.44.44.4

Heart Disease

Even though Hispanics have a lower death rate from heart disease than most groups, it is still a leading killer of Hispanics. In 2001 Hispanics—with a rate of 192.2 deaths per 100,000 population—were more likely than Asians/Pacific Islanders (137.6 deaths per 100,000) and Native Americans/Alaska Natives (159.6 deaths per 100,000), but less likely than non-Hispanic whites (245.6 per 100,000) or African-Americans (316.9 per 100,000), to die of heart disease. (See Table 6.16.)

Tobacco Cigarettes Cigars
Age, sex, race, and Hispanic origin 1999 2000 2001 1999 2000 2001 1999 2000 2001
Percent of population
12 years and over30.229.329.525.824.924.95.54.85.4
Age
12–13 years4.84.03.94.13.43.21.10.81.0
14–15 years16.414.213.414.312.111.45.14.33.7
16–17 years30.328.928.126.125.224.49.78.68.1
18–25 years44.642.943.939.738.339.111.510.410.4
26–34 years38.235.636.231.529.730.57.05.75.9
35 years and over27.427.327.323.322.922.73.93.44.4
Sex
Male36.635.235.628.326.927.19.58.49.4
Female24.323.923.823.423.123.01.71.51.6
Age and sex
12–17 years17.315.615.114.913.413.05.44.54.3
Male18.716.315.814.812.812.47.76.45.8
Female15.814.814.415.014.113.62.92.52.6
Hispanic origin and race3
Not Hispanic or Latino:
White only31.931.031.327.025.926.15.85.05.6
Black or African American only26.626.727.722.523.323.95.95.15.8
American Indian and Alaska Native only43.155.044.936.042.338.06.310.78.6
Native Hawaiian and Other Pacific
Islander only**28.5**27.74.43.12.8
Asian only18.717.913.616.716.512.91.91.61.4
2 or more races34.038.934.129.832.331.15.35.15.3
Hispanic or Latino, any race24.722.222.922.620.720.94.33.54.2
*Estimates are considered unreliable.
1Any illicit drug includes marijuana/hashish, cocaine (including crack), heroin, hallucinogens (including LSD and PCP), inhalants, or psychotherapeutic drug used nonmedically.
2Psychotherapeutic drugs include prescription-type pain relievers, tranquilizers, stimulants, or sedatives; does not include over-the-counter drugs.
3Persons of Hispanic origin may be of any race. Race and Hispanic origin were collected using the 1997 Standards for Federal data on Race and Ethnicity. Single race categories shown include persons who reported only one racial group. The category 2 or more races includes persons who reported more than one racial group.
4Binge alcohol use is defined as drinking five or more drinks on the same occasion on at least 1 day in the past 30 days. By "occasion" is meant at the same time or within a couple hours of each other.
5Heavy alcohol use is defined as drinking five or more drinks on the same occasion on each of 5 or more days in the past 30 days; all heavy alcohol users are also "binge" alcohol users.
6Any tobacco product includes cigarettes, smokeless tobacco (i.e., chewing tobacco or snuff), cigars, or pipe tobacco.
source: "Table 62 . Use of Selected Substances in the Past Month by Persons 12 Years of Age and over, According to Age, Sex, Race, and Hispanic Origin: United States, Selected Years 1999–2001," in Health, United States, 2003, Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, 2003 [Online] http://www.cdc.gov/nchs/data/hus/hus03.pdf [accessed March 11, 2004]

Diabetes

Diabetes is a major problem for Hispanics. In the United States, Hispanics have a higher death rate from diabetes than whites but with a lower rate than African-Americans and Native Americans/Alaska Natives. In 2001 there were 36.7 Hispanic deaths from diabetes per 100,000 people, compared to only 16.9 for Asians and Pacific Islanders, 22.1 for non-Hispanic whites, 40.4 for Native Americans/Alaska Natives, and 49.2 for Blacks and African-Americans. (See Table 6.16.)

Other Causes of Death

In 1990 Hispanics, like African-Americans, had a higher homicide rate than most other groups. However, between 1990 and 2001, the homicide death rate among Hispanics dropped from 16.2 deaths per 100,000 to 8.3 homicides per 100,000 in 2001. The 2001 suicide rate among Hispanics was 5.7 per 100,000 while the national average was 10.7. The death rate for Hispanics from lower respiratory diseases in 2001 was 20.7 per 100,000 population, considerably lower than the national average of 43.7. (See Table 6.16.)

HEALTH CARE FOR NATIVE AMERICANS

Native American diets have been negatively affected by the introduction of nonnative foods. Although there are considerable tribal variations in diet, studies show that the less Native Americans eat of their traditional foods, the greater their levels of obesity and adult-onset diabetes. High-carbohydrate, high-sodium, and high-saturated-fat contents can characterize most current Native American diets. Also, Native American diets are relatively low in meat and dairy products. Factors contributing to these eating habits include food availability, preference for non-native food, and place of residence.

1999 2000 2001 2002
Age as of end of year (yrs)
<132,5172,4882,4512,363
13—14242291394467
15—248,9849,4409,90110,295
25—3459,15357,34756,31455,789
35—4498,193106,376112,845118,714
45—5445,17153,00261,54770,472
55—6410,73212,83015,24018,591
≥652,9853,6354,4075,241
Race/ethnicity
White, not Hispanic91,03896,424101,943107,992
Black, not Hispanic112,483121,903131,360141,184
Hispanic21,25623,44925,73228,364
Asian/Pacific Islander7919231,0451,181
American Indian/Alaska Native1,2241,3391,4311,565
226,792 244,037 261,511 280,286
Exposure category
Male adult or adolescent
Male-to-male sexual contact100,582108,174116,250125,268
Injection drug use31,55432,88034,09335,380
Male-to-male sexual contact and injection drug use14,90015,29015,69616,1
Heterosexual contact19,59422,02124,38726,843
Other12,6732,7352,8192,922
Subtotal169,304181,099193,244206,557
Female adult or adolescent
Injection drug use16,66617,50418,20918,831
Heterosexual contact37,65742,23946,84151,538
Other11,3061,4141,5131,627
Subtotal55,62961,15866,56371,996
Child (<13 yrs)
Perinatal2,7412,8553,0063,114
Other2297291279260
Subtotal3,0383,1463,2853,374
Total3 227,976 245,409 263,098 281,931
Note: These numbers do not represent actual cases in persons living with HIV/AIDS. Rather, these numbers are point estimates of persons living with HIV/AIDS that have been adjusted for reporting delays and for redistribution of cases in persons initially reported without an identified risk. The estimates have not been adjusted for incomplete reporting.
Data include persons with a diagnosis of HIV infection. This includes persons with a diagnosis of HIV infection only, a diagnosis of HIV infection and a later AIDS diagnosis, and concurrent diagnoses of HIV infection and AIDS.
Since 1998, the following 30 areas have had laws or regulations requiring confidential name-based HIV infection reporting: Alabama, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Utah, Virginia, West Virginia, Wisconsin, Wyoming, and the U.S. Virgin Islands. Since July 1997, Florida has had confidential name-based HIV infection reporting only for new diagnoses.
1Includes hemophilia, blood transfusion, perinatal, and risk not reported or not identified.
2Includes hemophilia, blood transfusion, and risk not reported or not identified.
3Includes persons of unknown or multiple race and of unknown sex. Because column totals were calculated independently of the values for the subpopulations, the values in each column may not sum to the column total.
source: "Table 8. Estimated Numbers of Persons Living with HIV/AIDS by Year and Selected Characteristics, 1999–2002—30 Areas with Confidential Name-Based HIV Infection Reporting," in HIV/AIDS Surveillance Report, vol. 14, Centers for Disease Control and Prevention, Atlanta, GA, 2001 [Online] http://www.cdc.gov/hiv/stats/hasr1402/table8.htm [accessed March 11, 2004]

The customs and patterns of white culture imposed on Native Americans have disrupted their traditional way of life. As a result, the Native American population has been plagued by a sense of powerlessness and hopelessness. According to social researchers, the high incidence of alcohol abuse, suicide, and depression among Native Americans is likely to be related to this condition. In 2001 Native Americans/Alaska Natives had the second highest incidence of suicide, with a rate of 10.5 per 100,000 population, compared with 12.5 among non-Hispanic whites, 5.7 among Hispanics, 5.5 for African-Americans, and 5.4 among APIs. (See Table 6.16.)

Indian Health Service

Federal funding for Native American health care is provided through the Indian Health Service (IHS), which is "charged with raising Indians' health status to the highest possible level." Delivery of health care to Native Americans is complicated by the lack of services and the long distances that sometimes must be traveled to receive care. Alaska Natives are often able to get preventive medical care only by flying to a medical facility, and, while transportation costs are covered for emergency care, transportation costs are not provided for routine care.

Using Gambling Profits to Improve Health Services

Many Native American tribes have invested some of the money earned from their casinos to improve health services. The Sandia Pueblo in New Mexico, for example, now has a multimillion-dollar medical complex. This saves the residents the long drives to distant clinics that provide medical and dental care through the IHS. The center includes exam rooms, dental rooms, and state-ofthe-art equipment. There is an adjacent wellness and education center that houses a gymnasium, weight room, and aquatic therapy facilities.

Diabetes

Diabetes is a significant problem in the Native American community. According to the American Diabetes Association, nearly 108,000 Native Americans and Alaska Natives had diabetes in 2004. That represents about 14.5 percent of those who receive health care through the IHS. The Diabetes Association also reports that Native Americans in the Southeast are more likely to have diabetes, with a prevalence rate of 27 percent, compared with 6.8 percent of Alaska Natives. In 2001 there were 40.4 Native American/Alaska Native deaths per 100,000 people due to diabetes, compared to 49.2 among African-American deaths, 36.7 Hispanic deaths, 22.1 non-Hispanic white deaths, and 16.9 API deaths due to the disease. (See Table 6.16.)

Infant Mortality

The infant mortality rate for Native Americans and Alaska Natives fell from 15.2 deaths per 1,000 live births in 1983 to 8.3 per 1,000 live births in 2000, but 2001 saw an increase to 9.7 per 1,000 live births. The infant mortality rate for Native Americans and Alaska Natives was higher in 2001 than the rate for any other

White, not Hispanic Black, not Hispanic Hispanic
2001 Cumulative total 2001 Cumulative total 2001 Cumulative total
Exposure category No. (%) No. (%) No. (%) No. (%) No. (%) No. (%)
Hemophilia/coagulation disorder0(0)159(10)0(0)34(1)0(0)37(2)
Mother with/at risk for HIV infection:25(76)1,197(76)100(88)5,110(96)22(85)1,900(92)
Injecting drug use5493241,9664755
Sex with injecting drug user924247412495
Sex with bisexual male167475041
Sex with person with hemophilia1190608
Sex with transfusion recipient with HIV infection080809
Sex with HIV-infected person, risk not specified4155278957274
Receipt of blood transfusion, blood components, or tissue043275034
Has HIV infection, risk not specified5170391,3449284
Receipt of blood transfusion, blood components, or tissue2(6)191(12)0(0)86(2)0(0)93(5)
Risk not reported or identified6(18)32(2)13(12)107(2)4(15)30(1)
Total 33 (100) 1,579 (100) 113 (100) 5,337 (100) 26 (100) 2,060 (100)
Asian/Pacific Islander American Indian/Alaska Native Cumulative totals*
2001 Cumulative total 2001 Cumulative total 2001 Cumulative total
Exposure category No. (%) No. (%) No. (%) No. (%) No. (%) No. (%)
Hemophilia/coagulation disorder0(0)3(6)0(0)2(6)0(0)236(3)
Mother with/at risk for HIV infection:3(100)36(67)0(0)29(94)150(86)8,284(91)
Injecting drug use06014333,238
Sex with injecting drug user0606151,491
Sex with bisexual male02005186
Sex with person with hemophilia0000133
Sex with transfusion recipient with HIV infection0000025
Sex with HIV-infected person, risk not specified0904381,339
Receipt of blood transfusion, blood components, or tissue01012154
Has HIV infection, risk not specified31204561,818
Receipt of blood transfusion, blood components, or tissue0(0)11(20)0(0)0(0)2(1)381(4)
Risk not reported or identified0(0)4(7)0(0)0(0)23(13)173(2)
Total 3 (100) 54 (100) 0 (0) 31 (100) 175 (100) 9,074 (100)
*Includes 13 children whose race/ethnicity is unknown.
source: "Table 15. Pediatric AIDS Cases by Exposure Category and Race/Ethnicity Reported through December 2001, United States," in HIV/AIDS Surveillance Report, vol. 13, no. 2, Centers for Disease Control and Prevention, Atlanta, GA, 2001

racial or ethnic group except for African-Americans. (See Table 6.4.) While the infant mortality rate among Native Americans/Alaska Natives was higher than that of most other groups, the percentage of babies born with a low birth weight was not significantly higher than that of other groups. Approximately 7.3 percent of Native American and Alaska Native babies were born with a low birth weight in 2001, compared to 6.8 percent of non-Hispanic whites and 6.5 percent of Hispanics. Native Americans and Alaska Natives had a lower percentage of low-birth-weight babies than non-Hispanic African-Americans (13.1 percent) and APIs (7.5 percent). (See Table 6.3.)

Causes of Death

Heart disease, the number one cause of death in America, also claims the highest number of Native American/Alaska Native lives. However, in 2001, only APIs, at 137.6 per 100,000, had a lower mortality rate for heart disease than Native Americans/Alaska Natives, at 159.6 deaths per 100,000 population. (See Table 6.16.)

