When looking at the social epidemiology of the United States, it is hard to miss the disparities among races. Racial minorities exhibit lower life expectancy and a higher likelihood of death by heart disease and stroke. In terms of infant mortality, indigenous populations have an infant mortality rate that is 60% higher than the rate for whites, while infants born to African American women exhibited the highest rate of infant mortality.^[1] According to a report from the Henry J. Kaiser Foundation (2007), African Americans also have a higher incidence of several other diseases and causes of mortality, from cancer to heart disease to diabetes. In a similar vein, it is important to note that ethnic minorities, including Mexican Americans and Native Americans, also have higher rates of these diseases and causes of mortality than whites.

Lisa Berkman (2009) notes that this gap started to narrow during the Civil Rights movement in the 1960s, but it began widening again in the early 1980s. What accounts for these perpetual disparities in health outcomes among different ethnic groups? Much of the answer lies in the level of healthcare that these groups receive. The National Healthcare Disparities Report (2010) shows that even after adjusting for insurance differences, racial and ethnic minority groups receive poorer quality of care and less access to care than dominant groups. The Report identified these racial inequalities in care:

1. Black Americans, American Indians, and Alaskan Natives received inferior care when compared with white Americans for about 40 percent of measures.
2. Asian ethnic groups received inferior care for about 20 percent of measures.
3. Among whites, Hispanic whites received 60 percent inferior care of measures compared to non-Hispanic whites (Agency for Health Research and Quality, 2010). When considering access to care, the figures were comparable.

The Hispanic Paradox: The Curious Case of Hispanics in the United States

Recent academic research by Lariscy, Hummer, and Hayward (2015)^[2] has sought to explore what is traditionally known as the Hispanic paradox of health. The paradox suggests that Hispanic older adult mortality is similar to that of whites and that it actually exceeds white life expectancy, despite their initial lower life expectancy at birth and their socioeconomic disadvantage, which is comparable to the one found among African Americans. These scholars found that Hispanics, regardless of where they were born, exhibit higher life expectancy as adults than any other group. Foreign-born Hispanics living in the U.S. have an even higher life expectancy and exhibit lower mortality ratios for lung cancer and respiratory diseases, which is likely a result of lower rates of smoking. All of this despite their lower socioeconomic status—this suggests that the protective influence of lower smoking prevalence among Hispanics is slightly offsetting their socioeconomic disadvantage.

Watch this video for a dynamic talk given by Dr. Camara Jones, MD, MPH, PhD on levels of health interventions and how racism impacts health and healthcare in the U.S.:

Health by Socioeconomic Status

Discussions of health by race and ethnicity often overlap with discussions of health by socioeconomic status, since the two concepts are intertwined in the United States. As the Agency for Health Research and Quality (2010) notes, “racial and ethnic minorities are more likely than non-Hispanic whites to be poor or near poor,” so many of the data pertaining to subordinate groups is also likely to be pertinent to low socioeconomic groups. Marilyn Winkleby and her research associates (1992) state that “one of the strongest and most consistent predictors of a person’s morbidity and mortality experience is that person’s socioeconomic status (SES). This finding persists across all diseases with few exceptions, continues throughout the entire lifespan, and extends across numerous risk factors for disease.” Morbidity is the incidence of disease.

It is important to remember that economics are only part of the SES picture; research suggests that education also plays an important role. Phelan and Link (2003) note that many behavior-influenced diseases like lung cancer (from smoking), coronary artery disease (from poor eating and exercise habits), and AIDS initially were widespread across SES groups. However, once information linking habits to disease was disseminated, these diseases decreased in high SES groups and increased in low SES groups. This illustrates the important role of education initiatives regarding a given disease, as well as possible inequalities in how those initiatives effectively reach different SES groups.

Not unique to the United States, there is a pattern of social gradient in health based on education and socioeconomic status: wealthier and more educated households, on average, exhibit longer life expectancy at birth.

