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Vernellia R. Randall
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Annotated Bibliography

Spring 1997



This annotated bibliography attempts to provide and overview of the current status of minoritys' access to health care. Specifically, this bibliography will show that ethnic minorities have been and continue to be denied access to adequate health care because of numerous barriers. These barriers include institutional racism, lack of insurance, lack of money, inadequate location of health care facilities, poor relationships with non-minority physicians, stereotypes, misconceptions, fear, abusive history, the lack of enforcement of federal laws and lower socioeconomic status. Although these barriers provide a comprehensive analysis of the reasons that ethnic minorities face problems in attaining health care, there remain additional barriers.

Upon completion of reading this bibliography, the reader should have a general understanding of the numerous barriers that ethnic minorities face in gaining access to health care. Additionally, these articles should heighten an individuals awareness of the social, economic and historical roots of ethnic minoritys' denial of access of health care. Furthermore, African Americans should also be aware of the impact these barriers are having upon their health status and be prepared to improve their situation.

The following articles are included in this bibliography

Access to Medical Care for Black and White Americans: A Matter of Continuing Concer

Black and White Disparities in Health Care

Breaking the Barriers of Access to Health Care: A Discussion of the Role of Civil Rights Litigation and the Relationship Between Burdens of Proof and the Experience of Denia l

Hispanics, Health Care, and Title VI of the Civil Rights Act of 1964

Latina and African American Women: Continuing Disparities in Health

Locational and Population Factors in Health Care-Seeking Behavior in Savannah, Georgia

Race, Ethnicity, and Access to Ambulatory Care Among U.S. Adolescent

Race/ Ethnicity and Socioeconomic Status: Measurement and Methodological Issue

Racial Inequalities in the use of Procedures for Patients with Ischemic Heart Disease in Massachusett

Racism and Health Care Access: A Dialogue with Childbearing Women

Racist Health Care: Reforming an Unjust Health Care System to Meet the Needs of African American

Relationship Between Patient Race and the Intensity of Hospital Service

Segregation, Poverty, and Empowerment: Health Consequences for African American

Slavery, Segregation and Racism: Trusting the Health Care System Ain't Always Easy! An African American Perspective on Bioethic

White Doctors and Black Patients: Influence of Race on the Doctor-Patient Relationship


Lillie-Blanton, et. al., Latina and African American Women: Continuing Disparities in Health, International Journal of Health Services, vol. 23, no. 3, pages 555-84, 1993.

The journal suggests that women of all races, creeds, and color continue to face enormous obstacles as they attempt to realize their promise of America. For women of color-- women of various ethnicities-- the author suggests, the promise is even more difficult because they are perceived as second class citizens within their own racial and ethnic groups.

To help readers better understand the problems that women of color face in health care, this article seeks to provide information on racial/ethnic differences in women's social condition, health status, exposure to occupational and environmental risks, and use of health services. Other factors that are considered are an individuals income and class. This is done to attempt to provide the most comprehensive information available for women of equal financial status.

The author concluded that Latina and African American women are more likely than Caucasian American women to encounter negative social environments-- poverty and hazardous work conditions-- that will significantly impact their health. Moreover, the author found that racial disparities in health care are not only a result of an individuals negative social environments, but also a result of barriers in access to quality health care. The author noted that in order to rid society of the many disparities in health care, there must be an attempt to reduce social inequalities and enforce a policy of greater access to facilities that manifest healthier environments and lifestyles. To address many of these social inequalities, the laws need to be changed from the ground up; community based organizations should be used to directly reflect the needs of minority women.[Back]


Council on Judicial Affairs, Black and White Disparities in Health Care, JAMA, vol. 263, no. 17, pages 2344-2346, 1990.

The authors of this journal found that there are persistent differences in the quality of health care given to American citizens. Moreover, despite improvements in health care for African Americans over the last three decades, African Americans have twice the mortality rate of Caucasian Americans and have a significantly shorter lifer expectancy, 6 years less. This disparity in health care between African Americans and Caucasian Americans is synonymous with the continuing disparities in income, education, and other factors that relate to receiving expensive medical services. Furthermore, studies have shown that even when African Americans are given access to health care, they are less likely than Caucasian Americans to receive specific surgical therapies; also, this disparity is not limited to African Americans. Specifically, the studies have shown that African Americans' treatment is different than Caucasian Americans' treatment in the areas of cardiology and cardiac surgery, general internal medicine, kidney transplantation, and obstetrics. Although there has not been one single reason identified for the differences, income has been the primary reason. Moreover, race and income are the two most notable reasons for the disparity because people believe that individuals with higher income are better able to withstand the costs of medical procedures. Some experts have stated they are more willing to treat patients who are wealthier, more productively employed, more assertive, more likely to respond to therapy, and more of a value to society. Other factors, like education and the skills that result from it, continue to restrict African Americans from the ability to gain access to the best medical treatment.

