Naming and Measuring the Impacts of Racism on Health Camara Phyllis Jones, MD, MPH, PhD Research Director on Social Determinants of Health Emerging Investigations

Naming and Measuring the

Impacts of Racism on Health

Camara Phyllis Jones, MD, MPH, PhDResearch Director on Social Determinants of Health

Emerging Investigations and Analytic Methods BranchDivision of Adult and Community Health

National Center for Chronic Disease Prevention and Health Promotion

Centers for Disease Control and Prevention

Why discuss racism?

• To eliminate racial disparities in health, need examine fundamental causes– “Race” is only a rough proxy for SES,

culture, or genes– “Race” precisely measures the social

classification of people in our “race”-conscious society

• Hypothesize racism as a fundamental cause of racial disparities in health

What is racism?

A system

What is racism?

A system of structuring opportunity and assigning value

What is racism?

A system of structuring opportunity and assigning value based on the social interpretation of phenotype (“race”)

What is racism?

A system of structuring opportunity and assigning value based on the social interpretation of phenotype (“race”)– Unfairly disadvantages some

individuals and communities

What is racism?

A system of structuring opportunity and assigning value based on the social interpretation of phenotype (“race”)– Unfairly disadvantages some

individuals and communities– Unfairly advantages other individuals

and communities

What is racism?

A system of structuring opportunity and assigning value based on the social interpretation of phenotype (“race”)– Unfairly disadvantages some individuals

and communities– Unfairly advantages other individuals and

communities– Saps the strength of the whole society

through the waste of human resources

Levels of racism

• Institutionalized• Personally-mediated• Internalized

Institutionalized racism

• Differential access to the goods, services, and opportunities of society, by “race”

• Examples– Housing, education, employment, income– Medical facilities– Clean environment– Information, resources, voice

• Explains the association between SES and “race”

Personally-mediated racism

• Differential assumptions about the abilities, motives, and intents of others, by “race”

• Prejudice and discrimination• Examples

– Police brutality– Physician disrespect– Shopkeeper vigilance– Waiter indifference– Teacher devaluation

Internalized racism

• Acceptance by the stigmatized “races” of negative messages about our own abilities and intrinsic worth

• Examples– Self-devaluation– White man’s ice is colder– Resignation, helplessness, hopelessness

• Accepting limitations to our full humanity

Levels of Racism:

A Gardener’s Tale

Institutionalized racism

• Initial historical insult

• Structural barriers• Inaction in face of

need• Societal norms• Biological

determinism• Unearned privilege

Personally-mediated racism

• Intentional• Unintentional• Acts of

commission• Acts of omission• Maintains

structural barriers• Condoned by

societal norms

Internalized racism

• Reflects systems of privilege

• Reflects societal values

• Erodes individual sense of value

• Undermines collective action

Who is the gardener?

• Power to decide• Power to act• Control of

resources

Dangerous when• Allied with one

group• Not concerned with

equity

“Reactions to Race” module

Piloted on 2002 Behavioral Risk Factor Surveillance System by:

CaliforniaDelawareFloridaNew HampshireNew MexicoNorth Carolina

Question 1

How do other people usually

classify you in this country?

Would you say White, Black or African

American, Hispanic or Latino, Asian, Native

Hawaiian or Other Pacific Islander, American

Indian or Alaska Native, or some other group?

Two measures of “race”

White22,417

Black2,198

Hispanic2,694

White 95.2 0.9 3.0

Black 0.2 93.4 1.0

Hispanic

3.0 2.2 93.4

. . . 1.6 3.5 2.6

How

self-i

den

tify

How usually classified by others

Two measures of “race”

White Black Hispanic . . .

White21,658

98.6 0.1 0.4 0.9

Black2,197

1.6 93.5 1.2 3.7

Hispanic

3,39820.0 1.4 74.0 4.6H

ow

self

-id

en

tify


General health status

Would you say that in general your health is:

– Excellent– Very good– Good– Fair– Poor

020

4060

8010

0

39.4

55.1

63.1

perc

ent

of r

espo

nden

ts

Report excellent or very good healthHispanic-Hispanic Hispanic-White White-White

General health status, by self-identified and socially-assigned "race"

020

4060

8010

0

39.4

55.1

63.1

perc

ent

of r

espo

nden

ts

Report excellent or very good healthHispanic-Hispanic Hispanic-White White-White


24.8

18.9

12.7

perc

ent

of r

espo

nden

ts

Report fair or poor health

Asian NHOPI AIAN White . . .

Asian477

85.5 1.0 0.4 3.6 9.5

NHOPI

4914.3 32.7 8.2 16.3 28.5

AIAN479

0.6 1.7 57.8 24.4 15.5


How

self

-id

en

tify

020

4060

8010

0

33.7

66.263.1

perc

ent

of r

espo

nden

ts

Report excellent or very good healthAIAN-AIAN AIAN-White White-White


020

4060

8010

0

33.7

66.263.1

perc

ent

of r

espo

nden

ts

Report excellent or very good healthAIAN-AIAN AIAN-White White-White


37.6

15.312.7

perc

ent

of r

espo

nden

ts


Question 2

How often do you think about your

race?

