C 2005) Journal of Immigrant Health, Vol. 7, No. 3, July 2005 (
DOI: 10.1007/s10903-005-3677-6

Implications of Black Immigrant Health for U.S. Racial Disparities in Health Jen’nan Ghazal Read,1,5 Michael O. Emerson,2 and Alvin Tarlov3,4

This paper contributes to a growing understanding of U.S. black-white health disparities by using national-level data to disaggregate the health status of black Americans into the following subgroups: U.S.-born blacks, black immigrants from Africa, black immigrants from the West Indies, and black immigrants from Europe. Using new data on the 2000 and 2001 National Health Interview Surveys (NHIS), the authors compare the status of U.S.- and foreign-born blacks to that of U.S.-born whites on three measures of health. The analysis finds that U.S.-born and European-born blacks have worse self-rated health, higher odds of activity limitation, and higher odds of limitation due to hypertension compared to U.S.-born whites. In contrast, African-born blacks have better health than U.S.-born whites on all three measures, while West Indian-born blacks have poorer self-rated health and higher odds of limitation due to hypertension but lower odds of activity limitation. These findings suggest that grouping together foreign-born blacks misses important variations within this population. Rather than being uniform, the black immigrant health advantage varies by region of birth and by health status measure. The authors conclude by exploring the implications of these findings for researchers, health professionals, and public policy. KEY WORDS: blacks; racial disparities; immigrants; ethnic groups.

INTRODUCTION

disease were 29% higher among blacks than among whites, and death rates from stroke were 40% higher (3). Moreover, even though the average health of all U.S. populations has improved over the past century, the gap between blacks and whites has actually widened (4). Most researchers attempt to explain this gap in terms of genetic differences between blacks and whites; differential health behaviors; unequal access to medical care; discrimination in medical treatment; and socioeconomic differences at the individual, household, and neighborhood level. A substantial body of research has attempted to account for these disparities, yet questions about the causes of these differences remain unsolved. Adding to the complexity of this issue is the growing size of the black immigrant population. The foreign-born segment of the U.S. black population has doubled over the past 20 years, from 3% in 1980 to 6% in 2000 (5). On average, black immigrants have better health than U.S.-born black Americans. With respect to reproductive outcomes, for example, birthweight

The disparity in health between U.S. blacks and whites is one of the most challenging problems facing health care professionals and researchers. Compared to all other U.S. racial groups, blacks have the highest rates of morbidity and mortality for almost all diseases, highest disability rates, shortest life expectancies, lowest rates of insurance coverage, least access to health care, and startlingly lower rates of the use of modern technology in their treatment (1, 2). In 1999, for example, death rates from cardiovascular 1 Department

of Sociology, University of California, Irvine, California. 2 Department of Sociology, Rice University, Houston, Texas. 3 James Baker Institute for Public Policy, Rice University, Houston, Texas. 4 School of Public Health, University of Texas, Houston, Texas. 5 Correspondence should be directed to Jen’nan G. Read, 4201 Social Science Plaza B, University of California, Irvine, California 92697-5100; e-mail: [email protected].

205 C 2005 Springer Science+Business Media, Inc. 1096-4045/05/0700-0205/0


206 patterns of foreign-born black women are more closely related to U.S.-born white women than to U.S.-born black women (6, 7). In terms of mortality, foreign-born blacks have lower rates than even white Americans (8). However, whether the black immigrant health advantage is uniform or whether it varies by region of birth remains unclear. Although there have been few studies that examine the heterogeneity of the black immigrant population, research on other U.S. immigrant populations provides a basis for hypothesizing about health variations among black immigrants. In particular, studies of Hispanic and Asian groups indicate that the foreign-born are generally healthier than their U.S.-born counterparts and U.S.-born whites, an advantage that reflects a combination of healthier lifestyles in the countries of origin, the selective migration of healthy immigrants, and cultural buffering that reduces risky behavior and strengthens support networks (9, 10). With increased duration of U.S. residency and greater acculturation to American society, these advantages diminish. Thus, we should expect black immigrant health to vary by region of birth given that the costs of migration (and hence selectivity) are directly tied to the proximity and characteristics of the sending region. Moreover, we should expect to see a worsening health with increased incorporation into U.S. society. Answers to these questions have important implications for health care researchers, public policy advocates, and clinicians. If the black immigrant health advantage is driven largely by one or more groups, then researchers will need to continue their efforts to disaggregate the black population by region of birth in order to distinguish the mechanisms (e.g., selectivity) that contribute to differential health patterns among black Americans. If the health of black immigrants follows the same pattern as other immigrant populations and decays with increased duration of U.S. residence, then both researchers and public policy makers will need to address the deteriorating health of the black population, increased blackwhite health disparities, and a greater strain on the U.S. health care system. For clinicians, adequate diagnosis and treatment of medical problems among black Americans will require greater attention to the potential differences in their health profiles. Specifically, blacks may present differently and require different medical care based on their region of birth. To our knowledge, this study is the first to use national-level data to assess these questions by examining heterogeneity in the health status of black