The author concluded that whether or not these disparities are a result of race, education, or income, the result should not be condoned. "Not only do the disparities violate fundamental principles of fairness, justice, and medical ethics, they may be part of the reason for the poorer quality of health of blacks in the United States." (1) [Back]


T. Laveist, Segregation, Poverty, and Empowerment: Health Consequences for African Americans, Milbank Quarterly, vol. 71, no. 1, pages 41-64, 1993.

The journal suggest that cities across the United States have undergone substantial changes over the past two decades. Several factors have influenced this change: the development of a black political elite, sustained rates of black poverty and intensified racial segregation. The author notes that only over the course of the last twenty years, however, have dramatic differences in the health status of blacks and whites really emerged in research literature.

Specifically, this article relates its findings from its studies of cities with a population of 50,000 people, where at least 10 percent of which is black. As the study expected, there was a substantial geographic variation in black and white infant mortality rates. The study found that racial residential segregation, black political empowerment, and black and white poverty are the main characteristics that distinguish cities with a high degree of differentiation in the black and white mortality from cites that do not such a differentiation.[Back]


D. Williams, Race/ ethnicity and socioeconomic status: measurement and methodological issues, International Journal of Health Services, vol. 26, no. 3, pages 483-505.

The study was conducted to determine the adversarial relationship between race/ethnicity and an individuals socioeconomic status. Specifically, the study sought to determine how the two variables relate to each other and combine to affect variations in health status along racial lines. The study reviewed a number of issues concerning the interpretation of race in the United States that significantly affects the quality of information available on racial differences in health. Moreover, these issues include the discrepancy between self-identification and observer-reported race, the difficulties in categorizing people of mixed races, changing racial classifications categories and racial identification, and census undercounting.

In reaching its conclusions about the relationship of an individuals race/ethnicity to ones socioeconomic status, the author first discusses the relationship between race/ethnicity and socioeconomic status and shows how socioeconomic status influences the health care that one receives. Second, the author shows how ones socioeconomic status fails to completely account for the variations in health care. Finally, the author stresses the need of researchers to give greater attention to alternate factors that are linked to race that affect health care. Specifically, these factors include racism, migration, and the comprehensive assessment of socioeconomic status.[Back]


Wilbert M. Gesler and Melinda S. Meade, Locational and Population Factor in Health Care-Seeking Behavior in Savannah, Georgia, Health Services Research, vol. 23, no. 3, 1988.

The authors examination of the location of health care facilities is unique because it analyzes the importance of the facility within downtown Savannah, Georgia. This is unique because most reports regarding the location of a health care facility reports how ineffective health care facilities can be when they are located a great distance for the people that it seeks to treat.

In their study, the authors sought to examine the factors that influence an individuals use of health care facilities. These factors included the distance to health care facilities, differences among population subgroups in access to health care, the relative locations of people and their sources of health care, and citizens' activity places. The study came up with five main conclusions: 1) distance alone may have an important influence on the accessibility for of health care for a number of people that live at varying distances from the health care location; 2) the location of the health care relative to the people who use them is important; 3) the distance in travel to the health care facilities was not as affected by race, sex or age as other studies have shown; 4) each city has its own characteristics and health care facilities and providers should understand and observe these characteristics; and 5) the health care facility and providers should better understand the daily activity spaces of people to better understand and serve them.

In all, the authors found that health care facilities, like this one, that are located downtown better serve their clientele because the distance from home is a determinative factor in receiving health care. Specifically, the study found that the limitations on inner city residents did not allow them to travel far outside of their community to get medical attention. While individuals who lived in the suburbs or on the fringes of the city were able to commute to get health care.[Back]


Mark B. Wenneker and Arnold M. Epstein, Racial Inequalities in the use of Procedures for Patients with Ischemic Heart Disease in Massachusetts, JAMA, vol. 261, no. 2, page 253.