Figure 3. Life expectancy at birth by years of education, disaggregated by race and gender.

Health by Gender

Women are affected adversely both by unequal access to and institutionalized sexism in the healthcare industry. According a report from the Kaiser Family Foundation, women experienced a decline in their ability to see needed specialists between 2001 and 2008. In 2008, one quarter of females questioned the quality of her healthcare (Ranji and Salganico, 2011). In this report, we also see the explanatory value of intersection theory. Recall that feminist sociologist Patricia Hill Collins developed this theory, which suggests we cannot separate the effects of race, class, gender, sexual orientation, and other attributes. Further examination of the lack of confidence in the healthcare system by women, as identified in the Kaiser study, found, for example, women categorized as low income were more likely (32 percent compared to 23 percent) to express concerns about healthcare quality, illustrating the multiple layers of disadvantage caused by race and sex.

We can see an example of institutionalized sexism in the way that women are more likely than men to be diagnosed with certain kinds of mental disorders. Psychologist Dana Becker notes that 75 percent of all diagnoses of Borderline Personality Disorder (BPD) are for women, according to the Diagnostic Statistical Manual of Mental Disorders. This diagnosis is characterized by instability of identity, of mood, and of behavior, and Becker argues that it has been used as a catch-all diagnosis for too many women. She further decries the pejorative connotation of the diagnosis, saying that it predisposes many people, both within and outside of the profession of psychotherapy, against women who have been so diagnosed (Becker). This is an example of how BPD is a gendered medical condition.

Many critics also point to the medicalization of women’s issues as an example of institutionalized sexism. Medicalization refers to the process by which previously normal aspects of life are redefined as deviant and thus requiring medical attention. Historically and contemporaneously, many aspects of women’s lives have been medicalized, including menstruation, premenstrual syndrome, pregnancy, childbirth, and menopause. The medicalization of pregnancy and childbirth has been particularly contentious in recent decades, with many women opting out of the institutional medical process and choosing a more natural childbirth, perhaps at home and with the aid of a midwife. Fox and Worts (1999) find that all women experience pain and anxiety during the birth process, but that social support relieves both as effectively as medical support. In other words, medical interventions are no more effective than social ones at helping with the difficulties of pain and childbirth. Fox and Worts further found that women with supportive partners ended up with less medical intervention and fewer cases of postpartum depression. Of course, access to quality birth care outside the standard medical models may not be readily available to women of all social classes, and we again see the intersectionality of socioeconomic status and other markers of disadvantage or exclusion.

The State of Health in the United States: The Opioid Epidemic

The opioid epidemic, which is really a subset narrative of significant increases in fatal drug overdoses, affects all races, ethnicities, genders, geographical locations, and socioeconomic groups. By 2016, overdoses from heroin and other opioids kill over 27,000 people annually.^[3] (Note that “opioid” is a broad category that includes naturally-derived opiate substances like heroin as well as synthetic substances such as Oxycontin and fentanyl.) The opioid crisis is very closely linked to healthcare: a dozen states have more opioid prescriptions than people, suggesting that, on average, all individuals have been prescribed at least one drug. As such, healthcare providers are directly involved in the crisis, albeit not the culprit of it. Here are a few facts and graphics from PBS (2017) about the opioid crisis:

Figure 4. Data from 2014 shows that drugs kill more Americans that car accidents.