Compared to the national average, Native Americans/Alaska Natives have lower rates of deaths due to lung cancer and breast cancer. In 2001 the Native American and Alaska Native lung cancer mortality rate was 34.2 per 100,000 people versus the national average of 55.3;

White, not Hispanic Black, not Hispanic Hispanic
2001 Cumulative total 2001 Cumulative total 2001 Cumulative total
Exposure category No. (%) No. (%) No. (%) No. (%) No. (%) No. (%)
Men who have sex with men6,745(60)230,202(74)4,057(29)82,939(37)2,202(35)50,660(42)
Injecting drug use1,156(10)29,174(9)2,729(20)74,544(33)1,332(21)41,351(34)
Men who have sex with men and inject drugs682(6)25,960(8)548(4)16,718(7)231(4)8,050(7)
Hemophilia/coagulation disorder80(1)3,875(1)13(0)579(0)3(0)440(0)
Heterosexual contact:403(4)6,045(2)1,705(12)19,109(8)613(10)7,266(6)
Sex with injecting drug user942,0603305,7521171,929
Sex with person with hemophilia132425011
Sex with transfusion recipient with HIV infection71688176290
Sex with HIV-infected person, risk not specified3013,7851,36313,1564945,236
Receipt of blood transfusion, blood components, or tissue47(0)3,200(1)40(0)1,118(0)12(0)606(1)
Risk not reported or identified2,051(18)13,697(4)4,803(35)30,829(14)1,896(30)11,758(10)
Total 11,164 (100) 312,153 (100) 13,895 (100) 225,836 (100) 6,289 (100) 120,131 (100)
Asian/Pacific Islander American Indian/Alaska Native Cumulative totals*
2001 Cumulative total 2001 Cumulative total 2001 Cumulative total
Exposure category No. (%) No. (%) No. (%) No. (%) No. (%) No. (%)
Men who have sex with men188(53)3,757(71)55(36)1,122(55)13,265(42)368,971(55)
Injecting drug use12(3)267(5)29(19)326(16)5,261(16)145,750(22)
Men who have sex with men and inject drugs7(2)200(4)33(22)351(17)1,502(5)51,293(8)
Hemophilia/coagulation disorder1(0)71(1)0(0)30(1)97(0)5,000(1)
Heterosexual contact:30(8)233(4)9(6)65(3)2,762(9)32,735(5)
Sex with injecting drug user3554195499,821
Sex with person with hemophilia0100569
Sex with transfusion recipient with HIV infection290219446
Sex with HIV-infected person, risk not specified251685442,18922,399
Receipt of blood transfusion, blood components, or tissue6(2)116(2)0(0)9(0)105(0)5,057(1)
Risk not reported or identified114(32)683(13)26(17)136(7)8,909(28)57,220(9)
Total 358 (100) 5,327 (100) 152 (100) 2,039 (100) 31,901 (100) 666,026 (100)
*Includes 540 men whose race/ethnicity is unknown.
source: "Table 9. Male Adult/Adolescent AIDS Cases by Exposure Category and Race/Ethnicity, Reported through December 2001, United States," in HIV/AIDS Surveillance Report, vol. 13, no. 2, Centers for Disease Control and Prevention, Atlanta, GA, 2001 [Online] http://www.cdc.gov/hiv/stats/hasr1302.pdf [accessed March 11, 2004]

their female breast cancer mortality rate was 11.8 per 100,000 people versus the nationwide average of 26.0. The Native American and Alaska Native homicide rate of 6.8 per 100,000 population in 2001 compares with a nationwide average of 7.1 per 100,000, though the national average saw an unprecedented jump that year due to the homicides associated with the terrorist events of September 11, 2001. (See Table 6.16.)

In 2001 Native Americans and Alaska Natives were considerably more likely to die from injuries related to a motor vehicle accident than any other racial or ethnic group. The rate of Native American/Alaska Native deaths per 100,000 population was 25.9, compared to 15.5 among non-Hispanic whites, 15.4 among African-Americans, 15.0 for Hispanics, and 8.1 for APIs. (See Table 6.16.)

ASIAN-AMERICAN HEALTH CARE

The typical Asian/Pacific Islander (API) diet, low in fat and cholesterol, is generally healthful. The staple food for many APIs is rice. Consumption of vegetables is relatively high; pork and fish are also commonly eaten. Dairy products are used less frequently. The traditional sources of calcium are soybean curd, sardines, and green, leafy vegetables. At the same time, many Asian-Americans pride themselves on their independence and self-sufficiency. Consequently, some are particularly reluctant to

White, not Hispanic Black, not Hispanic Hispanic
2001 Cumulative total 2001 Cumulative total 2001 Cumulative total
Exposure category No. (%) No. (%) No. (%) No. (%) No. (%) No. (%)
Injecting drug use578(28)12,365(41)1,257(18)32,267(39)355(19)10,592(38)
Hemophilia/coagulation disorder5(0)112(0)3(0)112(0)1(0)57(0)
Heterosexual contact:707(35)12,083(40)2,606(37)31,763(39)781(41)12,975(47)
Sex with injecting drug user2124,80052111,1691935,597
Sex with bisexual male551,5741111,55221572
Sex with person with hemophilia4289390140
Sex with transfusion recipient with HIV infection231571743105
Sex with HIV-infected person, risk not specified4345,1051,96418,7785636,661
Receipt of blood transfusion, blood components, or tissue23(1)1,851(6)71(1)1,375(2)17(1)570(2)
Risk not reported or identified727(36)3,745(12)3,086(44)16,490(20)740(39)3,367(12)
Total 2,040 (100) 30,156 (100) 7,023 (100) 82,007 (100) 1,894 (100) 27,561 (100)
Asian/Pacific Islander American Indian/Alaska Native Cumulative totals*
2001 Cumulative total 2001 Cumulative total 2001 Cumulative total
Exposure category No. (%) No. (%) No. (%) No. (%) No. (%) No. (%)
Hemophilia/coagulation disorder0(0)6(1)0(0)3(1)9(0)292(0)
Heterosexual contact:29(42)378(49)13(31)173(37)4,142(37)57,396(41)
Sex with injecting drug user58767793721,736
Sex with bisexual male4761251923,801
Sex with person with hemophilia04028425
Sex with transfusion recipient with HIV infection1210313619
Sex with HIV-infected person, risk not specified191906662,99230,815
Receipt of blood transfusion, blood components, or tissue1(1)102(13)1(2)15(3)113(1)3,914(3)
Risk not reported or identified32(46)174(22)13(31)70(15)4,606(42)23,870(17)
Total 69 (100) 776 (100) 42 (100) 467 (100) 11,082 (100) 141,048 (100)
*Includes 81 women whose race/ethnicity is unknown.
source: "Table 11. Female Adult/Adolescent AIDS Cases by Exposure Category and Race/Ethnicity, Reported through December 2001, United States," in HIV/AIDS Surveillance Report, vol. 13, no. 2, Centers for Disease Control and Prevention, Atlanta, GA, 2001 [Online] http://www.cdc.gov/hiv/stats/hasr1302.pdf [accessed March 11, 2004]

seek health services outside of their own community. In 2001, 20.8 percent of Asian-Americans had made no visits to a doctor's office within the past year, a rate that was higher than that for both non-Hispanic whites and non-Hispanic African-Americans. (See Table 6.5.)

Infant Mortality

Infant mortality rates in the Asian-American community are generally lower than for any other race. In 2001 the rate was 4.7 deaths per 1,000 live births. In comparison, non-Hispanic whites had 5.7 deaths per 1,000 live births and non-Hispanic African-Americans had 13.5 deaths per 1,000 live births. (See Table 6.4.)

In 2001, 7.5 percent of Asian and Pacific Islander women had low-birth-weight babies. This proportion was higher than all other racial and ethnic groups except African-Americans, for whom approximately 13 percent of babies were low-birth-weight babies. (See Table 6.3.) Maternal education and socioeconomic status are relatively high among many Asian-Americans. In 2001, only 16 percent of API women received no prenatal care in their first trimester. This percentage is lower than for many other ethnic and racial groups. Among APIs, Japanese Americans had the highest percentage receiving prenatal care in the first trimester (90.1 percent), while Hawaiians had the lowest (79.1 percent).(See Table 6.20.)

Breast Cancer

Asian and Pacific Islander women are less likely than many other racial and ethnic groups to die of breast cancer. In 2001 there were 12.9 deaths per 100,000 population due to breast cancer among APIs, with only Native Americans and Alaska Natives, at 11.8, having a lower

Sex, race, Hispanic origin, and cause of death1 19502 19602 1970 1980 1990 1995 2000 2001
All persons Age-adjusted death rate per 100,000 population3
All causes1,446.01,339.21,222.61,039.1938.7909.8869.0854.5
Diseases of heart586.8559.0492.7412.1321.8293.4257.6247.8
Ischemic heart disease- - -- - -- - -345.2249.6219.7186.8177.8
Cerebrovascular diseases180.7177.9147.796.265.363.160.957.9
Malignant neoplasms193.9193.9198.6207.9216.0209.9199.6196.0
Trachea, bronchus, and lung15.024.137.149.959.358.456.155.3
Colon, rectum, and anus- - -30.328.927.424.522.520.820.1
Prostat428.628.728.832.838.437.030.429.1
Breast531.931.732.131.933.330.526.826.0
Chronic lower respiratory diseases- - -- - -- - -28.337.240.144.243.7
Influenza and pneumonia48.153.741.731.436.833.423.722.0
Chronic liver disease and cirrhosis11.313.317.815.111.19.99.59.5
Diabetes mellitus23.122.524.318.120.723.225.025.3
Human immunodeficiency virus (HIV) disease- - -- - -- - -- - -10.216.25.25.0
Unintentional injuries78.062.360.146.436.334.434.935.7
Motor vehicle-related injuries24.623.127.622.318.516.315.415.3
Suicide613.212.513.112.212.511.810.410.7
Homicide65.15.08.810.49.48.35.97.1
Male
All causes1,674.21,609.01,542.11,348.11,202.81,143.91,053.81,029.1
Diseases of heart697.0687.6634.0538.9412.4371.0320.0305.4
Ischemic heart disease- - -- - -- - -459.7328.2286.5241.4228.5
Cerebrovascular diseases186.4186.1157.4102.268.565.962.459.0
Malignant neoplasms208.1225.1247.6271.2280.4267.5248.9243.7
Trachea, bronchus, and lung24.643.667.585.291.184.276.775.2
Colon, rectum, and anus- - -31.832.332.830.427.425.124.2
Prostate28.628.728.832.838.437.030.429.1
Chronic lower respiratory diseases- - -- - -- - -49.955.454.855.854.0
Influenza and pneumonia55.065.854.042.147.842.828.926.6
Chronic liver disease and cirrhosis15.018.524.821.315.914.213.413.2
Diabetes mellitus18.819.923.018.121.725.027.828.1
Human immunodeficiency virus (HIV) disease- - -- - -- - -- - -18.527.37.97.5
Unintentional injuries101.885.587.469.052.949.649.350.2
Motor vehicle-related injuries38.535.441.533.626.522.821.721.8
Suicide621.220.019.819.921.520.317.718.2
Homicide67.97.514.316.614.812.89.010.8
Female
All causes1,236.01,105.3971.4817.9750.9739.4731.4721.8
Diseases of heart484.7447.0381.6320.8257.0236.6210.9203.9
Ischemic heart disease- - -- - -- - -263.1193.9171.3146.5139.9
Cerebrovascular diseases175.8170.7140.091.762.660.559.156.4
Malignant neoplasms182.3168.7163.2166.7175.7173.6167.6164.7
Trachea, bronchus, and lung5.87.513.124.437.140.441.341.0
Colon, rectum, and anus- - -29.126.523.820.619.117.717.2
Breast31.931.732.131.933.330.526.826.0
Chronic lower respiratory diseases- - -- - -- - -14.926.631.837.437.6
Influenza and pneumonia41.943.832.725.130.528.120.719.2
Chronic liver disease and cirrhosis7.88.711.99.97.16.26.26.2
Diabetes mellitus27.024.725.118.019.921.823.023.1
Human immunodeficiency virus (HIV) disease- - -- - -- - -2.25.32.52.5
Unintentional injuries54.040.035.126.121.521.022.022.5
Motor vehicle-related injuries11.511.714.911.811.010.39.59.3
Suicide65.65.67.45.74.84.34.04.0
Homicide62.42.63.74.44.03.72.83.3

rate. The API rate was significantly lower than the mortality rate for African-American women (34.4) and only half that of non-Hispanic whites (26.0). (See Table 6.16.)

Cardiovascular Disease

Among Asians and Pacific Islanders, there were 137.6 deaths per 100,000 in 2001 due to heart disease, compared to 159.6 per 100,000 among Native Americans and Alaska Natives, 192.2 per 100,000 among Hispanics, 316.9 per 100,000 African-Americans, and 245.6 per 100,000 among non-Hispanic whites. (See Table 6.16.)

