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3 Case Study – The Ongoing Impact of Discrimination in the United States
Case Study – The Ongoing Impact of Discrimination in the United States
neurological effects of syphilis. They were also offered free hot lunches at the
hospital, and free medicine for any other diseases they might have, and free burial
after autopsies were performed. This discriminatory research has had an ongoing
impact on medical science in that the results are used as the gold standard in our
clinical understanding of syphilis, and the findings are often cited by other
This was the longest running non-therapeutic experiment on human beings in
medical history. Between 1936 and 1973 Public Health Service scientists, physicians and nurses associated with the study published a total of 13 articles in peerreviewed journals, including such prestigious journals as the Public Health Reports,
Milbank Fund Memorial Quarterly, Journal of Chronic Diseases, and Archives of
Internal Medicine. Reviewers did not query the unethical nature of the experiment.
Medical textbooks were able to report the findings without any reference to the
extreme violation of the subjects of the experiment. The following is illustrative:
A prospective study involving 431 black men with seropositive latent syphilis of 3 or more
years’ duration was undertaken in 1932 (the Tuskegee study, 1932–1962). This study
showed that hypertension in syphilitic black men 25–50 years of age was 17 percent more
common than neurologic complications were, and both were increased over control populations. Anatomic evidence of aortitis was found to be 25–35 percent more common in autopsied syphilitics, while evidence of central nervous system syphilis was found in 4 percent
of the patients. (from G. L. Mandell et al. (1990) cited in Caplan 1992, 31).
The dry presentation of facts hides the discriminatory reality of the experiment.
Furthermore, modern day references argue that whilst the study’s comparison was
between a control (treated) group and an experimental (or untreated) group, the
original experimental group was not untreated, but was being treated with the
accepted treatment of 1932, which consisted of the ingestion of toxic heavy metals
such as mercury and arsenic. Penicillin, regarded as an effective treatment for syphilis, became available in the 1940s but the men were not given it. The original toxic
treatment meant that the untreated group was in fact contaminated by introducing a
toxic variable (Edgar 1992). The long-term study explained itself as a study of
untreated syphilis – but this was not the case. So in addition to being unethical science it was also poor science.
Some authors have suggested that this history of enforced experimentation and
unethical medical practices in relation to black people has consequences today,
with, for example, blacks being less likely than whites to receive Medicare, even in
the case of free services (Breslaw 2012). There has been a tendency for black people
to distrust health officials and the legacy of cases like the Tuskegee Syphilis
experiment has discouraged blacks from participating in experimental research
Gender and Ethnicity in Health
Gender disparities in health further complicate our understanding of health inequalities. Epidemiologists have demonstrated that women get sicker, but men die quicker
(Lorber 1997). As a world average women have around 4 years longer life expectancy than men (Therborn 2006a). Part of the explanation for this state of affairs is
the different roles that men and women are socialised into. Data from the United
States shows that of the 4383 fatal work injuries that occurred in 2012, 93 % were
suffered by men. This is primarily because of the different work roles taken, with
agriculture, forestry, fishing and hunting sectors having the highest fatal work injury
rate, and the construction industry having the highest total number of fatal injuries
(Bureau of Labor Statistics 2014). However, the relationship between gender, work,
and health is a changing one, and over recent decades more women have entered the
workforce and in a diverse range of occupations. This may mean the gap in workplace mortality and morbidity between genders starts to close. However, work is
also regarded as having an overall beneficial effect on health, with paid employment
providing more opportunities for women, which further complicates this picture
(Bartley and Head 2007).
It has been argued that men are also more likely to adopt health-damaging behaviors such as excessive drinking of alcohol and violent acts (Farrimond 2012) and are
more likely to die from suicide, homicide, and unintentional injury, including traffic
accidents (Feyer and Langley 2000). There are also differences in the way in which
men and women attempt suicide. Men are more likely to kill themselves using firearms and are therefore more successful than women who are more likely to use
poison. Men and women also deal with illness in different ways. Men tend to use
primary health services less than women and are more likely to delay seeking help
when they are ill. However, women are more likely than men to have a disability
and suffer from disease. This is not simply because women live longer as women
have lower health ratings than men even when they are at the same age (Davis
et al. 1999).
