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Why Race (still) Matters: Exploring the Public Health Impact of Racial Inequality in the U.S. Criminal Justice System

The Context of the Current Discussion of Race in America

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 The recent verdict in the case of a Black teenager, Trayvon Martin, who was shot to death in his neighborhood by a self-identified White-Hispanic man, George Zimmerman, has produced quite a bit of backlash, particularly among those who feel that the verdict was another example of racial injustice in the criminal justice system. Conversely, we have also heard the backlash from those who believe that we live in a postracial America, and that race should not be brought into the discussion. However, the fundamental flaw in the argument against bringing race into the issue is that race is already there; it is already part of the issue, and it is always has been. That is one point that I hope to explain in this piece.

As someone who was not there to witness the events that led to the shooting death of Trayvon Martin, I cannot and will not state that race was the reason that George Zimmerman shot an unarmed teenager. I can state, however, that racial injustice is still present in our country’s criminal justice system. This is more than a statement of opinion, but rather a statement of fact: the evidence from hundreds of research/government reports and scientific studies indubitably supports the conclusion that race does matter in the criminal justice system. Black men and women are more likely to be arrested, charged, convicted, and serve a longer sentence than White individuals who commit the same crime. Although I cannot say with confidence that race was a factor in the Trayvon Martin case, there is no question that race is still a significant source of injustice in our criminal justice system, and the recent verdict in this case mirrors a historical pattern of persistent and pervasive racial discrimination by the U.S. criminal justice system.

So what does this have to do with public health? Well, the effects of racial inequality in the criminal justice system do not end at the prison door. The increased rates of arrest and incarceration of Black men and women in our country lead to many other inequalities, including widespread health disparities….and that is what today’s post will focus on.  First, I will present the statistics that so clearly demonstrate the problem of racial inequality in the criminal justice system. Then, I will discuss several (of many) manifestations of racial injustice and describe the various pathways through which racial inequality in the criminal justice system  leads to inequalities in socioeconomic status, employment opportunities, and health (among other things).

My hope is to provide a factual perspective on current racial injustices in America, and to demonstrate that racial inequality is still affecting the lives of millions of our fellow Americans. To deny the role of race in our society is to deny the overwhelming evidence indicating that race still matters. Although it would be preferable to live in a postracial America, the fact is that we don’t. We have come a long way from the days of widespread institutional racism, but we have not gotten to the point where we can honestly say that race is not a cause of inequality, injustice, and unfair treatment.

A Few Personal Thoughts and Insights 

Over the past several weeks, I have seen and read many statements denying the existence of racism and criticizing those who discuss the ongoing role of race in our society. When President Obama spoke on the Trayvon Martin verdict, we saw a strong public response; while some people were thankful that the President acknowledged such a pressing issue as race in America, others were uncomfortable having such a public debate about race and racial discrimination, and yet others were outright angry at the President’s comments. Angry about what? Well, I have seen several different perspectives. First, it must be noted that there is a group of people who are angry with President Obama, period. He could announce a cure for world hunger, and there would still be a group of people who would find something to criticize – and that makes up one (surprisingly large) group of critics. Others are angry because they believe that the President is creating an issue of race where it did not previously exist; that the verdict of the Trayvon Martin case does not have anything to do with race, and that the President should not bring race into the issue. (Or at least they are repeating the talking points on conservative websites regarding President Obama’s remarks; either that or it is a coincidence that so many of the critics have been repeating the same exact statistics, e.g. “But what about Black on Black crime? Blacks get killed most often by Blacks!”- we will get to some of these misinterpreted/maligned talking points in a moment). However, the President’s speech was not intended to, nor did it, question the verdict of the Trayvon Martin case on the basis of race. When President Obama spoke, he was speaking to the millions of Black men and women who have been affected by inequality in the criminal justice system, as well as those of us who care deeply about fighting for true racial equality in America and recognize the historical significance of racial discrimination against Blacks. Through the lens of experience of a young Black man, the verdict of this case is likely to arouse strong emotions; for someone who has already experienced injustice in the criminal justice system and/or carries the historical burden of racism, the verdict of this case might take on a different meaning than it would for a person who has never experienced racial profiling, stereotyping, or inequality. Since the data tell us that White men and women are less likely to experience any of these injustices, it is unfair to judge the reactions of those who do experience these injustices. To delegitimize the experiences of millions of Americans simply because you have not personally experienced or witnessed racial injustice is not only unfair, but unhelpful in the ongoing fight for equality. If we are to seek greater equality among racial groups in our country, the first step is to acknowledge that racial inequality is still alive and well in almost every sector of our society. As the leader of our country, President Obama addressed an issue that has lived in the hearts and minds of Black men and women in America for generations. He validated the feelings of so many millions of Americans who have experienced injustice through an incredibly personal and powerful speech; at the same time, he also instilled confidence that our country is moving in the right direction and that, although racism still exists in America, we will not simply turn a blind eye to it as we have done so many times in the past. That brings me to the current discussion of racial inequality in the criminal justice system, an issue that has been studied extensively and for which the evidence is conclusive. Whether we want these facts to be true or not, the data do not lie: race still matters, and talking about it is not the problem… but it is most certainly part of the solution.

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Five Ways that Racial Inequality Manifests in the Criminal Justice System

I cannot possibly provide a comprehensive account of all of the manifestations of racial inequality in our society, so I have chosen to focus on five major areas pathways through which racial inequality leads to injustices in the criminal justice system. Before beginning this discussion, I feel that it is important to note that incarceration rates in the U.S. have been on the rise for several decades now, resulting in what many researchers refer to as an “epidemic of mass incarceration” (Dumont et al., 2012). Although the U.S. accounts for less than 5% of the worldwide population, we represent 25% of the world’s incarcerated population, placing us as the global “leader” in incarceration (Sentencing Project, 2013). Currently, 2.2 million Americans are incarcerated in U.S. prisons and jails; based on these numbers, we have seen a staggering 500% increase in the number of incarcerated Americans in just the past 3 decades. Although incarceration rates have risen universally, the rate of incarceration of African Americans- particularly young African American males- represents a disproportionate and unequal response from the criminal justice system.