Tuberculosis

Asians and Pacific Islanders have higher rates of tuberculosis than other racial and ethnic groups. In 2002 there were 27.8 cases of tuberculosis per 100,000 population, compared to 1.5 cases among non-Hispanic whites, 10.4 cases per 100,000 among Hispanics, 6.8 cases per 100,000 among

Sex, race, Hispanic origin, and cause of death1 19502 19602 1970 1980 1990 1995 2000 2001
White7 Age-adjusted death rate per 100,000 population3
All causes1,410.81,311.31,193.31,012.7909.8882.3849.8836.5
Diseases of heart584.8559.0492.2409.4317.0288.6253.4243.5
Ischemic heart disease- - -- - -- - -347.6249.7219.1185.6176.5
Cerebrovascular diseases175.5172.7143.593.262.860.758.855.8
Malignant neoplasms194.6193.1196.7204.2211.6206.2197.2193.9
Trachea, bronchus, and lung15.224.036.749.258.658.156.255.6
Colon, rectum, and anus- - -30.929.227.424.122.020.319.6
Prostate428.427.727.430.535.534.227.826.6
Breast532.432.032.532.133.230.126.325.5
Chronic lower respiratory diseases- - -- - -- - -29.338.341.546.045.6
Influenza and pneumonia44.850.439.830.936.433.023.521.7
Chronic liver disease and cirrhosis11.513.216.613.910.59.79.69.6
Diabetes mellitus22.921.722.916.718.820.922.823.0
Human immunodeficiency virus (HIV) disease- - -- - -- - -- - -8.311.42.82.6
Unintentional injuries77.060.457.845.335.533.935.136.0
Motor vehicle-related injuries24.422.927.122.618.516.315.615.6
Suicide613.913.113.813.013.412.611.311.7
Homicide62.62.74.76.75.55.03.64.9
Black or African American7
All causes1,722.11,577.51,518.11,314.81,250.31,213.91,121.41,101.2
Diseases of heart586.7548.3512.0455.3391.5363.8324.8316.9
Ischemic heart disease- - -- - -- - -334.5267.0244.9218.3211.6
Cerebrovascular diseases233.6235.2197.1129.191.686.981.978.8
Malignant neoplasms176.4199.1225.3256.4279.5267.7248.5243.1
Trachea, bronchus, and lung11.123.741.359.772.469.064.062.5
Colon, rectum, and anus- - -22.826.128.330.629.328.227.6
Prostate430.941.248.561.177.076.668.166.1
Breast525.327.928.931.738.138.034.534.4
Chronic lower respiratory diseases- - -- - -- - -19.228.130.131.630.9
Influenza and pneumonia76.781.157.234.439.436.425.624.1
Chronic liver disease and cirrhosis9.013.628.125.016.512.09.49.3
Diabetes mellitus23.530.938.832.740.546.749.549.2
Human immunodeficiency virus (HIV) disease- - -- - -- - -- - -26.754.223.322.8
Unintentional injuries79.974.078.357.643.841.037.737.6
Motor vehicle-related injuries26.024.231.120.218.816.715.715.4
Suicide64.55.06.26.57.16.85.55.5
Homicide628.326.044.039.036.329.720.521.2
American Indian or Alaska Native7
All causes- - -- - -- - -867.0716.3771.2709.3686.7
Diseases of heart- - -- - -- - -240.6200.6204.6178.2159.6
Ischemic heart disease- - -- - -- - -173.6139.1141.4129.1114.0
Cerebrovascular diseases- - -- - -- - -57.840.748.645.041.3
Malignant neoplasms- - -- - -- - -113.7121.8138.2127.8131.0
Trachea, bronchus, and lung- - -- - -- - -20.730.937.432.334.2
Colon, rectum, and anus- - -- - -- - -9.512.014.913.412.0
Prostate4- - -- - -- - -20.717.821.719.619.0
Breast5- - -- - -- - -10.813.715.03.611.8
Chronic lower respiratory diseases- - -- - -- - -14.225.427.632.830.0
Influenza and pneumonia- - -- - -- - -44.436.136.122.322.5
Chronic liver disease and cirrhosis- - -- - -- - -45.324.127.424.322.6
Diabetes mellitus- - -- - -- - -29.634.145.941.540.4
Human immunodeficiency virus (HIV) disease- - -- - -- - -- - -1.86.52.22.7
Unintentional injuries- - -- - -- - -99.062.655.351.351.3
Motor vehicle-related injuries- - -- - -- - -54.532.529.127.325.9
Suicide6- - -- - -- - -11.911.710.69.810.5
Homicide6- - -- -- - -15.510.49.96.86.8

Native Americans/Alaska Natives, and 12.6 cases per 100,000 among non-Hispanic African-Americans. (See Table 6.21.)

Other Causes of Death

Asians and Pacific Islanders were the least likely group to be killed in motor vehicle crashes. In 2001, 8.1 APIs per 100,000 population died in vehicle crashes, compared to the national average of 15.3 per 100,000 people. APIs were also the least likely group to commit suicide, at 5.4 per 100,000, compared to 10.5 for Native Americans/Alaska Natives, 12.5 for non-Hispanic whites, 5.5 for African-Americans, and 5.7 for Hispanics. In 2001 APIs had the second-lowest death rate due to homicide at 4.2 per 100,000. Non-Hispanic whites had the lowest at 4.0 per 100,000, while African-Americans had the highest at 21.2 per 100,000. (See Table 6.16.)