Men and women in the same or similar social situations may have different experiences of illness. Ivory and colleagues (2011) drew on Durkheim’s concepts of
integration and regulation to explore the impact of social fragmentation on mental
health at a neighbourhood level. They found that both social deprivation (material
resources) and social fragmentation (the level of integration and regulation) were
associated with mental health outcomes for men and women, but neighbourhood
fragmentation had a greater negative impact on women, particularly unemployed
An issue that has come under sustained scrutiny has been the relationship
between medical practitioners and women. It has been suggested that the medical
encounter reinforces patriarchal domination and is frequently based on assumptions
of stereotypical male and female roles. The idea of patriarchal domination suggests
that the way society is structured or organized means that women are oppressed and
dominated by men as a whole. Women health professionals may then reinforce this
patriarchal domination in the same ways as their male counterparts as they are part
of, or entangled in, this structural form of oppression.
An example to illustrate how the medical encounter may reinforce patriarchal
domination is that women have higher rates of diagnoses of depression than men
(Van de Velde et al. 2013). We can consider two broad explanation for this. One is
that women actually do have higher rates of depression as an outcome of their life
experiences and the social roles they perform. So women face greater risk of depression following events involving children, housing, and reproduction (Nazroo et al.
1998). Such events include miscarriage and medically complicated pregnancies
through to children facing criminal charges or being involved in drug consumption.
Depression has been linked to powerlessness, a lack of choice and role overload,
where gender-specific demands can mean that women take on paid work as well as
household caring duties (Van de Velde et al. 2013).
A second broad explanation for the differences in diagnoses of depression by
gender is sexism in medicine. Sexism in medicine is evident in the way in which
women’s accounts of their own symptoms are at times ignored by doctors (Broom
2009). In a study of people who had been diagnosed with chronic fatigue syndrome,
a contested condition in medicine, 85 % of women so-diagnosed were, at some
stage in their illness, given a psychiatric diagnosis, but only 30 % of men (Broom
and Woodward 1996). Men’s accounts of their physical symptoms were more likely
to be given credence by health professionals than women’s accounts (Broom and
As women are diagnosed with depression more frequently than men they also
consume larger quantities of psychotropic drugs. In cases where men and women
both have mental distress symptoms women consume more antidepressants and
hypnotics/anxiolytics (Hausken et al. 2007). Critics see this as a medicalized
response to personal troubles and potentially as a form of social control of women
where social problems are reconceptualized as individual problems and psychotropics are used as a medical means to constrain women (Norris et al. 2011).
In contrast to depression, women are under-diagnosed for coronary artery disease (Weisz et al. 2004). Men are more likely to be diagnosed correctly as having
heart disease than women (Curry and O’Brien 2006). It has been found that in the
case of ischaemic heart disease, women are less likely to receive medically proven
secondary prevention therapies such as beta blockers, aspirin and ACE inhibitors
than men, but more likely to be prescribed anxiolytic benzodiazepines (Williams
et al. 2003). This suggests that when physicians are confronted with a patient who
has symptoms of angina, which can include chest pain, nausea and fatigue, they are
more likely to attribute those symptoms to anxiety if the patient is a woman, and
more likely to attribute those symptoms to ischaemic heart disease if the patient is a
man. Women who are hospitalized for strokes are also less likely to receive interventions, like carotid endarterectomies, than men (Ramani et al. 2000). So what
applies to heart disease applies to cerebrovascular disease. This also applies to some
acute conditions, for instance, women are more likely to die from hospital-acquired
pneumonia than men (Crabtree et al. 1999).
