Race, Ethnicity, and Health A Public Health Reader - (Introduction The Ethnic Demographic Transition)

INTRODUCTION
THE ETHNIC DEMOGRAPHIC TRANSITION
Thomas A. LaVeist
During the twentieth century there was a literal change in “the “face of
America.” At the beginning of the century, racial issues were essentially black and
white. The nineteenth century’s Manifest Destiny policies rendered Mexicans immi-
grants in their native land, and left what remained of the Indian nations defeated
and living on reservations. The country was only a few decades removed from slav-
ery, but former slaves lived among whites as constant reminders of an ignoble his-
tory at odds with the noble principles of the nation’s founding declaration that all
men are created equal.
By the end of the twentieth century America’s ethnic composition had changed
dramatically. Latinos and Asian Americans made up a growing proportion of the
U.S. population. The percentage of white non-Hispanics declined from about
90 percent in 1950 to about 71 percent by century’s end. According to projections
from the U.S. Census Bureau (summarized in Figure I.1), this pattern is part of a
Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved.
long-term trend. By the middle of the twenty-first century American racial and eth-
nic minorities are expected to become a larger minority and eventually a majority
of the U.S. population. Viewed through a broad lens, the twentieth century’s ethnic
demographic transition may be a natural progression along the developmental
pathway of societies.
The term demographic transition comes from the most thoroughly studied model
of how societies evolve. The demographic transition model says that societies
progress through four stages of economic development, each of which has implica-
tions for birth rates, death rates, and population changes (see Figure I.2).
Stage 1 of the demographic transition model is the premodern stage. This stage
is characterized by high birth rates and high (and unstable) death rates, resulting in
a low and stable population. Stage 1 societies are mainly agrarian economies domi-
nated by family-based farming. The highly labor intensive nature of family farming,
and the high child mortality rate necessitates large family sizes. The large number
of children increases the likelihood that at least some of the children will survive to
1
Race, Ethnicity, and Health : A Public Health Reader, edited by Lydia A. Isaac, and Thomas A. LaVeist, John Wiley & Sons, Incorporated, 2012.
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2 r ac e , e t h n icity, and h ealth
Figure I.1. Projected Racial Diversity in the Twenty-First Century, Percentages of

Total U.S. Population
80
70
60
50
40
30
20
10
0
2000 2020 2040 2060 2070
Black White Asian Hispanic All Minorities
Source: Data from Population Projections Program, Population Division, U.S. Census
Bureau
Figure I.2. Demographic Transition Model

Population size
Birth and Death Rates
Birth rate
Death rate
Stage 1 Stage 2 Stage 3 Stage 4

(Premodern) (Early Industrial) (Mature Industrial) (Postindustrial)
Time

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childbearing age. The high death rate is the result of uncontrolled infections, injuries,
famine, and food insecurity.
Stage 2 societies are in the early industrial stage. Mechanization is beginning to
be used in agriculture, which increases food production and lessens the labor
needed to produce food. People begin to migrate to urban areas for jobs. And death
rates begin to decline as food availability improves. Birth rates remain high, mainly
because of cultural norms favoring large family sizes. As a result the population
begins to expand.
Stage 3 is the mature industrial stage. During this stage the death rate continues
to decline, as public health controls improve water quality and food safety and
prevent infectious diseases. Birth rates begin to decline as women find more oppor-
tunities in urban areas, large families are no longer necessary and cultural norms
about family size that were prevalent in agrarian times begin to change in urban
life. Life expectancy rises as the primary causes of death transition from infectious
diseases to chronic diseases (the epidemiological transition).
The fourth stage is the postindustrial stage. During this stage highly mechanized
agriculture brings excellent food security, and a highly evolved public health infra-
structure prevents much of the infectious disease burden of the past. Medical
advances help to extend life and increase life expectancy. Total population growth
slows as birth rates plummet along with death rates.
In the early twentieth century when the demographic transition model was developed,
I imagine it would have been difficult to determine if a fifth demographic stage was
likely and, if so, what it would be. But now it seems clear that there is one. I call the
fifth demographic stage the stage of multiculturalism. In stage 5, birthrates drop
below the replacement rate (the number of births needed to balance deaths to sus-
tain the population). But, the population continues to increase because migration
brings immigration from pre–stage 4 countries. The immigrant populations have
higher birth rates than the native population, as their cultures have not yet passed
through the transforming processes of stages 2 and 3. As Table I.1 reveals, in the
year 2009 the fertility rate for foreign-born U.S. residents was 70 percent greater
than the rate for U.S.-born women. Additionally, immigrants tend to be young
adults, resulting in a concentration of immigrants in the childbearing ages (Figure
I.3). Their combined younger age and higher birth rate, relative to the U.S.-born
population, will accelerate the cultural diversity of the society.
Another important phenomenon, which may be different from past immigration
waves, is the degree to which these immigrants will be absorbed into the American
cultural “melting pot.” It may be that rather than being absorbed, as was the case