1. Drugs kill more Americans than cars do. The odds of dying from an accidental opioid overdose are 1 in 96, while the chances of dying in a motor vehicle crash are 1 in 103. Compare this to other leading causes of death: death from suicide (1 in 88) death from a fall (1 in 114),gun assaults (1 in 285), drowning (1 in 1,117), or choking (1 in 2,696). According to the CDC, 130 Americans die every day because of opioid overdoses.^[4]
2. The group analyzed preventable injuries and deaths in 2017 and found the odds of dying by accidental opioid overdose to be 1 in 96 and the odds of a motor vehicle crash 1 in 103.
3. On average, 130 Americans die each day after overdosing on opioids, according to the Centers for Disease Control and Prevention.
4. Opioids and heroin surpassed cocaine for most deaths. In 2014, Opiods caused 18,893 deaths from overdose, heroin caused 10,574, benzodiazephines caused 7,945, and cocaine caused 5,415.
5. Opioids and heroin have affected all races. While studies shows that some doctors are less likely to prescribe narcotics and painkillers to minority populations, potentially decreasing the number of minorities with access to opioids, minority populations are still affected by the crisis, with rates of deaths by overdoses for whites and Native Americans rising the most between 2010 and 2014.
6. Heroin affects younger populations; opioids older ones, especially those between ages 45 to 65.

Figure 5. All races and ethnic groups have been affected by the opioid crisis.

Watch this video to better understand the extent of the opioid epidemic in the U.S., the most detrimental drug crisis in American history, and a challenge faced by the medical field, sociologists, policymakers, and everyday people.

Medicalization of Sleeplessness

Figure 6. Many people fail to get enough sleep. But is insomnia a disease that should be cured with medication? (Photo courtesy of Wikimedia Commons)

How is your “sleep hygiene?” Sleep hygiene refers to the lifestyle and sleep habits that contribute to sleeplessness. Bad habits that can lead to sleeplessness include inconsistent bedtimes, lack of exercise, late-night employment, napping during the day, and sleep environments that include noise, lights, or screen time (National Institutes of Health, 2011a).

According to the National Institute of Health, examining sleep hygiene is the first step in trying to solve a problem with sleeplessness.

For many people in the United States, however, making changes in sleep hygiene does not seem to be enough. According to a 2006 report from the Institute of Medicine, sleeplessness is an under-recognized public health problem affecting up to 70 million people. It is interesting to note that in the months (or years) after this report was released, advertising by the pharmaceutical companies behind Ambien, Lunesta, and Sepracor (three sleep aids) averaged $188 million weekly promoting these drugs (Gellene, 2009).

According to a study in the American Journal of Public Health (2011), prescriptions for sleep medications increased dramatically from 1993 to 2007. While complaints of sleeplessness during doctor’s office visits more than doubled during this time, insomnia diagnoses increased more than seven-fold, from about 840,000 to 6.1 million. The authors of the study conclude that sleeplessness has been medicalized as insomnia, and that “insomnia may be a public health concern, but potential over-treatment with marginally effective, expensive medications with nontrivial side effects raises definite population health concerns” (Moloney, Konrad, and Zimmer, 2011). Indeed, a study published in 2004 in the Archives of Internal Medicine shows that cognitive behavioral therapy, not medication, was the most effective sleep intervention (Jacobs, Pace-Schott, Stickgold, and Otto, 2004).

A century ago, people who couldn’t sleep were told to count sheep. Now they pop a pill, and all those pills add up to a very lucrative market for the pharmaceutical industry. Is this industry behind the medicalization of sleeplessness, or is it just responding to a need?

People with mental disorders (a condition that makes it more difficult to cope with everyday life) and people with mental illness (a severe, lasting mental disorder that requires long-term treatment) experience a wide range of effects.

According to the National Institute of Mental Health (NIMH), one in five adults in the U.S. live with a mental illness, numbering 46.6 million in 2017.^[5] The most common mental disorders in the United States are anxiety disorders. It is important to distinguish between occasional feelings of anxiety and a true anxiety disorder. Anxiety is a normal reaction to stress that we all feel at some point, but anxiety disorders are feelings of worry and fearfulness that last for months at a time. Anxiety disorders include obsessive compulsive disorder (OCD), panic disorders, post-traumatic stress disorder (PTSD), separation anxiety disoder, and both social and specific phobias. The NIMH reports that the prevalence of any anxiety disorder is higher for females than for males, estimating the prevalence at 23.4 percent and 14.3 percent, respectively. Anxiety is a prominent mental condition; one in three U.S. adults experience any anxiety disorder at some point throughout their lives.

