"The Contribution of Black-White Health Differences to the Academic Achievement Gap,"by Richard Rothstein & Tamara Wilder September/October 2005 issue of Poverty & Race
The health characteristics of African Americans and their access to good healthcare are systematically poorer than those of white Americans. These systematic differences begin before birth, continue through early childhood and school years, and continue into adulthood.
These health and healthcare differences partially explain the inability of black students to achieve academically at levels comparable to whites. Because there has been so little research on the topic, including a failure to conduct feasible experiments, we can’t say how much of the black-white test score gap is attributable to health and healthcare differences. Health disparities themselves may stem from inferior schooling for black students—for example, if black students have less adequate physical education, or if inferior education in the prior generation led to greater adult economic insecurity which, in turn, causes poor health for both parents and children today.
Yet despite our inability to be precise about causal relationships between poor health and the academic achievement gap, the poorer health and access to care of African Americans certainly contributes to the gap. Children with more exposure to toxins (children with lead poisoning, for example) or more nutritional inadequacies (iron deficiency anemia, for example) have inferior cognitive ability—lower IQs. Children with poorer vision cannot read as well; children less likely to be immunized and more likely to be ill have higher school absenteeism rates; children with more discomfort, from ear infections or toothaches, or with labored breathing from asthmatic attacks, are less able to pay attention to classroom lessons. Parents in poor health are less able to care for their children and less likely to guide their children to good health habits. Each of these average statistical health differences between black and white children and their parents may make a tiny contribution to the achievement gap, but their cumulative effect is bound to be significant.
In what follows, we describe some of these differences, in life cycle sequence, beginning before a child’s birth, and continuing into adulthood. In each case, data are from the most recent year available, which may vary from indicator to indicator.
Pregnancy, Childbirth and Neonatality
Inequality begins shortly after conception. One indicator of a child’s healthy birth, making other lifetime outcomes more likely to be successful, is whether mothers get early medical attention during pregnancy. Twenty-five percent of black mothers get no prenatal care during the first trimester, while 11% of white mothers get none. For black mothers, 6% get no prenatal care at all (or get it only during the last trimester, when it is almost too late), but only 2% of white mothers, one-third the number of blacks, get no or too-late care. These data, describing only care during pregnancies that end with live births, probably understate the disparity.
We have no good data on unsuccessful pregnancies, but it is probable that black women also miscarry more frequently than whites. Data on neonatal deaths strengthen this conclusion. For black newborns, there are 9 deaths within the first month for every 1,000 live births. For whites, there are only 4 such deaths. Considering infant mortality during the first year of life, there are 14 deaths for blacks and 6 whites. Adequate prenatal care could have prevented some of these.
Infant mortality and morbidity are continuous, so the higher rate of black infant mortality suggests a similarly higher rate of black infants who survive with unhealthy conditions that make school and lifetime success more difficult.
These differences in pregnancy and childbirth are reflections of racial inequality itself and are not eliminated by controlling for maternal education. For black mothers who are high school drop-outs, 15 of every 1,000 live births die within the first year; for white drop-outs, 9 do so. For mothers who graduated from high school but got no further education, infant deaths are 13 for blacks and 6 for whites. And for mothers with at least one year of college, infant deaths are 12 for blacks and 4 for whites.
Racial differences in pregnancies and live births are paralleled by differences in birthweight. Low birthweight predicts special education placement, lower academic achievement, emotional maladjustment and likelihood of criminal behavior. For blacks, 3% of newborns have very low birthweight (less than 1,500 grams—3 lbs., 5 oz.), the condition most likely to lead to adverse educational and lifetime outcomes. For whites, the rate is only one-third as great. For low birthweight (less than 2,500 grams—5½ lbs.), a condition still putting children at risk, 13% of black babies have low birthweight, versus 7% of whites.
Again, these disparities narrow only slightly after controlling for education. For black mothers who are high-school drop-outs, 15% of live births are low birthweight; for white dropouts, it is 9%. For mothers who graduated from high school but got no further education, 14% of live births are low birthweight for blacks and 7% for whites. And for mothers with at least one year of college, the rates are 12% for blacks and 6% for whites.
Black mothers are less likely than whites to follow practices recommended for the best infant outcomes. For example, 54% of black mothers breastfeed their infants in the early postpartum period, compared to 73% of white mothers. When infants are six months of age, the relative disparity is even greater: 19% of black mothers breastfeeding, compared to 36% of white mothers. At one year of age, the rates are 12% and 21%, respectively.