Increase in # of State and Federal Prisoners (Data from the Dept. Of Justice, 2011)

Increase in # of State and Federal Prisoners from 1925-2010 (Data from the Dept. Of Justice, 2011)

Geographical distribution of incarceration rates in 2010

Geographical distribution of incarceration rates in 2010

Bar graph representing the disproportionate rates of incarceration among African Americans (and Hispanic/Latinos) compared to Whites

Bar graph representing the disproportionate rate of incarceration among African Americans (and Hispanic/Latinos) compared to Whites

The figures above provide a bit of context for the discussion of how racial disparities in incarceration can (and do) lead to health disparities among African Americans. Having said that, let us begin our discussion by exploring 5 major causes of racial inequality in the criminal justice system.

1. Stereotypes and Media Portrayals

Racial stereotypes about criminals are pervasive in our country. The perception of Blacks as criminals is evident in our society and has been documented in numerous studies (Drummond, 1990; Hawkins, 1995; Mauer, 1999; Russell, 2002); this view is particularly pronounced among Whites, who are most likely (when compared to other racial groups) to believe that criminal behavior is “an inherent characteristic of Blacks” (Higgibotham, 2002; Mauer, 1999). Although studies show that many people believe that Blacks are responsible for a majority of crimes in the country (Gilens, 1996; Higgibotham, 2002; Sigelman & Tuch, 1996), government statistics indicate that the majority of crimes in the United States are committed by Whites (U.S. Department of Justice, 2003, 2004).

*A brief side note here* The myth of “Black on Black Crime” is often used as an argument against the existence of racial inequalities in the criminal justice system. Conservative activist Ben Shapiro, along with many others, used this myth in an attempt to downplay the role of race and deny the racial disparities faced by Blacks in the criminal justice system. The general argument presented by Shapiro (and similar conservative critics) is that Blacks cause a disproportionate amount of crime within their own community, and thus, the disparities in the criminal justice system are simply a response to the higher incidence of “Black on Black Crime.” Specifically, Shapiro presents the argument that Blacks are responsible for over 90% of the homicides of other Blacks, thus suggesting that Blacks are somehow more criminal than other groups. The problem with this argument is that homicide is largely an intraracial crime- not an interracial crime- and the same statistics that are presented about Black on Black homicide are also true for White-on-White homicide, Hispanic-on-Hispanic homicide, Asian-on-Asian homicide, etc. For example, 88% of White homicide victims are killed by White offenders. Thus, the myth of “Black on Black Crime” is yet another unfounded stereotype about the perceived criminality of Blacks in America.*End of Side Note*

Despite the insistence of many that we are living in a postracial America, national studies of public perceptions regarding race and crime indicate that the general public perceives Blacks as being involved in crime at much greater rates than is indicated in analyses of official government statistics (Chiricos, Welch, & Gertz, 2004; Welch, Chiricos, & Gertz, 2002). These statistics are not congruent with the notion of a “postracial” society, but rather suggest that racial discrimination is still prevalent among individuals and within mainstream society in America.

Media portrayals of Black men as being inherently violent and/or prone to criminal behavior have contributed to the stereotype of the Black male as the criminal (Entman, 1990). In addition to the skewed portrayals of Black men in the media, news coverage of crime devotes a disproportionate amount of time to cover crimes for which Black men are more likely to be arrested, therefore overrepresenting Black criminals in media coverage (Chiricos & Escholz, 2002). As a result, the maligned perception of Black criminality is reinforced and spread to the masses. Media coverage also tends to conjure up and/or manipulate images and factual details to make Black criminals appear “scarier” and more likely to be a future threat to society (Anderson, 1995; Entman, 1990).

2.Racial Profiling

Although racial profiling is a difficult issue to prove, both because of the lack of data and the ambiguous nature of profiling, there is evidence suggesting that Black men are targeted more by the police than White men. For example, during traffic stops Black drivers are significantly more likely to be subjected to physical searches of the driver and/or vehicle when compared with White drivers (Druose et al., 2005). A report from the Sentencing Project discusses the results of one study, in which African Americans represented 70% of all drivers who were stopped and searched by law enforcement, but only represented 17.5% of all drivers on the road and were no more likely to speed than any other racial group (Sentencing Project, 2000). Unfortunately, we have very little useful data to study the incidence of racial profiling, as noted by the U.S. Department of Justice (2000). However, the available data show a clear pattern of racial profiling in the criminal justice system, with African Americans experiencing the most detrimental effects of discrimination at the hands of law enforcement.

3. School Arrests

Black and Hispanic students are more likely to be arrested and punished through the criminal justice system compared to White students, who are less likely to be referred to the criminal justice system and more likely to receive punishment from the school (e.g. suspension). Thus, many young Black and Hispanic school children are introduced to the criminal justice at a very young age, while White students are significantly less likely to be referred to the criminal justice system (U.S. Commission on Civil Rights, School Discipline and Disparate Impact Briefing Report, March 2012)

4. Biased Legislation and/or Discriminatory Enforcement Practices

Although the bias present in current criminal justice policies and federal/state laws is not as apparent as it was in decades past, we can still clearly see that the application of specific laws is often carried out in such a way that Blacks are disadvantaged compared to other racial groups. Two current examples of racially biased legislation include drug policies and the “Stand Your Ground Law.”

The so-called “War on Drugs” has had a disproportionate impact on Black men and women, with arrest rates of Blacks far exceeding those of Whites- even though rates of illicit drug use are no different among Blacks and Whites. Despite the common public perception that Blacks are more likely to be drug-users than Whites (Sigelman & Tuch, 1996), the actual data tell a different story. In a recent study by a team of researchers at Duke University led by Dr. Dan Blazer (with whom I am proud to say I have had the privilege to collaborate!), data from the National Survey on Drug Use and Health were utilized to conduct analyses of racial/ethnic variations in substance-related disorders (Wu, Woody, Yang, Pan, & Blazer, 2011). The study sample was comprised of 75,561 adolescents in the United States, with White (n = 43,778), Hispanic (n = 12,257) and African American (n = 10,109) adolescents representing the largest racial/ethnic groups, followed by “mixed” racial groups (n = 2,814), Asian/Pacific Islanders (n = 2,481) and Native Americans (n = 1,122). The results are clear and may come as a surprise to some: the prevalence of any drug or alcohol use among White adolescents (39.2%) is significantly higher than that of African American adolescents (32.2%). Even when researchers evaluated the use of specific drugs such as marijuana and cocaine, White adolescents still demonstrated significantly higher levels of use than African American adolescents. The prevalence of alcohol use was dramatically higher among White adolescents, with over 35% of White teens consuming alcohol compared to just 24% of African American teens.