Sex, race, Hispanic origin, and cause of death1 19502 19602 1970 1980 1990 1995 2000 2001
Asian or Pacific Islander7 Age-adjusted death rate per 100,000 population3
All causes- - -- - -- - -589.9582.0554.8506.4492.1
Diseases of heart- - -- - -- - -202.1181.7171.3146.0137.6
Ischemic heart disease- - -- - -- - -168.2139.6128.0109.6103.0
Cerebrovascular diseases- - -- - -- - -66.156.955.252.951.2
Malignant neoplasms- - -- - -- - -126.1134.2131.8121.9119.5
Trachea, bronchus, and lung- - -- - -- - -28.430.229.928.128.2
Colon, rectum, and anus- - -- - -- - -16.414.414.012.713.2
Prostate4- - -- - -- - -10.216.818.012.511.6
Breast5- - -- - -- - -11.913.713.912.312.9
Chronic lower respiratory diseases- - -- - -- - -12.919.419.318.617.7
Influenza and pneumonia- - -- - -- - -24.031.429.119.719.0
Chronic liver disease and cirrhosis- - -- - -- - -6.15.23.93.53.5
Diabetes mellitus- - -- - -- - -12.614.616.816.416.9
Human immunodeficiency virus (HIV) disease- - -- - -- - -2.23.20.60.7
Unintentional injuries- - -- - -- - -27.023.920.217.917.4
Motor vehicle-related injuries- - -- - -- - -13.914.011.48.68.1
Suicide6- - -- - -- - -7.86.76.75.55.4
Homicide6- - -- - -- - -5.95.04.73.04.2
Hispanic or Latino7,8
All causes- - -- - -- - -- - -692.0700.2665.7658.7
Diseases of heart- - -- - -- - -- - -217.1211.0196.0192.2
Ischemic heart disease- - -- - -- - -- - -173.3166.4153.2149.9
Cerebrovascular diseases- - -- - -- - -- - -45.246.346.444.9
Malignant neoplasms- - -- - -- - -- - -136.8138.5134.9132.3
Trachea, bronchus, and lung- - -- - -- - -- - -26.525.924.823.8
Colon, rectum, and anus- - -- - -- - -- - -14.714.114.114.1
Prostate4- - -- - -- - -- - -23.327.421.623.5
Breast5- - -- - -- - -- - -19.518.716.916.3
Chronic lower respiratory diseases- - -- - -- - -- - -19.322.621.120.7
Influenza and pneumonia- - -- - -- - -- - -29.726.220.620.5
Chronic liver disease and cirrhosis- - -- - -- - -- - -18.317.416.515.8
Diabetes mellitus- - -- - -- - -- - -28.235.736.936.7
Human immunodeficiency virus (HIV) disease- - -- - -- - -- - -16.324.96.76.2
Unintentional injuries- - -- - -- - -- - -34.632.230.130.7
Motor vehicle-related injuries- - -- - -- - -- - -19.516.414.715.0
Suicide6- - -- - -- - -- - -7.87.25.95.7
Homicide6- - -- - -- - -- - -6.212.57.58.3
Sex, race, Hispanic origin, and cause of death1 19502 19602 1970 1980 1990 1995 20003 2001
White, not Hispanic or Latino9 Age-adjusted death rate per 100,000 population3
All causes- - -- - -- - -- - -914.5882.3855.5842.9
Diseases of heart- - -- - -- - -- - -319.7289.9255.5245.6
Ischemic heart disease- - -- - -- - -- - -251.9219.9186.6177.5
Cerebrovascular diseases- - -- - -- - -- - -63.560.859.056.0
Malignant neoplasms- - -- - -- - -- - -215.4208.9200.6197.4
Trachea, bronchus, and lung- - -- - -- - -- - -60.359.658.257.7
Colon, rectum, and anus- - -- - -- - -- - -24.622.320.519.9
Prostate5- - -- - -- - -- - -36.134.428.026.7
Breast6- - -- - -- - -- - -33.930.626.826.0
Chronic lower respiratory diseases- - -- - -- - -- - -39.242.147.247.0
Influenza and pneumonia- - -- - -- - -- - -36.533.023.521.7
Chronic liver disease and cirrhosis- - -- - -- - -- - -9.99.09.09.0
Diabetes mellitus- - -- - -- - -- - -18.320.121.822.1
Human immunodeficiency virus (HIV) disease- - -- - -- - -- - -7.49.82.22.1
Unintentional injuries- - -- - -- - -- - -35.033.435.336.2
Motor vehicle-related injuries- - -- - -- - -- - -8.216.115.615.5
Suicide7- - -- - -- - -- - -13.813.112.012.5
Homicide7- - -- - -- - -- - -4.03.62.84.0
- - - Data not available.
1Underlying cause of death code numbers are based on the applicable revision of the International Classification of Diseases (ICD) for data years shown.
2Includes deaths of persons who were not residents of the 50 states and the District of Columbia.
3Age-adjusted rates are calculated using the year 2000 standard population starting with Health, United States, 2001.
4Rate for male population only.
5Rate for female population only.
6Figures for 2001 include September 11 related deaths for which death certificates were filed as of October 24, 2002.
7The race groups, white, black, Asian or Pacific Islander, and American Indian or Alaska Native, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Death rates for the American Indian or Alaska Native and Asian or Pacific Islander populations are known to be underestimated.
8Prior to 1997, excludes data from states lacking an Hispanic-origin item on the death certificate.
source: "Table 29. Age-Adjusted Death Rates for Selected Causes of Death, according to Sex, Race, and Hispanic Origin: United States, Selected Years 1950–2001," in Health, United States, 2003, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, 2003 [Online] http://www.cdc.gov/nchs/data/hus/tables/2003/03hus029.pdf [accessed May 6, 2004]
All races White Black or African American1
Specified age and year Both sexes Male Female Both sexes Male Female Both sexes Male Female
At birth Remaining life expectancy in years
19002,347.346.348.347.646.648.733.032.533.5
1950368.265.671.169.166.572.260.859.162.9
1960369.766.673.170.667.474.163.661.166.3
197070.867.174.771.768.075.664.160.068.3
198073.770.077.474.470.778.168.163.872.5
198574.771.178.275.371.878.769.365.073.4
199075.471.878.876.172.779.469.164.573.6
199175.572.078.976.372.979.669.364.673.8
199275.872.379.176.573.279.869.665.073.9
199375.572.278.876.373.179.569.264.673.7
199475.772.479.076.573.379.669.564.973.9
199575.872.578.976.573.479.669.665.273.9
199676.173.179.176.873.979.770.266.174.2
199776.573.679.477.174.379.971.167.274.7
199876.773.879.577.374.580.071.367.674.8
199976.773.979.477.374.679.971.467.874.7
2000477.074.379.777.674.980.171.968.375.2
2001577.274.479.877.775.080.272.268.675.5
At 65 years
1950313.912.815.0- - -12.815.113.912.914.9
1960314.312.815.814.412.915.913.912.715.1
197015.213.117.015.213.117.114.212.515.7
198016.414.118.316.514.218.415.113.016.8
198516.714.518.516.814.518.715.213.016.9
199017.215.118.917.315.219.115.413.217.2
199117.415.319.117.515.419.215.513.417.2
199217.515.419.217.615.519.315.713.517.4
199317.315.318.917.415.419.015.513.417.1
199417.415.519.017.515.619.115.713.617.2
199517.415.618.917.615.719.115.613.617.1
199617.515.719.017.615.819.115.813.917.2
199717.715.919.217.816.019.316.114.217.6
199817.816.019.217.816.119.316.114.317.4
199917.716.119.117.816.119.216.014.317.3
2000418.016.219.318.016.319.416.214.217.7
2001518.116.419.418.216.519.516.414.417.9
At 75 years
198010.48.811.510.48.811.59.78.310.7
198510.69.011.710.69.011.710.18.711.1
199010.99.412.011.09.412.010.28.611.2
199111.19.512.111.19.512.110.28.711.2
199211.29.612.211.29.612.210.48.911.4
199310.99.511.911.09.512.010.28.711.1
199411.09.612.011.19.612.010.38.911.2
199511.09.711.911.19.712.010.28.811.1
199611.19.812.011.19.812.010.39.011.2
199711.29.912.111.29.912.110.79.311.5
199811.310.012.211.310.012.210.59.211.3
199911.210.012.111.210.012.110.49.211.1
2000411.410.112.311.410.112.310.79.211.6
2001511.510.212.411.510.212.310.89.311.7
1Data shown for 1900–60 are for the nonwhite population.
2Death registration area only. The death registration area increased from 10 states and the District of Columbia in 1900 to the coterminous United States in 1933.
3Includes deaths of persons who were not residents of the 50 states and the District of Columbia.
4Life expectancies (LEs) for 2000 were revised and may differ from those shown previously. LEs for 2000 were computed using population counts from Census 2000 and replace LEs for 2000 using 1990-based postcensal estimates.
5Life expectancies for 2001 were computed using 2000-based postcensal estimates.
Notes: Populations used for computing life expectancy and other life table values for 1991–1999 are postcensal estimates of U.S. resident population, based on the 1990 census. Beginning in 1997 life table methodology was revised to construct complete life tables by single years of age that extend to age 100. (Anderson RN. Method for Constructing Complete Annual U.S. Life Tables. National Center for Health Statistics. Vital Health Stat 2(129). 1999.) Previously abridged life tables were constructed for 5-year age groups ending with the age group 85 years and over. Life table values for 2000 and 2001 were computed using a slight modification of the new life table method due to a change in the age detail of populations received from t he U.S. Census Bureau.
source: "Table 27. Life Expectancy at Birth, at 65 Years of Age, and at 75 Years of Age, According to Race and Sex: United States, Selected Years 1900–2001," in Health, United States, 2003, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, 2003 [Online] http://www.cdc.gov/nchs/data/hus/tables/2003/03hus027.pdf [accessed May 14, 2004]
2001 2000
Age, race, and sex Number Rate Number Rate
All races, both sexes
All ages2,417,762848.92,403,351854.0
Under 1 year127,801689.228,035736.7
1–4 years5,12533.44,97932.4
5–14 years7,10017.37,41318.0
15–24 years32,15780.531,30779.9
25–34 years41,474104.740,451101.4
35–44 years91,457203.289,798198.9
45–54 years167,836428.3160,341425.6
55–64 years244,002964.1240,846992.2
65–74 years431,3062,355.2441,2092,399.1
75–84 years702,6575,588.2700,4455,666.5
85 years and over666,45615,133.8658,17115,524.4
Not stated390356
Age-adjusted rate855.0869.0
All races, male
All ages1,183,721846.61,177,578853.0
Under 1 year115,591755.315,718806.5
1–4 years2,92237.32,82435.9
5–14 years4,17219.84,40120.9
15–24 years23,880116.623,071114.9
25–34 years28,626143.027,890138.6
35–44 years58,007258.957,297255.2
45–54 years104,697544.3100,398542.8
55–64 years144,8311,191.6143,3211,230.7
65–74 years241,7762,913.9247,4082,979.6
75–84 years341,1826,841.8340,2196,972.6
85 years and over217,73016,760.0214,74217,501.4
Not stated309289
Age-adjusted rate1,029.51,053.8
All races, female
All ages1,234,041851.21,225,773855.0
Under 1 year112,211620.012,317663.4
1–4 years2,20329.42,15528.7
5–14 years2,92814.63,01215.0
15–24 years8,27742.58,23643.1
25–34 years12,84965.612,56163.5
35–44 years33,451147.932,501143.2
45–54 years63,139316.559,943312.5
55–64 years99,171753.997,525772.2
65–74 years189,5301,892.3193,8011,921.2
75–84 years361,4764,764.3360,2264,814.7
85 years and over448,72714,453.4443,42914,719.2
Not stated8167
Age-adjusted rate722.4731.4
White, total2, both sexes
All ages2,081,842896.02,071,287900.2
Under 1 year118,094575.318,144610.6
1–4 years3,68130.83,49429.2
5–14 years5,16716.25,45017.0
15–24 years23,68775.323,01874.5
25–34 years29,83394.728,71990.3
35–44 years68,001185.366,496179.9
45–54 years128,589392.8122,674388.3
55–64 years197,786913.2195,541940.2
65–74 years367,6562,302.2376,9862,341.5
75–84 years628,7135,569.4627,7295,637.7
85 years and over610,33715,314.4602,76115,707.0
Not stated 298275
Age-adjusted rate837.3849.8
2001 2000
Age, race, and sex Number Rate Number Rate
White2, male
All ages1,011,922882.51,007,191887.8
Under 1 year110,157631.210,177667.6
1–4 years2,11234.52,00432.6
5–14 years3,01818.43,25519.8
15–24 years17,480107.716,868105.8
25–34 years20,869129.620,140124.1
35–44 years44,139239.143,378233.6
45–54 years81,318500.777,866496.9
55–64 years118,2771,126.8117,1141,163.3
65–74 years208,1042,846.5213,3792,905.7
75–84 years306,7996,811.2306,3706,933.1
85 years and over199,41016,955.1196,40917,716.4
Not stated239231
Age-adjusted rate1,006.91,029.4
White2, female
All ages1,069,920909.11,064,096912.3
Under 1 year17,937516.87,967550.5
1–4 years1,56926.91,49025.5
5–14 years2,14913.82,19514.1
15–24 years6,20840.76,15041.1
25–34 years8,96458.38,57955.1
35–44 years23,861130.823,118125.7
45–54 years47,270286.644,808281.4
55–64 years79,509712.378,427730.9
65–74 years159,5521,842.7163,6071,868.3
75–84 years321,9144,744.9321,3594,785.3
85 years and over410,92714,627.6406,35214,890.7
Not stated5944
Age-adjusted rate707.5715.3
White, non-Hispanic, both sexes
All ages1,965,750992.61,959,919993.2
Under 1 year113,391558.813,513596.5
1–4 years2,78430.32,64128.5
5–14 years4,16316.34,39717.1
15–24 years18,74174.118,26173.6
25–34 years24,14696.323,19190.1
35–44 years59,495188.158,231181.0
45–54 years117,106396.0111,964390.5
55–64 years184,189924.4182,348950.2
65–74 years346,9722,329.4356,8692,366.2
75–84 years604,2765,614.9604,6585,675.4
85 years and over590,37415,400.0583,75715,799.7
Not stated11289
Age-adjusted rate844.2855.5
White, non-Hispanic, male
All ages947,249976.9944,781978.5
Under 1 year17,543614.57,660658.7
1–4 years1,60534.01,54132.4
5–14 years2,43818.62,65220.0
15–24 years13,556105.213,066103.5
25–34 years16,599131.415,934123.0
35–44 years38,157241.337,622233.9
45–54 years73,758502.870,788497.7
55–64 years110,0251,136.6109,0311,170.9
65–74 years196,5102,874.5202,0382,930.5
75–84 years294,6186,865.6294,8426,977.8
85 years and over192,34717,078.7189,53717,853.2
Not stated9370
Age-adjusted rate1,014.21,035.4
2001 2000
Age, race, and sex Number Rate Number Rate
White, non-Hispanic, female
All ages1,018,5011,007.71,015,1381,007.3
Under 1 year15,848500.35,853530.9
1–4 years1,17926.31,10024.4
5–14 years1,72513.91,74513.9
15–24 years5,18641.85,19542.6
25–34 years7,54660.67,25756.8
35–44 years21,338135.020,609128.1
45–54 years43,348290.941,176285.0
55–64 years74,165724.073,317742.1
65–74 years150,4621,867.0154,8311,891.0
75–84 years309,6584,785.5309,8164,819.3
85 years and over398,02614,701.7394,22014,971.7
Not stated1919
Age-adjusted rate714.6721.5
Black, total2, both sexes
All ages287,110771.9285,826781.1
Under 1 year18,5631,314.58,7711,426.1
1–4 years1,18147.51,24849.9
5–14 years1,59023.31,64324.2
15–24 years7,122117.37,049119.4
25–34 years10,004184.610,239187.8
35–44 years20,622355.420,557356.9
45–54 years34,437770.133,289786.9
55–64 years39,8841,573.139,2811,607.8
65–74 years54,2443,249.555,1953,335.6
75–84 years62,0916,570.661,4446,701.3
85 years and over47,29114,521.347,03814,714.3
Not stated8172
Age-adjusted rate1,098.81,121.4
Black2, male
All ages145,617822.2145,184834.1
Under 1 year14,8001,437.24,9011,567.6
1–4 years67153.169254.5
5–14 years95827.797428.2
15–24 years5,457179.95,318181.4
25–34 years6,658258.66,750261.0
35–44 years12,091443.412,251453.0
45–54 years20,562994.519,9131,017.7
55–64 years22,8342,019.022,6782,080.1
65–74 years28,6984,155.429,0714,253.5
75–84 years28,3548,343.828,0268,486.0
85 years and over14,47116,419.514,56016,791.0
Not stated6350
Age-adjusted rate1,372.41,403.5
Black2, female
All ages141,493726.1140,642733.0
Under 1 year13,7631,185.43,8701,279.8
1–4 years50941.755645.3
5–14 years63218.866920.0
15–24 years1,66554.81,73158.3
25–34 years3,346117.63,489121.8
35–44 years8,531277.38,306271.9
45–54 years13,875577.013,376588.3
55–64 years17,0501,214.116,6031,227.2
65–74 years25,5462,610.226,1242,689.6
75–84 years33,7375,574.933,4185,696.5
85 years and over32,82013,817.032,47813,941.3
Not stated1822
Age-adjusted rate910.4927.6
2001 2000
Age, race, and sex Number Rate Number Rate
Black, non-Hispanic, both sexes
All ages283,739796.4282,676805.5
Under 1 year18,3331,363.68,5251,477.8
1–4 years1,15649.51,21751.7
5–14 years1,55924.01,62025.0
15–24 years6,997120.96,926123.2
25–34 years9,832190.910,103194.6
35–44 years20,373364.720,279365.1
45–54 years34,016785.032,911802.2
55–64 years39,4331,598.938,8671,633.9
65–74 years53,6683,292.454,6453,378.8
75–84 years61,4496,629.960,8746,764.3
85 years and over46,87314,631.146,66014,837.5
Not stated5149
Age-adjusted rate1,114.01,137.0
Black, non-Hispanic, male
All ages143,678848.0143,297859.5
Under 1 year14,6851,495.04,7571,623.2
1–4 years65555.167256.1
5–14 years93928.595929.1
15–24 years5,354185.45,224187.2
25–34 years6,532267.26,649270.2
35–44 years11,930454.812,061462.7
45–54 years20,2741,012.919,6471,036.2
55–64 years22,5282,048.922,4022,111.4
65–74 years28,3664,207.128,7454,303.9
75–84 years28,0408,413.927,7158,551.0
85 years and over14,33516,556.614,43116,944.8
Not stated4135
Age-adjusted rate1,391.01,422.0
Black, non-Hispanic, female
All ages140,061749.6139,379756.7
Under 1 year13,6481,225.23,7681,327.7
1–4 years50143.654547.1
5–14 years62019.466120.7
15–24 years1,64356.71,70260.1
25–34 years3,301122.03,454126.5
35–44 years8,443285.08,218278.8
45–54 years13,741589.413,264601.2
55–64 years16,9041,236.816,4651,249.4
65–74 years25,3022,647.225,9002,728.0
75–84 years33,4095,628.333,1595,758.6
85 years and over32,53813,918.032,22914,054.9
Not stated1014
Age-adjusted rate923.3941.2
American Indian, total2,3, both sexes
All ages12,017393.411,363380.8
Under 1 year1375653.9323598.4
1–4 years10549.09142.4
5–14 years13322.611319.0
15–24 years552101.651998.8
25–34 years602133.3596132.9
35–44 years1,137242.21,081232.5
45–54 years1,567435.01,354399.3
55–64 years1,768896.21,698925.5
65–74 years2,2102,076.12,1412,162.2
75–84 years2,1564,237.92,0624,448.6
85 years and over1,4058,916.11,3829,642.1
Not stated63
Age-adjusted rate688.8709.3
2001 2000
Age, race, and sex Number Rate Number Rate
American Indian2,3, male
All ages6,495426.16,185415.6
Under 1 year1212723.6193700.2
1–4 years5449.54944.9
5–14 years7826.26120.2
15–24 years398142.2369136.2
25–34 years422182.2410179.1
35–44 years725312.7675295.2
45–54 years947540.9858520.0
55–64 years1,0091,058.69641,090.4
65–74 years1,1632,389.41,1132,478.3
75–84 years9894,804.59895,351.2
85 years and over4949,797.750110,725.8
Not stated53
Age-adjusted rate802.3841.5
American Indian2,3, female
All ages5,522360.95,178346.1
Under 1 year1163581.0130492.2
1–4 years5148.54239.8
5–14 years5519.05217.7
15–24 years15458.515058.9
25–34 years18081.818684.8
35–44 years412173.4406171.9
45–54 years620334.9496284.9
55–64 years760745.4734772.1
65–74 years1,0471,812.11,0281,899.8
75–84 years1,1673,852.91,0733,850.0
85 years and over9118,501.38819,118.2
Not stated1-
Age-adjusted rate595.3604.5
Asian or Pacific Islander, total2, both sexes
All ages36,794301.734,875296.6
Under 1 year1769427.5797483.0