Read, Emerson, and Tarlov Americans. We draw on new data on the 2000 and 2001 National Health Interview Survey (NHIS) to compare the health status of blacks born in the United States, Africa, the West Indies, and Europe to that of U.S.-born whites. The analysis focuses on three measures of health (self-rated health, activity limitation, and limitation due to hypertension) to determine whether the black immigrant advantage applies to black immigrants broadly, or is largely driven by one or more groups. The analysis also examines the extent to which the health advantage erodes with increased acculturation to the United States. METHODS To examine diversity in the health status of black Americans, we draw on merged data from the 2000 and 2001 NHIS, an annual multipurpose health survey conducted by the National Center for Health Statistics and Centers for Disease Control and Prevention and administered by the U.S. Census Bureau. NHIS uses a multistage, stratified, cluster design to oversample the black and Hispanic populations and to obtain a nationally representative sample of the noninstitutionalized civilian population. The U.S. Census Bureau conducts face-to-face interviews in a nationally representative sample of households, collecting information about the health and other characteristics of each member of the household. Sample The combined sample for 2000–2001 consists of 77,565 households, which yielded 201,379 persons in 78,897 families. The 2000 and 2001 questionnaires are the first to include a question on the region of birth, which categorizes all respondents into one of the twelve categories depending on their country of origin.6 The analyses are based on non-Hispanic respondents ages 18 and above in the following categories: U.S.-born whites (n = 85, 707), U.S.-born blacks (n = 16, 891), and foreign-born blacks (n = 2, 015). Of the foreign-born 6 The

categories are the United States; Mexico/Central America/ Caribbean Islands; South America; Europe; Russia (USSR); Africa; Middle East; Indian subcontinent; Asia; SE Asia; Elsewhere (including Canada); and Unknown (includes refused, don’t know, foreign-born but country not provided, and stopped answering).

Black Immigrant Health blacks, 66.7 percent (n = 1, 343) were born in the Caribbean/Central America/Mexico (hereafter West Indies); 21.2 percent (n = 427) were born in Africa; 3.1 percent (n = 62) were born in Europe, and 9.0 percent (n = 183) have unknown birthplaces and are not included in the analysis.7

207 in household), and an estimate of degree of assimilation based on proxies (duration of U.S. residency and U.S. citizenship). In the analysis, region of birth is included in Model 1 as a baseline measure, and changes in the coefficients from Model 1 to Model 2 will help explain differences in health of U.S.- and foreign-born blacks compared to U.S.-born whites.

Variables and Analytic Strategy RESULTS The dependent variables include three measures of health status: self-rated health, activity limitation, and limitation due to hypertension. Self-rated health is assessed with a single item that asks, “Would you rate your health as excellent, very good, good, fair, or poor?” This item which captures several dimensions of health status, has been shown to have high validity and reliability, and is highly predictive of mortality (11). As the subjective assessments of health may vary across ethnic groups, we also include more objective measures of activity limitation and limitation due to hypertension. The former is asked a single question, “Are you limited in any way in any activities because of physical, mental, or emotional problems?” and the latter asks if there are limitations due to hypertension (12). Hypertension is also useful to include because it represents an anomaly among black immigrants, with foreign-born blacks experiencing higher risks of hypertension than U.S.-born whites (8). The analysis consists of logistic regression models that compare U.S.- and foreign-born blacks to U.S.-born whites on these three outcomes. We dichotomize the dependent variables into “fair/poor” health, “any activity limitation,” and “any limitation due to hypertension.” We also adjust for several social, demographic, and immigrant characteristics typically thought to influence health.8 These include measures of socioeconomic status (educational attainment, family poverty status, insurance coverage, employment status), demographic factors (age, gender, metropolitan residence, region of U.S. residence), family characteristics that tap family size and social support (marital status and number of persons 7 Internal

analyses from NHIS staff reveals that the “unknown” category includes responses of “don’t know,” “refused,” “stopped responding,” and “not born in the U.S., country not provided.” 8 Adult health behaviors, such as smoking and drinking, are only measured in the sample adult file of the NHIS, which contains too few cases of black immigrants to examine differences in their health by region of origin. Therefore, adult health behaviors are not included in the analyses.