Table I.1. General Fertility Rates of U.S.-Born and Foreign-Born Women, Aged
15–44, 2009
Number of Women Age Birth Rate
15–44 (in thousands) Total Births per 1,000
U.S.-Born 61,568 3,398,400 55.20
Foreign-Born 9,291 873,078 93.97
Ratio of foreign .15 .26 1.70
born to U.S. born
Source: Pew Hispanic Center, 2009; U.S. Census Bureau, 2009, tables 1.1 and 2.1.
Figure I.3. Population Pyramids for U.S.-Born and Foreign-Born Populations,

2009 (in percentages)
U.S.-Born Foreign-Born
85 Plus 85 Plus
80 to 84 80 to 84
75 to 79 75 to 79
70 to 74 70 to 74
65 to 69 65 to 69
60 to 64 60 to 64
55 to 59 55 to 59
50 to 54 50 to 54
45 to 49 45 to 49
40 to 44 40 to 44
35 to 39 35 to 39
30 to 34 30 to 34
25 to 29 25 to 29
20 to 24 20 to 24
15 to 19 15 to 19
10 to 14 10 to 14
5 to 9 5 to 9
0 to 4 0 to 4
10% 8% 6% 4% 2% 0 2% 4% 6% 8% 10% 10% 8% 6% 4% 2% 0 2% 4% 6% 8% 10%

Male Female Male Female
Source: U.S. Census Bureau, 2009, tables 1.1 and 2.1.
with previous migration waves, the new immigrant populations will transform the
society. For example, according to the U.S. Census Bureau (Shin & Kominski,
2010), in 1980 just under 11 percent of U.S. residents regularly spoke a language
other than English at home. But by 2007 the percentage had risen to 19.7 percent.
Race, Ethnicity, and Health

In addition to the ethnic demographic transition, another important trend that
unfolded during the twentieth century was the steadily improving health profile of
Americans. As Figure I.4 shows, early in the century the average white American

intro ductio n 5
Figure I.4. Life Expectancy by Race—United States, 1900–1997

90
80
70
60
50
40
30
20
10
0
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2007
White male White female Black male Black female
Source: Data from Centers for Disease Control and Prevention, National Center for
Health Statistics, National Vital Statistics System; Grove & Hetzel, 1968; Arias, Rostron,
& Tejada-Vera, 2010; Xu, Kochanek, Murphy, & Tejada-Vera, 2010.
lived fewer than fifty years. Life expectancy for African Americans was around
thirty-five years. By the end of the century life expectancy for all Americans
exceeded sixty-five years, but the disparities among the racial and ethnic groups
remained generally constant. As racial and ethnic minorities constitute ever larger
percentages of the total U.S. population, the overall health statistics of the nation
will increasingly be a reflection of the health status of America’s racial and ethnic
minorities. Consequently, it is becoming increasingly important to monitor the health
status of racial and ethnic minorities, and finding ways to improve minority
health has taken on heightened urgency.
There are substantial differences among the health profiles of various U.S.-based
racial and ethnic groups (Eberhardt et. al., 2001). Researchers have demonstrated
this fact for centuries, using various research methods and statistics (Savitt, 1982;
Byrd & Clayton, 1992; Jones, LaVeist, & Lillie-Blanton, 1991). Figure I.5 shows
mortality rates for U.S. racial and ethnic groups for the year 2007. They reveal that

Figure I.5. Age-Adjusted Death Rates, by Race and Hispanic Origin, 2007
1200
Black
White
1000
Hispanic
Asian and Pacific Islander
800 Indian
600
400
200
Note: Rates per 100,000 standard population.

Source: Data from Centers for Disease Control and Prevention, National Center for
Health Statistics, National Vital Statistics System; Grove & Hetzel, 1968; numerator data
from National Vital Statistics System, annual mortality files; denominator data from
national population estimates for race groups from Table 1 and unpublished Hispanic
population estimates for 1985–1996 prepared by the U.S. Census Bureau, Housing and
Household Economic Statistics Division; additional mortality tables are available from http://
www.cdc.gov/nchs/nvss/mortality_tables.htm; Xu, Kochanek, Murphy, & Tejada-Vera, 2010.
African Americans have the worst health profile and Asian Americans have the
fewest health problems. Disparities in health status are well documented and
widely known. However, research on race, ethnicity, and health is controversial.
The reason for this is probably linked to the thorny role that race has played in
American history and contemporary culture (Krieger, 1987). Because of this history,
race engenders emotion, and emotion is the antidote to rationality. Some have
called for the end of research on race and health (Stolley, 1999; Fullilove, 1998;
Osborne & Feit, 1992; Leslie, 1990). Medical journal editors now discourage the
use of the term race in manuscripts submitted for consideration. In fact, physical
anthropologists no longer recognize race as a valid concept (Brace, 1964;

