Anyone who thinks America is a “post-racial” society is delusional. “Post-racial” is political discourse that aims to deny any presence of racism or racial inequality in modern society. Racism is visible everyday. From visible neighbourhood segregation to everyday instances of white privilege to population-level statistics, it can be seen and felt (1-7). For example, in 2013, the average white family had a net worth 13 times greater than the average black family ($141,900 vs. $11,000), a gap twice the size it was prior to the Great Recession (1).
Why does racism matter for public health?
Racism is not only a social, cultural, political, and legal issue; it is also a health issue. Across history, racism has consistently been manifested in terms of the ultimate health outcome: death. When Europeans colonised the Americas hundreds of years ago, the aboriginal populations perished in scores. America’s legacy of slavery almost goes without mentioning. Still today, the life expectancy of American Indians and Alaska Natives is, on average, 4.2 years lower than all races and origins in the U.S. population combined (6).Black men are more likely to die than non-black men, with a life expectancy 5 years lower than white men in America (see graph below) (7).
Recently, we’ve seen the ultimate outcome of racism dramatically played out in the streets of America. This form of overt violence, where unarmed yet “suspicious-looking” black men are shot down by officers of the law is nothing new, yet requires contextualisation. Let’s not forget that while African Americans have been living in the United States for over 400 years, they have only had legal rights for about a tenth of that time. Let’s not forget how recent the civil rights movement was. It will take more than a couple of generations to repair the legacy of slavery, if it ever can be repaired.
The effects of racism on health, while undoubtedly negative, are not well understood. Racism is a personal experience, the manifestation of which is politically and socially situated in specific places and times. It is institutional, interpersonal, overt, covert, and violent.
The field of epidemiology and public health has only accumulated a small body of inquiry into racism and health, and most of it deals with the social experience of racial discrimination in people’s daily lives. As of 5 January 2015, a PubMed search of the term “racism” returns 2,263 articles from all medical disciplines. By contrast, a search for the term “obesity” returns 210,214 articles, about ten times more. This quick example is not meant to imply that obesity is not an important and urgent research topic (it is), or that these are even comparable topics, but rather to demonstrate the relative dearth of knowledge on racism in the quantitative health sciences.
Without empirical research we cannot record the effects of racism on population health and inequalities, we cannot transcribe the embodiment of discrimination in marginalised groups on a large scale. By “embodiment,” I mean the literal embodying of social and ecological environments in terms of their biological effects in and on our bodies (8,9). A useful framework for quantitative health scientists wishing to investigate the effects of race and racism is ecosocial theory (8,9). The ecosocial theory of disease distribution concerns who and what drive social inequalities in health (8). I’ll leave the juicy bits to the paper and book referenced above, but will briefly describe what the theory posits with respect to racism:
Inequitable race relations simultaneously – and not sequentially
- Benefit the groups who claim racial superiority at the expense of those whom they deem intrinsically inferior,
- Racialize biology to produce and justify the very categories used to demarcate racial/ethnic groups, and
- Generate inequitable living and working conditions that, via embodiment, result in the biological expression of racism – and hence racial/ethnic health inequalities (9).
These ideas are nothing new to those familiar with critical race theory, social constructionism, or intersectionality theory. However, they are often foreign to quantitative health scientists. We are taught how to count, classify, and categorise people in order to fit them into complex statistical models not designed to account for the social construction of biology. So, how do we move forward? We need to ground our work in theory (epidemiology, as a field, is notoriously atheoretical, although that’s a subject for another day), which means looking outside of our discipline to the social sciences. We need to collaborate with other fields and explore mixed methods. As epidemiology evolves, theories like the ecosocial theory may become entrenched in our discipline.
This is important because research is a key piece in the patchwork of knowledge, activism, policy, and public will that is required to make the world a more just place. The media attention and public demonstrations that have occurred in aftermath of Ferguson and other recent incidents of racialized violence perhaps signal a change in the public consciousness. Let’s keep moving in this direction.
Note: Although I refer to “black lives” in this title, it is not to privilege any minority group over any other. Linking to current public discourse and providing a focus for this article, the intent is purely demonstrative. The ecosocial framework can be applied to many inequitable social relations across place and time.
1) Kochhar R, Fry R. Wealth inequality has widened along racial, ethnic lines since end of Great Recession. http://www.pewresearch.org/fact-tank/2014/12/12/racial-wealth-gaps-great-recession/ (accessed 1 January 2014).
2) Nico Lang. It’s time to wake up from the myth of a “post-racial America.” Daily Dot. 25 November 2014. http://www.dailydot.com/opinion/ferguson-michael-brown-post-racial-myth/ (accessed 3 January 2015).
3) McIntosh P. White privilege: unpacking the invisible backpack. Independent School, Winter, 1990, pp. 31-6.
4) Vanhemert K. The best map ever made of America’s racial segregation. Wired. 26 August 2013. http://www.wired.com/2013/08/how-segregated-is-your-city-this-eye-opening-map-shows-you/ (accessed 3 January 2015).
5) Baird-Remba R, Lubin G. 21 maps of highly segregated cities in America. Business Insider. http://www.businessinsider.com/most-segregated-cities-census-maps-2013-4?op=1&IR=T (accessed 3 January 2015).
6) Indian Health Service: The Federal Health Program for American Indians and Alaska Natives. Disparities. http://www.ihs.gov/newsroom/factsheets/disparities/ (accessed 3 January 2015).
7) Centers for Disease Control and Prevention. NCHS Data Brief: Death in the United States, 2010. http://www.cdc.gov/nchs/data/databriefs/db99.htm (accessed 3 January 2015).
8) Krieger N. Methods for the scientific study of discrimination and health: an ecosocial approach. Am J Public Health 2012;102(5):936-45.
9) Krieger N. Epidemiology and the people’s health: theory and context. New York: Oxford University Press; 2011.
(Originally published by Public Health Perspectives.)