Table I displays our regression results and Figs. 1–3 summarizes our findings. The figures also illustrate the utility of examining the differences in black immigrant’s health by their region of birth rather than combining all foreign-born blacks into one category (i.e., the standard categorization in research on black immigrants). As seen in Table I, U.S.-born blacks have significantly poorer self-rated health, higher odds of activity limitation, and higher odds of limitation due to hypertension compared to U.S.-born whites. These differences remain even after adjusting for differences in factors such as socioeconomic status, sex, and age. The results for foreign-born blacks are more varied by region of birth and health status measure. In stark contrast to U.S.-born blacks, African-born blacks fare better than U.S.-born whites on all three measures of health status. They have a 36% lower odds of reporting “fair/poor” health, 66% lower odds of reporting activity limitation, and equal odds of reporting limitation due to hypertension. West Indianborn blacks fare slightly worse than African-born blacks, reporting worse self-rated health (41% higher odds of reporting “fair/poor” health) than U.S.-born whites and more limitations due to hypertension (twice as likely) but lower odds of activity limitations (22% lower odds). European-born blacks do the least well compared to U.S.-born whites. They are nearly four times as likely to report “fair/poor” health and six times more likely to be limited due to hypertension. They are also more likely to be limited in their activities, but the coefficient is not statistically significant. Despite the small sample size of European blacks, it is worth noting that the odds ratios for self-rated health and limitation due to hypertension are highly significant. In analysis not shown here, we also find that black immigrants differ significantly from each other, with Africans experiencing the best health, followed by West Indians, and Europeans. In short, the

208

Read, Emerson, and Tarlov Table I. Odds Ratios for the Effects of Region of Origin on the Health Status of U.S. Blacks and Whites (n = 109, 079) Self-rated health

Group origin (U.S.-born whites)a U.S.-born blacks Foreign-born blacks: Africa West Indian Europe Education (less than high school)a High school graduate Some college Bachelor’s degree or higher Employed Family income <$20,000 per year Not insured Citizenship/U.S. duration (Citizen, in U.S. 5 years or more)a Citizen, In U.S. less than 5 years Non-citizen, In U.S. less than 5 years Non-citizen, In U.S. 5 years or more Background factors Female Marital status (married)a Never married Divorced/widowed/separated Living with partner/other Number of persons in household Non-metropolitan residence Region (south)a Northeast Midwest West Age in years Constant Nagelkerke R2

Activity limitation

Hypertension limitation

Model 1

Model 2

Model 1

Model 2

Model 1

Model 2

1.879∗∗

1.709∗∗

1.219∗∗

1.103∗∗

2.648∗∗

2.557∗∗

.281∗∗ .923 1.576+

.636∗ 1.408∗∗ 3.693∗∗

.138∗∗ .448∗∗ .709

.336∗∗ .783∗ 1.448

1.000∗∗ .819 2.263

1.000∗∗ 2.145∗∗ 6.253∗∗

.122∗∗ .014

.602∗∗ .503∗∗ .273∗∗ .314∗∗ 1.820∗∗ 1.017∗∗

.679∗∗ .684∗∗ .458∗∗ .225∗∗ 1.809∗∗ .738∗∗

.703∗∗ .690∗∗ .405∗∗ .167∗∗ 1.806∗∗ .698∗∗

1.207 .627∗∗ .763∗

1.027 .560∗∗ .704∗∗

.029 .160∗∗ .643+

.867∗∗

.816∗∗

.987

.824∗∗ 1.094∗∗ 1.152∗∗ 1.029∗∗ 1.156∗∗

1.365∗∗ 1.690∗∗ 1.317∗∗ .951∗∗ 1.299∗∗

.753∗∗ 1.232∗∗ 1.116 .996 1.391∗∗

.715∗∗ .847∗∗ .886∗∗ 1.025∗∗ .104∗∗ .243

.933∗∗ 1.194∗∗ 1.315∗∗ 1.024∗∗ .140∗∗ .294

.638∗∗ 1.113∗ .860∗ 1.028∗∗ .007∗∗ .222

.180∗∗ .003

.015∗∗ .020

a Adjusted

for age, sex, socioeconomic status, family characteristics, U.S. region, metropolitan residence, duration of U.S. residency, and citizenship status. + p ≤ .10; ∗ p ≤ .05; ∗∗ p ≤ .01.

