chronically high blood
to be high if systolic
pressure exceeds 160
and diastolic exceeds
involves damage to the
brain as a result of
either bleeding into
the brain tissue or a
blockage in an artery,
which prevents oxygen
and other nutrients
reaching parts of the
brain. More scientifically
known as a cerebrovascular
48 CHAPTER 2 • HEALTH INEQUALITIES
n Differential health behaviour
As with SES, the behavioural hypothesis suggests that variations in health
outcomes may be explained by differences in behaviour across ethnic groups.
In the UK, for example, many African-Caribbean men and Asian males of
Punjabi origin consume high levels of alcohol and develop alcohol-related
disorders: levels of consumption among Muslim people are minimal, with
total abstinence being common. The British Asian population has a relatively
high level of fat consumption and its associated illnesses such as CHD (Rudat
1994; Nazroo 1997). Smoking is more common among African-Caribbean
and Bangladeshi men than in the white population (Nazroo 1997).
Fewer men and women aged 16–74 from minority ethnic groups than the
majority population engage in levels of activity that would benefit their
health. The Health Education Authority (1997), for example, reported that
67 percent of Indians, 72 percent of Pakistanis and 75 percent of Bangladeshis
reported that they did not engage in enough physical activity to benefit their
health. This contrasts with 59 percent of men in the general population.
A similar pattern emerged among women. Different levels of such health
behaviour may reflect social and cultural beliefs and behavioural norms that
differ across ethnic groups.
n The stress of occupying a minority status
A second explanation for the health disadvantages of people in minority
groups focuses on the social impact of occupying minority status. Ethnic
minorities may experience wider sources of stress than majority populations
as a consequence of specific stressors such as discrimination, racial harassment,
and the demands of maintaining or shifting culture.
One area where this has become evident is in the relatively high rates of
CHD and hypertension among black American men (Onwuanyi, Clarke and
Vanderbush 2003). A number of explanations have been proposed to account
for this phenomenon. One that was frequently expounded in the 1970s was
that black men’s blood pressure rose more while they experienced stress and
strong emotions such as anger than did that of their white counterparts,
and that they experienced such emotions more frequently. This process
was thought to gradually push up resting blood pressure until an affected
individual would present with long-term hypertension (see also Chapter 8).
In other words, this health problem was linked to genetically mediated
biological differences between black and white populations. More recently,
these differences have been ascribed to the different social contexts that
people in these two groups may experience. Rises in blood pressure and
the higher reactivity found among black men are now seen as a result of the
increased stress to which they are exposed in comparison with their white
Evidence to support this explanation can be found in the work of Harburg,
Erfurt, Chape et al. (1973), who found no differences in blood pressure
between black and white people living in low-stress areas. By contrast, the
highest blood pressure readings they had were those of black people living in
areas of low income and high crime. Similarly, James, LaCroix, Kleinbaum
et al. (1984) found high blood pressure in black men to be associated with
low job security, lack of job success and discrimination. An experimental
MINORITY STATUS AND HEALTH 49
study conducted by Clarke (2000) added to these population data. In this,
Clarke found that among a sample of young African American women,
the more they reported experiencing racism, the greater their rises in blood
pressure during a task in which they talked about their views and feelings
about animal rights. They took this to indicate that they had developed
a stronger emotional and physiological reaction to general stress as a result
of their long-term responses to racism. This, in turn, was contributing to
the long-term development of hypertension (Brosschot and Thayer 1998).
A related explanation is known as ‘John Henryism’. This suggests that successful
black men have had to push harder than their white equivalents
to achieve such success, and their increases in blood pressure reflect the
stress of such effort (Merritt, Bennett, Williams et al. 2004; see also in the
spotlight in Chapter 8).
n Access to healthcare
A third explanation for the relatively poor health among ethnic minorities
may be found in the problems some face in accessing healthcare. In addition,
once within the hospital system, ethnic minority patients may be less likely
to receive expensive treatments than the equivalent white patient. Mitchell,
Ballard, Matchar et al. (2000), for example, found that, even after adjusting
for demographic factors, the presence of other health conditions, and the
ability of patients to pay, African American patients with transient ischaemic
attacks were significantly less likely to receive specialist diagnostic tests or to
have a specialist doctor than white patients. In addition, there is consistent
evidence that in the USA blacks are less likely than whites to receive curative
surgery for early-stage lung, colon or breast cancer (e.g. Brawley and Freeman
1999) and that these failures result in higher mortality rates among black
people than among whites. Furthermore, blacks with chronic renal failure
are less likely to be referred for transplantation and are less likely to undergo
transplantation than are whites (Ayanian, Cleary, Weissman et al. 1999).