Gender and Ethnicity in Health
Efforts to determine the efficacy and safety of medications have played out differently for men and women. In ascertaining therapeutic effectiveness or appropriate doses, research subjects in clinical trials are more likely to be male. The United
States Food and Drug Administration (FDA) policy from 1977 to 1993 was to
exclude women of child bearing potential from phase 1 and phase 2 trials (Pinnow
et al. 2009). Phase 1 trials are designed to screen for safety and phase 2 trials are to
demonstrate effectiveness. Even with the reversal of this policy women are still
underrepresented in phase 1 and 2 trials and some trials for drugs to treat conditions
that occur in men and women are conducted only on men (Pinnow et al. 2009). The
problem here is that for various pharmacokinetic and physiological reasons there
are differences by gender in responses to drugs, so excluding one gender from clinical trials may mean that issues of safety and effectiveness are missed.
Systemic issues related to social and political organization play an important part
in gendered differences in the experience of illness. In a study based on twenty-five
European countries Van de Velde and colleagues found that in jurisdictions with
greater levels of macro-gender equality, measured by such things as women’s economic participation, power over economic resources and political participation,
men and women equally benefitted with lower levels of depression. But there was
some complexity here in that different outcomes applied to different circumstances.
For example, in a jurisdiction where there were high levels of gender equality in
power over resources, such as equality in income, this equality benefitted women
who were not in traditional roles, such as not cohabiting and being in paid employment. The converse implication, Van de Velde and colleagues (2013) argue, is that
women who do not conform to traditional roles in societies of low equality in power
over resources will have higher levels of depression.
In understanding different health outcomes by gender structural, institutional and
interpersonal factors play a part. It is to the last of these that we now turn to inform
our understanding of health inequalities in general.
Interpersonal Impacts on Health Inequalities
It has been shown that different social groups get different outcomes and interactions with health personnel when accessing and using health services. There are
many reasons why health professionals might respond to or interact with patients
In order to deal with the massive amount and complexity of information we confront in our daily lives we all categorize and stereotype (van Ryn and Burke 2000).
We assign people to a particular group, and we associate particular groups with
certain characteristics. Categorizing people is an everyday activity – but it is also an
activity that occurs in institutional settings such as the clinical encounter. It may be
even more pressing for clinicians to categorize patients given the complexity of the
task. The short consultation times, or the emergency situations being dealt with,
Interpersonal Impacts on Health Inequalities
may require the need to make quick judgments about situations (van Ryn and Burke
A great deal of evidence suggests that clinicians categorize in ways that may at
times be inappropriate. Research undertaken at New York State hospitals revealed
that clinicians were more likely to perceive African American patients with coronary artery disease as “at risk for noncompliance with cardiac rehabilitation, substance abuse, and having inadequate social support” and clinicians reported “less
affiliative feelings toward African American patients” (van Ryn and Burke 2000,
821). African Americans were perceived as being less rational, less intelligent and
less pleasant than whites and were rated as less educated than whites even at the
same levels of educational attainment. Similarly patients with lower socio-economic
status were more likely to be seen by clinicians as having responsibility for the care
of family members than patients with higher socio-economic status. This attitude
persisted even when the researchers controlled for dependent family members (van
Ryn and Burke 2000). Clinicians had more positive perceptions of white and higher
class groups than African American and lower class groups, and associated different
activities with these groups.
Categorizing can then be influenced by the cultural representations that are available to us, which tell us something about the social norms that we are influenced by
and how those social norms are reinforced. Another illustration of this is research on
medical advertising which showed that in advertisements for cardiovascular medications in medical journals by far the majority of users of the drugs portrayed in the
advertisements were male, whereas in advertisements for antidepressants by far the
majority of users of the drugs were portrayed as female (Curry and O’Brien 2006).
The advertisements aimed at clinicians drew on stereotypes discussed above in relation to anxiety or mental health problems being associated with women and heart
problems being associated with men for the same symptoms, and by doing so the
advertisements reinforce those stereotypes.