Some of these indicators are more important than others. For example, if we closed the gap in prenatal care, the low birthweight gap might, at least partly, solve itself. Nonetheless, we can roughly summarize the overall black disadvantage in pregnancy, childbirth and neonatality. The summary requires two oversimplifying assumptions: that each indicator we’ve mentioned describes normally distributed characteristics, and that each is equally important. We can then say that the average black experience with healthy pregnancy, childbirth and neonatality is at the 37th percentile of the experience of all U.S. mothers and babies, while the average white experience is at the 53rd percentile.
This distribution is only somewhat more equal than that of black and white test scores in elementary school. In an average of black and white fourth- and eighth-grade student performance on the most recent administrations (in all subjects) of the National Assessment of Educational Progress, black students are at the 28th percentile of achievement, while white students are at the 60th percentile. Certainly other factors besides pregnancy, childbirth and neonatal experiences are involved, but life’s earliest experiences of inequality are not easily overcome.
Access to Health Care
Partly, racial inequalities in pregnancy and infancy stem from inequalities in health insurance. For children under 18, 14% of blacks lack health insurance, including Medicaid or CHIP (federally-subsidized children’s insurance), whereas for whites, 7% lack coverage.
These numbers understate inequality—less health insurance for black families is compounded by inaccessibility of primary care physicians, even when families have insurance. In many low-income minority communities, insurance cards in practice confer only the right to wait in lines at clinics or emergency rooms, because few obstetricians, pediatricians or other primary care physicians practice in these communities. We have no national data on this, but a California analysis found that urban neighborhoods with high poverty and concentrations of black and Hispanic residents had one primary care physician for every 4,000 residents. Neighborhoods that were neither high-poverty nor high-minority had one per 1,200.
Black children are thus less likely to get primary and preventive medical care than whites. Eighty-seven percent of black children (under 18) have seen a doctor in the previous year, compared to 90% of whites. Keep in mind that this relatively small disparity does not reflect the much larger disparities in the average number of doctor visits or in the type of medical facility visited. This inequality also has both a racial and socioeconomic aspect. Relatively more poor black children lack medical care than do poor whites, and relatively more non-poor black children lack medical care than do non-poor whites.
Similar inequalities characterize oral health: 69% of black children age 2-17 have seen a dentist in the previous year, compared to 79% of white children.
These inequalities in access to healthcare compound the inequalities of birth outcomes to contribute to differences in health between black and white children that, in turn, contribute to differences in educational and lifelong outcomes. By the age of 35 months, 25% black children have not received standard vaccinations for diptheria, tetanus, pertussis, polio, measles and influenza. For whites, the non-vaccinated share is 16%.
Ear infections afflict all children, but disadvantaged children are less likely to get prompt treatment. Parents rarely take children to emergency rooms for common ear infections; if primary pediatric care is unavailable, parents are more likely to let the infection take its own course, and it will, most probably, take care of itself. But before then, children with earaches are more likely to miss school, or be inattentive or irritable from pain. Forty-five percent of black children have received antibiotics for ear infections by age 5, compared to 65% of whites.
Again, assuming that each of these indicators reflects normally distributed characteristics and each has equal weight, black children, on average, are at the 43rd percentile in the distribution of children’s access to good healthcare, while white children, on average, are at the 56th percentile.
Health of Young Children
Black children get less adequate nutrition—lacking not calories, but some essential nutrients. For example, iron deficiency anemia, which adversely affects cognitive ability and predicts special education placement and school failure, is more prevalent among black children. In federal programs for low-income children, 19 percent of blacks under the age of 5 are anemic, versus 10% of whites. Iron deficiency anemia also predisposes to lead absorption, further depressing cognitive ability.
Educational inadequacy also results from disparities in vision—not only in near- or farsightedness, but also in poor eye-muscle development, leading to less facility in skills needed for reading, like tracking print, converging and focusing. Optometrists who have tested children in low-income black communities report that as many as 50% of the children may come to elementary school with vision difficulties that impair reading ability, compared to 25% of children in non-poor communities. These difficulties do not always require correction with eyeglasses; eye exercise therapy may suffice, but such therapy is generally unavailable to low-income children.
Disparate rates of lead poisoning also exacerbate the academic achievement gap. Children who live in older buildings have more lead dust exposure that harms cognitive functioning and behavior. High lead levels also contribute to hearing loss. Three percent of black children but only 1% of whites age 1-5 have blood lead levels that are dangerously high.