In the UK, many of the inequities associated with healthcare appear to
result more from economic than from ethnic disparities. Chinese people consult
their GP less than whites and African Asians. However, all other groups
consult more (Nazroo 1997). Unfortunately, poor communities that are most
at risk of ill-health tend to experience the least access to the full range of
prevention services: a phenomenon known as the ‘inverse prevention law’
(Acheson 1998). In addition, specific factors may affect some ethnic groups.
Access to female GPs is lowest in areas with high concentrations of Asian
residents (Birmingham Health Authority 1995): a factor that may inhibit
Asian women’s use of healthcare services, and, in particular, uptake of
screening for cervical cancer (Naish, Brown and Denton 1994). Access to
secondary (hospital) care may also affect some people from ethnic minorities.
As mortality rates for CHD in South Asians is 40 percent higher than in
the general population, rates of medical and surgical intervention should be
higher for this population than the general norm. The evidence suggests the
opposite is the case – even after adjusting for SES and geographical factors
(Goddard and Smith 1998). However, there is no evidence of systematic
inequities in access for many other hospital treatments (Gillam, Jarman,
White and Law 1989).
a short period of
reduced blood flow to
the brain, resulting in
short periods of
and other minor
50 CHAPTER 2 • HEALTH INEQUALITIES
Minority status may also result from differences in behaviour from the norm.
Following the initial onset of HIV and AIDS, both infection and death rates
were higher among gay men than in the rest of the sexually active population.
As a result, it was initially considered to be a consequence of the ‘gay
lifestyle’; indeed, AIDS was called the ‘gay plague’ by many in the media (see
Shilts 2000). Now, levels of HIV infection among the heterosexual population
in most Western countries are similar to those in the gay community,
and the most prevalent mode of transmission is through heterosexual sex.
Accordingly, HIV infection can no longer be considered to affect minority
groups in society. However, the isolation experienced as a consequence of
sexual orientation may impact significantly on the development of AIDS
following infection with the HIV. Cole, Kemeny, Taylor et al. (1996), for
example, found that HIV-infected gay men who experienced social rejection
as a result of their sexuality showed a significant acceleration towards a
critically low CD4+ lymphocyte level (see Chapter 8) and time to diagnosis
of AIDS in comparison with their counterparts who were more socially integrated.
They also found that healthy gay men who hid their sexual identity
were significantly more likely to develop cancer or infectious diseases than
those men who felt able to express their sexuality, even in the absence of any
underlying viral infection.
Gender and health
An average woman’s life expectancy in the West is significantly greater than
that of men in the same birth cohort. In the United Kingdom, for example,
at the time of writing women were likely to live six years longer than
men, with women dying on average at the age of 80 and men at 74,
(WHO 2002: www.who.int; note that this differs from the WHO data
reported earlier which is based on years lived with ‘good health’). A large
part of this difference is the result of the earlier onset of CHD in men than
in women. Nearly three-quarters of those who die of an MI before the age
of 65 are men (American Heart Association 1995). However, cancer rates
for men and women of the same age also favour women (Reddy et al. 1992).
Reddy, Fleming and Adesso (1992) identified the following risk ratios
of dying prematurely from a variety of diseases for men versus women
These data indicate, for example, that men are nearly twice as likely to die
before the age of 65 of heart disease than women – and also three times more
likely to die from violence (legal intervention appears to be a US euphemism
for the death penalty). Despite these differences in mortality, men report
higher levels of self-rated health, contact medical services less frequently and
experience less acute illness than women (Reddy et al. 1992). By contrast,
women report higher levels of physical symptoms and longstanding illnesses
than men (Lahelma, Martikainen, Rahkonen et al. 1999).
a way of comparing
whether the probability
of a certain event is the
same for two groups.
A risk ratio of 1 implies
that the event is equally
likely in both groups.
A risk ratio greater than
1 implies that the event
is more likely in the first
group. A risk ratio of less
than 1 implies that the
event is less likely in
the first group.
GENDER AND HEALTH 51
It is, perhaps, cautionary to note that while this pattern of mortality is
common among industrialised countries, the pattern of health advantage
is often different in industrialising countries. Here, differences in the life
expectancy of men and women are smaller and in some cases are reversed.
Women in many industrialising countries are more likely to experience
higher rates of premature illness and mortality than men as a result of their
more frequent experience of pregnancy and its associated health risks, as well
as inadequate health services (Doyal 2001).