Cultural representations and assumptions about risk intermingle. In vignette
studies of primary care doctors’ diagnosis of coronary heart disease (CHD) women
patients were asked fewer questions than men (Arber et al. 2004), were less likely
to receive components of a physical examination than men (McKinlay et al. 2007)
and physicians were more certain of a CHD diagnosis for men compared to women
(Lutfey et al. 2010). Physicians treated a demographic variable – gender – as a diagnostic feature that lowered the risk of CHD. This occurred in a situation where the
presentation of symptoms by the men and women actors in the vignettes was the
same (Lutfey et al. 2010). An explanation for this is that physicians had prior
assumptions about risk that overrode presenting symptoms in the determination of
In medicine, statistical discrimination is where a health professional applies a
“reasonable decision making rule” that leads to unequal treatments of different
groups (Balsa and McGuire 2001, 881). Physicians draw on statistical averages or
their previous experience of a set of symptoms with people from a particular group
(gender, ethnicity, social class and age being obvious groupings) (Lutfey et al.
2010). If research indicates that people with a particular characteristic are less likely
Gender and Ethnicity in Health
to comply with a particular drug regime then the physician is less likely to prescribe
that drug regime to a patient who has that particular characteristic (Balsa and
McGuire 2001). The characteristic may be related to age, gender, ethnicity or some
other variable. Where there is uncertainty about a diagnosis and the prevalence of
illness is higher or lower in a particular group, that prevalence rate might have an
important influence on health care decision making (Balsa et al. 2005). The reliance
on disease statistics in diagnosis may become more prominent if the physician finds
the patient difficult to understand. In this instance the noise of the miscommunication may sharpen the focus on the signal provided by prior research on probabilities
and risk profiles (Balsa et al. 2005). That is, in situations of diagnostic uncertainty
in relation to the individual patient the health professional is more likely to make a
diagnosis on the basis of statistics about the particular group that the patient can be
categorized as belonging to. The health professional is using a reasonable decision
The social distance between the physician and the patient can have a bearing on
the interaction between them. For example, physicians tend to perceive working
class patients as not seeking a role in decision-making and having a limited capacity
to understand health information (Davies and Elwyn 2008). Middle class patients
with higher levels of education may deal better with bureaucratic organizations and
be more assertive in consultations (Arber et al. 2006). The capacity of middle class
people to better negotiate the healthcare system relates to their level of cultural capital. Cultural capital is a kind of resource that accrues to people in the early stages of
socialization. It provides them with the skills and knowledge that they draw on, but
do not have to be conscious of (Bourdieu 1986). Patients with more privileged backgrounds accrue more cultural capital and so are more likely to get their views across
in the consultation.
The concept of aversive racism has been used to explain why clinicians treat
patients from other ethnic groups differently. Aversive racism occurs when dominant groups avoid interactions with subordinate groups (Smedley et al. 2003).
Aversive racism may occur amongst individuals who hold on to liberal values,
including wanting to overcome and combat racism, but at the same time are uncomfortable or uneasy around members of a different ethnic group. If we translate this
to the health setting, this may mean being ill at ease with the social chit-chat that
provides important opportunities for the clinician to establish trust and communication lines, and to informally assess a patient’s condition.
Social inequality is not simply about assets and wealth. Histories of slavery, migration and colonization have on-going effects, as do histories of gender discrimination
and patriarchy. Men and women do not have the same experience of health or interaction with the health system. To understand this we need to consider processes of
socialisation and explore the impact of patriarchy. Being alert to the complex
interactions between ethnicity, gender and other forms of social stratification and
health outcomes makes it clear that we must go beyond blaming individuals for their
poor health and instead apprehend what aspects of social organization are having
unwanted and unjust health effects. When considering aspects of social organization
our brief is wide-ranging, involving reflection on the impacts of everyday interactions in health encounters through to understanding the systemic features of social
organization that foster forms of discrimination and oppression.
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The Health of Indigenous Communities
Abstract Indigenous peoples in all settler societies have poorer health outcomes
than settler groups. This chapter outlines the history of colonization in settler societies, the role of the state in controlling and disenfranchising indigenous peoples, and
the health disparities that are a result of this historical legacy. Various examples of
indigenous communities are used, including those in North America and New
Zealand, with a detailed case study of indigenous life in Australia. The chapter
addresses various explanations for why health disparities continue to exist between
indigenous and settler populations, as well as the evolution of a range of health
initiatives to try to mitigate these disparities.