intro ductio n 7
Livingstone, 1962). And other disciplines have begun to debate the use of race as a
term and a concept as well (Scarr, 1988; Betancourt & Lopez, 1993).
The argument against continuing to conduct research on race and health goes
like this:
Proposition 1: race is not a valid biological concept, therefore
Proposition 2: race is not a valid scientific concept, therefore
Proposition 3: continuing to document race differences in health bolsters
pseudoscientific—even racist—arguments about the existence of biological
differences between groups that we call races, and about the genetic inferiority
of certain groups.
Although it is easy to be sympathetic to propositions 1 and 3, it is at the second

proposition where the reasoning goes astray. The problem is in using biology as
the arbiter of what is scientific. As knowledge of the human genomic makeup
has unfolded, it has become increasing clear that the widely held belief that
there are biological differences between race groups is incorrect. However, race
may be a biological fiction, but—as the articles in this reader demonstrate—
race is a profoundly important determinant of health status and health care
quality.
About This Book

So what is race, and why do race disparities exist? These are the central questions
this book is designed to address. Race, Ethnicity, and Health contains a set of chap-
ters that provide an overview of the current state of knowledge regarding these
questions.
Most of the chapters offer selected, previously published articles from scientific
journals. In addition, there are three original chapters, which have not been pub-
lished before. Two of them were written by the coeditors of this book and the third
by two other authors. We communicated with instructors throughout the country
who used the first edition of Race, Ethnicity, and Health in their courses. After
weighing their advice we retained thirteen chapters from the first edition that were
the ones most commonly used in courses. We replaced twenty chapters that instruc-
tors found less useful, and we also added five chapters that represent the evolution
of the field since the publication of the first edition.
Since the first edition came out, there have been several interesting and important
advances in public health research on race and ethnicity. We attempted to cover each

of these important new directions with representative chapters. Camara Jones and
her colleagues provide a nuanced treatment of race as a social variable. James
Jackson and colleagues present an innovative approach to understanding race dis-
parities as arising from negative health behavior resulting from ineffectively coping
with stress. LaVeist and colleagues turn the social determinants of health perspective
on its head by examining the nature of racial disparities within racially integrated
communities without race differences in socioeconomic status. In these settings black
and white Americans are exposed to similar social and environmental factors, which
allows for an examination of the question, What is the nature of race disparities
when black and white Americans live under similar conditions? And Alexander
Green and his colleagues employ a highly innovative measure of unconscious racial
bias to examine the effects of racial bias on physician decision making.
As in the first edition, we limited the chapters to those that address race and
ethnicity in relation to health in the United States. Because different cultures
and countries respond differently to race and ethnicity, we felt it best to address the
broader international context in a separate volume.
It is important to point out what may be obvious to some. This compilation is
not intended to be a listing of the “best” journal articles. Our goal was to compile
a set of chapters that can provide a strong foundation for those interested in learn-
ing about health inequalities by race and ethnicity in the United States.
In selecting the readings for the book we relied on input from experts in health
inequalities, including, as I mentioned previously, instructors who have used the
first edition in their courses. Although these experts were kind enough to provide
us with valuable feedback during the selection process, the final selections were
determined by the coeditors; any perceived omissions should be attributed to our
judgment (or misjudgment).
This second edition of Race, Ethnicity, and Health begins with two original chap-
ters (this Introduction and Chapter One), each authored by one of the coeditors, that
provide frameworks for understanding the rapidly increasing diversity in the United
States and that also address issues of nomenclature for conversations about so-called
minority and majority populations. Following that introductory material, this book
is divided into five parts. New to this second edition are part introductions that give
an overview of the chapters in each part. Parts One and Two provide important back-
ground to the subject. Part One (“Historical and Political Considerations”) comprises
two chapters that provide historical context to the study of race, ethnicity, and health.
Part Two (“Conceptualizing Race and Ethnicity”) offers chapters that take on the