The second most common mental disorders in the United States are mood disorders; roughly 10 percent of U.S. adults are likely to be affected yearly, while 21 percent are likely to be affected over the course of a lifetime (National Institute of Mental Health, 2017). Major mood disorders are depression, bipolar disorder, and dysthymic disorder. Like anxiety, depression might seem like something that everyone experiences at some point, and it is true that most people feel sad or “blue” at times in their lives. A true depressive episode, however, is more than just feeling sad for a short period. It is a long-term, debilitating illness that usually needs treatment to cure. And bipolar disorder is characterized by dramatic shifts in energy and mood, often affecting the individual’s ability to carry out day-to-day tasks. Bipolar disorder used to be called manic depression because of the way people would swing between manic and depressive episodes. As with anxiety disorders, mood disorders are more prevalent among females than among males, and over 20 percent of adults in the U.S. experience a mood disorder at some point throughout their lifetime.

Depending on what definition is used, there is some overlap between mood disorders and personality disorders, which affect 9 percent of people in the United States yearly. Unlike with other types of mental disorders, there is no significant gender difference, although 84 percent of individuals with personality disorders also had one or more other mental disorders.

After a multilevel review of proposed revisions in the early 2010s, including reducing the number of listed personality disorders to six, the American Psychiatric Association Board of Trustees ultimately decided to retain the DSM-IV categorical approach in the new DSM-5 with the same ten personality disorders (paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, antisocial personality disorder, borderline personality disorder, histrionic personality, narcissistic personality disorder, avoidant personality disorder, dependent personality disorder and obsessive-compulsive personality disorder). Personality disorders represent “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it” (National Institute of Mental Health). In other words, personality disorders cause people to behave in ways that are seen as abnormal and deviant to society but seem normal to them. During revisions to the DSM, there were proposals to broaden this definition, and there was heated debate over the appropriate labels and proper diagnosis for personality disorders. As you’ve learned in this module already, the label we give an illness can impact how the affected person views themself as well as how they are treated by others.

Figure 7. Medication is a common option for children with ADHD. (Photo courtesy of Deviation56/Wikimedia Commons)

Figure 8. The handicapped accessible sign indicates that people with disabilities can access the facility. The Americans with Disabilities Act requires that access be provided to everyone. (Photo courtesy of Ltljltlj/Wikimedia Commons)

The National Institute of Mental Health (NIMH) distinguishes between serious mental illness and other disorders. The key feature of serious mental illness is that it results in “serious functional impairment, which substantially interferes with or limits one or more major life activities” (National Institute of Mental Health). Thus, the characterization of “serious” refers to the effect of the illness (functional impairment), not the illness itself.

Disability refers to a reduction in one’s ability to perform everyday tasks. The World Health Organization makes a distinction between the various terms used to describe handicaps that’s important to the sociological perspective. They use the term impairment to describe the physical limitations, while reserving the term disability to refer to the social limitation.

Before the passage of the Americans with Disabilities Act (ADA) in 1990, people in the United States with disabilities were often excluded from opportunities and social institutions many of us take for granted. This occurred not only through employment and other kinds of discrimination, but also through casual acceptance by most people in the United States of a world designed for the convenience of the able-bodied. Imagine being in a wheelchair and trying to use a sidewalk without the benefit of wheelchair-accessible curbs. Imagine as a blind person trying to access information without the widespread availability of Braille. Imagine having limited motor control and being faced with a difficult-to-grasp round door handle. Issues like these are what the ADA tries to address. Ramps on sidewalks, Braille instructions, and more accessible door levers are all accommodations to help people with disabilities.