We have made great progress in eliminating lead from children’s blood; 15 years ago, 11% of very young black children had dangerously high lead levels, compared to 2% of whites. The reduction to today’s lower levels is mostly attributable to the elimination of leaded automobile fuel, and to a 1978 prohibition on lead-based paint in residential construction. Yet low-income and minority children still today are more likely to live in poorly maintained, pre-1978 buildings with peeling older layers of paint. And the higher lead poisoning levels of only a decade ago still affect the academic potential of children who are now in the upper grades. Urban children are also more likely to attend older schools, built when water pipes contained lead. New York City, Baltimore and Washington, DC have recently found it necessary to shut off school drinking fountains because lead exceeded dangerous levels.
Other serious diseases are also more common for young black children. Twenty-six of every 100,000 black children under age 2 contract bacterial meningitis; for whites, less than half that number do, 11 of 100,000. Bacterial meningitis is treatable, but requires prompt diagnosis. Although a small number of children, black or white, get the disease, for those who do it can lead to death or, for survivors, hearing loss, mental retardation, paralysis and seizures. So it, too, makes a contribution to the academic achievement gap.
Similar inequalities characterize children under 5 for other bacterial diseases, such as pneumonia and ear, blood stream and sinus infections. For black children under 5, 155 of every 100,000 get such infections each year; for whites, only 63 do.
At this early age, racial differences in oral health are relatively small. Twenty-five percent of black children between the ages of 2 and 5 have untreated dental cavities; for whites, it is 23%. As we will see below, however, these small disparities grow large as children mature.
Summarizing these indicators of young children’s health, again assuming that each reflects normally distributed characteristics and has equal weight, young black children, on average, are at the 41st percentile in good health characteristics, while young white children, on average, are at the 52nd percentile.
Health of School-Age Children
Mentioned above was that black children enter school with a rate of vision difficulty that makes reading difficulty more probable. For children under 18, for the most severe cases of blindness and vision difficulty that cannot be corrected by eyeglasses, the rate for blacks is 2.6%; for whites, 2.3%.
Because the environmental conditions in neighborhoods where disadvantaged children reside contain more allergens, minority and low-income children are more likely to suffer from asthma. Eighteen percent of black children suffer from asthma, versus 11% of white children. (Because black children get worse primary medical care and are less likely to be diagnosed, these numbers may understate the disparity.) Again, this is a racial and socioeconomic disparity; although poor children suffer from asthma more than non-poor children, the disparity for poverty (15% for poor children, versus 12% for non-poor) is smaller than the racial disparity.
Asthma is the single largest cause of chronic school absenteeism. It keeps children up at night, and, if they do make it to school the next day, they are likely to be drowsy and less attentive. Middle-class asthma sufferers typically get treatment for its symptoms, while disadvantaged children get relief less often. As a result, low-income asthmatic children are about 80% more likely than middle-class asthmatic children to miss more than seven days of school a year from the disease. Children with asthma refrain from exercise and so are less physically fit. Irritable from sleeplessness, they also have more behavioral problems that depress achievement.
Perhaps because of environmental factors, asthma increased for children overall by 50% from 1980 to 1996. But it increased twice as rapidly for black children, perhaps partly because their environments are worse, or partly because their low rate of diagnosis is improving. Unequal increases in asthma, with its impact on children’s attendance and behavior, will undermine other efforts to raise black student achievement.
We noted above that although lead poisoning has diminished, black preschoolers have three times the rate of whites. Disparities in blood lead levels continue during the school years. There is no clear cut-off between dangerous and safe blood lead levels. Many school-age children have less-than “dangerous” levels that still have subtle depressing effects on cognitive ability. In particular, school-age children with levels even half as high as those considered dangerous have lower reading scores, lower math scores, lower non-verbal reasoning scores and less short-term memory. For black and white children age 6 to 16, 22% of blacks have this half-dangerous level, more than three times the white rate of 6%.
Perhaps because of differences in diet, perhaps because of differences in sports and physical activity opportunities, black children are more likely to be overweight than whites. In the elementary school years, 21% of black children are overweight, versus 14% of whites. Including those heavy enough to be seriously at risk of overweight, 35% of black elementary school children are either overweight or at risk of being overweight, compared to 29% of whites. In high school, 18% of black students are overweight, compared to 12% of whites; 36% of black high school students are either overweight or at risk of being overweight, compared to 26% of whites.
Black students are more likely to engage in risky sexual behaviors than whites. Nine percent of black high- school students have either been pregnant or gotten someone pregnant, compared to 2% of whites. Although white students are somewhat more likely to use contraception than blacks (mostly because white students are more likely to take birth control pills; condom use is similar for black and white teenagers), most of the difference is attributable to the fact that 49% of black high-school students are sexually active, compared to 30% of whites. As a result, 9% of black and 4% of white high-school students are sexually active without practicing regular contraception.