1–4 years15923.214621.6
5–14 years21012.320712.3
15–24 years79642.872139.0
25–34 years1,03546.189741.0
35–44 years1,69783.21,66484.5
45–54 years3,244199.93,024199.3
55–64 years4,564497.74,326509.0
65–74 years7,1961,266.96,8871,283.0
75–84 years9,6973,350.49,2103,495.2
85 years and over7,4239,644.66,99010,270.7
Not stated56
Age-adjusted rate488.5506.4
Asian or Pacific Islander2, male
All ages19,687332.619,018332.9
Under 1 year1421458.4447529.4
1–4 years8524.77923.3
5–14 years11813.511112.9
15–24 years54558.151655.2
25–34 years67661.259055.0
35–44 years1,051106.9993104.9
45–54 years1,870248.11,761249.7
55–64 years2,712629.22,565642.4
65–74 years3,8121,541.43,8451,661.0
75–84 years5,0404,131.24,8344,328.2
85 years and over3,35511,248.63,27212,125.3
Not stated25
Age-adjusted rate593.2624.2
2001 2000
Age, race, and sex Number Rate Number Rate
Asian or Pacific Islander2, female
All ages17,107272.615,857262.3
Under 1 year1348395.2350434.3
1–4 years7421.76720.0
5–14 years9211.09611.7
15–24 years25127.220522.4
25–34 years35931.430727.6
35–44 years64661.167165.6
45–54 years1,374158.11,263155.5
55–64 years1,851380.91,761390.9
65–74 years3,3851,055.53,042996.4
75–84 years4,6572,781.54,3762,882.4
85 years and over4,0688,629.83,7189,052.2
Not stated31
Age-adjusted rate409.0416.8
Hispanic4, both sexes
All ages112,584304.5107,254303.8
Under 1 year14,744580.54,598596.3
1–4 years91630.587229.6
5–14 years1,02714.61,06515.7
15–24 years4,98174.54,79372.8
25–34 years5,68382.85,50984.6
35–44 years8,350153.28,085157.6
45–54 years11,219330.210,356330.2
55–64 years13,189714.212,733744.4
65–74 years20,1001,769.719,4201,803.8
75–84 years23,4494,228.721,9514,335.9
85 years and over18,86711,796.717,81811,822.9
Not stated5954
Age-adjusted rate654.6665.7
Hispanic4, male
All ages62,706329.760,172331.3
Under 1 year12,625630.12,514637.1
1–4 years52334.147531.5
5–14 years59516.562217.9
15–24 years3,952109.63,837107.7
25–34 years4,271115.54,200120.2
35–44 years5,841206.65,597211.0
45–54 years7,358436.96,808439.0
55–64 years7,919911.67,760965.7
65–74 years11,1812,232.710,8422,287.9
75–84 years11,6625,214.710,9735,395.3
85 years and over6,73212,821.66,49313,086.2
Not stated4951
Age-adjusted rate796.0818.1
2001 2000
Age, race, and sex Number Rate Number Rate
Hispanic4, female
All ages49,878277.847,082274.6
Under 1 year12,119528.92,084553.6
1–4 years39326.839727.5
5–14 years43212.544313.4
15–24 years1,03033.495631.7
25–34 years1,41344.71,30943.4
35–44 years2,51095.72,488100.5
45–54 years3,861225.33,548223.8
55–64 years5,270538.94,973548.4
65–74 years8,9191,404.58,5781,423.2
75–84 years11,7873,562.310,9783,624.5
85 years and over12,13511,295.811,32511,202.8
Not stated103
Age-adjusted rate541.9546.0
…Category not applicable.
- Quantity zero.
1Death rates for "Under 1 year" (based on population estimates) differ from infant mortality rates (based on live births).
2Race and Hispanic origin are reported separately on the death certificate. Data for persons of Hispanic origin are included in the data for each race group, according to the race.
3Includes deaths among Aleuts and Eskimos.
4Includes all persons of Hispanic origin of any race.
Notes: Data are subject to sampling and/or random variation. The number of deaths and death rates for Hispanic origin and specified races other than white and black should be interpreted with caution because of inconsistencies between reporting Hispanic origin and race on death certificates and censuses and surveys1. Figures for 2001 are based on weighted data rounded to the nearest individual, so categories may not add to totals.
source: Elizabeth Arias and Betty L. Smith, "Table 1. Deaths and Death Rates by Ages, Sex, and Race and Hispanic Origin and Age-Adjusted Death Rates, by Sex and Race and Hispanic Origin: United States, Final 2000 and Preliminary 2001," in "Deaths Preliminary Data for 2001," National Vital Statistics Reports, vol. 51, no. 5, March 14, 2003 [Online] http://www.cdc.gov/nchs/data/nvsr/nvsr51/nvsr51_05.pdf [accessed March 11, 2004]
Sex, race, Hispanic origin, and age 19501 19601 1970 1980 1990 1995 2000 2001
All persons Deaths per 100,000 resident population
All ages, age adjusted5.15.08.810.49.48.35.97.1
All ages, crude5.04.68.110.69.98.56.07.1
Under 1 year4.44.84.35.98.48.29.28.2
1–14 years0.60.61.11.51.81.91.31.3
1–4 years0.60.71.92.52.52.92.32.7
5–14 years0.50.50.91.21.51.50.90.8
15–24 years5.85.611.315.419.719.612.613.3
15–19 years3.93.97.710.516.917.89.59.4
20–24 years8.57.715.620.222.221.516.017.3
25–44 years8.98.514.917.514.711.98.711.2
25–34 years9.39.216.219.317.414.410.413.1
35–44 years8.47.813.514.911.69.47.19.5
45–64 years5.05.38.79.06.35.44.05.4
45–54 years5.96.110.011.07.56.04.76.3
55–64 years3.94.17.17.05.04.43.04.0
65 years and over3.02.74.65.54.03.12.42.7
65–74 years3.22.84.95.73.83.22.42.9
75–84 years2.52.34.05.24.33.02.42.5
85 years and over2.32.44.25.34.63.22.42.4
Male
All ages, age adjusted7.97.514.316.614.812.89.010.8
All ages, crude7.76.813.117.115.913.49.311.1
Under 1 year4.54.74.56.38.89.010.49.5
1–14 years0.60.61.21.62.02.21.51.5
1–4 years0.50.71.92.72.73.12.53.0
5–14 years0.60.51.01.21.71.91.10.9
15–24 years8.68.418.224.032.532.820.922.2
15–19 years5.55.712.115.927.829.115.515.7
20–24 years13.511.825.632.236.936.526.728.9
25–44 years13.812.824.428.923.518.213.317.2
25–34 years14.413.926.831.927.722.516.720.8
35–44 years13.211.721.724.518.614.010.313.9
45–64 years8.18.114.815.210.28.36.08.1
45–54 years9.59.416.818.411.99.26.99.5
55–64 years6.36.412.111.88.07.04.65.9
65 years and over4.84.37.78.85.84.23.33.6
65–74 years5.24.68.59.25.84.53.44.0
75–84 years3.93.75.98.15.73.73.23.1
85 years and over2.53.67.47.56.74.13.33.2
Female
All ages, age adjusted2.42.63.74.44.03.72.83.3
All ages, crude2.42.43.44.54.23.82.83.3
Under 1 year4.24.94.15.68.07.47.96.9
1–14 years0.60.51.01.41.61.51.11.1
1–4 years0.70.71.92.22.32.62.12.4
5–14 years0.50.40.71.11.21.00.70.7
15–24 years3.02.84.66.66.25.93.93.9
15–19 years2.41.93.24.95.45.83.12.7
20–24 years3.73.86.28.27.06.04.75.1
25–44 years4.24.35.86.46.05.64.05.2
25–34 years4.54.66.06.97.16.34.15.3
35–44 years3.84.05.75.74.84.94.05.1
45–64 years1.92.53.13.42.82.62.12.8
45–54 years2.32.93.74.13.22.92.53.2
55–64 years1.42.02.52.82.32.11.62.2
65 years and over1.41.32.33.32.82.41.82.0
65–74 years1.31.32.23.02.22.11.62.0
75–84 years1.41.32.73.53.42.62.02.1
85 years and over2.11.62.54.33.82.92.02.0
Sex, race, Hispanic origin, and age 19501 19601 1970 1980 1990 1995 2000 2001
White male2 Deaths per 100,000 resident population
All ages, age adjusted3.83.97.210.48.37.35.27.1
All ages, crude3.63.66.610.78.87.55.27.2
Under 1 year4.33.82.94.36.47.18.27.3
1–14 years0.40.50.71.21.31.51.21.1
15–24 years3.25.07.615.115.215.99.911.2
25–44 years5.45.511.617.213.010.47.411.5
25–34 years4.95.712.518.514.712.18.412.3
35–44 years6.15.210.815.211.18.76.510.7
45–64 years4.84.68.39.86.95.54.16.4
65 years and over3.83.15.46.74.12.92.53.0
Black or African American male2
All ages, age adjusted47.042.378.269.463.151.135.436.2
All ages, crude44.735.066.065.768.554.537.238.3
Under 1 year- - -10.314.318.621.420.323.321.0
1–14 years 3 1.81.54.44.15.85.83.13.6
15–24 years53.843.298.382.6137.1129.485.385.7
25–44 years92.880.5140.2130.0105.475.855.858.1
25–34 years104.386.4154.5142.9123.795.173.978.8
35–44 years80.074.4124.0109.381.254.938.538.5
45–64 years46.044.682.370.641.433.421.922.7
65 years and over16.517.333.330.925.720.312.811.5
American Indian or Alaska Native male2
All ages, age adjusted- - -- - -- - -23.316.714.410.79.3
All ages, crude- - -- - -- - -23.116.615.710.79.6
15–24 years- - -- - -- - -35.425.128.017.016.1
25–44 years- - -- - -- - -39.225.724.617.013.6
45–64 years- - -- - -- - -22.114.812.0*8.9
Asian or Pacific Islander male2
All ages, age adjusted- - -- - -- - -9.17.37.24.36.0
All ages, crude- - -- - -- - -8.37.97.54.46.3
15–24 years- - -- - -- - -9.314.917.27.89.1
25–44 years- - -- - -- - -11.39.67.44.68.5
45–64 years- - -- - -- - -10.47.07.76.17.7
Hispanic or Latino male2,4
All ages, age adjusted- - -- - -- - -- - -27.420.411.812.9
All ages, crude- - -- - -- - -- - -31.023.513.414.5
Under 1 year- - -- - -- - -- - -8.75.96.67.9
1–14 years- - -- - -- - -- - -3.13.21.71.5
15–24 years- - -- - -- - -- - -55.454.728.530.5
25–44 years- - -- - -- - -- - -46.428.817.219.2
25–34 years- - -- - -- - -- - -50.933.019.921.6
35–44 years- - -- - -- - -- - -39.322.813.515.9
45–64 years- - -- - -- - -- - -20.514.79.19.8
65 years and over- - -- - -- - -- - -9.45.84.45.5
White, not Hispanic or Latino male4
All ages, age adjusted- - -- - -- - -- - -5.64.83.65.6
All ages, crude- - -- - -- - -- - -5.84.93.65.6
Under 1 year- - -- - -- - -- - -5.46.88.36.8
1–14 years- - -- - -- - -- - -0.91.11.01.0
15–24 years- - -- - -- - -- - -7.57.24.75.7
25–44 years- - -- - -- - -- - -8.77.25.29.4
25–34 years- - -- - -- - -- - -9.37.75.29.3
35–44 years- - -- - -- - -- - -8.06.75.29.5
45–64 years- - -- - -- - -- - -5.74.63.65.9
65 years and over- - -- - -- - -- - -3.72.62.32.8
Sex, race, Hispanic origin, and age 19501 19601 1970 1980 1990 1995 2000 2001
White female2 Deaths per 100,000 resident population
All ages, age adjusted1.41.52.33.22.72.72.12.6
All ages, crude1.41.42.13.22.82.72.12.6
Under 1 year3.93.52.94.35.15.15.05.1
1–14 years0.40.40.71.11.01.10.80.9
15–24 years1.31.52.74.74.04.02.73.0
25–44 years2.02.13.34.23.83.72.94.0
45–64 years1.51.72.12.62.32.21.82.4
65 years and over1.21.21.92.92.22.01.61.8
Black or African American female3
All ages, age adjusted11.111.414.713.212.510.47.17.4
All ages, crude11.510.413.213.513.410.97.27.4
Under 1 year- - -13.810.712.822.820.122.216.7
1–14 years31.81.23.13.34.73.42.72.1
15–24 years16.511.917.718.418.916.410.78.9
25–44 years22.522.725.322.621.017.111.012.5
45–64 years6.810.313.410.86.55.94.55.7
65 years and over3.63.07.48.09.46.83.53.7
American Indian or Alaska Native female2
All ages, age adjusted- - -- - -- - -8.14.65.33.04.2
All ages, crude- - -- --- - -7.74.85.12.94.2
15–24 years- - -- --- - -*****
25–44 years- - -- --- - -13.76.98.35.95.9
45–64 years- - -- --- - -*****
Asian or Pacific Islander female2
All ages, age adjusted- - -- --- - -3.12.82.41.72.5
All ages, crude- - -- --- - -3.12.82.61.72.7
15–24 years- - -- --- - -**3.4**
25–44 years- - -- --- - -4.63.83.62.24.0
45–64 years- - -- --- - -**2.22.02.7
Hispanic or Latino female2,4
All ages, age adjusted- - -- --- - -- - -4.34.02.83.1
All ages, crude- - -- --- - -- - -4.74.22.83.2
Under 1 year- - -- --- - -- - -**7.45.5
1–14 years- - -- --- - -- - -1.91.81.01.0
15–24 years- - -- --- - -- - -8.16.43.74.0
25–44 years- - -- --- - -- - -6.15.63.74.8
45–64 years- - -- --- - -- - -3.33.42.93.0
65 years and over- - -- --- - -- - -*2.42.42.0
Sex, race, Hispanic origin, and age 19501 19601 1970 1980 1990 1995 2000 2001
White, not Hispanic or Latino female6
All ages, age adjusted- - -- - -- - -- - -2.52.31.92.5
All ages, crude- - -- - -- - -- - -2.52.31.92.4
Under 1 year- - -- - -- - -- - -4.44.44.14.7
1–14 years- - -- - -- - -- - -0.80.90.80.9
15–24 years- - -- - -- - -- - -3.33.42.32.7
25–44 years- - -- - -- - -- - -3.53.32.73.7
45–64 years- - -- - -- - -- - -2.21.91.62.3
65 years and over- - -- - -- - -- - -2.21.91.61.8
- - - Data not available.
*Rates based on fewer than 20 deaths are considered unreliable and are not shown.
1Includes deaths of persons who were not residents of the 50 states and the District of Columbia.
2The race groups, white, black, Asian or Pacific Islander, and American Indian or Alaska Native, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Death rates for the American Indian or Alaska Native and Asian or Pacific Islander populations are known to be underestimated.
3In 1950 rate is for the age group under 15 years.
4Prior to 1997, excludes data from states lacking an Hispanic-origin item on the death certificate.
Notes: Population estimates used to compute r ates for 1991–2000 differ from those used previously. Starting with Health, United States, 2003, rates for 1991–99 were revised using intercensal population estimates based on Census 2000. Rates for 2000 were revised based on Census 2000 counts. Rates for 2001 were computed using 2000-based postcensal estimates. Figures for 2001 include September 11 related deaths for which death certificates were filed as of October 24, 2002. Age groups were selected to minimize the presentation of unstable age-specific death rates based on small numbers of deaths and for consistency among comparison groups.
source: "Table 45. Death Rates for Homicide, according to Sex, Race, Hispanic Origin, and Age: United States, Selected Years 1950–2001," in Health, United States, 2003, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, 2003 [Online] http://www.cdc.gov/nchs/data/hus/tables/2003/03hus045.pdf [accessed May 6, 2004]
Prenatal care, race, and Hispanic origin of mother 1970 1975 1980 1985 1990 1995 1996 1997 1998 1999 2000 2001
Prenatal care began during 1st trimester Percent of live births1
All races68.072.476.376.275.881.381.982.582.883.283.283.4
White72.375.879.279.379.283.684.084.784.885.185.085.2
Black or African American44.255.562.461.560.670.471.472.373.374.174.374.5
American Indian or Alaska Native38.245.455.857.557.966.767.768.168.869.569.369.3
Asian or Pacific Islander- - -- - -73.774.175.179.981.282.183.183.784.084.0
Chinese71.876.782.682.081.385.786.887.488.588.587.687.0
Japanese78.182.786.184.787.089.789.389.390.290.791.090.1
Filipino60.670.677.376.577.180.982.583.384.284.284.985.0
Hawaiian- - -- - -68.867.765.875.978.578.078.879.679.979.1
Other Asian or Pacific Islander- - -- - -67.469.971.977.078.479.780.981.882.582.7
Hispanic or Latino2- - -- - -60.261.260.270.872.273.774.374.474.475.7
Mexican- - -- - -59.660.057.869.170.772.172.873.172.974.6
Puerto Rican- - -- - -55.158.363.574.075.076.576.977.778.579.1
Cuban- - -- - -82.782.584.889.289.290.491.891.491.791.8
Central and South American- - -- - -58.860.661.573.275.076.978.077.677.677.4
Other and unknown Hispanic or Latino- - -- - -66.465.866.474.374.676.074.874.875.877.3
Not Hispanic or Latino2
White- - -- - -81.281.483.387.187.487.987.988.488.588.5
Black or African American- - -- - -60.760.160.770.471.572.373.374.174.374.5
Prenatal care began during
3d trimester or no prenatal care
All races7.96.05.15.76.14.24.03.93.93.83.93.7
White6.35.04.34.84.93.53.33.23.33.23.33.2
Black or African American16.610.58.910.211.37.67.37.37.06.66.76.5
American Indian or Alaska Native28.922.415.212.912.99.58.68.68.58.28.68.2
Asian or Pacific Islander- - -- - -6.56.55.84.33.93.83.63.53.33.4
Chinese6.54.43.74.43.43.02.52.42.22.02.22.4
Japanese4.12.72.13.12.92.32.22.72.12.11.82.0
Filipino7.24.14.04.84.54.13.33.33.12.83.03.0
Hawaiian- - -- - -6.77.48.75.15.05.44.74.04.24.8
Other Asian or Pacific Islander- - -- - -9.38.27.15.04.64.44.24.13.83.8
Hispanic or Latino2- - -- - -12.012.412.07.46.76.26.36.36.35.9
Mexican- - -- - -11.812.913.28.17.26.76.86.76.96.2
Puerto Rican- - -- - -16.215.510.65.55.75.45.15.04.54.6
Cuban- - -- - -3.93.72.82.11.61.51.21.41.41.3
Central and South American- - -- - -13.112.510.96.15.55.04.95.25.45.7
Other and unknown Hispanic or Latino- - -- - -9.29.48.56.05.95.36.06.35.95.4
Not Hispanic or Latino2
White- - -- - -3.54.03.42.52.42.42.42.32.32.2
Black or African American- - -- - -9.710.911.27.67.37.37.06.66.76.5
- - - Data not available.
1Excludes live births for whom trimester when prenatal care began is unknown.
2Prior to 1993, data from states lacking an Hispanic-origin item on the birth certificate were excluded.
Notes: Data for 1970 and 1975 exclude births that occurred in states not reporting prenatal care. The race groups, white, black, American Indian or Alaska Native, and Asian or Pacific Islander, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Interpretation of trend data should take into consideration expansion of reporting areas and immigration.
source: "Table 6. Prenatal Care for Live Births, According to Detailed Race and Hispanic Origin of Mother: United States, Selected Years 1970–2001," in Health, United States, 2003, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, 2003 [Online] http://www.cdc.gov/nchs/data/hus/tables/2003/03hus006.pdf [accessed May 14, 2004]
White, non-Hispanic Black, non-Hispanic Hispanic1 American Indian/Alaska Native Asian/Pacific Islander Unknown or missing
Year Total cases No. % Rate No. % Rate No. % Rate No. % Rate No. % Rate No. %
199226,6737,618294.09,6233631.75,4372022.4299116.23,6491446.3470
199325,2876,922273.68,9513529.15,1942120.6274114.63,6801544.52661
199424,3616,494273.48,3453426.85,0742119.5332117.43,8211645.32951
199522,8605,989263.17,5553323.94,8472118.0319116.53,9971745.91531
199621,3375,506262.87,1063322.34,5332116.0284114.53,8141841.6940
199719,8514,872252.56,6103320.54,2282114.4264113.43,8331940.6440
199818,3614,495242.35,8313217.84,0992213.6253112.63,6232036.6600
199917,5314,224242.25,5523216.83,8752212.4240111.83,5912035.3490
200016,3773,674221.95,1613215.23,8052310.8236111.43,4512132.9500
200115,9893,357211.74,7963013.84,0012510.823318.53,5522230.9500
200215,0753,041201.54,4392912.63,9762610.418716.83,3452227.8871
1Persons of Hispanic origin may be of any race.
Note: Denominators for computing case rates were obtained as follows: 2000, April 2000 U.S. Census population figures; 2001 and 2002, midyear U.S. Census population estimates by age, race, sex, and Hispanic origin (eire.census.gov/popest/data/national/asro.php).
source: "Table 3. Tuberculosis Cases and Case Rates per 100,000 Population by Race/Ethnicity: United States, 1992–2002," in Reported Tuberculosis in the United States, 2002, Centers for Disease Control and Prevention, Atlanta, GA, 2003 [Online] http://www.cdc.gov/nchstp/tb/surv/surv2002/PDF/T2and3.pdf [accessed May 8, 2004]