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These trends are confirmed by other research, including a 2011 report by the U.S. Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA, 2011). Although racial trends in drug use are slightly different among adults (compared to adolescents and young adults), SAMHSA (2011) found that White adults are more likely to have substance use disorders than Black adults; considering the findings of the previous study in which White adolescents were more likely to use drugs and/or alcohol than Black adolescents (Wu et al., 2011), it is not surprising that White adults would go on to develop higher rates of substance use disorders. What is surprising is how skewed the public perception of drug use is: Blacks are more likely than any other racial group to be characterized as drug users, despite the evidence indicating otherwise. However, because Blacks are overrepresented in drug-related arrests and incarceration, the public perception of Blacks as drug users is reinforced and perpetuated throughout society. According to the Sentencing Project (2001), data from the Department of Justice indicate that although African Americans represent only 15% of all drug users in the country, they represent almost 40% of those arrested for drug offenses, 53% of those convicted of drug offenses, and 56% of those in prison for drug offenses. Although the prevalence of drug use among Black men and women is comparable to that of Whites (and in many cases, as mentioned above, the prevalence is actually lower among Blacks compared to other racial groups), the “War on Drugs” has disproportionately affected the Black community, with young Black males among the hardest hit (Austin & Irwin, 2001; Mauer, 1999; Miller, 1996). For example, arrest rates for drug possession among Black youths are 2.8-5.5 times higher than those among White youths (Poe-Yamagata & Jones, 2000; Sentencing Project 2001; U.S. Dept. Of Justice, 1998; 1999). A recent report by the ACLU found that Blacks are 3.3 times more likely to be arrested for marijuana than Whites, despite the equal rates of marijuana use among Blacks and Whites in the sample.

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In addition to the disproportionate rates of arrest, Black juvenile drug offenders are less likely to be referred to diversion programs (e.g. drug treatment and rehabilitation instead of incarceration) than Whites, which is a leading factor contributing to the high rates of recidivism in U.S. jails and prisons (Bishop & Frazier, 1996; Poe-Yamagata & Jones, 2000). The unequal treatment of Blacks, particularly young Black males, by the criminal justice system also contributes to other inequalities (e.g. having a permanent criminal conviction at a younger age; limited employment opportunities; health disparities) via the additive effects of injustice.

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Disparities in Incarceration Rates by Race and Age

For example, young Black males are more likely than their White counterparts to be: A) arrested for a drug offense, B) charged as an adult, C) convicted of a drug offense, and D) given a harsher sentence, including being incarcerated rather than offered treatment. When analyzed individually, one “layer” of injustice (e.g. “A”, “B”, “C”, or “D”) may appear to have a minimal effect on the criminal justice experiences of Black males. However, the effects of all four of these factors (e.g. “A”, “B”, “C”, and “D”) combined produce significant results showing that discrimination and inequality are not only present in the criminal justice system, but much more pervasive and powerful than is initially apparent in basic analyses (Bishop & Frazier, 1996). One possible pathway through which multiple additive inequalities lead to significant cumulative effects is given in the following example:

Since young Black males are more likely to be arrested, charged as adults, convicted, and given harsher sentences, they are also more likely to end up with a permanent criminal record. Having a criminal record not only affects employment opportunities, but also future interactions with the criminal justice system; since Black males are more likely to be charged with a drug offense rather than offered the opportunity to attend a diversion program (which leaves the offender with a clean record), and (coming full circle here!) since Black males are more likely to be targeted and arrested for drug offenses, future interactions with law enforcement are more likely to result in arrest, conviction, and more severe sentencing (based on the presence of a criminal record with prior drug-related charges). Thus, it is not simply the disproportionate rates of drug-related arrests among Blacks that contribute to inequalities in the criminal justice system, but also the harsher treatment and sentencing of Black offenders that results in a cyclical pattern of injustice.

In addition to drug laws, the application of other laws and policies is often carried out in such a way that Blacks are disadvantaged compared to other racial groups. A second example, relevant to the death of Trayvon Martin and subsequent “not-guilty” verdict of his killer, are ‘Stand Your Ground Laws.’ Currently, about half of the states in the country have some form of a Stand Your Ground Law; traditionally, these laws- also known as Castle Doctrine statutes– were applied to allow reasonable force to be used to protect oneself inside of the home. However, in 2005, Florida became the first state to explicitly allow the use of lethal force for self-defense in the home or “any other place where he or she has a right to be.”  Since then, other states have similarly expanded the scope of traditional Castle Doctrine statutes, although Florida still has one of the most unrestricted Stand Your Ground laws in the nation. In many states, a person who is outside of their home still has a “duty to retreat,” which means that a person should first seek to retreat if it is possible to get away and avoid confrontation with an attacker. However, in Florida and about 20 other states across the country, the duty to retreat clause has been removed from Stand Your Ground laws, such that the use of deadly force is still permissible even if the person could have taken steps to avoid the confrontation; thus, removing the duty to retreat from state laws allows for someone to use a self-defense claim for killing someone who they could have avoided in the first place. These states also allow for the use of reasonable or deadly force (state laws vary in their wording) anywhere a person has a right to be, without having the duty to retreat if possible. Other states, such as New Hampshire, have adopted Stand Your Ground Laws; however, the New Hampshire law specifically states when a person cannot “stand their ground”, such as when he/she was the initial aggressor or provoked the other person.

Using data on cases invoking Florida’s ‘Stand Your Ground Law’ , the Tampa Bay Times performed analyses of 133 fatal cases in which the Stand Your Ground law was used to defend the killing and classify it as justifiable. The results are as follows: When the victim is white, the person who kills him/her is convicted 43% of the time (e.g. Stand Your Ground law fails 43% of the time for those on trial for killing a White man or woman). When the victim is Black, the killer is only convicted in 22% of cases (e.g. the Stand Your Ground law works 78% of the time for those who are on trial for killing a Black man or woman). In circumstances in which the killer is White or Hispanic and the victim is Black, the Stand Your Ground law will be successful 90% of the time; in other words, when a White of Hispanic person kills a Black person and uses a “Stand Your Ground Defense” in Florida, they only have a 10% chance of being charged with wrongful/negligent manslaughter or homicide, while they have a 90% chance of walking away with no charges. Thus, if the victim is Black and the killer is not Black, the killer will walk away without charges in 9 out of 10 cases; however, when the victim is White and the killer is Black, the Stand Your Ground defense is only successful in 4 out of 10 cases. Quite apparently, the law is not applied equally across racial groups, with Black men and women suffering the most negative consequences as a result.