apparent black immigrant health “advantage” noted by other researchers is in good part due to African immigrants (2). Figures 1–3 provide a visual illustration that the superior health of foreign-born blacks varies by health status measure and by region of birth. As a group, foreign-born blacks are more likely to rate their health as “fair or poor” compared to U.S.-born whites (Fig. 1); however, this is only true for West Indian and European black immigrants. African immigrants, on the other hand, are significantly healthier. In terms of activity limitation, the health advantage of foreign-born blacks is reserved for African and West Indian immigrants, with Europeans faring less well (Fig. 2). Based on prior studies (8), we expected foreign-born blacks to have higher rates of

limitation due to hypertension than U.S.-born whites, and we find that this is largely the case (Fig. 3). However, it is worth noting that African immigrants do not differ from U.S.-born whites.

DISCUSSION AND CONCLUSION To our knowledge, this is the first study to use nationally representative data to examine heterogeneity in the health status of black Americans. Not surprisingly, we find that the health status of U.S.born blacks is far below that of U.S.-born whites, which follows a long tradition of research on racial disparities in U.S. health. Importantly, we find that the health profile of recent black immigrants to the

Black Immigrant Health

209

Fig. 1. Self-rated health for U.S.- and foreign-born Blacks compared to U.S.-born whites, NHIS 2000–2001 (adjusted for age, sex, socioeconomic status, family characteristics, U.S. region, metropolitan residence, duration of U.S. residency, and citizenship status. ∗ p < .05, ∗∗ p < .01).

Fig. 3. Limitation due to hypertension for U.S.- and foreign-born blacks compared to U.S.-born whites, NHIS 2000–2001 (adjusted for age, sex, socioeconomic status, family characteristics, U.S. region, metropolitan residence, duration of U.S. residency, and citizenship status. ∗ p < .05, ∗∗ p < .01).

United States varies with their region of origin and health status measure. In general, compared to white Americans, black emigrants from African nations report superior health, West Indies nations report approximately equal health, and European nations report poorer health. The results remain even after adjustments for demographic, socioeconomic, family, assimilation, and geographic factors, suggesting that the nation of origin and majority-minority status within that nation exert an independent effect on the health of Black immigrants in the U.S. This finding is similar to previous studies that suggest lifelong minority status contributes to black American’s disadvantage (13).

There are several explanations for the differential health of the various black immigrant groups. Most notably, a selection based on who emigrates from where might account for our findings. The principal argument for selective migration is that persons who immigrate are those who are more likely to recoup the costs of the journey, and health is one important component of this calculation. The costs of the journey to the U.S. are likely to be substantially higher from Africa, not simply because of the higher transportation costs, but even more because immigrant networks that can assist with resettlement are less established from African compared to West Indian sending areas. The United States also likely has more control over immigration flows from Africa. West Indians are more likely than Africans to be able to use family re-unification visa categories, while Africans are more likely to use educational and occupational categories. Another selection-related argument would be that the health ordering among black immigrants may simply reflect the inverse of the per capita income of the originating region, because the poorer the region, the more selective is the opportunity to migrate. An alternative explanation for our findings builds on prior work that notes the deleterious effects of lifelong minority status on health (13). Specifically, the racial context of origin (minority vs. majority) may contribute to differential health among black immigrants—what matters is the experience of being a racial majority or a minority in one’s region of origin. For U.S.-born blacks, the reference location is the United States. For black immigrants, the

Fig. 2. Activity Limitation for U.S.- and foreign-born blacks compared to U.S.-born whites, NHIS 2000–2001 (adjusted for age, sex, socioeconomic status, family characteristics, U.S. region, metropolitan residence, duration of U.S. residency, and citizenship status. ∗ p < .05, ∗∗ p < .01).

