Creating a New Narrative for Health Disparities

It’s becoming more common within public health to discuss health disparity in the context of social determinants of health and moving the national dialogue towards health equity. The groundbreaking 1985 task force on Black and Minority Health brought the reality of health disparity among marginalized groups to a national stage that catalyzed a shift in policies and research to identify the root causes of the health disparities faced among communities of color.[1] While this is a huge step forward, what’s largely missing in this dialogue is the use of language in active form to name the cause and culprit that has lead us to these unacceptably disproportionate rates of suffering. Racism needs to be called out as the act of oppression rather than simply stating that disparities exist by “race.”

Developing a shared definition of racism is necessary to build a basis to begin the conversation of identifying and working to undo racism. Dr. Camara Jones, regarded as a leader in health equity, defines racism as “ a system of structuring opportunity and assigning value based on phenotype (race) that: unfairly disadvantages some individuals and communities; unfairly advantages other individuals and communities.”[2] The existence of “racism” is complex and multifaceted, making it important to identify the different levels of racism and how they manifest in public health. These include:

1) Institutional: macrolevel systems, social forces, institutions, ideologies, and processes that interact with one another to generate and reinforce inequities among racial and ethnic groups[3]

2) Personally-mediated: prejudice and discrimination, where prejudice means differential assumptions about the abilities, motives, and intentions of others according to their race[2]

3) Internalized: acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth.[4]

Institutional racism is linked to various health outcomes ranging from infant mortality, diabetes rates, asthma, and cancer.[3] It is a determining factor in socio-economic status and influences many social determinants of health, including education, income (job access), and environmental health. Segregation laws following Emancipation are an explicit example of how racism was built into systems of policy and have created a ripple effect in diminishing health and quality of life. Redlining, the legal practice of loan discrimination and house sales based on race created concentrated regions of poverty, lowered access to quality education and food. Urban development can reflect the value, or devaluation, of specific communities. The industrialization of the Duwamish river valley is a local example, having strong impact on the disproportionate rates of asthma and lower life expectancy among South Park residents.[5] Hurricane Katrina and the water contamination in Flint are other examples of how systems of racism determine where people live, how resources are accessed, and how decisions are made.[6] This is why terms like “underserved” feel dismissive to the fact that communities were actively “served under” by people in power who intentionally designed policies and made decisions to keep them down while keeping themselves up.

Interpersonal racism has been the focus of much research and showed up prominently in the Institute of Medicine’s report “Unequal Treatment.”[7] These interpersonal interactions can be further categorized as explicit and implicit bias. The historic norm of explicit bias has become hidden in the shadows of dog whistle commentary and slogans like “Make America Great Again.” Implicit biases are the unconscious beliefs one holds about different groups of people, developed from a young age and often reinforced by social stereotypes. There are numerous studies looking at implicit bias and the role it has in doctor-patient relationships, decision-making, and treatment. As Dr. Camara Jones notes in her TED X Talk on “Allegories on Race and Racism,” people may mean well in their actions but have unintentional negative consequences. This is the real danger of implicit bias; causing harm even when harm was not intended. It has been found that in the same person, explicit and implicit bias can be opposing to each other, yet the implicit bias appears to influence perceptions and choices more than explicit bias.[8] These implicit biases are the result of growing up in white dominant culture that teaches and reinforces that White is superior and valuable, while Black and Brown are disposable and inferior.

Application to Public Health Practice

The role of the public health practitioner is critical to dismantle the racism that exists within the institution of health care. As public health advocates, we can examine policies and systems that have the potential to influence across our communities and the country. Below are several ways health professionals can begin working to dismantle racism within the healthcare system:[9]

1. Learn about and accept the history of the United States based on a racist system of white supremacy and social construct of race to maintain dominance.

2. Establish a common definition of racism and name it when it appears in our workplace, writing, research, and interactions.

3. Examine your own biases, where they come from, and actively work to minimize your implicit and explicit biases.

4. Share stories of resilience and change the narrative from savior complex to dynamic examples of solutions developed by the communities impacted.

5. Organize and strategize with other disciplines to take action in dismantling systems of racism.

References

1. OMH-HecklerReport. 2017. https://www.cms.gov/About-CMS/Agency-Information/OMH/OMH-HecklerReport.html. Accessed September 27, 2018.

2. Levels of racism: a theoretic framework and a gardener’s tale. Am J Public Health. 2000;90(8):1212–1215. doi:10.2105/AJPH.90.8.1212

3. Gee GC, Ford CL. STRUCTURAL RACISM AND HEALTH INEQUITIES: Old Issues, New Directions. Du Bois Rev. 2011;8(1):115–132. doi:10.1017/S1742058X11000130

4. Phyllis Jones C. Going Public. Vol 90.; 2000. https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.90.8.1212. Accessed September 26, 2018.

5. Duwamish Valley Cumulative Health Impacts Analysis: Seattle, Washington.; 2014. http://justhealthaction.org/wp-content/uploads/2013/03/CHIA-EPA-TRI-Conference-DC-May-2014.pdf. Accessed September 27, 2018.

6. Law B, Repository S, Powell JA. Structural Racism: Building upon the Insights of John Calmore.; 2007. http://scholarship.law.berkeley.edu/facpubs. Accessed September 26, 2018.

7. UNEQUAL TREATMENT: WHAT HEALTHCARE PROVIDERS NEED TO KNOW ABOUT RACIAL AND ETHNIC DISPARITIES IN HEALTH-CARE.; 2002. http://www.nationalacademies.org/hmd/~/media/Files/Report Files/2003/Unequal-Treatment-Confronting-Racial-and-Ethnic-Disparities-in-Health-Care/Disparitieshcproviders8pgFINAL.pdf. Accessed September 26, 2018.

8. Chapman EN, Kaatz A, Carnes M. Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities. J Gen Intern Med. 2013;28(11):1504–1510. doi:10.1007/s11606–013–2441–1

9. Hardeman RR, Medina EM, Kozhimannil KB. Structural Racism and Supporting Black Lives — The Role of Health Professionals. N Engl J Med. 2016;375(22):2113–2115. doi:10.1056/NEJMp1609535