With all of the discussion about Stand Your Ground laws, are they even effective? The available empirical evidence indicates that they are not only ineffective, but may actually increase homicide rates in states with Stand Your Ground laws. In a recent study forthcoming in the Journal of Human Resources, Cheng and Hoekstra (2013) evaluated the impact of Stand Your Ground Laws on statewide crime levels in 20 states that passed similar laws between 2005-2009. The analysis presented by Cheng and Hoekstra compares crime rates in states with Stand Your Ground Laws (i.e. the “treatment” group) and states without such laws (i.e. the “control” group), both before and after the enactment of the law. Data for their analyses were obtained from the FBI’s Uniform Crime Reporting System. In their study, the authors use several techniques, including placebo (i.e. “falsification”) testing and analysis of time-varying covariates such as economic conditions, political climate, and policing, as well as inclusion of state-specific linear time trends. All of these methods contribute to the preciseness and robustness of the results, therefore allowing the authors- as well as the reader- to have more confidence in the results. For example, placebo testing is a method to determine whether the main independent variable (in this case, Stand Your Ground Laws) has an impact on dependent variables that should not be affected by Stand Your Ground Laws, such as car thefts. Thus, if the authors found that Stand Your Ground Laws were associated with decreased car theft, this would be a clue that the analyses are not capturing the true effects of the law, but rather some other phenomenon. On a side note, I have seen several critical statements about this study, but many of these criticisms were written by authors with little or no understanding of the statistical techniques employed by the authors. For example, one writer criticized the researchers for failing to consider whether pre-existing crime rates led to the enactment of Stand Your Ground laws; however, the authors do account for this by looking for any signs of divergence (among states) for two years prior to the adoption of Stand Your Ground laws. Thus, the authors were able to ensure that no significant differences in preexisting crime rates were evident among states with Stand Your Ground laws vs. states without Stand Your Ground laws, as well as between each individual state in the country- in fact, this was a basic assumption of the statistical model used in their analyses. The results of the study indicate that Stand Your Ground laws do not deter crimes such as burglary, robbery, and aggravated assault. However, Stand Your Ground laws do have an impact on homicide rates…. just not in the direction that most would expect. Instead of seeing lower homicide rates, states with Stand Your Ground laws actually demonstrated a significant 8% net increase in the number of murders and non-negligent manslaughters, an increase that equates to 600 additional homicides per year across the 21 states with Stand Your Ground laws. As the authors state, these findings are “robust to a wide set of difference-in-differences specifications, including region-by-year fixed effects, state-specific linear time trends, and controls for time-varying factors such as economic conditions, state welfare spending, and policing and incarceration rates. These findings provide evidence that lowering the expected cost of lethal force causes there to be more of it.” (p. 28).

In summary, laws pertaining to the War on Drugs, as well as statewide Stand Your Ground laws, tend to have a disproportionately negative impact on Blacks compared to other racial groups, while at the same time lack evidence regarding their utility and effectiveness.

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5. Inequality at all levels of Criminal Justice System

The inequalities and injustices experienced by Black men and women in the U.S. criminal justice system are present throughout all levels of the system. First, as discussed above, racial profiling leads to inequalities in the proportions of Black drivers who are A) pulled over and B) subject to searches of the person and/or vehicle. Of course, this increases the probability of being arrested; as discussed above, arrest rates for Blacks are higher than for Whites, despite a lack of evidence for their increased participation in crime. Once arrested, inequalities are also seen during the pretrial stage. For example, Blacks and Hispanics are more likely to be detained during the pretrial stage than Whites, who are less likely to be held for the pretrial stage (Bishop & Frazier, 1995; Hagan & Palloni, 1999; Sentencing Project, 2001). Because of this, Black offenders may have restricted access to important resources for trial, as well as limited access to legal counsel and support from family.

Before proceeding to trial, White offenders are significantly more likely to be referred to criminal justice diversion programs, which allow the offender to escape jail time by completing the requirements of the program. Even when the contextual factors are comparable (e.g. criminal history; nature of crime; age of offender), Black males are less likely to be allowed the opportunity to avoid harsh criminal prosecution and incarceration via diversion programs (Bishop, 2005). During conviction and sentencing, Blacks are also at a distinct disadvantage. Common prosecutorial strategies include presenting the Black defendant as inherently violent and prone to future criminal behavior; these strategies have been demonstrated to lead to higher conviction rates for Blacks compared to Whites (Higginbotham, 2002). Once convicted, Black offenders are generally given harsher sentences than comparable White offenders (Petersilia, 1983); this is particularly true for juvenile offenders. Black youth offenders are significantly more likely to be tried as adults compared to White youth offenders; as a result, Black juvenile offenders are more likely to be sent to adult prisons than White juvenile offenders (Poe-Yamagata & Jones, 2000; Snyder & Sickmund, 2006). In a report by the Sentencing Project , researchers found that 58% of Black juvenile offenders are sent to adult prisons, a percentage that is disproportionately higher than all other racial groups. Since sentencing is harsher for offenders tried as adults, Black juvenile offenders also tend to receive longer sentences than White juvenile offenders and are significantly more likely to have a permanent criminal record at a younger age (Bishop, 2005; Kurlychek & Johnson, 2004). Once convicted, Black offenders are given sentences that are an average of 10% longer than sentences given to White offenders for the same crime; further, Blacks are 21% more likely than Whites to receive mandatory-minimum sentences and 20% more likely to be sentenced to prison.