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Health

Health

Health is a word used in a multitude of circumstances to convey a variety of different meanings. In its most general usage, health is a word to convey a state of being, a reflection of the overall condition of an organism, from the state of an individual cell to that of the entire body, at a particular time. Health is synonymous with a soundness of mind and body, consistent with a freedom from disease or abnormality.

Health is a word whose origins extend to the Old English expression used when drinking or offering a toast to a person's welfare. When paired with different adjectives, health becomes a specific descriptor of many physical or mental conditions, a focused phrase that can be adapted to create a perspective describing more discrete measures of performance.

Although used in a broad range of contexts, health has a number of fundamental aspects. A sound diet, with a proper distribution of carbohydrates, fats, and proteins, combined with the ingestion of sufficient quantities of vitamins and minerals is the first such component. Exercise sufficient to maintain a proper weight, as well as stimulating the various human systems such as the cardiovascular and musculoskeletal structures, is another important component. Sleep sufficient to permit the rest and repair of the body is another critical foundation to human health.

Health is also used to represent a companion state when paired with the term fitness. While health is an all-encompassing expression of the present physical condition of the human body, fitness is a word that is properly used with respect to the level of muscular and cardiovascular conditioning. While both health and fitness are states that must be achieved and maintained, as opposed to simply persisting for an indefinite period, it is likely impossible to possess one of these positive physical attributes without also having the other to at least some degree; for example, poor health and excellent fitness would be a difficult and dubious achievement.

It is when the mental health of an athlete is added to the consideration of total health and fitness that apparent contradictions may arise. The closer one comes to achieving elite status in a sport, the more crucial the maintenance of optimal mental health will be. Mental health includes such diverse components as concentration skills, psychological preparedness, the ability to maintain commitment to training regimes, and the ability to properly distinguish between normally occurring discomfort and actual injury. No athlete, from the recreational level to the world-class competitor, can ever perform at the maximum level as an automaton, a machine able to entirely divorce current mental state from physical performance. Comprehensive health and fitness will include all of the mental and physical aspects associated with human performance.

The word health is often paired with a broadly descriptive adjective, such as good health, excellent health, poor health, or failing health. Health is given a clearer and more precise meaning when it is applied to a specific aspect of the human experience, such as physical, mental or spiritual health; the well-known nostrum that begins "early to bed, early to rise" was humorously adapted by American humorist James Thurber to state: "Early to bed and early to rise, makes a man healthy, wealthy, and dead." Health is commonly used as a part of a description or assessment of the function of a defined physical process, particularly in various sports science contexts. Examples include cardiovascular health, cardiorespiratory health, and heart health. Health in these applications is used to provide a general overview or assessment of the function involved; the substitution of the term "fitness for health" conveys a better impression of the functionality, both in capability and capacity, of the subject physical system.

Health is also used as a modifier as well as a noun. The most common examples are health promotion and health protection, general expressions of the advancement of wellness that often include the promotion of sport. The advancement and maintenance of health usually includes specific sport or more general physical exercise as a primary tool in these pursuits. Health, as an adverb, is found is expressions such as healthy living, lifestyle, outlook, or diet; the opposite, unhealthy, may also be used.

see also Age-related responses to injury; Diet; Fitness; Sleep.

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Health and Disease

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Health and Disease

HEALTH AND DISEASE

Why care about the precise definitions of the words health, disease, and illness? Their meanings seem self-evident: Health is the absence of disease, illness the experience of disease. However the multiple dimensions of these concepts, their moral underpinnings, and the purposes for which they are used are enormously complex, especially in a technological society strongly oriented toward the production of health.

Health and disease are more than just medical terms; they have social, political, moral, and economic dimensions. For example, a pharmaceutical company may advertise its new compound as the cure for a heretofore-unnamed disease such as erectile dysfunction or attention deficit disorder (ADD). Medical or disability coverage is granted or denied based on sociopolitical interpretations of what constitutes a disease or disability. A couple decides to use in vitro fertilization and preimplantation genetic screening to avoid creating a baby with a genetic disease or one who will be a carrier of a diseased gene. Or perhaps a soft drink producer enhances sales by touting the benefits of its new and improved healthier beverages. Professional codes of ethics commonly commit engineers to protect public safety, health, and welfare. The concepts of health and disease are invoked in various ways, for purposes weighty and mundane.

Indeed health has been construed not simply as the absence of disease (whatever that is), but much more. In the preamble to its constitution, the World Health Organization (WHO) defines health as "a state of complete physical, mental and social well-being not merely the absence of disease or infirmity." Such statements rely on medico-moral presuppositions of what a disease actually is, how and which diseases ought to be treated, and ultimately on visions of what it means to live the good life.

Recognition of the complexity of the concepts of health and disease has stimulated scholarship in the fields of history and philosophy of medicine, sociology of medicine, and the medicalization of deviance, as well as crucially important policy developments in managed care and resource allocation. Philosophical questions range from clarifying the ontological status of disease (What is a disease?) to understanding particular conditions and the meaning of being diseased. The social sciences, including medical sociology and anthropology, examine the extent to which disease is a value-laden concept shaped and socially constructed. How do power relations influence what is considered to be normal and healthy or abnormal and diseased? On the level of individual experience, still other questions emerge: What is the personal meaning of being healthy or sick? At what point, if any, are the sick blameworthy for their illnesses? What role ought a sick person play in society? How does stigma affect the sick? More broadly framed questions regarding matters of policy ask what responsibilities society has to care for those who are diseased or ill.

Different responses to such questions are associated with diverse historical and philosophical approaches to health and disease. Sociological contributions to the debate and their policy implications also deserve consideration. This simple conceptual breakdown is appropriate for present purposes, but it is important to note that a more holistic picture requires interdisciplinary dialogue.

Historical Sketch

The concepts of health and disease were foundational to the ancient medical arts and bound up with distinct philosophical perspectives. To explain illness or symptoms of disease, as well as to cure the sick, pre-Socratic philosophers and ancient Greek physicians in the Hippocratic tradition (c. 400 b.c.e.) developed a basic explanation of health as balance (isonomia). The balance of the four humors—black and yellow bile, phlegm, and blood—in conjunction with environmental and temporal factors was central to the formalized model of health created by the Greek physician Galen (130–199 c.e.). A rudimentary nosology (classification of diseases) was developed around the imbalance of the humors.

Galen's humoral model persisted through the Middle Ages when it was augmented by Christian ideals of salvific suffering. Although the link between disease and sin was not a new development, moral dimensions of health and disease were described in terms of tests from God, punishment for sin, or demonic possession (Gunderman 2000). Toward the end of the Middle Ages, a new model was espoused by the physician-philosopher Paracelsus (Philippus Aureolus Theophrastus Bombastus von Hohenheim 1493–1541) indicating three elemental components (salt, mercury, and sulfur) as critical to healthy physiology. Paracelsus went on to claim that diseases were not simply internal imbalances, but rather resulted from autonomous entities "springing from the body" (Vichow 1981, p. 192). The ontologists—those thinkers who viewed diseases as actual entities—find the roots of their approach in the work of Paracelsus.

Modern concepts of health and disease (and the practice of scientific medicine itself) are grounded in Cartesian dualism. René Descartes (1596–1650) separated the mind and the body, and described the body as a set of parts working together according to mechanical rules. Because disease was the malfunctioning of the bodily machine, treatment consisted of diagnosing the malfunction and repairing the body, bringing it back to normal functioning (von Engelhardt 1995).

Over the next few centuries, the locus of disease shifted from the macroscopic to the microscopic, and eventually to the molecular. Contributions by the anatomists at the University of Padua—in particular Giovanni Morgagni (1682–1771)—opened discussion on pathophysiology and etiology through postmortem dissections of diseased organs. Marie Francis Xavier Bichat (1771–1802) explained the origins of disease in terms of histopathology—disease in tissues. On the cellular level, Rudolf Virchow (1821–1902) synthesized breakthroughs in bacteriology and microbiology and described mycotic diseases in terms of ens morbi and causa morbi (a being with a cause), and as a disruption in interrelated cellular territories which, in turn, compound and spread the disease process. With the rediscovery of Mendelian genetics in the late-nineteenth century, inheritance factors were singled out as disease entities that caused such disorders as Huntingdon's Disease and sickle cell anemia. Indeed sickle cell anemia was the first modern genetic disease identified as such by Linus Pauling.

In contrast to the ontologists were the nomino-physiologists, such as François-Joseph-Victor Broussais (1772–1838), who opposed the idea that diseases were actual entities. Such entity-based nosologies, he claimed, were not classifications of disease entities but rather were driven by a physician's instrumental and pragmatic need to diagnose or prognosticate. Claude Bernard (1813–1878) emphasized the need for clinical experimentation and observation in describing diseases. Through his diverse research projects, particularly studies of digestion, glycogen function, and vasoconstriction and dilation, Bernard developed physiological models that emphasized homeostasis and feedback loops in the regulation and maintenance of health. So too, the American physiologist Walter Cannon (1871–1945), in The Wisdom of the Body (1932), described health and disease in homeostatic terms.

Philosophical Trends

Philosophers of medicine and science began a more formal analysis of the concepts of health and disease during the first half of the twentieth century. The medical history and epistemology of Georges Canguilhem (1904–1995) and his student Michel Foucault (1926–1984) stimulated a renewed discussion of the normal and the pathological. Eventually a cannon of philosophical writings on the concepts of health and disease was formed during the period 1960 to 1981, a development that was driven in part by the birth and development of bioethics and its need for definitional precision for basic medical concepts (Caplan et al. 1981).

During the 1970s, a conceptual dichotomy in philosophy of medicine developed as new accounts of the status of disease took two tracks. First, reminiscent of the earliest philosophical constructions of disease, various versions of naturalism reemerged. Naturalistic accounts explained disease as deviations in natural form and function. As such, a disease was described as an entity or causal factor of that deviation independent of social norms or cultural values. This perspective is sometimes referred to as nonnormativism (Caplan 1988). Christopher Boorse (1975) presented the quintessential nonnormative position by referring to an objective biological framework that guides the identification and diagnosis of disease:

[B]ehind this conceptual framework of medical practice stands an autonomous framework of medical theory, a body of doctrine that describes the functioning of a healthy body, classifies various deviations from such functioning as diseases, predicts their behavior under various forms of treatment, etc. This theoretical corpus looks in every way continuous with theory in biology and the other natural sciences, and I believe it to be value-free. (Boorse 1975, p. 55.)