The authors of this study found that among patients with ischemic heart disease, Caucasian Americans were more likely to receive treatment than their African American counterparts. To develop their hypothesis, the authors examined the interracial differences in the use of coronary angiography, coronary artery bypass grafting, and coronary angioplasty for both Caucasian and African American patients in Massachusetts hospitals in 1985. Specifically, during the course of the study the authors looked at the patients payer, zip code, and admission type. The controlled study found that Caucasian Americans were given significantly more angiography and coronary artery bypass grafting procedures. Caucasian Americans underwent 1/3 more coronary catheterizations and more than twice as many coronary artery bypass grafts and coronary angioplasties.

The authors noted that the procedures are expensive, but also have a significant impact on the prolonged life of the patient. As a result, African Americans and other indigent populations were more likely to not receive treatment. Some of the factors that the authors found that might have influenced the study were the preconceived risk factors in allowing African Americans to participate, the individuals ability to pay, and the fact that African Americans are less likely to seek medical treatment-- even when it is necessary. In conclusion, the authors found that African Americans are denied access to preventive health care on the basis of race.[Back]


Marianne L. Engleman Lado, Breaking the Barriers of Access to Health Care: A Discussion of the Role of Civil Rights Litigation and the Relationship Between Burdens of Proof and the Experience of Denial, 60 Brook. L. Rev. 239 (1994).

The author suggests that the highest levels of security and the benefits of medical research and technology are reserved for the elite of American society. Moreover, institutional racism, segregation and discriminatory practices by health care providers of medical services ensure that these benefits are not given to African Americans. In the three part article, the author discusses the barriers to health care, the role of civil rights litigation in addressing all of the barriers to health care, the relationship between the burdens of proof and the experience of denial.

The author concluded that courts, as a whole, are not dispensing impact oriented standards in a neutral way. Moreover, the author believes that judges administer justice in a biased manner that is often not favorable to African Americans-- regardless of whether or not they are conscious of it. The author stresses, however, that it is vital that attorneys find ways to show the disparate effect that current barriers possess in allowing for health care to the indigent and African Americans. As advocates, the author suggests that the most effective ways to show the courts the negative effects of racism is through the use of strengthening relationships with social scientists working in areas like health planning and epidemiology who advocate for the use of area specific surveys and in-depth interviews.[Back]


Ralphael Metzger, Hispanics, Health Care, and Title VI of the Civil Rights Act of 1964, 3-WTR Kan. J.L. & Pub. Pol'y 31 (Winter 1993/1994).

This article was designed to analyze the use of Title VI of the 1964 Civil Rights Act of 1964 in relation to the adequacy of health care to Hispanics. As a whole, Hispanics are a large and growing part of the American population. Numerous studies have shown that Hispanics health status is worse than its non-Hispanic counterparts. This statistic is attributed to a lack of access to health care services. This article develops the authors theory that Hispanics lack of access to health care services is a direct result of the numerous barriers to access that are related to language and culture.

As part of their barriers hypothesis, the author states that there are two reasons why Hispanics have such a low access to health care services: culture and language. Of these barriers, the author tends to believe that the language barrier weighs more heavily in the balance. Specifically, because there are so few Spanish speaking physicians in the medical arena, Hispanics are less likely to attempt to get medical services. Moreover, an individual who does not have medical insurance is less likely to ask questions on how to get insurance, and therefore will not receive medical attention.

In conclusion, the author suggests that if regulations like the Limited English Proficiency Regulation were passed, Spanish speaking people would be better accommodated by health care services. The regulation would require Spanish speaking individuals to be employed by all organizations that receive money from the Department of Health and Human Services. Moreover, the law would "prohibit specific practices resulting in a disparate impact on persons with limited-English proficiency and [create] affirmative obligations for covered entities, including the provision of interpreters, the posting of signs, and the provisions of informational literature." (2) The article concludes by restating that public health experts realize that linguistic accommodation would greatly increase Hispanics access to health care.[Back]


Vernellia R. Randall, Racist Health Care: Reforming an Unjust Health Care System to Meet the Needs of African Americans, 3 Health Matrix 127 (1993).

The author of this article argues that institutional racism is the main cause of African Americans' poor health status and serves as the primary barrier to adequate health care. Moreover, until institutional racism is analyzed and dealt with, African Americans will continue to receive substandard health care.

The author begins her analysis by looking at the health status of African American. In this endeavor, the author weighs several factors: African American's dissatisfaction, discomfort, disability, disease, low-birth weight, and death rate. The author concluded that the above mentioned factors show the disparity in health care services given to African Americans and Caucasian Americans. Furthermore, the author states that, "[i]f African-Americans are sicker as a result of disparate treatment in the health care system, then they are victims of unequal access to health care." (3)

The author continues by looking at institutional racism and its effect on the African American health status. Realizing that African Americans are sicker than their Caucasian counterparts, the author seeks to find out why this is the case. The authors main theory is that barriers to access to health care have adverse effects on African Americans. Specifically, barriers to hospitals, nursing homes, and barriers to physicians and other providers do not allow African American the ability to get the care they need-- or desire.