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Racial inequalities in sentencing are perhaps most startling for the most serious punishment of all: the death penalty. Although the overt bias in capital punishment for Blacks has declined over the past several decades since the landmark case of Furman v. Georgia (1972) established new standards for consistency in the application of capital punishment, there is still clear evidence that Blacks (and other minorities, including Hispanics) are more likely to be sentenced to death than comparable White offenders (U.S. General Accounting Office, 1990; Walker, Cassia, & DeLone, 2000). However, the disparities in sentencing are most apparent when the race of the offender and the victim are considered. In particular, Black offenders who are convicted of killing White victims are more likely to receive capital punishment than any other combination of offender/victim racial composition (Baldus, Pulaski, & Woodworth, 1990; U.S. General Accounting Office, 1990). In the case of a Black offender and a White victim, 22% of offenders will be sentenced to death; however, when the roles are reversed and the offender is White and the victim is Black, only 3% of offenders are sentenced to death (Baldus, Pulaski, & Woodworth, 1990). Other researchers have investigated different predictors of death sentencing among Black vs. White offenders, such as the influence of physical appearance and stereotyping. Eberhardt and colleagues (2006) found that prosecutorial strategies emphasizing stereotypical beliefs about Blacks and specific physical characteristics that fit stereotypical profiles of Black criminals can both significantly increase the probability that a Black offender will receive the death penalty.

Summary of Section One

“Democratic rights and liberties are defined in relation to what is denied to people in prison. So we might ask, what kind of democracy do we currently inhabit?” –Angela Davis, political activist and Professor Emeritus

I hope I have provided enough examples and evidence to paint a picture of the current and ongoing presence of racial inequalities in our country. Now I want to switch gears a little bit to look at a few of the pathways through which racial disparities in the criminal justice system lead to health disparities among African American men and women. I struggled to decide how to conceptualize and write this next section, as the relationships between the racial inequality in the criminal justice system and health disparities among African Americans are very complex and multidimensional, encompassing the broader association between racial discrimination and negative health outcomes in addition to the specific racial health disparities and disease risks associated with incarceration and involvement in the criminal justice system. As I considered the more fundamental issues underlying this specific manifestation of racial inequality, I decided that I want (need) to write a second post addressing the broader relationships between racial discrimination and poor health outcomes; for this post, I am going to stay within the specific context of racial inequality in the criminal justice system. Having said that, let’s take a look at just a few of pathways through which racial disparities in the criminal justice system can result in racial disparities in health.

Public Health Implications of Racial Inequality in the Criminal Justice System                                                            

1. Disenfranchisement

One pathway to health disparities is through disenfranchisement, which can be defined as the removal of the rights and privileges inherent in an association with a group; depriving a free citizen of civil privileges, rights or citizenship, or constitutional rights; taking away of the rights of a free citizen, especially the right to vote.

Individuals who are charged with felonies are subject to disenfranchisement in the most fundamental meaning of the word, i.e. having their right to vote taken away, but this represents only one type of disenfranchisement. In addition to the loss of the constitutional right to vote, ex-offenders also face the loss of access to many services, benefits, and opportunities that are otherwise available to free citizens of the United States. Although the mantra “Do the Crime, Do the Time” has become common in our society, it does not represent the truth; for those who have committed certain crimes, they continue to “do the time” long after the end of their sentence. A more accurate mantra seems to be “One strike and you’re out.” For those who have a prior felony conviction, the loss of access to public housing, food stamps, health and welfare benefits, student loans, and other public assistance programs is a lifelong sentence that does not end once the ex-offender has “done the time.” In a recent example of the ongoing disenfranchisement of ex-offenders, Senator Davis Vitter (Republican from Louisiana) proposed an amendment to the Farm Bill that was recently passed; in this amendment is the provision that food stamps will be permanently taken away from certain classes of ex-offenders. On the surface, many people may agree with the sentiment that a murderer should not be granted benefits such as food stamps; however, a more thoughtful examination of the consequences of such a law may change many people’s minds. The loss of benefits does not simply apply to the ex-offender, but also to any dependents of said offender. So, a person who committed a crime in their late teens and is now an elderly adult caring for their grandchildren would not be eligible for benefits to help care for these children; it is not the offender who is being punished, but also any future dependents.

Since the 1996 welfare reform, drug-offenders have been subjected to lifetime bans on federal benefits including food stamps and welfare benefits. Although some of the more progressive states in the nation have loosened the lifetime ban, 10 states- Alabama, Alaska, Georgia, Mississippi, Missouri, South Carolina, Texas, West Virginia, Wyoming- still enforce the lifetime ban on federal benefits for anyone convicted of a drug-related felony at any point in the past. To make matters worse, ex-offenders also face tremendous barriers to employment, thus further restricting their ability to reestablish themselves upon release from prison. Although these consequences affect inmates of all races, the evidence indicates that African Americans are disproportionately harmed by the ongoing punishment of ex-offenders who have already “done the time.” For example: following release from prison, if an ex-offender is even able to find employment, wages for African American ex-offenders grow at a rate 21% slower than their White counterparts (Lyons & Pettit, 2011).

How does this relate to public health? Although we could discuss several negative outcomes including limited opportunities for employment, residential segregation, and the impact of social stigma, I want to first discuss the relationship between the risk of HIV among ex-offenders and the disproportionate impact of HIV/AIDS on the African American community. Although African Americans make up only 13% of the population in the U.S., they represent almost 40% of all AIDS cases reported through the year 2002 (CDC, 2004). Even more telling, African Americans represent 54% of new HIV diagnoses, and among women and children, African Americans make up almost two-thirds of reported AIDS cases. In a recent study published in the April 2013 edition of the academic journal AIDS Education & Prevention, Wang et al. evaluated the link between food insecurity and HIV risk/HIV risk behaviors among ex-offenders reentering society. Specifically, the study focused on the impact of the 1996 law banning those with prior felony drug convictions from receiving benefits via the Supplemental Nutritional Assistance Program (SNAP) (more commonly known as food stamps) and Temporary Assistance for Needy Families (TANF). In the study, 91% of ex-offenders reported being “food insecure,” and among the 37% who reported not eating anything for one day or more in the past month, HIV risk behaviors were significantly higher. In the absence of food stamps, it seems, ex-offenders increasingly turn to risky behaviors such as prostitution to earn money for food. Further, disenfranchisement contributes to geographic and residential segregation by limiting the opportunities of ex-offenders to successfully reenter society, which in turn serves to maintain racial health disparities. Again, this is true for all racial groups, but the persistent and disproportionate rates of residential segregation of African Americans (compared to other racial groups, including other minority groups) leads to more negative consequences for African Americans (Massey, 2004; Williams & Collins, 2001). It has long been known that residential segregation of racial minorities is a significant contributor to the disparities in mortality rates among African Americans (Collins & Williams, 1999; Guest, Almgren, & Hussey, 1998; Hart, Kunitz, Sell, & Mukamel, 1998; Polednak, 1993; Potter, 1991). Residential segregation serves as a proxy for other social disadvantages such as poverty, limited opportunities for employment and fair wages, neighborhood disorder and violence, limited access to high quality healthcare, and poorer educational systems (Adler & Newman, 2002; Link & Phelan, 1995; Marmot, 2002). There are almost limitless pathways from incarceration to residential segregation (Clear, 2003) and likewise, almost limitless health disparities linked to residential segregation. A few examples of racial health disparities associated with residential segregation of African Americans include: infectious disease and tuberculosis (Acevedo-Garcia, 2000; 2001), cardiovascular disease (Cooper, 2001), exposure to environmental toxins (Lopez, 2002), infant mortality and poor birth outcomes (Geronimus 1992, 1996; Polednak, 1996), and death from homicide (Shihadeh & Maume, 1997).