Black teenagers are diagnosed with new cases of AIDS at nearly 20 times the annual rate of whites—for every million black teenagers, there are 29 new cases; for every million whites, 1.5 new cases.
Another mortal danger is firearms. Each year, of every 100,000 black teenagers (age 15 to 19), 27 are victims of homicide by firearms. For whites, the rate is only 2 per 100,000. Black teenagers are also more likely to be suicidal. Four percent of black high-school students require medical attention annually for a suicide attempt; only 2% of white high-school students require it.
We reported above that black preschoolers are only slightly less likely to have healthy teeth than whites. But by school age, the gap has widened. Seventy-two percent of black children 6 to 17 have healthy teeth (with no untreated dental cavities), compared to 82% of whites. Not only does pain, including toothaches, make it more difficult for children to learn, but their poor oral health makes serious oral diseases more likely when they become adults.
All these add up to overall inequality in the health status of schoolchildren. Black parents report that 74% of their school-aged children are in overall good health, compared to white parents who report that 87% are in good health. These parent-reported data are consistent with what we find from a simple average of the other indicators we’ve presented on school-children’s health.
In a few important respects, the health of black teenagers is superior to that of whites. For example, black high-school students are less like to engage in substance abuse (smoking, alcohol and drugs) and less likely to die in automobile accidents than whites (perhaps partly because black youths, less likely to consume alcohol, are less likely to drive when under its influence, and perhaps partly because black youths are less likely to own cars).
Notwithstanding these few contrary indicators, if we again assume that children’s experiences are normally distributed on each of the indicators of school-aged children’s physical and mental health, and weighting each indicator equally, we conclude that black school-aged children, on average, are at the 47th percentile in a distribution of favorable health characteristics, while white children, on average, are at the 55th percentile.
Health of Adults
Health inequalities, for which foundations are laid in early childhood and the school years, continue and, in some cases, grow for young adults who, then, are less able to care for their own children and pass good health habits on to the next generation. The poor health of parents is, therefore, another determinant of children’s lower achievement.
For adults in prime childbearing years, age 18-34, only 68% of blacks are covered by health insurance, compared to 79% of whites.
Of every 100,000 young (age 20-24) black adults, 18 are newly diagnosed each year with AIDS. For whites, there is only 1 such diagnosis per 100,000.
Differences in overweight, established in childhood, continue into adulthood. Sixty-three percent of black young (age 20-39) adults are overweight, compared to 55% of whites. Considering only those who are obese, 36% of blacks and 24% of whites are in this category.
Unequal exercise habits also persist into adulthood. Fifty-one percent of black young (age 18-24) adults engage in the minimal amount of physical activity recommended for good health (including recreational exercise or activity integrated into household work or employment); for whites, 61% of young adults do so. Considering adults from 25 to 34 years old, 44% of blacks engage in the minimal amount of physical activity, compared to 54% of whites.
These data are consistent with adults’ overall health conditions. Eighty-one percent of black adults consider themselves to be in excellent or good health, compared to 90% of whites. These subjective reports reflect a reality that black adults are more likely to die prematurely from cardiovascular disease and cancer than whites. Of every 100,000 black adults age 45 to 54, 181 die from heart disease, more than twice the number (88) of whites who do. Forty-one blacks in this group die of stroke, nearly four times the number (11) of whites. One hundred and eighty-two die of cancer, nearly half again as many deaths as the rate for whites (124).
Summarizing these adult health indicators, with the same simplifying assumptions used previously, we conclude that black adults, on average, are at the 42nd percentile in a distribution of favorable health characteristics, while white adults, on average, are at the 54th percentile.
As noted at the beginning of this article, it is impossible to say precisely to what extent these inequalities in health, extending from before birth to adulthood, contribute to black-white educational inequalities, and to what extent educational inequalities perpetuate disparities in health. It would be hard to argue, however, that causality does not run in both directions. For blacks and whites to have equal chances of academic and lifetime success, remedying health inequalities must be part of the solution.
Richard Rothstein is Research Associate at the Economic Policy Institute and Visiting Professor, Teachers College, Columbia University. firstname.lastname@example.org
Tamara Wilder is a Ph.D. Candidate in Politics and Education, Teachers College, Columbia University.
This article is based on a forthcoming paper for the Campaign for Educational Equity, Teachers College, Columbia University. Full source citations for all of the data presented here, along with explanations of statistical methods employed, will be available in the published paper on the Campaign's website: http://www.tc.edu/equitycampaign/papers.
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