The author also states in her article that by analyzing the current health care policy and looking at possible solutions to the disparity we can effect some positive change. The author calls the current policy a "Do Nothing" policy in which African Americans are not able to improve their health status. As an alternative, the author suggests that the United States expand its insurance coverage to cover all Americans, as many countries already have. The author also looks at targeting health services to the needs of African Americans. Although this would be a cumbersome task, it would allow health care providers an opportunity to confront problems that are specific to African Americans. Finally, the author suggests that the United States use Title VI to eliminate institutional racism. Although the law was passed to confront racism, it currently is unable to correct covert racism that has a disparate effect on African Americans.

The author concludes by noting that African Americans' poor health status is a direct result of institutional racism. Only by purging the health care system of institutional racism can African Americans improve their health status.[Back]


Vernellia R. Randall, Slavery, Segregation and Racism: Trusting the Health Care System Ain't Always Easy! An African American Perspective on Bioethics, 15 St. Louis U.Pub.L.rev. 191 (1996).

The author suggests that African Americans have a high level of distrust for the health care system. This distrust is a direct result of the United States' history of nonconsensual experimentation and abuse of African Americans. Moreover, fear has shaped the manner in which African Americans perceive the health care industry, and created a perspective of distrust. Consequently, African Americans have a tendency to not peruse medical treatment, participate in medical research, from signing living wills, and from donating organs. In general, African American's fear of the health care industry negatively affects the care that they receive.

The author begins by showing that African Americans' fear of the health care industry is real and entrenched in the United States history. Moreover, African Americans were the target of experimentation by the same health care industry that attempts to console it now. The author shows that nonconsensual experimentation was occurring during slavery as well as afterwards. Another area that African Americans were exploited was in the prison system-- African Americans comprise forty-four percent of the prison population. Other areas of the health care system's experimentation of African Americans revolved around the sickle cell screening and the family planning and involuntary sterilization procedures undertaken by the health care industry.

The author concludes her article by showing that in present day America African Americans are still bombarded by unfair practices of the health care industry. Specifically, the author show that in the areas of abortion, general health status, the use of racial barriers to health care, the racial disparities in medical treatment, genetic testing, managed care, organ transplant, and reproductive technology oppression still exists.

In all, the author shows that the continued destruction of African Americans is a direct result of a failure to recognize that individuals perspectives are shaped by experience and history. Until that perspective is understood and accepted, African Americans will continue to have a great deal of distrust of the health care industry.[Back]


J. Yergan, et. al., Relationship Between Patient Race and the Intensity of Hospital Services, Med. Care, vol. 25, no. 7, page 592-603 (1987).

The authors undertook their survey to determine whether or not the hospital services rendered to its patients varied by racial group. In particular, the authors looked at the quality and equity of the services given. As for the test subjects, the authors analyzed the treatment of pneumonia patients from 16 hospitals that were randomly chosen. During the course of their observations, the authors looked t the intensity of the diagnostic and therapeutic services given to patients, and the death rate during their hospital stay.

The results of the survey were closely compared to the status of the patients before they were treated to excentuate the disparities in the treatment. The authors observed that the nonwhite patients received fewer hospital services than were expected based on their poor condition. The authors concluded that race was the primary determinant in the intensity of care given to patients.[Back]


T. Lieu, Race, Ethnicity, and Access to Ambulatory Care Among U.S. Adolescents, American Journal of Public Health, vol. 87, no. 7, pages 960-65 (1993).

The study conducted by the author is an attempt to analyze the differences in access to health care for Caucasian Americans, African Americans and Hispanic Americans, and how those differences affect the availability of insurance. The author conducted its survey by looking at 7465 youths 10 to 17 years of age of the various races. The survey found that as a direct result of the differences and use of children of various races, Hispanic Americans had the highest percentage of lack of insurance (28%), African Americans had the second highest percentage (16%) and Caucasian American had the lowest rate of uninsurance (11%).