In contrast, normativist philosophers point to the value-laden nature of disease constructions, eschewing the possibility that natural is definable and that diseases are value-free. These scholars directly counter the Boorsian model by pointing to research in philosophy and sociology of science that described science and medicine as social endeavors. Because of this social embeddedness, an autonomous and value-free framework of medico-biological theory does not exist independently of values. (Kuhn 1962, Longino 1990, Engelhardt 1981). Arthur Caplan, H. Tristam Engelhardt, and Joseph Margolis are among those who write a defense of moderate normativism. Caplan (1981) points out that, while some objective criteria for defining disease exist, nonnormativism as characterized by Boorse is fraught with conceptual inadequacies. Some conditions generally considered to be normal or natural (e.g., the common cold, dental plaque, acne, and others) are disvalued, while others considered to be abnormal may be valued (for example, dysfunctional gonads in a person who does not wish to reproduce). Margolis (1976) claimed that while certain biological functions may be conceived in universal terms, the actual concept necessarily reflects the state of the technology, social explanations, division of labor, and the environmental conditions of a given population. Engelhardt (1974) describes the pragmatic and value-laden nature of the concept of disease particularly in his historical exposition of the disease of masturbation.

The philosophical debate about the nature of somatic disease spills over into the analysis of mental health and disease. With the rise of scientific medicine, the prevailing model of psychiatric illness became biologically based. Mental illness was considered similar to other somatic diseases, rooted in a dysfunction, or even an ens morbus. This model was vigorously challenged by physician George Engel (1913–1999) as being overly reductionistic; he offered his own biopsychosocial model to account for the role of relationships and society in health and disease (Engel 1977). Thomas Szasz's The Myth of Mental Illness (1961) attacked the notion that mental illness was a disease of the brain or that mental illness existed at all. Szasz claimed that the notion of mental illness was a way to subjugate dissidents of the community's collective ethos or assuage sick individuals of their responsibilities.

In the early-twenty-first century, genetic technology and medicine as well as the results of the Human Genome Project added another level of complexity to analyses of health and disease. A greater understanding of epigenetics and the complexities of gene-environment interactions show it is difficult to identify the genetic causes of diseases that are outside the basic Mendelian framework. Nonetheless health and disease are increasingly described in genetic terms. Reification of genetic anomalies as being diseases has raised the very real possibility that all people are diseased in some way (Jüngst 2000).

Sociological Perspectives and the Medicalization of Deviance

Philosophical debates about health and disease as normative concepts grade into descriptive analyses of how society constructs, describes, and reacts to the realities of health, disease, and illness. Talcott Parsons (1902–1979) explained the concepts of health and illness as manifestations of certain role-types.

In framing the sick role, Parsons took the first step in describing illness as a form of deviant behavior legitimized by the medical institution (Bosk 1995). The sick role is characterized first by an exemption from social duties, exculpating patients for their illness. Parsons described the physician-patient relationship as analogous to the relationship between a child and parent in which the patient follows doctor's orders in a team effort directed toward the patient's wellness. Often this is a form of social control because a sick person needs to enlist the help of persons who are not sick and their therapeutic agencies.

Some social scientists have theorized the construction of disease emerges out of power structures, sanctioned under the guise of medical objectivity. Looking back in history, an early example of this dynamic was the description of drapetomania—a disease of slaves that caused them to try to run away. Physician Samuel Cartwright (1793–1868) presented an account of this disease and potential cures, which included, first, kind treatment, but later various forms of severe bondage and punishment. Since then, health and disease have sometimes been hijacked in the name of ideology or the betterment of common good. In hindsight these instances are obvious, for example, eugenics movements during the early-twentieth century in the United States and in Germany in which diseased individuals, their families, or their entire race were treated (Caplan 1992b). In contrast to these more egregious cases, some social scientists suggest more insidious forms of disease construction have occurred through the medicalization of deviant behavior.

Peter Conrad (1975, 2000) describes how hyperkinesis—now called attention deficit and hyperactivity disorder (ADHD)—became a disease. Conrad explains that, with the invention of the stimulant Ritalin and observation of its paradoxical effect on children, the manufacturer, CIBA, sought to market the compound to parents and teachers of unruly children. The cure preceded the disease. The administration of a drug that reigned in nonconformist children strengthened the status quo: educational systems not equipped to accommodate certain children and parents released from blame for their children's behavior. Similar examples can be found in feminist accounts of the social construction and medicalization of menopause and premenstrual syndrome (McCrea 1983, Richardson 1995).

Labeling theorists, such as Howard Becker (1928), describe the actions of moral entrepreneurs who create and enforce social rules. In medicine, moral entrepreneurs may be physicians who ascribe the label diseased to those who break with accepted conventions, thus suppressing or stripping them of opportunity, thereby expanding their own domain of professional influence (Becker 1963, Pfohl 1977, Bosk 1995).

As a result of labeling, stigma is often closely associated with disease. In certain cases, sick people remain closeted because of the stigma of their illness. Norma Ware (1992) offers the example of chronic fatigue syndrome. Delegitimation of the subjective experience of illness leads to further suffering arising from the stigma of the disorder, the alienation resulting from a decision to keep the illness secret, and the shame of being wrong in one's own definition of reality.

Broad Policy Implications

The ways in which the concepts of health and disease are framed have significant impact on health policy. In particular, defining what constitutes the appropriate level of medical care provided by a just society has been difficult to determine.

Several nosological frameworks driving insurance schedules and socialized coverage plans have been espoused over the years. Norman Daniels, in Just Health Care (1994), proposes a policy framework based not on definitions of disease or health but on species-typical functioning. Daniels proposes that normal functioning is an important baseline not because it is natural, but because it is a convenient point at which to determine what society should owe to its members. Indeed a consensus of what society ought to give to all its members has been elusive precisely because a common framework of health and disease has been impossible to construct.

Equally important to providing care and treatment of disease is the scientific quest to prevent and cure disease. Operational definitions of health and disease ground biomedical research priorities in government and private funding agencies. The National Institutes of Health (NIH) determine research priorities based on a broad range of criteria related to severity of diseases, epidemiological evidence, cost-benefit analyses, as well as projects that offer promises and opportunities, and interest groups/patient lobbying. Investment in research and development and biotechnology, as well as in allied fields of technology, rest on the social framework and disciplinary matrix within which technicians work. As such core concepts such as health and disease have a profound, albeit overlooked, influence on the trajectory of important advancements in technology.

The concepts of health and disease underlie decisions to fund basic bench research through clinical biomedical research and public health initiatives. Clearly a robust understanding of the complexities of these concepts is crucial for policymakers, clinicians, and patients alike.

DOMINIC A. SISTI

SEE ALSO Bioengineering Ethics; Cancer; Complementary and Alternative Medicine; Emergent Infectious Diseases; Eugenics; Galenic Medicine; Genethics; HIV/AIDS; Medical Ethics; National Institutes of Health; Therapy versus Enhancement; World Health Organization.


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INTERNET RESOURCE

World Health Organization. (1948). "Preamble to the Constitution." Available from http://whqlibdoc.who.int/hist/official_records/constitution.pdf. WHO Constitution adopted by the International Health Conference, New York, June 19–22, 1946; signed on July 22, 1946 by the representatives of sixty-one states and entered into force on April 7, 1948. Can also be found in the Official Records of the World Health Organization, no. 2, p. 100.

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Health and Disease

HEALTH AND DISEASE

Until the beginning of the twentieth century, infectious diseases were by far the most important causes of mortality; they took their greatest toll among infants and children. Indeed, if individuals managed to survive to the age of twenty, they could for the most part look forward to an additional forty years or more of life. High rates of infant and child mortality (as well as fertility) meant that the number of aged persons in the population would be correspondingly small. Hence, chronic and long-term diseases—many related to advancing age—were less important causes of mortality. To emphasize the significance of infectious diseases, however, is not to imply that their impact on populations was constant. Infectious diseases appeared and disappeared and were often dependent on the interaction of social, economic, behavioral, and environmental factors. Nowhere is this better illustrated than in the history of health and disease in late-eighteenth and early-nineteenth-century America.

colonial background

The first settlers who came to the North American continent in the seventeenth century faced a strange and unfamiliar environment. In the initial stages of settlement, there were extraordinarily high death rates from dysentery, typhoid fever, a variety of enteric diseases, and respiratory infections. Nutritional diseases, inadequate housing, contaminated water supplies, and deficient disposal of organic wastes further compounded health risks. New England and the mid-Atlantic or middle colonies adjusted to their new environment relatively quickly, and mortality rates declined rapidly. The rural character of these colonies also minimized the spread of epidemic and endemic infectious diseases. The environment of the Chesapeake and southern colonies, by contrast, was far more threatening to human life. In addition to gastrointestinal disorders, the presence of infected individuals and insect vectors made malaria one of the gravest health problems in these areas. High mortality rates made it difficult for the white population to sustain itself through natural growth. The overwhelming majority of individuals who lived through the vicissitudes of infancy and childhood and reached the age of twenty rarely survived to the age of fifty. Unlike their neighbors to the north, the residents of the Chesapeake and southern settlements continued to face an environment that posed severe health risks.

The native Indian population was hardest hit by the movement of Europeans to the Americas. During the seventeenth and eighteenth centuries, their numbers declined rapidly because of the impact of imported diseases. Having never been exposed to many of the diseases common in England and Europe, they constituted a highly vulnerable population. High mortality from infectious diseases (notably smallpox), periodic famines, and the social dislocations that accompanied these crises also reduced fertility to such low levels that population recovery became impossible. From a high of three thousand in the late seventeenth century, the Indian population on Nantucket had fallen to twenty by 1792. Much the same was true for many other East Coast tribes.

eighteenth-century health patterns

After the dangers posed by a new environment were surmounted, population began to grow rapidly. Between 1700 and 1770 there was a ninefold increase from 250,000 to an estimated 2.15 million. Health indicators in the Northeast and middle colonies improved dramatically during these decades. Nevertheless, increasing population density, the expansion of internal and external trade and commerce, the development of new forms of agriculture, and the transformation of the landscape began to alter health patterns. Toward the end of the eighteenth century, there was an increase in mortality from a variety of infectious diseases, particularly among infants and children and residents of larger towns and urban port areas. In the seventeenth century the rural character of colonial society inhibited the spread of infectious epidemic diseases that had such a dramatic impact on societies in Europe, Asia, and the Middle East. In the eighteenth century, by contrast, colonial port communities began to experience the ravages of infectious epidemic diseases. Although small if not infinitesimal by modern standards, they contained larger numbers of people living in close quarters. The maritime character of Boston, New York, Philadelphia, and Charleston—the most important colonial ports—brought their residents into contact with each other and, more important, with Europe, the Caribbean, and Africa. These ports were also the entry points for both sailors and immigrants. Such population movements became the means of transporting a variety of pathogens capable of causing epidemic outbreaks. Moreover, the physical environment of port villages—crowded living conditions, crude sewage disposal, and stagnant or contaminated water—facilitated periodic epidemics. Many residents were susceptible to the invading pathogens and hence lacked antibodies that prior exposure would have produced. The large number of susceptible individuals facilitated the rapid spread of infectious diseases.

During the eighteenth century periodic smallpox epidemics became common in New England and the middle colonies. Despite efforts at containment, it was difficult to prevent the spread of the disease. The movement of people in trade and commerce provided a convenient means of transporting the virus. The war with the French in the 1760s merely exacerbated the problem. In Philadelphia, smallpox was the single largest cause of mortality during the third quarter of the eighteenth century. The disease was less significant in the Chesapeake and South because a more dispersed population and an agricultural economy inhibited the spread of the virus (which can only survive in human tissue). South Carolina was an exception, since Charleston was an important seaport and commercial center with links to the interior. It therefore served as a port of entry for infectious diseases. In 1760, 6,000 of 8,000 residents were infected with smallpox, and estimates of mortality ranged from a low of 730 to a high of 940.

Smallpox was by no means the only imported disease. Yellow fever (a viral disease) was another. Transmitted by an insect vector biting an infected individual, it flourished in moist tropical areas. During the first two-thirds of the eighteenth century, there were at least twenty-five outbreaks. The interruption of trade during the Revolutionary crisis caused the disease to disappear. But with the return of peace, yellow fever returned. In 1793 Philadelphia experienced an epidemic that threatened its very existence. A slave rebellion in French Saint Domingue (later Santo Domingo) brought two thousand refugees to the city, some of whom were infected. A hot and humid summer provided ideal conditions for the proliferation of the mosquito population. Perhaps half of the fifty-one thousand residents fled the city during the outbreak. Of those that remained, a large number became ill and between 9 and 12 percent perished. Nor was Philadelphia the only city to experience an epidemic. Between 1793 and 1822 yellow fever was also present in Baltimore, Boston, and New York. After the latter year it disappeared from New England and the mid-Atlantic states, where the climate was not conducive to the insect vector, while appearing periodically in the South, notably New Orleans, which had five epidemics between 1804 and 1819.

Spectacular periodic smallpox and yellow fever epidemics tended to overshadow other diseases that played a more important role in shaping population development. Indeed, the health advantages enjoyed by seventeenth- and early-eighteenth-century settlements, once the period of adjustment passed, slowly began to diminish. In the eighteenth century infectious diseases traditionally associated with infancy and childhood became common. Many of these diseases were not indigenous to the Americas. When imported they affected the entire population, since adults as well as children were susceptible. Measles, for example, struck New England and the mid-Atlantic colonies; the Chesapeake and South were less affected. Mortality from measles was extraordinarily high, equaling modern death rates from cancer and cardiovascular diseases. Other infectious diseases, including diphtheria, scarlet fever, pertussis (whooping cough), and chickenpox, also resulted in high mortality.

Despite high mortality rates associated with periodic epidemics, certain endemic diseases—notably dysentery and malaria—took a far higher toll. In general, sporadic and spectacular outbreaks of epidemic diseases produced much greater fear than did endemic diseases that had a much greater demographic impact. Dysentery was undoubtedly the most significant disease in eighteenth-century America. Outbreaks were especially common in such towns as Boston, New York, Philadelphia, and Charleston. These ports were the entry points for ships bringing thousands of immigrants to the colonies. Conditions aboard vessels were conducive to outbreaks of dysentery, and infected immigrants disseminated the causative pathogens upon their arrival. Infants and children were especially vulnerable, since there was no understanding that dehydration could lead to rapid death. Local data revealed that during an epidemic, perhaps half of a community's population would become infected and that one of every six or seven would perish.

Malaria had the same endemic characteristics as dysentery. Although important south of the Mason Dixon line, it had its greatest impact in South Carolina, where the cultivation of rice and indigo created ideal conditions for the breeding of the anopheles mosquito. The colony acquired a deserved reputation as a graveyard. High mortality among whites provided a rationale for the introduction and spread of slavery, since they believed that Africans were better equipped physiologically to labor in a sunny, hot, and humid climate.