Would you say never, once a year, once a

month, once a week, once a day, once an

hour, or constantly?

04

08

0

pe

rce

nt

never yearly monthly weekly daily hourly constantly

White respondents (n = 21649, weighted)

57.1

14.6 12.4 7.9 5.4 0.1 2.5

"How often do you think about your race?", all six states, 2002 BRFSS

04

08

0

pe

rce

nt



57.1

14.6 12.4 7.9 5.4 0.1 2.5


04

08

0

pe

rce

nt


Black respondents (n = 2093, weighted)

35.3

8.2 8.9 9.319

2.217.1


04

08

0

pe

rce

nt



57.1

14.6 12.4 7.9 5.4 0.1 2.5


04

08

0

pe

rce

nt


Black respondents (n = 2093, weighted)

35.3

8.2 8.9 9.319

2.217.1


04

08

0

pe

rce

nt


Hispanic respondents (n = 2619, weighted)

19.98.2 11.1 10.8 14.4

1.3

34.3


04

08

0

pe

rce

nt o

f re

spo

nd

en

ts

never 1/year 1/month 1/week 1/day constantly

California (n = 2737)

46.6

18 15.7 10.3 6.5 2.8

04

08

0

pe

rce

nt o

f re

spo

nd

en

ts


Delaware (n = 2828)

61.3

12.3 12.5 7.7 4.5 1.7

04

08

0

pe

rce

nt o

f re

spo

nd

en

ts


Florida (n = 4229)

66.8

11 9.1 5.6 5.1 2.5

How often do you think about your race? White respondents, 2002 BRFSS

04

08

0

pe

rce

nt o

f re

spo

nd

en

ts


New Hampshire (n = 4473)

62.8

15.4 11.4 5.7 3.4 1.3

04

08

0

pe

rce

nt o

f re

spo

nd

en

ts


New Mexico (n = 2703)

57.4

15 11.5 8.9 5.7 1.6

04

08

0

pe

rce

nt o

f re

spo

nd

en

ts


North Carolina (n = 4679)

69.8

11 8.7 4.9 3.8 1.7

How often do you think about your race? White respondents, 2002 BRFSS

04

08

0

pe

rce

nt o

f re

spo

nd

en

ts


California (n = 709)

16.4 8.4 11.6 11.9 16.735

04

08

0

pe

rce

nt o

f re

spo

nd

en

ts


Delaware (n = 64)

17.53.5 9.3 11.8 18.8

39

04

08

0

pe

rce

nt o

f re

spo

nd

en

ts


Florida (n = 397)

37.8

6.8 8.1 6.2 13.627.5

How often do you think about your race? Hispanic respondents, 2002 BRFSS

04

08

0

pe

rce

nt o

f re

spo

nd

en

ts


New Hampshire (n = 41)

39.9

6.9 10.4 18.5 11.3 13

04

08

0

pe

rce

nt o

f re

spo

nd

en

ts


New Mexico (n = 1191)

33.6

11.4 14 10.6 15.5 14.9

04

08

0

pe

rce

nt o

f re

spo

nd

en

ts


North Carolina (n = 217)

9.5 4.7 10.2 6.7 3.9

65.1

How often do you think about your race? Hispanic respondents, 2002 BRFSS

Racial climate

• Pertinence of “race” as a basis for classification

• Rules for “racial” classification– Number and names of categories– Sorting rules

• Opportunities and value accorded the different “racial” groups

• Affects how often you think about your “race”

020

4060

8010

0

58.8

68.573.6

64.760.2

49.5

perc

ent

of r

espo

nden

ts

Report excellent or very good healthnever yearly monthly weekly daily constantly

General health status, by "How often do you think about your race?"

White respondents, all six states, 2002 BRFSS (n = 21649, weighted)

020

4060

8010

0

58.8

68.573.6

64.760.2

49.5

perc

ent

of r

espo

nden

ts



White respondents, all six states, 2002 BRFSS (n = 21649, weighted)

15.7

8.4 8.4 9.6

15.620.4


020

4060

8010

0

45.341.9

55.451.1

34.4 32.2

perc

ent

of r

espo

nden

ts



Hispanic respondents, all six states, 2002 BRFSS (n = 2619, weighted)

020

4060

8010

0

45.341.9

55.451.1

34.4 32.2

perc

ent

of r

espo

nden

ts



Hispanic respondents, all six states, 2002 BRFSS (n = 2619, weighted)

20.517.3

14.6 16.6

28.931.8


020

4060

8010

0

38.9

45.8

52.5

59.8 61.2

51.9

perc

ent

of r

espo

nden

ts



Black respondents, all six states, 2002 BRFSS (n = 2093, weighted)

020

4060

8010

0

38.9

45.8

52.5

59.8 61.2

51.9

perc

ent

of r

espo

nden

ts



Black respondents, all six states, 2002 BRFSS (n = 2093, weighted)

28.7

18.413.7

10.6 12.1

23.4


Question 3

[For those who are employed for wages, self-

employed, or out of work for less than one year]

Within the past 12 months at work,

do you feel you were treated worse

than, the same as, or better than

people of other races?