intro ductio n 9
concepts of race and genetics; one of these chapters takes an innovative spin on con-
ceptualizing race as a social construct.
For Part Three we compiled a set of chapters that seek to explain how racial and
ethnic disparities are produced, and we divided these chapters into four groups, or
subparts. The first subpart looks at psychosocial and individual-level effects and
presents chapters that lay out a conceptual framework for understanding racism as
a stressor among African Americans. The second subpart examines the effects of
culture and includes chapters that explore various aspects of acculturation. The
third subpart addresses social determinants of health, and the last is composed of
chapters that provide frameworks and evidence for understanding how the social
environment affects health inequalities.
The chapters in Part Four are divided into three parts. The first subpart, focused
on patients, advances our understanding of the role of patient preferences in
explaining disparities in health care. The second subpart, on providers, examines
race differences in treatment and examines racial and socioeconomic status bias
among health care providers. The last subpart addresses issues that are systemic in
the health care system and lead to health care disparities.
Finally, Part Five of this reader presents three chapters that examine possible
solutions for reducing the burden of racial and ethnic health disparities.
Acknowledgments
We would like to express our sincere gratitude and thanks to Ryan Birkholz,
Romana Hasnain-Wynia, Kate E. Masley, and Dawood H. Sultan, who offered their
insights and suggestions on this second edition. We would also like to thank all the
instructors who used the first edition and provided valuable feedback on how to
improve this second edition.
References
Arias, E., Rostron, B. L., & Tejada-Vera, B. (2010). United States life tables, 2005. National
Vital Statistics Reports, 58(10).
Betancourt, H., & Lopez, S. R. (1993). The study of culture, ethnicity and race in American
psychology. American Psychologist, 48(6), 229–237.
Brace, C. L. (1964). On the race concept. Current Anthropology, 5, 313–320.
Byrd, W. M., & Clayton, L. A. (1992). An American health dilemma: A history of blacks in
the health system. Journal of the National Medical Association, 84(2), 189–200.

Eberhardt, M. S., Ingram, D. D., Makuc, D. M., et al. (2001). Urban and rural health chart-
book: Health, United States, 2001. Hyattsville, MD: National Center for Health
Statistics.
Fullilove, M. T. (1998). Comment: Abandoning “race” as a variable in public health
research—an idea whose time has come. American Journal of Public Health, 88(9),
1297–1298.
Grove, R. D., & Hetzel, A. M. (1968). Vital statistics rates in the United States, 1940–1960.
Washington, DC: U.S. Government Printing Office.
Jones, C. P., LaVeist, T. A., & Lillie-Blanton, M. (1991). “Race” in the epidemiologic litera-
ture: An examination of the American Journal of Epidemiology. American Journal of
Epidemiology, 134, 1079–1084.
Krieger, N. (1987). Shades of difference: Theoretical underpinnings of the medical contro-
versy on black/white differences in the United States, 1830–1870. International
Journal of Health Services, 17(2), 259–278.
Leslie, C. (1990). Scientific racism: Reflections on peer review, science and ideology. Social
Science & Medicine, 31(8), 891–905.
Livingston, F. B. (1962). On the non-existence of human races. Current Anthropology, 3,
279–281.
Osborne, N. G., & Feit, M. D. (1992). Using race in medical research. Journal of the
American Medical Association, 267(2), 275–279.
Pew Hispanic Center. (2009). Statistical portrait of the foreign-born population of the
United States, 2009. Retrieved from http://pewhispanic.org/factsheets/factsheet
.php?FactsheetID=69 accessed
Savitt, T. (1982). The use of blacks for medical experimentation and demonstration in the
old south. Journal of Southern History, 48(3), 331–348.

Scarr, A. (1988). Race and gender as psychological variables. American Psychologist, 43(1),
56–59.
Shin, H. B., & Kominski, R. A. (2010). Language use in the United States: 2007 (American
Community Survey Reports, ACS-12). Washington, DC: U.S. Census Bureau.
Stolley, P. D. (1999). Race in epidemiology. International Journal of Health Services, 29(4),
905–909.
U.S. Census Bureau. (2009). Current population survey: Annual social and economic sup-
plement, 2009. Washington, DC: Author.
Xu, J., Kochanek, K. D., Murphy, S. L., & Tejada-Vera, B. (2010). Deaths: Final data for
2007. National Vital Statistics Reports; 58(19). Retrieved from http://www.cdc.gov
/nchs/data/nvsr/nvsr58/nvsr58_19.pdf
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INTRODUCTION

THE ETHNIC DEMOGRAPHIC TRANSITION

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Figure I.1. Projected Racial Diversity in the Twenty-First Century, Percentages of

Figure I.2. Demographic Transition Model

Stage 1 Stage 2 Stage 3 Stage 4

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Figure I.3. Population Pyramids for U.S.-Born and Foreign-Born Populations,

10% 8% 6% 4% 2% 0 2% 4% 6% 8% 10% 10% 8% 6% 4% 2% 0 2% 4% 6% 8% 10%

Source: U.S. Census Bureau, 2009, tables 1.1 and 2.1.

Race, Ethnicity, and Health

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Figure I.4. Life Expectancy by Race—United States, 1900–1997

White male White female Black male Black female

& Tejada-Vera, 2010; Xu, Kochanek, Murphy, & Tejada-Vera, 2010.

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Note: Rates per 100,000 standard population.

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Although it is easy to be sympathetic to propositions 1 and 3, it is at the second

About This Book

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old south. Journal of Southern History, 48(3), 331–348.

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