Ironically, despite the fact that Hispanic Americans and African Americans have a worse health status, they have a significantly lower rate of visits to see physicians. The study found that health insurance as directly related to greater access and use of health services. Logically, individuals without insurance tend not to go out and get medical help. More importantly, the study found that even among Hispanic Americans and African Americans that had heath insurance, there was still a disproportionately low number of nonwhites receiving medical services. The study concluded nonwhite adolescents are at an increased risk for attaining adequate access to health care because they are less likely to have insurance and therefore make fewer visits to see the physician.[Back]


N. Murrell, Racism and Health Care Access A Dialogue with Childbearing Women, Health Care Women International, vol. 17, no. 2, pages 149-59 (1996).

The study sought to show that African American women have a far greater complications during birth than their Caucasian counterparts because of inherent racism. The study showed that African American women are twice as likely as their Caucasian American counterparts to have children that have low birth weights and delivered before term.

To better analyze the problem, the author conducted a survey to study African American women both prenatally and after labor. As part of the survey, the authors conducted one to two hour interviews with the women in the study and discussed their access to health care, treatment, differences in care, stereotypes and their experiences with racism. The results revealed some important findings: 1) a pervasiveness of negative stereotypes about African American women; 2) when health care was given, it indifferent, inaccessible and undignified; 3) the women experienced a general feeling of racism directed towards them. The author concluded by stating that African American womens' perception of their access to health care encompasses social, political and economic factors that mandate need for further investigation.[Back]


Robert J. Blendon, et. al.,Access to Medical Care for Black and White American: A Matter of Continuing Concern, JAMA, vol. 261, no. 2, page 278.

In their article, the authors found that a national survey revealed that African Americans of all income levels have a significant deficit in health care access when compared to Caucasian Americans. The study also indicated that African Americans underused their medical resources when in need of medical attention. Furthermore, the study found, African Americans are less likely to be satisfied with their medical treatment when they are ill, more dissatisfied with the care that they receive when they are hospitalized, and more likely to believe that their hospital stay was too short.

The study was quick to point out that African American's access to health care has improved over the last three decades-- "[i]n 1963 the, the proportion of blacks who saw a physician was 18% lower than for whites; by 1982 this gap had been almost eliminated." (4) Moreover, African Americans' improvements in health care over the years also improved general health outcomes-- infant mortality declined by over 50% during that time period. The authors found, however, that researchers were quick to point out all of the advances that African Americans have made in terms of their access to health care should not lead to believing that the problem has been eradicated-- African Americans have a 1 1/2 higher death rate, as compared to Caucasian Americans, and the infant mortality rate for African Americans is twice as high for that of Caucasian Americans.

In conclusion, the authors found that the 1986 national study found that there continued to be a lack of equality in access to health care. As a result, there were a large number of unmet medical needs for African Americans as a whole. Although the lower economic status of African Americans contributes to the lack of access to medical services, the study showed that even African Americans who were above the poverty line have less access to health care when compared to their Caucasian American counterparts. In all, the authors concluded that in spite of all of the advances that African Americans have made over the last three decades in improving their access to health care, there is still a long way to go until parity is reached.[Back]


David R. Levy, White Doctors and Black Patient: Influence of Race on the Doctor-Patient Relationship, Pediatrics, vol. 75, page 639- 643, 1985.

The author found that the communication between a physician and his patient-- a relationship that is not given a great deal of attention during medical school-- is very important for the patients satisfaction and care. Moreover, in a large number of situations, the attending physician is middle class and Caucasian, and the patient is lower class and African American. Interestingly, the author found that racial differences, without any type of class differences, has a negative effect of the physician-patient relationship. Through the course of the article the author made several recommendations to improve the relationship between the physician and the patient. These recommendations include: having good manners, understanding, do not stereotype the people you help, reassess ones criteria for diagnosing the pathology in black patients, and try and learn more about the black experience. All of these recommendations are an attempt to help African Americans receive greater access to health care in America.[Back]


1. Council on Judicial Affairs, Black and White Disparities in Health Care, JAMA, vol. 263, no. 17, pages 2344-2346, 1990.

2. Ralphael Metzger, Hispanics, Health Care, and Title VI of the Civil Rights Act of 1964, 3-WTR Kan. J.L. & Pub. Pol'y 31 (Winter 1993/1994).

3. Vernellia R. Randall, Racist Health Care: Reforming an Unjust Health Care System to Meet the Needs of African Americans, 3 Health Matrix 127 (1993).

4. Robert J. Blendon, et. al., Access to Medical Care for Black and White Americans: A Matter of Continuing Concern, JAMA, vol. 261, no. 2, page 278. 


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Professor Vernellia R. Randall
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The University of Dayton School of Law
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