Comparison of the effects of metropolitan area isolation and effects on birth outcomes. For White women, residential segregation shows no impact on birth outcomes; conversely, for Black women, residential segregation significantly increases the risk of preterm birth. *Calculated using a Bayesian spatial statistical model.

Comparison of the effects of metropolitan area isolation and effects on birth outcomes. For White women, residential segregation shows no impact on birth outcomes; conversely, for Black women, residential segregation significantly increases the risk of preterm birth. *Calculated using a Bayesian spatial statistical model.

2. Prison Environment

Another pathway from racial disparities in the criminal justice to health disparities among African Americans is the prison environment itself. Since African Americans are disproportionately affected by incarceration, the health problems associated with prison also fall heavily on the African American community. Some of the major health problems in the U.S. correctional system include:

  1. a.  Lack of access to quality healthcare
  2. b.  Infectious Diseases
  3. c.  Chronic Diseases
  4. d.  Mental Illness
  5. e.  Fighting
  6. f.   Drug Use

Incarceration rates among African Americans have been identified as a leading cause of racial disparities in HIV infection (Blankenship et al., 2005; Laurecin et al., 2008) as well as infectious diseases such as tuberculosis (Hammet et al., 2002; Massoglia, 2008; Stead et al., 1990). Other consequences of imprisonment include increased rates of chronic diseases such as asthma and heart disease, mental illness, substance abuse, risky sexual behaviors, increased exposure to violence, poor birth outcomes, and even childhood behavioral problems (Dumont et al., 2012; Fogel, 1993; Fogel & Belyea, 1999; Massoglia, 2008; Schnittker & John, 2007; Wakefield & Wildeman, 2011; Wang & Green, 2011). The violent and hostile environment in many prisons has long-term effects on the physical, behavioral, and mental health of inmates and ex-offenders, leading many to question whether prisons are even serving the purpose they were created for (i.e. reducing cime) (Smith, 2000; Sykes, 1958; Sim, 1994; Toch, 1998).

 

Path Model of HIV Risk Factors and Disparities among Incarcerated African Americans

Path Model of HIV Risk Factors and Disparities among Incarcerated African Americans

3. Criminalization of mental illness and substance use disorders

The third pathway to health disparities that I will discuss is an important one, as recent trends show that the criminalization of mental illness and substance use disorders is on the rise. As we discussed previously, African Americans are targeted for drug crimes at disproportionate rates that fail to be explained by racial differences in drug use or drug-related activities. Dumont and colleagues (2012) describe this trend in a stunning but factually correct statement: “The twenty-first century opened with blacks disproportionately arrested and incarcerated to a greater extent than they were during the Jim Crow 1920s.” Although many jails and prisons offer short-term substance abuse treatment, the long-term effectiveness of these programs is questionable at best. The result of the criminalization of substance use disorders has not only resulted in disparities in incarceration, but also in health disparities among African Americans. One example of this is the increasing application of punitive responses (rather than rehabilitative treatment) to deal with the problem of substance use during pregnancy. Currently, 16 states can (and do) punish prenatal substance use under civil child-welfare statutes and 14 states require health care professionals to report suspected prenatal drug abuse to be used against the mother in child-welfare and custody proceedings (Guttmacher Institute, 2013). Conversely, only 18 states have created or funded substance abuse treatment programs for pregnant women, and only 4 states prohibit substance abuse treatment centers from discriminating against pregnant women (Guttmacher Institute, 2013). The criminalization of substance use disorders- which are classified as psychiatric disorders, not as a type of criminal behavior- has negatively affected pregnant women of all races, but once again the burden has fallen most heavily on African American women (Berrien, 1989; Bulger, 1999; Kerker et al., 2004, 2006; Roberts, 1990, 2000). African American women are more likely to be screened for illicit drug use by their healthcare providers and more likely to be the targets of criminal and/or civil prosecution compared to White women, who are less likely to be screened in the first place and more likely to be referred to treatment and/or rehabilitative services instead of facing punitive policies. African American women already suffer from higher rates of poor birth outcomes, and the punitive response to prenatal substance abuse is thought to contribute to this problem by scaring women away from prenatal care and thus, increasing the risk of unhealthy pregnancies (Berrien, 1989; Figdor & Kaeser, 1998). The constitutionality of such punitive approaches to prenatal substance use has been repeatedly called into question, yet many states still employ punishment over treatment for pregnant women with substance use disorders, and racial disparities in birth outcomes persist to this day (VanRaalte, 1995; Guttmacher Institute, 2013).

This is just one example of many; racial disparities in health resulting from the criminalization of mental illness and substance abuse are unfortunately quite prevalent in today’s society, and many more articles could be written on this issue alone. However, I will save the comprehensive review for my dissertation!

tower_n_razor_wire03

Conclusions and Final Thoughts

Racial inequalities are pervasive in our society, even if they have become more inconspicuous in recent decades; in fact, the insidious nature of racial discrimination in American society contributes to the widespread denial of its very existence,  Researchers have even developed new statistical methods for measuring and evaluating current trends in racial disparities, as the changing nature of inequality calls for more thorough and thoughtful investigation. Though we have seen great progress towards achieving racial equality, we are not there yet; as the evidence shows, we still live in a society in which African Americans and other minority groups face disadvantages from which the White population in America is generally immune. With the history of racism in our country and the ongoing racial inequalities that still affect African Americans today, it is not difficult to understand why a verdict like the one in the Trayvon Martin case would take on a special meaning for those who have experienced injustices, whether in the criminal justice system or elsewhere.