People with disabilities can be stigmatized by their illnesses. Stigmatization means their identity is spoiled; they are labeled as different, discriminated against, and sometimes even shunned. They are labeled (as an interactionist might point out) and ascribed a master status (as a functionalist might note), becoming “the blind girl” or “the boy in the wheelchair” instead of someone afforded a full identity by society. This can be especially true for people who are disabled due to mental illness or disorders.

As discussed in the section on mental health, many mental health disorders can be debilitating and can affect a person’s ability to cope with everyday life as well as their social interactions. This can affect social status, housing, and especially employment. According to the Bureau of Labor Statistics (2019), people with a disability had a higher rate of unemployment than people without a disability in 2018—8 percent compared to 3.7 percent. This unemployment rate refers only to people actively looking for a job. In fact, four out of five people with a disability are considered “out of the labor force;” that is, they do not have jobs and are not looking for them. The combination of this population and the high unemployment rate leads to an employment-population ratio of 19.1 percent among those with disabilities. The employment-population ratio for people without disabilities was much higher, at 65.9 percent (U.S. Bureau of Labor Statistics, 2019).^[6]

Obesity: The Last Acceptable Prejudice

Figure 9. Obesity is considered the last acceptable social stigma. (Photo courtesy of Kyle May/flickr)

What is your reaction to the picture above? Compassion? Fear? Disgust? Many people will look at this picture and make negative assumptions about the man based on his weight. According to a study from the Yale Rudd Center for Food Policy and Obesity, large people are the object of “widespread negative stereotypes that overweight and obese persons are lazy, unmotivated, lacking in self-discipline, less competent, non-compliant, and sloppy” (Puhl and Heuer, 2009).

Historically, both in the United States and elsewhere, it was considered acceptable to discriminate against people based on prejudiced opinions. Even after slavery was abolished in 1865, the next 100 years of U.S. history saw institutionalized racism and prejudice against black people. In an example of stereotype interchangeability, the same insults that are flung today at the overweight and obese population (lazy, for instance), have been flung at various racial and ethnic groups in earlier history. Of course, no one gives voice to these kinds of views in public now, except when talking about obese people.

Why is it considered acceptable to feel prejudice toward—even to hate—obese people? Puhl and Heuer suggest that these feelings stem from the perception that obesity is preventable through self-control, better diet, and more exercise. Highlighting this contention is the fact that studies have shown that people’s perceptions of obesity are more positive when they think the obesity was caused by non-controllable factors like biology (a thyroid condition, for instance) or genetics.

Even with some understanding of non-controllable factors that might affect obesity, obese people are still subject to stigmatization. Puhl and Heuer’s study is one of many that document discrimination at work, in the media, and even in the medical profession. Obese people are less likely to get into college than thinner people, and they are less likely to succeed at work. Recent research finds that discrimination against obese people is still pervasive in employment.^[7]

Stigmatization of obese people comes in many forms, from the seemingly benign to the potentially illegal. In movies and television shows, overweight people are often portrayed negatively, or as stock characters who are the butt of jokes. One study found that in children’s movies “obesity was equated with negative traits (evil, unattractive, unfriendly, cruel) in 64 percent of the most popular children’s videos. In 72 percent of the videos, characters with thin bodies had desirable traits, such as kindness or happiness” (Hines and Thompson, 2007). In movies and television for adults, the negative portrayal is often meant to be funny. “Fat suits”—inflatable suits that make people look obese—are commonly used in a way that perpetuates negative stereotypes. Think about the way you have seen obese people portrayed in movies and on television; now think of any other subordinate group being openly denigrated in such a way—it is difficult to find a parallel example.

Healthcare coverage can broadly be divided into two main categories: public healthcare (government-funded) and private healthcare (privately-funded).

