Health Disparities Due to Minorities’ Diminished Returns (MDRs)

Dear Colleagues,

Racial disparities exist in almost all aspects of health. Robust health differences between African Americans and Whites have been documented from before birth to end of life. Despite extensive investments to eliminate such disparities, many remain and some have widened over the years.

One of the reasons we have not been able to eliminate the racial gaps in health is that research has traditionally overlooked some of the mechanisms by which daily operations in the US society consistently generate inequality. Only some of health disparities are due to population differences in exposure to risk factors and stressors. Thus, policies that merely equalize access to resources and reduce additional risk factors that impact marginalized populations are not enough.
The social forces that shape gaps between advantaged and disadvantaged groups are beyond group differences in exposure. As we tend to overlook some of the underlying mechanisms that result in inequalities as society operates, the gap between the HAVES and the HAVE NOTS increases. This is the cost of inaction.

What is not well-addressed is that race and ethnicity not only shape access to resources and exposure to risk factors, but also their health effects. Although differential exposure and differential vulnerability both contribute to racial differences in health, the latter is systematically under-studied. Differential exposure suggests that disadvantaged groups are more commonly exposed to environmental risk factors and have less access to resources and buffers that can protect them. That is, differential exposure mediates racial and ethnic differences in health. Differential vulnerability, however, suggests that even equal resources result in unequal outcomes, with marginalized groups being at a systemic disadvantage relative to the dominant group. Based on this hypothesis, some of the worse health outcomes of marginalized groups are due to the fact that their resources generate less tangible health outcomes than the privileged group.

Considerable empirical support exists for the minorities’ diminished returns (MDRs) theory (Assari, 2018). MDRs are well documented for African Americans, Hispanics, and sexual minorities. Regardless of the type of stigmatizing identities, marginalized groups show smaller effects in educational attainment, income, employment, and marital status on tangible health outcomes. Similar patterns are shown for a wide range of outcomes including diet, smoking, drinking, obesity, impulse control, depression, anxiety, mental well-being, self-rated health, health care access, chronic disease, and mortality. For example, high family SES reduces the risk of ADHD, asthma, and obesity and chronic disease in general, but all of these effects are weaker for minority groups.

The exact mechanisms that explain MDRs are still unclear. Some research suggests that discrimination has a role. High SES African Americans are more likely to be close to Whites, which is associated with increased perceived discrimination. It has been shown that African Americans in majority White areas report more discrimination and depression. Another mechanism is more difficult and costly upward social mobility for non-Whites. In other words, even when African Americans climb the social ladder, society does not similarly reward them. The same is true for highly educated African Americans who work in predominantly White workplaces and high income African American kids who go to predominantly White schools. Disparity and inequality in wealth are also major causes.

There are more nuances to be learned regarding MDRs. Major differences can be seen in MDRs between men and women. As mentioned before, some evidence suggests that MDRs are more pronounced for African American men than women. This is probably why some studies have documented worse mental health for high education/high income African American men and boys in the US. It is, however, unknown why MDRs are more pronounced for African American men than women, both in children, adults, and older adults. In one study, high educational attainment reduced the distress of African American women but not African American men. Other studies have documented worse mental health for high SES African American men, a pattern which was not shown for African American women. In this view, high SES becomes a risk factor for depression. Gendered racism may play some role in more pronounced MDRs for African American men.

These MDRs have several major health implications. First, as disparities are generated by how society operates and distributes opportunities, the solutions do not lie within the health care system but in reducing inequality in the performance of all aspects of the society, such as education, labor market, and policymaking. That is, some of the health disparities are not generated because of bad intentions on the part of policymakers or people in power but simply because of the fact that the rich get richer and the poor get poorer. This means inaction will result in widening gaps. Second, merely focusing on socioeconomic resources may not be enough to eliminate health disparities. Third, universal interventions that only focus on access will not eliminate health disparities. In fact, the universal enhancement of SES may unintentionally increase the gaps across social groups. Fourth, some disparities are not due to socioeconomic status but due to the social processes that are associated with being a member of a racial category. These are, in part, due to the legacy of slavery, residential segregation, deep inequalities in the quality of education, differential policing, the war on drugs, etc. All of these can be seen as structural and institutional racism. Fifth, racial disparities are larger, rather than smaller, in the highest SES strata. Finally, policymakers should be aware that many policies have less than expected effects across underserved and disadvantaged groups. As a result, policy evaluations should always consider the possibility that a well-intended policy may widen the health gap, by better serving the privileged groups.

The MDRs may be considered a paradigm shift in our approach to health disparities and social justice policy making. It widens our view from the traditional focus on poverty and lack of resources to address racism and other social processes that hinder non-White populations. Such a change in conceptualizing health disparities changes how we set policies to fight inequalities. It reminds us that we cannot eliminate health disparities without tackling the unfair daily processes that are embedded in the fabric of US society and consistently and intentionally generate inequalities and disparities.

The MDRs also advocate for health promotion approaches that consider context. The MDRs view tailored and targeted programs as superior to universal programs and interventions, suggesting that effective programs should address the specific needs of sub-populations that reduce their chance of benefiting from those programs and turning them into tangible outcomes. Employment and training programs that help racial and ethnic minorities secure high paying jobs should also help them perform well in their high demanding jobs. Parallel programs should reduce workplace discrimination through education and enforcing anti-discriminatory laws in the workplace.

The Special Issue "Health Disparities Due to Minorities Diminished Returns (MDRs)" invites state-of-the-art original and review articles that are written on MDRs and their implications for health disparities. Potential areas of interest include but not limited to: 1) studies that deconstruct the differential effects of differential exposure; 2) studies that test how differential effects or exposure mediate or moderate health disparities; 3) studies on health disparities due to the additive and multiplicative effects of marginalizing social identities (e.g. race, ethnicity, gender, class, etc.); 4) studies focusing on male gender and high SES as sources of vulnerability; 5) studies that evaluate tailored interventions for sub-populations; 6) studies that use large national data sets or registries; 7) studies on the life course aspect of MDRs using longitudinal design; 8) studies on the transgenerational aspects of MDRs; 9) studies using an intersectionality approach; 10) studies on conceptual and theoretical aspects of MDRs; 11) studies that advance measurement and methodologies related to investigating group differences; 12) studies that advance the current MDR literature to other groups or countries; 13) studies that conduct meta-analysis or systemic reviews on MDRs; and 14) studies that provide policy solutions to minimize MDRs.

Dr. Shervin Assari
Guest Editor

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