Chapter 12 The social determination of ethnic/racial inequalities in health James Y. Nazroo and David R. Williams 12.1 Introduction Differences in health across ethnic groups, in terms of both morbidity and mortality, have been repeatedly documented in the US (Department of Health and Human Services 1985; Rogers 1992; Sorlie et al. 1992, 1995; Rogot et al. 1993; Krieger et al. 1993; Davey Smith et al. 1998; Pamuk et al. 1998; Williams 2001), the UK (Marmot et al. 1984; Rudat 1994; Harding and Maxwell 1997; Nazroo 1997a,b, 2001; Erens et al. 2001), Latin America (Pan American Health Organization 2001), South Africa (Sidiropoulos et al. 1997), Australia (McLennan and Madden 1999), and elsewhere (Polednak 1989). However, the factors underlying such differences remain contested. In particular, the significance of social determinants, particularly the social inequalities that ethnic minority groups face, remains the subject of considerable debate. Some claim that social and economic inequalities make a minimal, or no, contribution to ethnic inequalities in health (Wild and McKeigue 1997); others suggest that even if they do contribute, the cultural and genetic elements of ethnicity must also play a role (Smaje 1996); and others argue that ethnic inequalities in health are predominantly determined by socio-economic inequalities (Navarro 1990; Sheldon and Parker 1992). In part, the ongoing debate about the significance of social inequalities to ethnic dif- ferences in health is a consequence of the empirical complexity of the field, both in terms of the difficulties of undertaking research and the sometimes poor quality data that result, and in terms of the difficulty of interpreting findings. Take, for example, Table 12.1, which shows infant mortality rates for Black and white mothers in the US stratified by mother’s educational status. The table shows that infant mortality rates are strongly patterned by education for both Black and white women, with increasing years of education predicting lower levels of infant mortality. However, there is an eth- nic/racial difference in mortality rate at each educational level, with the Black/white ratio for infant mortality increasing with level of education. And, the most disadvan- taged group of white women (those who have not completed high school) have a lower infant mortality rate than the most advantaged group of Black women (college gradu- ates). How are such data to be interpreted? Which other explanations may be relevant? 12-Marmot-Ch12.qxd 29/7/05 5:16 PM Page 238