In the United States, the healthcare system is more complex than what is found in other countries—there is no uniform health system nor universal healthcare coverage provided, and it is more of a hybrid system that what is found in other developed nations. In 2014, 48 percent of healthcare spending came from private funds, both from businesses and individuals, 28 percent came from the federal government, and 17 percent came from state and local governments. Political changes have also resulted in drastic policy changes regarding healthcare.^[8]

The two main public, government funded healthcare programs are Medicare, which provides health services to people over sixty-five years old as well as people who meet certain standards for disability, and Medicaid, which provides services to people with very low incomes who meet other eligibility requirements. Other government-funded programs include service agencies focused on Native Americans (the Indian Health Service), Veterans (the Veterans Health Administration), and children (the Children’s Health Insurance Program).

The most recent U.S. census (2011) divides private insurance into employment-based insurance and direct-purchase insurance. Employment-based insurance is health plan coverage that is provided in whole or in part by an employer or union; it can cover just the employee, or the employee and their family. Direct purchase insurance is coverage that an individual buys directly from a private company.

With all these insurance options, ranging from government-provided to employee-provided and individual-provided, insurance coverage must be almost universal, right? Unfortunately, the U.S. Census Current Population Survey of 2013 showed that 18 percent of people in the United States had no health insurance at all. Equally alarming, a study by the Commonwealth Fund showed that in 2010, 81 million adults were either uninsured or under-insured; that is, people who pay at least 10 percent of their income on healthcare costs not covered by insurance or, for low-income adults, those whose medical expenses or deductibles are at least 5 percent of their income (Schoen, Doty, Robertson, and Collins, 2011). The Commonwealth study further reported that while under-insurance had historically been an issue that low-income families faced, today it is affecting middle-income families more and more.

Figure 10. Some in the United States worry that governmental oversight of healthcare represents a federal overstepping of constitutional guarantees of individual freedom. Others welcome a program that they believe will make healthcare accessible and affordable to everyone. (Photo courtesy of Fibonacci Blue/flickr)

Why were so many people uninsured or under-insured? Skyrocketing healthcare costs were part of the issue. Many people cannot afford private health insurance, but their income level is not low enough to meet eligibility standards for government supported insurance. Further, even for those who are eligible for Medicaid, the program is less than perfect. Many physicians refuse to accept Medicaid patients, citing low payments and extensive paperwork (Washington University Center for Health Policy, n.d.).

Healthcare in the United States looks different today than it did just a few years ago—a result of changes in policy, such as the Affordable Care Act (PPACA or ACA or “Obamacare”). You’ve probably heard of Obamacare at some point—but what did it seek to do? Obamacare expanded eligibility to programs like Medicaid and CHIP, helped guarantee insurance coverage for people with preexisting conditions, and established regulations to make sure that the premium funds collected by insurers and care providers go directly to medical care. It also included an individual mandate, which required everyone to have insurance coverage by 2014 or pay a penalty in their taxes. A series of provisions, including significant subsidies, were intended to address the discrepancies in income that are currently contributing to high rates of uninsurance and under-insurance.

While the program has been controversial and something of a flashpoint for strongly partisan politics, in 2012 the U.S. Supreme Court upheld the constitutionality of the PPACA’s individual mandate. According to Blumenthal (2014), by 2014, 20 million people in the United States had gained health insurance under PPACA. This lowered the number of uninsured people to 13 percent. Three years later, by 2017, healthcare reform had lowered the number of uninsured people to the lowest it has ever been in the United States. In 2017, less than 9 percent of the population was uninsured at some point during the year^[9]—a drastic drop relative to the alarming 18 percent in the early 2010s. Over half of the population was insured by an employer, over one third was covered by government-funded programs, and the rest were either covered by direct-purchase or by military funding.

The PPACA remains contentious and at the forefront of political debates. The Supreme Court ruled in the case of National Federation of Independent Businesses v. Sebelius in 2012, that states cannot be forced to participate in the PPACA’s Medicaid expansion. This ruling has opened the door to challenges to the PPACA in Congress and the Federal courts, in some state governments, and among conservative groups and independent businesses.