Regarding the President’s brief commentary on the issue, I am still somewhat perplexed by the backlash and negativity that emerged in response to his comments. As the first African American President, he is in a unique position that allows him to address the racial inequalities that have plagued our society for centuries; no other United States President has ever been able to comment on these issues from a firsthand perspective, and his public acknowledgment of the pervasiveness of racial discrimination was an appropriate and heartfelt response to the outcry of millions of Americans. I fail to see any wrongdoing in making a speech aimed at healing the hearts of those who have experienced the pain of racial discrimination, and I applaud his courage for speaking out about an issue that remains in the hearts and minds of Americans of all races. In the end, this was an issue of human compassion and empathy, of acknowledging pain and suffering, and of beginning to heal the wounds that have long been ignored and even denied in American society. As long as we have such a large part of our society willing to deny the existence of racism, we will never achieve true equality. Regardless of our racial background, human suffering based on historical and lived experiences is something that we can all relate to- but only if we are willing to open our minds to the experiences of those other than our own.

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References:

Acevedo-Garcia D. Zip code level risk factors for tuberculosis: neighborhood environment and residential segregation, New Jersey, 1985–1992. Am J Public Health. 2001;91:734–741

Acevedo-Garcia D. Residential segregation and the epidemiology of infectious diseases. Soc Sci Med. 2000;51:1143–1161.

Adler, N.E. and Newman, K. “Socioeconomic Disparities in Health: Pathways and Pol- icies,” Health Affairs 21, no. 2 (2002): 60–76.

Anderson, D. C. (1995). Crime and the politics of hysteria. New York: Random House.

Baldus, D., & Woodworth, G. (2002). Race discrimination and the legitimacy of capital punishment: Reflections on the Interaction of fact and perception. Depaul Law Review, 53(1411).

Baldus, D., Pulaski, C., & Woodworth, G. (1990). Equal Justice and the Death Penalty. Boston, MA: Northeastern University Press.

Berrien, J. (1989). Pregnancy and drug use: The dangerous and unequal use of punitive measures. Yale JL & Feminism, 2, 239.

Bishop, D.M. (2005). The Role of Race and Ethnicity in Juvenile Justice Processing. In: D. F. Hawkins and K. Kempf-Leonard (Eds), Our Children, Their Children: Confronting Racial and Ethnic Differences in American Juvenile Justice, pp. 23–82. Chicago, IL: University of Chicago Press)

Bishop, D.M., & Frazier, C.E. (1996). Race Effects in Juvenile Justice Decision-Making: Findings of a Statewide Analysis. Journal of Criminal Law and Criminology 86(2):392–41

Blankenship, K. M., Smoyer, A. B., Bray, S. J., & Mattocks, K. (2005). Black-white disparities in HIV/AIDS: the role of drug policy and the corrections system. Journal of Health Care for the Poor and Underserved16(4 Suppl B), 140.

Bulger, C. M. (1999). In the Best Interest of the Child? Race and Class Discrimination in Prenatal Drug Use Prosecutions: Private Choices, Public Consequences: Reproductive Technology and the New Ethics of Conception, Pregnancy, and Family. By Lynda Beck Fenwick. BC Third World LJ19, 709-733.

Centers for Disease Control and Prevention (CDC). Fact Sheet – HIV/AIDS among African Americans. Atlanta: CDC, National Center for HIV, STD and TB Prevention, Division of HIV/AIDS Prevention (DHAP), 2004

Clear, T. R., Rose, D. R., Waring, E., & Scully, K. (2003). Coercive mobility and crime: A preliminary examination of concentrated incarceration and social disorganization. Justice Quarterly, 20(1), 33-64.

Collins C, Williams DR. Segregation and mortality: the deadly effects of racism. Sociol Forum. 1999;14:495–523.

Cooper R. Social inequality, ethnicity and cardiovascular disease. Int J Epidemiol. 2001;30(suppl 1):S48–S52.

Cunningham, M. D., & Vigen, M. P. (2002). Death row inmate characteristics, adjustment, and confinement: A critical review of the literature. Behavioral sciences & the law, 20(1‐2), 191-210.

Currie, E. (1998). Crime and punishment in America. New York: Henry Holt

Dumont, D. M., Brockmann, B., Dickman, S., Alexander, N., & Rich, J. D. (2012). Public health and the epidemic of incarceration. Annual review of public health, 33, 325.

Eberhardt, J. L., Davies, P. G., Purdie-Vaughns, V. J., & Johnson, S. L. (2006). Looking deathworthy perceived stereotypicality of black defendants predicts capital-sentencing outcomes. Psychological Science, 17(5), 383-386.

Figdor, E., & Kaeser, L. (1998). Concerns mount over punitive approaches to substance abuse among pregnant women. The Guttmacher Report on Public Policy (October 1998), 3-5.

Fogel, C.I. (1993b). Pregnant inmates: Risk factors and pregnancy outcomes. Journal of Obstetric, Gynecology, & Neonatal Nursing, 22, 33-39.

Fogel, C., & Belyea, M. (1999). The lives of incarcerated women: Violence, substance abuse, and at risk for HIV. Journal for the Association of Nurses in AIDS Care, 10(6), 66-74.

Geronimus AT. The weathering hypothesis and the health of African-American women and infants: evidence and speculations. Ethn Dis. 1992;2:207–221

Geronimus AT. Black/white differences in the relationship of maternal age to birthweight: a population-based test of the weathering hypothesis. Soc Sci Med. 1996;42:589–597

Guest AM, Almgren G, Hussey JM. The ecology of race and socioeconomic distress: infant and working-age mortality in Chicago. Demography. 1998;35:23–34

Guttmacher Institute (2013). Policies in brief: Substance abuse during pregnancy (Feb. 2013). New York, NY: Guttmacher Institute.