210 reference location is their region of origin, usually either Africa, the Caribbean (West Indies), or Europe. If racial context in the nation of origin matters, this has serious implications for population health in the United States because black immigrants and their children from all origins will eventually resemble U.S.-born blacks, as their racial contexts shift from abroad to the United States. In turn, this will expand the already large U.S. black-white health gap. There are several pathways through which racial context of origin may influence the health status of black Americans. First, racial context of origin may affect health through exposure to stressful events, such as discrimination, that accumulate over the life course and heighten allostatic load (14, 15). Social epidemiologists have shown that early life experiences, especially subdesirable ones such as discrimination, become permanently embedded and have negative consequences in all phases of human development (16). Likewise, positive early life experiences may result in greater resilience and better health over the life course. Racial identity formation is another early life experience that may link racial context of origin to health outcomes. For racial minorities, the conflict between identity and the developing reality of adulthood—that one’s aspirations are often unachievable because of one’s racial category—has negative consequences for both physical and mental health (17).

Limitations Despite multiple measures of health, this study relied on self-declared health status. This raises the possibility of variation in responses due to cultural variation rather than to actual health differences. This is an unlikely possibility, however, as an extensive validity literature across cultures finds that very little variation is due to cultural differences. Due to data limitations, we were unable to assess the role of health behaviors (e.g., smoking) or additional health status measures (e.g., chronic conditions) because these items are only contained in the sample adult file of the NHIS, which contains too few cases of black immigrants by region of birth for analysis. For example, there are only 12 African blacks in the 2000 sample adult file, and only 11 in the 2001 file. Similarly, data limitations required us to analyze regions instead of nations in order to protect the anonymity and confidentiality of the respondents. Regional data is limiting because we cannot

Read, Emerson, and Tarlov adequately address selectivity without having background information on the immigrants’ nations of origin. For example, we do not know the general health status of blacks in European countries or West Indian countries because such aggregate data does not exist. We also had a small sample of black European emigrants. When statistically nonsignificant findings were found with this group, we were unable to determine if the sample differences were sampling error or the small sample size. Immigrants in general are more self-efficacious, have better health, and are more capable than the general population of their emigrant nation. These variations have not been measured and could introduce errors in interpretation. As with any nonexperimental design, there is the possibility that there are unrecognized variations that have not been adjusted for and which could introduce selection bias. Finally, the social context of the individuals (such as neighborhood of residence and place of work) in both their nation of origin and their immigrant nation has not been assessed in this study. This limitation must be studied in future work, especially relative to interracial attitudes and the forms of dominance and subordinance.

Public Health and Policy Implications It is known from epidemiologic work that the average health of black Americans of all ages throughout the life course is remarkably below that of most Americans. This is true in relation to reproductive health; infant survival; prevalence of childhood diseases; child success in school; truancy, violence and school dropout; midlife prevalence of chronic diseases especially high blood pressure, and prostate cancer and other chronic diseases; disability related to chronic disease and injury in later life; and life expectancy and death rates from almost all causes throughout the life course. Although some portion of these disparities between black and white Americans can be accounted for by unhealthy habits with respect to alcohol, tobacco, diet, and physical conditioning, and by disparities in medical care factors such as decreased access and poor quality, the largest proportion of variations (disparity) resides in the social determinants of health category. The rising proportion of U.S. Blacks who are first-generation immigrants to the U.S. will affect the demographic, cultural, and health profile of the U.S.black population. Moreover, the superior health of

Black Immigrant Health most black immigrants from Africa and the West Indies is likely to decline as is observable in MexicanAmerican immigrants with longer residence in the U.S. and with the tendency to assimilate and acculturate. These two factors—the rising numbers of black immigrants and the decline in their health with continued residence in the U.S.—will create complex dynamics of demography and health production that will be challenging to the interpretation of census data, to the medical care system, and to public policy formulation. Of overwhelming social and public policy relevance is the need to understand and respond to the decay in health status of immigrants to the U.S. from Mexico, Africa, the Caribbean and elsewhere. The decline in immigrant health with increasing length of U.S. residence, together with the low U.S. ranking in health compared to most other Organization for Economic Cooperation and Development (OECD) member nations provides compelling evidence that American society is a risk factor in the health production equation. We must become more introspective with respect to U.S. social organization and begin to make the course corrections required for more healthful life circumstances. Revisions in medical care will not accomplish that, although the revisions are needed in their own right. Public policies to reduce the wide inequalities in social advantage that have crept into the U.S. society over the past 50 years are required for health’s sake.

Research Horizons Finally, the findings reported here are relevant particularly to a nation that was and continues to be built on immigration. Two findings are worthy of research attention. First, this study has shown that region of origin confers a major health effect on its black citizens who emigrate to the U.S. With caution commanded by the study’s limitations expressed earlier in this section, it seems intuitively compelling to speculate that dominant/subordinate social structures related to race are ordered by a racial subpopulation’s percentage of the total population, at least with regard to emigrant Blacks. As in other research on population health, the specificsocial context within which living takes place imposes a forceful effect on the population’s health. Racial relations/racism is one specific social context, but its role in the lives of the populations reported here was not studied.

