UNNATURAL CAUSES is inequality making us sick? HEALTH EQUITY research topics and resources to learn more
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Race / Racism

Background: More than 100 studies now link racism to worse health. Many people of color experience a wide range of serious health issues at higher rates than do whites, including breast cancer, heart disease, stroke, diabetes, hypertension, respiratory illness and pain-related problems. On average, African Americans, Native Americans, Pacific Islanders and some Asian American groups live shorter lives and have poorer health outcomes than whites. But why?

According to the Centers for Disease Control, African American men die on average 5.1 years sooner than white men (69.6 vs. 75.7 years), while African American women die 4.3 years sooner than white women (76.5 vs. 80.8 years). Vietnamese American and Korean American women suffer some of the highest rates of cervical cancer in the nation; Vietnamese American men die from liver cancer at a rate seven times that of non-Hispanic white men.

Class certainly plays a role. Because of historical discrimination and structural racism, people of color are likely to be less wealthy, to have less education and to live in segregated communities with underfunded schools, insufficient services, poor transportation and housing, and higher levels of exposure to toxic and environmental hazards. A wide body of evidence has shown that wealth predicts health: the higher you are on the class pyramid, the better your health. Every step down corresponds to slightly worse health, from top to bottom. Inequitable distribution of resources helps explain why.

Yet socioeconomic status doesn't account for the whole picture. In many instances, African Americans and other groups fare worse than whites at the same income levels. In fact, infant mortality rates among babies born to college-educated African American women are higher than those of white Americans who haven't finished high school. Recent Latino immigrants, though typically poorer, are healthier than the average American; yet the longer they're here, the more their relative health status declines even as their socioeconomic situation improves. Racism has proven to be a factor affecting health "upstream" and independent of class.

Could there be a genetic reason? Researchers funded by the National Institutes of Health, for example, have spent 40 years and several millions of dollars studying Native Americans in southern Arizona, trying to discover a biological reason for their high rates of Type 2 diabetes. Yet their findings remain inconclusive. Hypotheses like the "salt retention gene" explanation for high rates of hypertension among African Americans have also long been debunked scientifically, although they continue to hold currency in the popular press and public imagination.

In fact, studies comparing birth outcomes among white and Black American women showed that more low birth-weight babies are born to African Americans, but birth outcomes among white Americans and African-born immigrants to America were comparable. Moreover, the daughters of the African immigrants gave birth to low birth-weight babies at the same rate as African Americans.

One risk factor researchers are investigating is how the lived experience of racism can increase chronic stress levels and thus worse health among people of color. According to their thinking, addressing unequal birth outcomes, for example, requires more than just better prenatal care; it also requires that we change the social conditions that produce negative experiences over a lifetime. African Americans have among the worst hypertension rates not because of their genes but because of difficulties they face in their lives.

As sociologist Troy Duster explains, the impact of race on disease is not biological in origin but in effect. Anxiety, anger, or frustration from racist experiences trigger the body's stress response, which over time, creates wear and tear on the body's organs and systems. Dr. Camara Jones, a leading expert on racism and health at the Centers for Disease Control, puts it this way: "It's like gunning the engine of a car, without ever letting up. Just wearing it out, wearing it out without rest. And I think that the stresses of everyday racism are doing that." Dr. Jones and others are studying three kinds of racism - institutional, interpersonal and internalized - and how each contributes to health.

Whether it takes the form of overt discrimination or structural disadvantage, racism continues to influence how people are treated, what resources and jobs are available, where we are likely to live, how we perceive the world and our place in it, what environmental exposures we face, and what chances we have to reach our full potential. Important policies to address racism and its impact on health include more equitable school funding, better enforcement of anti-discrimination laws, housing mobility programs, better transportation, affirmative action, tax policy and land use, as well as economic revitalization, business investment and wealth accumulation in communities of color.

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Image Thumbnail Race, Racial Inequality, and Health Inequities: Separating Myth from Fact (pdf) E-mail to a friend
ARTICLE by Brian Smedley, Michael Jeffries, Larry Adelman and Jean Cheng

This paper, prepared by staff at The Opportunity Agenda and California Newsreel, provides background, statistics, and theoretical frameworks to help the reader better understand the role that "race" plays in health inequities. Evidence is presented that discounts popularly accepted genetic explanations and supports theories of socially-based factors.