Most eighteenth-century respiratory disorders were endemic and seasonal in character. But the growth of population and expansion of trade rendered the colonies somewhat more vulnerable to influenza pandemics and epidemics. By the time of the American Revolution, the newly independent colonies had become part of a larger disease pool. In 1781–1782 and 1788–1789, influenza appeared in pandemic form, affecting millions of people in both Europe and America. Nevertheless, case fatality rates remained low, although it did pose a mortal threat to elderly and chronically ill persons.

During these decades, tuberculosis and other pulmonary disorders also emerged as important causes of mortality. They were most prevalent in more densely populated areas, although rural areas were affected as well. The critical element was not total population, but household size. Many households contained from seven to ten inhabitants, thus permitting the dissemination of the tubercle bacillus and other pathogens. Moreover, relatively inefficient heating led inhabitants to seal windows and doors. Behavioral patterns thus facilitated the spread of the infection within households.

Nowhere was the complex relationship between pathogens, humans, and the environment better illustrated than during war. In the American Revolution a large number of recruits came from rural areas and had never been exposed to many common communicable diseases. Crowded camp quarters and contaminated water supplies from both human and animal wastes, inadequate diets, and the absence of personal hygiene provided ideal conditions for the spread of infectious diseases. Perhaps 200,000 served in the military (comprising the total of all American armed forces, including militia). About 7,100 were killed in military engagements, 10,000 died in camps, and 8,500 perished as prisoners of war. Deaths in camps and among prisoners resulted from a variety of diseases, notably dysentery and respiratory disorders. A similar situation prevailed during the War of 1812. About two and half times as many soldiers perished from disease or accident as were killed in battle.

the early nation

Toward the end of the eighteenth century, mortality from infectious diseases began to increase. In New England and the mid-Atlantic regions, this increase did not appreciably affect population growth. Mortality, however, was not equally distributed. After 1760 health indicators improved among the white middle and upper classes. Among the poor—both white and black—mortality rose. Philadelphia—a center of commerce and immigration—proved to be a dangerous place. Its mortality rates, particularly among recent immigrants, exceeded many European cities. Despite high fertility, Philadelphia's growth was made possible only because of migration from rural areas and immigration of younger people.

Mortality rates in the South remained excessive even by the standards of that age. South Carolina presented the greatest risks to life; the Chesapeake region and North Carolina followed. Without a constant supply of immigrants to replenish a population devastated by extraordinary mortality rates, these areas would not have developed economically and their very survival as societies would have become dubious. Neither wealth nor status conferred a distinct advantage insofar as survival was concerned. Mortality rates, admittedly unequally distributed, remained high among all groups, both white and black.

By the beginning of the nineteenth century, the health advantages that Americans had enjoyed after the initial period of adjustment had begun to diminish. Rapid population and economic growth created conditions conducive to the spread of infectious diseases. In succeeding decades, health indicators would begin to fall. Ironically, the increase in mortality and decline in life expectancy occurred at a time when the standard of living was rising.

Although the United States was still a predominantly rural nation, cities were growing in number, size, and importance. Their growth, together with the simultaneous acceleration in economic activity, magnified the risks from infectious diseases. Municipal governments moved relatively slowly in protecting health. There was little provision for safe and accessible water supplies or removal of wastes. Because horses were used for transportation, streets were covered with manure. Housing standards were virtually unknown; there were no provisions for drainage or ventilation in most structures. The accumulation of organic wastes and rising odors caused inhabitants to keep their windows shut, thus preventing the circulation of fresh air and facilitating the dissemination of infectious organisms. The movement of large masses of immigrants and susceptible individuals from rural areas only served to magnify the impact of infectious diseases.

In these urban areas, tuberculosis and pulmonary diseases took a high toll. Nearly a quarter of all deaths in Boston between 1812 and 1821 were due to "consumption" (a generic category that included tuberculosis and other pulmonary diseases). Native-born whites had the lowest mortality rate, African Americans the highest, and foreign-born individuals fell between the two. The circumstances of urban life—crowding and the absence of facilities to bathe and wash clothes, among other things—led to the emergence of such infectious diseases as typhus, which at times could result in a mortality rate of 50 percent in adult populations. Other infections—diarrheal and respiratory diseases, diphtheria and croup, measles, whooping cough, and scarlet fever—added to the burden of disease. Mortality was largely a function of age: infants and children were at highest risk. In 1830, 1,974 deaths were recorded in Baltimore. Of these, 406 were under the age of 1 and 932 under 10. Suicide, homicide, accidents, and occupational diseases also contributed to total urban mortality. To emphasize that infectious diseases were the major element in urban morbidity and mortality patterns is not to suggest that such chronic and long-duration diseases as cancers, cardiovascular and renal diseases, and diseases of the central nervous system were absent. Their incidence and prevalence, however, were low, because high mortality rates among the young meant that the older cohort constituted a relatively small percentage of the total population.

Rural areas had lower mortality rates than their urban counterparts. For the nation as a whole in 1830, about 54 percent of those alive at age 5 survived to 60. In rural areas the figure was 57.5 percent, as compared with 43.6 in such small towns as Salem, Massachusetts, and New Haven, Connecticut, and 16.4 in the large cities of Boston, New York, and Philadelphia. Nevertheless, the increase in mortality that set in toward the end of the eighteenth century was not confined to cities; the same occurred in rural areas.

Aggregate data reveal the magnitude of the decline. In the period from 1800 to 1809, a white male and female age 20 could expect to live an additional 46.4 and 47.9 years, respectively; by 1850 to 1859 the comparable figures were 40.8 and 39.5. Declining life expectancy was also accompanied by a decline in height as well. By the American Revolution, Americans had achieved heights not fundamentally different from their twentieth-century successors; during and after the 1820s heights declined, reflecting a comparable decline in health. In these decades the standard of living rose, calling into question the familiar generalization that health indicators rise with increasing affluence.

What accounts for the declining health of Americans, a decline that lasted beyond the Civil War and was not reversed until the end of the nineteenth century? The answer to this question remains somewhat murky. Whatever the reasons, it is clear that economic development negatively affected health. The beginnings of a national transportation network increased both internal migration rates and interregional trade and thus contributed to the movement of pathogens from urban to rural and semirural regions where more susceptible populations resided. The movement across the Appalachian Mountains after the War of 1812 enhanced the significance of such debilitating and fatal diseases as malaria and various forms of dysentery, to say nothing about the health risks in a new and undeveloped environment. The rise of artisan workshops and factories concentrated employees in surroundings conducive to the spread of infectious diseases. The advent of large-scale migration of poor immigrants exacerbated the prevailing disease environment, particularly in urban areas. Fundamental changes would be required to alter an environment in which infectious diseases flourished.

See alsoEpidemics; Malaria; Smallpox; Water Supply and Sewage .

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Health and Disease

HEALTH AND DISEASE

Kenneth F. Kiple

Studies centered on political, economic, military, or church affairs are very old avenues of historical investigation in Europe. By considerable contrast the study of disease and history is quite new.

In part this is because until the beginning of germ theory in the late 1800s, people did not know what caused them to be sick and to die. When court chroniclers and historians felt pressed to account for the presence of diseases, "God's will" was a handy explanation—a "will" that was routinely credited with epidemics that delivered misery and death to thousands, even hundreds of thousands, of individuals. Perhaps because God might be credited but never blamed, this explanation was also generally laden with the suspicion that divine will had gotten a helping hand from secular sources such as the ragged and dirty poor, or outsiders, or Jews, all of whom came to comprise the usual scapegoats during epidemics.

However, the study of disease in history is also a phenomenon of the last two centuries or so because the writing of history was an enterprise that tended to deal with the affairs of a highly visible elite as opposed to the murky masses. Hence epidemics—the most dramatic manifestation of disease—which as a rule fed on those masses while sparing the elite (whose wealth separated them physically and nutritionally from the masses and permitted flight from epidemic sites), were often not counted as very noteworthy events for those in a position to record them.

It was the birth of both germ theory and social history that changed this state of historiographical affairs by clearing the way for twentieth-century historians to focus on the role of human health in history. These historians, in turn, have made the study of the impact of disease on societies indispensable to any holistic understanding of those societies. This article looks at the march of a number of diseases across Europe from the Renaissance to the present. It attempts to do so in chronological order, but sections of the article sometimes overlap because an effort has also been made to present diseases in categories. Most of these categories feature diseases of an epidemic or pandemic nature. However, the less dramatic endemic diseases are also discussed, as are those caused by foods and nutritional deficiencies.

As for nomenclature, "epidemic" is defined as a disease suddenly appearing to attack many people in the same region at roughly the same time and "pandemic" as an epidemic disease that becomes widely distributed throughout a region, continent, or the globe; "endemic" refers to a disease that is always present in a population.

DISEASE AND THE RENAISSANCE

Somewhat ironically, given its connotation of "rebirth," a distinctive feature of the Renaissance was widespread death, much of it caused by bubonic plague, which had become pandemic. It is generally said (but not without dispute) that the disease originated east of the Caspian Sea, then followed the caravan routes westward to burst upon Europe in 1347–1348, just as the Mediterranean Renaissance was getting under way. The disease, however, apparently failed to establish an endemic focus in Europe, meaning that it had to be reintroduced if Europe was to experience another epidemic; indeed it was reintroduced with an awful regularity, reappearing somewhere every quarter of a century or so until 1720—almost four hundred years of plague that began in the Renaissance and ceased only in the modern period.

The initial wave of plague, which we call the Black Death, lasted a terrible seven years, beginning with its appearance in Sicily in 1347. It subsequently reached the Italian peninsula, then marched through the Iberian Peninsula in the summer of 1348 and northward to reach Paris and the ports of southern England. The following year saw the British Isles devastated; then plague plunged into northern Europe and by 1350 was moving through eastern Europe. This first European tour of the plague culminated with an assault on Russia that saw Moscow under siege in 1353.

Although its trajectory was such that no region suffered plague for more than a few months, historians generally agree that the mortality it inflicted was in the 20 to 50 percent range. In the Mediterranean, in urban areas where people lived in close proximity to one another, such as Florence, Venice, Rome, Milan, and Barcelona (which were nurturing the early Renaissance), mortality rates were probably the highest. But it was in the myriad towns, villages, and hamlets, which contained the vast bulk of the population of a Europe still lingering in the late Middle Ages, that the plague harvested the overwhelming majority of its victims.

The impact of the Black Death, combined with that of the recurrent plague epidemics that followed, is difficult to comprehend in both breadth and magnitude. Populations that had been enjoying a period of sustained population growth were drastically pruned practically overnight, and a Europe that had been relatively crowded was so no longer. Whole villages were empty and fields deserted save for equally deserted sheep, cattle, and hogs. A great shortage of labor meant that patterns of landholding and land use had to change. Although not always without strife, landlords became easier to deal with, and many peasants became landowners. Population pressure on food supplies was reduced, and prices fell because of a lack of demand. Animal protein—suddenly abundant—began to grace even the tables of the poor, and the pace of urbanization quickened as individuals no longer needed in the countryside found nonagricultural jobs in cities and towns.

In addition to these significant changes, the onset of plague seems to have wrought some curious microparasitic alterations in Europe's disease ecology beyond the obvious introduction of the rodent disease Yersinia pestis, which we call bubonic plague. For reasons not fully understood, leprosy—a disease present in Europe since at least the sixth century—went into an abrupt recession while, at the same time, pulmonary tuberculosis began an ever increasingly prosperous career that would elevate it to the status of a major plague by the eighteenth century. One explanation offered by the American historian William McNeill for the decline of leprosy at this time takes note of the fact that the arrival of plague coincided with climatic change that saw average temperatures falling precipitously in Europe. Prior to the Black Death, with most of Europe put to the plow, firewood was scarce, and people doubtless kept warm on cold nights by huddling together, thereby increasing the ability of leprosy to spread. But in the wake of the Black Death there would have been less need to huddle, with some 40 percent fewer individuals putting pressure on the firewood supply; such a population reduction also meant that wool (and hence clothing) was more readily available. All of these factors may have acted in concert to interrupt leprosy's pattern of skin-to-skin transmission. As for the rise of tuberculosis (TB), the growth of crowded urban areas encouraged by the plague would have proven a fine incubator for this illness, which most frequently spreads from person to person by infected droplets from the lungs.

Populations did begin to recover with the improved conditions of life ushered in by the plague, and despite renewed appearances of this disease, urban areas did grow to support still other illnesses. Indeed, although it is difficult for historians to put a name to most epidemic diseases prior to the sixteenth century, there is no question that their pathogens were ricocheting about inside the walls of the swelling cities and towns, whose rivers and wells festered with human waste, whose markets swarmed with flies, whose dwellings were alive with rodents, and whose human inhabitants avoided bathing and seldom changed woolen clothing and bedding even though they harbored lice, bedbugs, and other assorted vermin.

EPIDEMIC DISEASE DURING THE EXPANSION OF EUROPE

While Europeans were cultivating pathogens at home, they were also importing them from abroad. The Crusaders have been suspected of returning home with some novel microorganisms as well as exciting new plants and an enhanced weltanschauung, but it was the Portuguese, in leading the expansion of Europe with their century of African exploration, who brought many in Europe into contact with tropical ailments for the first time. Yaws—a disease caused by treponemas, a genus of spirochetes—may or may not have been present in an earlier and warmer Europe, but the illness began regularly reaching Iberia via a Portuguese–run slave trade and, according to epidemiologist E. H. Hudson, could have evolved into the syphilis that would soon engulf the Continent.

Falciparum malaria was another African contribution to Europe's pool of pathogens. Europeans had suffered from other types of malaria that were widespread during the Middle Ages; but falciparum malaria is by far the most lethal of the malarial types, so deadly in fact that it summons genetic defenses against it through the process of natural selection—defenses such as the sickle-cell trait and blood enzyme deficiencies that hold down the level of parasitization in the human body. The disease had been present in the eastern Mediterranean for thousands of years—long enough to have encouraged the development of such defenses (as discovered by the Crusaders, who did not possess them)—and in some nearby Greek and southern Italian populations as well. But the Iberians had had no opportunity to develop protection against this illness now arriving directly from Africa, which took root in the peni