211 Second, it appears but has not been demonstrated empirically that the health of black immigrants to the U.S. declines with longer residence and perhaps greater acculturation and assimilation in the U.S. Such a decline in health has been shown to occur in Mexican immigrants to the U.S. Is the progressive decline in health of black and Mexican immigrants to the U.S. due to the stresses of acculturation and the loss of cultural identity, to demeaning social marginalization, to the adoption of unhealthy habits of living, to inadequate medical services, or to other deprivations? Longitudinal cohort studies of health combined with ethnographic studies and social contextual analyses will be advantageous. These issues, together with those referred to in the Public Policy Relevance (PPR) subsection, command research attention.

REFERENCES 1. CDC. Influence of homocide on racial disparity in life expectancy—United States, 1998. J Am Med Assoc 2001; 22:2805–2807. Hyattsville, Maryland: US Department of Health and Human Services, CDC, Morbidity and Mortality Weekly Report. 2. Kington R, Nickens HW: Racial and ethnic differences in health: Recent trends, current patterns, and future directions. In: Smelser N, Wilson WJ, Mitchell F, eds. America Becoming: Racial Trends and Their Consequences, Vol. 2. Washington, DC: National Academy Press; 2001, pp. 253– 310 3. CDC: Racial and Ethnic Approaches to Community Health (REACH 2010): Addressing disparities in health. Hyattsville, Maryland: U.S. Department of Health and Human Services, CDC, Division of Data Services, 2003. Available at http://www.cdc.gov/nccdphp/aag reach.htm 4. Williams DR: Racial variations in adult health status: Patterns, paradoxes, and prospects. In: Smelser N, Wilson WJ, Mitchell F, eds. America Becoming: Racial Trends and Their Consequences, Vol. 2. Washington, DC: National Academy Press; 2001, pp. 371–410 5. Profile of the foreign-born population in the United States and decennial census data. Washington, DC: U.S. Bureau of the Census, 1980, 2001 6. David RJ, Collins JW: Differing birth weight among infants of U.S.-born blacks, African-born blacks, and U.S.-born whites. N Engl J Med 1997; 337(17):1209–1214 7. Pallotto EK, Collins JW Jr, David RJ: Enigma of maternal race and infant birth weight: A population-based study of US-born Black and Caribbean-born Black women. Am J Epidemiol.2000; 151(11(1 June)):1080–1085 8. Singh GK, Siahpush M: Ethnic-immigrant differentials in health behaviors, morbidity, and cause-specific mortality in the United States: An analysis of two national data bases. Hum Biol 2002; 74:83–109 9. Hummer RA, Rogers R, Nam CB, LeClere FB: Race/ ethnicity, nativity, and U.S. adult mortality. Soc Sci Q 1999; 80:136–154 10. Marmot MG, Syme SL: Acculturation and Coronary Heart Disease in Japanese-Americans. Am J Epidemiol 1976; 104:225–247

212 11. Idler E, Angel R: Self-rated health and mortality in the NHANES-I epidemiologic follow-up study. Am J Public Health 1990; 80:446–452 12. NCHS: Data file documentation, National Health Interview Survey, 2000 (machine readable data file and documentation). Hyattsville, Maryland: National Center for Health Statistics, 2002. Available on-line at http://www.cdc.gov/nchs/nhis.htm 13. Collins JW, Wu SY, David RJ: Differing intergenerational birth weights among the descendants of US-born and foreignborn whites and African Americans in Illinois. Am J Epidemiol 2002; 155:210–216

Read, Emerson, and Tarlov 14. McEwen B, Lasley E: The End of Stress As We Know It. Washington, DC: Joseph Henry Press; 2002 15. Greenberg M, Schneider D: Region of birth and mortality of blacks in the United States. Int J Epidemiol 1992; 21:324–328 16. Power C, Hertzman C: Health, wellbeing, and coping skills: In: Keating DP, Hertzman C, eds. Developmental Health and a Wealth of Nations: Social, Educational, and Biological Dynamics. New York: Guilford Press; 1999, pp. 41–63 17. Fang J, Madhavan S, Alderman MH: Influence of nativity on cancer mortality among black New Yorkers. Cancer 1997; 80:129–135