Image Thumbnail Race, Racism and the Practice of Epidemiology E-mail to a friend
SCHOLARLY ARTICLE by Camara Phyllis Jones, American Journal of Epidemiology, 2001

This commentary explores the meanings of race, particularly with regard to the practice of epidemiology. The author asserts that race is a contextual variable, not a
characteristic of an individual person. Examining the five uses of race discussed by Kaufman and Cooper elsewhere in the same publication, she raises a larger issue about which questions get asked when race-associated differences in health outcomes are under scrutiny. The author concludes by asking readers to consider underlying causes and suggests eight recommendations for practice.

Image Thumbnail Race, racism, and racial disparities in adverse birth outcomes E-mail to a friend
Clinical Obstetrics and Gynecology

The chronic stress of racism and the social inequality it engenders may be underlying social determinants of persistent racial disparities in health, including infant mortality, preterm delivery, and low birth weight. This article describes the problem of racial disparities in adverse birth outcomes; outlines the multidimensional nature of racism and the pathways by which it may adversely affect health; and discusses the implications for clinical practice.

Image Thumbnail Race, Stress, and Social Support: Addressing the Crisis in Black Infant Mortality E-mail to a friend
REPORT by Fleda Mask Jackson, from the Health Policy Institute, 2007

This background paper examines the impact of stress and stress mediators on pregnancy outcomes for African American women. The report also examines social support and other relational experiences, and makes recommedations for related changes in public policy and maternal and child health practices.

Image Thumbnail Racial and Ethnic Disparities in Birth Outcomes: A Life-Course Perspective E-mail to a friend
SCHOLARLY ARTICLE by Michael Lu, MD, Journal of Maternal Child Health, 2003

Learn more about Dr. Michael Lu’s “life-course perspective”
(Abstract only)

Image Thumbnail Racial and Ethnic Disparities in Women's Health Status (pdf) E-mail to a friend
PRESENTATION TRANSCRIPT, Carol J. Rowland Hogue, PhD, MPH, Maternal and Child Health Leadership Conference, April 2003

Hogue eloquently describes the prevalence and effects of racism and poverty on a wide variety of health issues, and makes a case for better social supports. This links to a pdf of the transcript. The talk is also available on the conference website in HTML, along with an audio recording, and Hogue's slides.

Image Thumbnail Racial Categories in Medical Practice: How Useful Are They? E-mail to a friend
ARTICLE by Lundy Braun, Anne Fausto-Sterling, Duana Fullwiley, Evelynn M Hammonds, Alondra Nelson, William Quivers, Susan M Reverby, and Alexandra E Shields, PLoS Med. 2007 September; 4(9): e271.

Is it good medical practice for physicians to consider race when making a diagnosis or conducting research? How should they do this? The existence of health disparities suggests the need for race-based data, yet "racial profiling" in medicine - assuming there's an underlying biological basis for race - can lead to incorrect, even fatal judgments. This article discusses the complex history of socially constructed U.S. racial categories and offers suggestions for how to improve outcomes and avoid pitfalls.

Image Thumbnail Racial differences in birth outcomes: the role of general, pregnancy, and racism stress E-mail to a friend
Health Psychology

This study examined the role of psychosocial stress in racial differences in birth outcomes.  Perceived racism and indicators of general stress were correlated with birth weight and tested in regression analyses. In the sample as a whole, lifetime and childhood indicators of perceived racism predicted birth weight and attenuated racial differences, independent of medical and sociodemographic control variables. Models within each race group showed that perceived racism was a significant predictor of birth weight in African Americans, but not in non-Hispanic Whites.

These findings are among the first to indicate the significance of psychosocial factors that occur early in the life course for these specific health outcomes.

Image Thumbnail Racial Residential Segregation: A Fundamental Cause of Racial Disparities in Health (pdf) E-mail to a friend
SCHOLARLY ARTICLE by David R. Williams and Chiquita Collins, Public Health Reports, 2001

The authors review evidence that suggests that segregation is a primary cause of racial differences in socioeconomic status (SES) by determining access to education and employment opportunities. SES in turn remains a fundamental cause of racial differences in health. Segregation also creates conditions inimical to health in the social and physical environment. The authors conclude that effective efforts to eliminate racial disparities in health must seriously confront segregation and its pervasive consequences.