Hagan, J. & Palloni, A. (1999). Sociological Criminology and the Mythology of Hispanic Immigration and Crime. Social Problems 46(4):617–32.

Hart KD, Kunitz SJ, Sell RR, Mukamel DB. Metropolitan governance, residential segregation, and mortality among African Americans. Am J Public Health. 1998;88:434–438.

Higginbotham, A. L., Jr. (2002). Unequal justice in the state criminal justice system. In S. L. Gabbidon, H. T. Greene, & V. D. Young (Eds.), African American classics in criminology and criminal justice (pp. 135-158). Thousand Oaks, CA: Sage.

Kerker, B.D., Horwitz, S.M., Leventhal, J.M., 2004. Patients’ characteristics and providers’ attitudes: predictors of screening pregnant women for illicit substance use. Child Abuse Negl. 28, 209–223.

Kerker, B.D., Leventhal, J.M., Schlesinger, M., Horwitz, S.M., 2006. Racial and ethnic disparities in medical history taking: detecting substance use among low-income pregnant women. Ethn. Dis. 16, 28–34.

Kurlychek, M.C., & Johnson, B.D. (2004). The Juvenile Penalty: A Comparison of Juvenile and Young Adult Sentencing Outcomes in Criminal Court. Criminology 42(2), 485–517

Laurecin, C. T., Christensen, D. M., & Taylor, E. D. (2008). HIV/AIDS and the African-American community: a state of emergency. Journal of the National Medical Association, 100(1), 35-43.

Lanier, C. S., & Acker, J. R. (2004). Capital punishment, the moratorium movement, and empirical questions: Looking beyond innocence, race, and bad lawyering in death penalty cases. Psychology, Public Policy, and Law, 10(4), 577.

Link, B.G. and Phelan, J. “Social Conditions as Fundamental Causes of Disease,” Journal of Health and Social Be- havior, Extra Issue (1995): 80–94.

Lopez R. Segregation and black/white differences in exposure to air toxics in 1990. Environ Health Perspect. 2002;110(suppl 2):289–295.

Lyons, C.J., & Pettit, B. (2011). Race, incarceration, and wage growth. Social Problems, 58(2), 257-280.

Marmot, M. “The Influence of Income on Health: Views of an Epidemiologist,” Health Affairs 21, no. 2 (2002): 31–46

Massey, D.S.  “Segregation and Stratification: A Biosocial Perspective, ”DuBoisReview1,no.1(2004):7–25.

Massoglia, M. (2008). Incarceration, health, and racial disparities in health. Law & Society Review, 42(2), 275-306.

Mauer, M. (1999). Race to incarcerate. New York: New Press.

Miller, J. (1996). Search and destroy: African-American males in the criminal justice system. Cambridge, UK: Cambridge University Press.

Morland K, Wing S, Diez-Roux A, Poole C. Neighborhood characteristics associated with the location of food stores and food service places. Am J Prev Med. 2002;22:23–29

Peterson RD, Krivo LJ. Racial segregation and black urban homicide. Soc Forces. 1993;71:1001–1026.

Polednak AP. Poverty, residential segregation, and black/white mortality ratios in urban areas. J Health Care Poor Underserved. 1993;4:363–373.

Polednak AP. Trends in US urban black infant mortality, by degree of residential segregation. Am J Public Health. 1996;86:723–726.

Potter LB. Socioeconomic determinants of white and black males’ life expectancy differentials, 1980. Demography. 1991;28:303–321.

Roberts, D. E. (1990). Punishing drug addicts who have babies: Women of color, equality, and the right of privacy. Harv. L. Rev., 104, 1419.

Roberts, D. E. (2000). Creating and solving the problem of drug use during pregnancy.

Schnittker, J., & John, A. (2007). Enduring stigma: the long-term effects of incarceration on health. Journal of Health and Social Behavior, 48(2), 115-130.

Shihadeh ES, Maume MO. Segregation and crime: the relationship between black centralization and urban black homicide. Homicide Stud. 1997;1:254–280.

Sim, J. (1994) Tougher than the rest? Men in prison. In Newburn, T. and Stanko, E. (eds) Just Boys Doing Business: Men, Masculinities and Crime. London: Routledge.

Smith, C. (2000) Healthy prisons: a contradiction in terms? The Howard Journal, 39, 339–53.

Snyder, H.N., & Sickmund, M. (2006). Juvenile Offenders and Victims: 2006 National Report. Pittsburgh, PA: National Center for Juvenile Justice

Substance Abuse and Mental Health Services Administration (SAMHSA) (2012). Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Sykes, D. (1958) The Society of Captives: a Study of a Maximum Security Prison. New Jersey: Princeton University Press.

Toch, H. (1998) Hypermasculinity and prison violence. In Bowker, L.H. (ed.) Masculinities and Violence. London: Sage Publications.

U.S. General Accounting Office. 1990. Death Penalty Sentencing: Research Indicates Pattern of Racial Disparities. GGD-90-57. Washington, DC: General Accounting Office.

VanRaalte IV, D. B. (1995). Punitive Policies: Constitutional Hazards of Non-Consentual Testing of Women for Prenatal Drug Use. Health Matrix, 5, 443.

Walker, Samuel, Cassia Spohn, and Miriam DeLone. 2000. The Color of Justice: Race, Ethnicity, and Crime in America. 2nd ed. Belmont, CA: Wadsworth Thomson Learning.

Wakefield, S., & Uggen, C. (2010). Incarceration and stratification. Annual Review of Sociology, 36, 387-406.

Wakefield, S., & Wildeman, C. (2011). Mass imprisonment and racial disparities in childhood behavioral problems. Criminology & Public Policy10(3), 793-817.

Wang, E. A., & Green, J. (2010). Incarceration as a key variable in racial disparities of asthma prevalence. BMC public health, 10(1), 290.

Weiser, S. D., Young, S. L., Cohen, C. R., Kushel, M. B., Tsai, A. C., Tien, P. C., … & Bangsberg, D. R. (2011). Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS. The American journal of clinical nutrition, 94(6), 1729S-1739S.

Williams, D.R. & Collins, C. “Racial Residential Segregation: A Fundamental Cause of Racial Disparities in Health,” Public Health Reports 116, no. 5 (2001): 404–416.

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