Socioeconomic status (SES) and access to health care are posited as pathways through which institu- tionalized racism affects health. Williams and Wil- liams-Morris, 10 in their recent overview of experi- ences of racism and mental health, provide a dismal portrait of the process and consequences of institu- tional racism for African Americans. Driven by the dominant mechanism of continuing residential seg- regation, limited and unequal access to services and resources, education, and employment opportuni- ties, the socioeconomic mobility of African Ameri- cans has been seriously truncated. Not only is there more poverty (African Americans are 3 times more likely to be poor, and more than half of black house- holds are in an economically vulnerable category), but blacks are twice as likely to be unemployed. Furthermore, most socioeconomic indicators are not equivalent across race. A given level of education does not necessarily reflect equivalent skills and preparation. At each level of education, blacks earn substantially less than whites at comparable years of schooling. 17 At a given level of income, the pur- chasing power is reduced for blacks, 18 with signifi- cant racial differences in wealth at every level of income. 19 Let us turn to the evidence regarding the relationship of socioeconomic differences, access, and neighborhood variables to CVD risk factors and outcomes. Socioeconomic Differences and CVD Differences in SES have a profound and well- documented impact on cardiovascular health out- comes. Whether measured by education, income, occupation, or other factors (neighborhood, indica- tors of wealth, occupational prestige), SES is among the most potent predictors of adverse changes in cardiovascular health. For nearly a decade, it has been argued that SES is an independent risk factor for CVD. 20 The lower the SES, the greater the risk of CVD. The moderating effects of SES on CVD are clearly seen in relation to ethnicity. SES accounts for much of the observed racial disparities in health, although racial differences often persist after statis- tical adjustment even at “ equivalent ” levels of SES. These findings suggest that there may be a very different experience of SES among ethnic groups; thus, even when statistical controls for SES “ ex- plain ” differences, the processes by which these dif- ferences occur are not uniform among or within ethnic groups. More than a confounder, race is both an antecedent and determinant of SES that reflects, in part, successful implementation of racist policies. Williams 1 provides an extensive review of the ways in which race, racism, and SES affect health out- comes. That these differences may persist from birth is suggested by cumulating work in childhood and life course SES. 21,22 At least 1 study has linked racism and low birth weight, 23 an increasingly rec- ognized correlate for adult CVD.
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