Image Thumbnail Racial/Ethnic Discrimination and Health: Findings from Community Studies E-mail to a friend
SCHOLARLY ARTICLE by David Williams et al., American Journal of Public Health, 2003

This review of available empirical evidence from population-based studies of the association between perceptions of racial/ethnic discrimination and health indicates that discrimination is associated with multiple indicators of poorer physical and, especially, mental health status. However, current research does not adequately address whether and how exposure to discrimination leads to increased risk of disease. Research on stress points to important directions for future research on mechanisms by which discrimination can lead to changes in health.

Image Thumbnail Racialized Medical Genomics: Shiny, Bright and Wrong E-mail to a friend
ARTICLE by Robert Wallace, Department of Biology at the City College of New York

Several writers have recently claimed that new genomics findings demonstrate that race is biologically real after all, perhaps most notably Armand Marie Leroi's New York Times op-ed of March 14, 2005. This excellent article by Robert Wallace disputes that assertion.

Image Thumbnail Racism and Health: A Presentation by David Williams E-mail to a friend
David R. Williams, Professor of Public Health, Harvard University

These slides by David R. Williams, Norman Professor of Public Health, Harvard University, demonstrate evidence of the pathways by which racism, especially residential segregation, shapes health outcomes.

Image Thumbnail Racism and Racial Discrimination in the U.S. (PDF) E-mail to a friend
REPORT from the Center for Social Inclusion, June 2008

To support the U.S. 2008 visit of the UN Special Rapporteur on Contemporary Forms of Racism, Racial Discrimination, Xenophobia and Related Intolerance, CSI provided an analysis of the ways in which U.S. policies perpetuate racialized poverty and fail to meet our international obligations to end racial discrimination.  CSI examined public policy in light of our treaty obligations under the International Convention on the Elimination of All Forms of Racial Discrimination (CERD), which commits the United States to take concrete steps to combat racism, and to submit regular progress reports on its efforts.
Highlighting the connections between human rights and the structural racism approach, the report tries to illuminate how "federal policy impacting housing, education and transportation have the effect of exacerbating concentrated poverty in communities of color, and ensuring that racial discrimination is perpetuated, rather than eliminated."

Image Thumbnail Racism and Stress: A Partial Bibliography E-mail to a friend

Alan Zaslavsky put out a request for studies on racism and stress in April 2010 on the Spirit of 1848 listserv.  This bibliography is a list of the studies suggested to him.

Image Thumbnail Racism's Hidden Toll E-mail to a friend
MAGAZINE ARTICLE, Miller McCune, June 2009

In profiling researcher Arline Geronimus and the development of her weathering hypothesis, this article lays out evidence for the relevance of racism and other social factors for understanding population health, particularly in the example of teen pregnancies in low-income Black communities. Could serve as an introduction to the topic for those new to health equity ideas.

Image Thumbnail Recommendations for the Prevention and Wellness Funds (pdf) E-mail to a friend
POLICY MEMO from PolicyLink and Prevention Institute, April 2009

This memo offers recommendations for targeting Prevention and Wellness recovery funds to maximize the health and equity benefits in the Recovery Act of spring 2009. It makes the case that prioritizing disease prevention – particularly among the most impacted communities – is imperative to strengthening the nation. It makes specific recommendations for using funds to
- Build upon and leverage existing prevention initiatives;
- Promote equity by targeting America’s low-income communities and communities of color;
- Target multi-disciplinary strategies focused on environmental change;
- Develop the health workforce to effectively shape and implement prevention efforts; and
- Advance a vision of healthy people, healthy places.

Image Thumbnail Reducing Inequities in Health and Safety through Prevention (pdf) E-mail to a friend
POLICY MEMO from Prevention Institute and the Health Policy Institute of the Joint Center for Political and Economic Studies, January 23, 2009

Advancing health equity to ensure all Americans have the opportunity to lead healthy lives should be a priority. We have an opportunity to do so in a way that alleviates pressure on the health system and saves money. This memo was developed in January '09 to provide background and recommendations for developing a comprehensive, prevention-oriented strategy for acheiving health equity.