Keywords Health of indigenous peoples • Colonization • Australia • Historical
trauma • Indigenous health practices • Traditional healing • Cultural competence
Between the ﬁfteenth and nineteenth centuries European states embarked on an
unprecedented process of imperialist expansion. Millions of migrants moved from
Europe to the Paciﬁc and to the continents of Asia, Africa and the Americas. This
massive settlement of non-indigenous groups, known as colonization, led to the
establishment of what have been called settler societies with political domination
over indigenous peoples (Pearson 2001). There are a number of terms in English
that are used as labels for those people who inhabited the lands that were to become
the new homes of settlers: aboriginals, natives, indigenes, ﬁrst nations’ peoples and
other terms. Terms take on particular connotations in different settings and at different times. In this chapter a variety of terms will be used that are deemed most appropriate by contemporary authors in referring to these people who found themselves a
minority in their own lands.
This chapter will touch upon the experiences of a variety of indigenous communities but in order to provide some limits on the discussion there will be a focus on
those nation-states where the Anglo-Celtic diaspora played a signiﬁcant role, particularly in North America, Australia and New Zealand. Indigenous communities in
all settler societies have poorer health outcomes than settler groups in those societies.
© Springer International Publishing Switzerland 2016
K. Dew et al., Social, Political and Cultural Dimensions of Health,
The Health of Indigenous Communities
This chapter describes the history of colonization in settler societies and its consequences for the health of indigenous populations, as well as some of the efforts
made to ameliorate the impacts of colonization.
The Colonized Experience
Although indigenous communities across geographical areas differ markedly in
their social structures, physical environments and encounters with settlers, there are
also a number of similarities in their experiences, particularly land dispossession
and population loss. The two phenomena intertwine, and cause and effect could
work in both directions. Population loss could lead to land dispossession or land
dispossession could lead to population loss. Land dispossession was also facilitated
by particular legal and political strategies. Direct military aggression in the shape of
major battles between the indigenes and the professional armies of the colonists
occurred in New Zealand and the United States as indigenes attempted to resist land
dispossession, but not in Canada where there was a long history of economic and
political alliances prior to mass settlement, or in Australia where skirmishes and
raids were smaller in scale (Pearson 2001).
Land dispossession could be facilitated by the impact of diseases and deterioration in health of indigenous populations. As Breslaw (2012) notes, in the early
1600s populous native American villages on the north eastern coast of America that
had kept potential colonizers at bay became deserted as a result of an unidentiﬁed
plague (possibly smallpox) killing 90 % of the population. These newly emptied
spaces became a ﬁrst home for the Pilgrims as the colonizers gained a foothold in
North America. The Pilgrims believed that God had cleared the land of inhabitants
for them to occupy. Having no immunity to diseases like smallpox, measles, inﬂuenza, chicken pox and whooping cough meant adults and children were affected by
these diseases, leaving few in the community able to care for the sick, and this in
turn was exacerbated by a lack of knowledge about how to respond to these new
forms of disease, with no concept of contagion or quarantine being available. So the
death toll from these introduced diseases could be extremely high (Breslaw 2012).
With increasing colonization the stress of displacement and a range of ecological
changes such as alterations in land use, introduction of pests and so on exacerbated
health problems for native Americans (Breslaw 2012).
A century before this devastation to the communities on the north eastern coast
of America an epidemic devastated the Aztecs, facilitating the Spanish conquest of
Mexico (Breslaw 2012). This obliteration of thriving communities throughout
America was a common experience, with an estimate of 95 % of the American
Native population dying within the ﬁrst 100 years of Spanish exploration (Breslaw
2012). For the Spanish the high death toll of American Indians meant a loss of
workers, and this led to the development of slave labour from Africa to ﬁll the gap