Question 4

Within the past 12 months when

seeking health care, do you feel

your experiences were worse than,

the same as, or better than for

people of other races?

Question 5

Within the past 30 days, have you

felt emotionally upset, for example

angry, sad, or frustrated, as a

result of how you were treated

based on your race?

Question 6

Within the past 30 days, have you

experienced any physical symptoms,

for example a headache, an upset

stomach, tensing of your muscles, or a

pounding heart, as a result of how you

were treated based on your race?

States using “Reactions to Race”

Arkansas 2004California 2002Colorado 2004Delaware 2002 2004 2005District of Columbia 2004

Florida 2002Mississippi 2004New Hampshire 2002New Mexico 2002North Carolina 2002

Ohio 2003 2005Rhode Island 2004South Carolina 2003 2004Wisconsin 2004 2005

w

ww

w

w

01

02

03

04

05

06

0

Education level

Pe

rce

nt "

fair"

or

"po

or"

16+ 13-15 12 9-11 K-8

b

bb

b

b

General health status by education, 2002 BRFSS

w

ww

w

w

01

02

03

04

05

06

0

Education level

Pe

rce

nt "

fair"

or

"po

or"

16+ 13-15 12 9-11 K-8

b

bb

b

b

02

46

81

01

2

16+ 13-15 12 9-11 K-8

Education level

Pe

rce

nt d

istr

ibu

tion

non-blackblack


w

ww

w

w

01

02

03

04

05

06

0

Education level

Pe

rce

nt "

fair"

or

"po

or"

16+ 13-15 12 9-11 K-8

h

hh

h

h


w

ww

w

w

01

02

03

04

05

06

0

Education level

Pe

rce

nt "

fair"

or

"po

or"

16+ 13-15 12 9-11 K-8

h

hh

h

h

01

02

03

04

0

16+ 13-15 12 9-11 K-8

Education level

Pe

rce

nt d

istr

ibu

tion

non-hispanichispanic


w

w

w

w

w

02

04

06

08

0

Education level

Pe

rce

nt "

exc

elle

nt"

or

"ve

ry g

oo

d"

16+ 13-15 12 9-11 K-8

bb

b

b b


w

w

w

w

w

02

04

06

08

0

Education level

Pe

rce

nt "

exc

elle

nt"

or

"ve

ry g

oo

d"

16+ 13-15 12 9-11 K-8

bb

b

b b

02

46

81

01

2

16+ 13-15 12 9-11 K-8

Education level

Pe

rce

nt d

istr

ibu

tion

non-blackblack


w

w

w

w

w

02

04

06

08

0

Education level

Pe

rce

nt "

exc

elle

nt"

or

"ve

ry g

oo

d"

16+ 13-15 12 9-11 K-8

h

h

h

h

h


w

w

w

w

w

02

04

06

08

0

Education level

Pe

rce

nt "

exc

elle

nt"

or

"ve

ry g

oo

d"

16+ 13-15 12 9-11 K-8

h

h

h

h

h0

10

20

30

40

16+ 13-15 12 9-11 K-8

Education level

Pe

rce

nt d

istr

ibu

tion

non-hispanichispanic


Measuring institutionalized racism

• Scan for evidence of “racial” disparities– Routinely monitor outcomes by “race”– “Could racism be operating here?”

• Identify mechanisms– Examine structures and written policies– Query unwritten practices and norms– “How is racism operating here?”

Policies of interest

• Policies allowing segregation of resources and risks

• Policies creating inherited group-disadvantage

• Policies favoring the differential valuation of human life by “race”

• Policies limiting self-determination

Our tasks

• Put racism on the agenda– Name racism as a force determining

the distribution of other social determinants of health

– Routinely monitor for differential exposures, opportunities, and outcomes by “race”

Our tasks

• Ask, “How is racism operating here?”– Identify mechanisms in structures,

policies, practices, and norms– Attend to both what exists and what

is lacking

Our tasks

• Organize and strategize to act– Join in grassroots organizing around

the conditions of people’s lives– Identify the structural factors creating

and perpetuating those conditions– Link with similar efforts across the

country and around the world

Resources

Levels of Racism: A Theoretic Framework and a Gardener’s Tale.Am J Public Health 2000;90(8):1212-1215.

“Race”, Racism, and the Practice of Epidemiology.Am J Epidemiol 2001;154(4):299-304.

Confronting Institutionalized Racism.Phylon 2003;50(1-2):7-22.

E-mail me: [email protected]

Documents

Naming and Measuring the Impacts of Racism on Health Camara Phyllis Jones, MD, MPH, PhD Research Director on Social Determinants of Health Emerging Investigations