Image Thumbnail Reducing Racial and Social Inequalities in Health: The Need for a New Approach E-mail to a friend
SCHOLARLY ARTICLE by S. Leonard Syme, Health Affairs 2008

It is well known that people in racial and ethnic minority groups and in lower social-class positions have higher morbidity and mortality rates from virtually every disease. To effectively deal with the problem, we will need to adopt a more appropriate conceptual model that focuses on the fundamental determinants of health, we will need to understand how important this is for all Americans as a society, and we will need to better deal with the issues people care about: their children, homes, jobs, safety, education, families, retirement, and future prospects.

Abstract only. Subscription required to read full text.

Image Thumbnail Report of the National Expert Panel on Social Determinants of Health Equity: Recommendations for Advancing Efforts to Achieve Health Equity E-mail to a friend

This report encapsulates the critical thinking, key arguments and recommendations of nationally  recognized experts in the area of social determinants of health equity.  A principle thesis of the Expert Panel is that the inequitable distribution of resources needed for health is the major contributor to persistent health inequities.  These experts called to account conditions and processes, including class disadvantage and racism, that prevent many Americans from enjoying the health and long life that affluent and privileged citizens take for granted.  Many of the strategies for addressing social determinants of health equity fall outside current public health practice but not outside the profession’s historic role in public policy decisions that promote social justice.

Image Thumbnail Richmond California Struggles for Clean Air E-mail to a friend

Community activist Torm Nompraseurt leads a "toxic tour" of Richmond, California where high levels of industrial pollution are wreaking havoc on the health and wellbeing of residents.

Image Thumbnail Social Exclusion Knowledge Network E-mail to a friend
WEB SITE by the WHO Commission on the Social Determinants of Health

This Knowledge Network (KN) examines the relational processes that lead to the exclusion of particular groups of people from engaging fully in community/social life. These processes may operate at: the macro-level (access to affordable education, equal employment opportunity legislation, cultural and gender norms), and/or the micro-levels (income, occupational status, social networks - around race, gender, religion). The network also examines the linkages between social exclusion and proximal concepts such as social capital, networks and integration.

Image Thumbnail Sorting People: Can You Tell Someone's Race by Looking at Them? E-mail to a friend
INTERACTIVITY from RACE: The Power of an Illusion, 2003

How easy is it to group people into “races” based on appearance? What about using individual traits? Does everybody classify the same way?

Try your hand at "sorting" individuals and see if it matches how people think of themselves. Or explore how we might sort people by physical traits.

Image Thumbnail Still Toxic After All These Years: Air Quality and Environmental Justice in the San Francisco Bay Area (pdf) E-mail to a friend
REPORT by the Center for Justice, Tolerance, & Community, UC Santa Cruz

From West Oakland's diesel-choked neighborhoods to San Francisco's traffic-snarled Mission District to the fenceline communities abutting Richmond's refineries, poor and minority residents of the San Francisco Bay Area get more than their share of exposure to air pollution and environmental hazards, this report finds.

Image Thumbnail Strategic Review of Health Inequalities in England Post 2010 E-mail to a friend

Professor Sir Michael Marmot has been asked by the British government to Chair an independent Review to propose the most effective strategies for reducing health inequalities in England from 2010. This review is a response to the recommendation of the WHO Commission on Social Determinants of Health that national governments develop and implement strategies and policies suited to their particular national context aimed at improving health equity.

Image Thumbnail Tackling Health Inequities Through Public Health Practice: Theory to Action E-mail to a friend
BOOK edited by Richard Hofrichter and Rajiv Bhatia

Social justice has always been a core value driving public health. Today, much of the etiology of avoidable disease is rooted in inequitable social conditions brought on by disparities in wealth and power and reproduced through ongoing forms of oppression, exploitation, and marginalization.

Tackling Health Inequities raises questions and provides a starting point for health practitioners ready to reorient public health practice to address the fundamental causes of health inequities. This reorientation involves restructuring the organization, culture and daily work of public health. Tackling Health Inequities is meant to inspire readers to imagine or envision public health practice and their role in ways that question contemporary thinking and assumptions, as emerging trends, social conditions, and policies generate increasing inequities in health.

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