Addressing Racism as a Threat to the Health and Well-Being of Our Nation

Health begins where we
live, learn, work, and play
Addressing racism as a threat
to the health and well-being
of our nation
Camara Phyllis Jones, MD, MPH, PhD
Social Determinants of Health and Equity

Leadership Challenge
Fairfax, Virginia
September 17, 2012

Levels of health intervention

Source: Jones CP et al. J Health Care Poor Underserved 2009.

Addressing the Primary prevention
social determinants of health

Safety net programs and
secondary prevention

Medical care and
tertiary prevention

But how do disparities arise?
 Differences in the quality of care received within the
health care system

 Differences in access to health care, including
preventive and curative services

 Differences in life opportunities, exposures, and
stresses that result in differences in underlying health
status
Source: Smedley BD, Stith AY, Nelson AR (editors). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.
Washington, DC: The National Academies Press, 2002.
Source: Byrd WM, Clayton LA. An American Health Dilemma: Race, Medicine, and Health Care in the United States, 1900-2000.
New York, NY: Routledge, 2002.
Source: Phelan JC, Link BG, Tehranifar P. Social Conditions as Fundamental Causes of Health Inequalities. J Health Soc Behav
2010;51(S):S28-S40.

Differences in

Differences in access to care
exposures and
opportunities

Differences in quality of care
(ambulance slow or goes the wrong way)

Addressing the
social determinants of equity:

Why are there differences
in resources
along the cliff face?

Why are there differences
in who is found
at different parts of the cliff?


3 dimensions of health intervention



Health services



Health services

Addressing social determinants of health



Health services

Addressing social determinants of health

Addressing social determinants of equity


Determinants of health

Individual
behaviors



Social determinants
of health (contexts)

Individual
behaviors



Determinants
of health and
illness that are
Social determinants
outside of the of health (contexts)
individual

Individual
Beyond genetic behaviors
predispositions

Beyond individual
behaviors



Determinants The contexts in
of health and which
illness that are individual
Social determinants
outside of the of health (contexts) behaviors arise
individual

Individual
Beyond genetic behaviors
predispositions

Beyond individual
behaviors



Individual
resources
Education, Social determinants
occupation, of health (contexts)
income, wealth
Individual
behaviors

Source: CSDH. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the
Commission on Social Determinants of Health. Geneva: World Health Organization, 2008.


Individual
resources
Education, Social determinants
occupation, of health (contexts)
income, wealth
Neighborhood
Individual
resources behaviors
Housing, food
choices, public
safety,
transportation,
parks and
recreation,
political clout


Individual Hazards and
resources toxic exposures
Education, Social determinants Pesticides, lead,
occupation, of health (contexts) reservoirs of
income, wealth infection
Neighborhood
Individual
resources behaviors
Housing, food
choices, public
safety,
transportation,
parks and
recreation,
political clout


Individual Hazards and
resources toxic exposures
Education, Social determinants Pesticides, lead,
occupation, of health (contexts) reservoirs of
income, wealth infection
Neighborhood Opportunity
Individual
resources behaviors structures
Housing, food Schools, jobs,
choices, public justice
safety,
transportation,
parks and
recreation,
political clout


Structural determinants of context

Social determinants

Individual
behaviors


Determine the
range of
observed contexts

Social determinants

Individual
behaviors


Determine the
range of
observed contexts

Social determinants

Individual
behaviors

Determine the
distribution of
different populations
into those contexts


Determine the Include economic
range of systems, racism,
observed contexts and other systems
Structural determinants of context of power

Social determinants

Individual
behaviors

Determine the
distribution of
different populations
into those contexts


Determine the Include economic
range of systems, racism,
observed contexts and other systems
Structural determinants of context of power

Social determinants

Individual
behaviors

Determine the The social
distribution of determinants of
different populations equity
into those contexts


Addressing the social determinants
of HEALTH
 Involves the medical care and public health systems,
but clearly extends beyond these

 Requires collaboration with multiple sectors outside of
health, including education, housing, labor, justice,
transportation, agriculture, immigration, and
environment

Source: National Prevention Council. National Prevention Strategy. Washington, DC: U.S. Department of Health and Human
Services, Office of the Surgeon General, 2011.

Source: Jones CP, Jones CY, Perry GS, Barclay G. Addressing the Social Determinants of Children’s Health: A Cliff Analogy.
J Health Care Poor Underserved 2009;20(4)Suppl:1-12.

Addressing the social determinants
of EQUITY
 Involves monitoring for inequities in exposures and
opportunities, as well as for disparities in outcomes

 Involves examination of and intervention on the
mechanisms of power
 Structures: the who?, what?, when?, and where? of
decision-making
 Policies: the written how?
 Practices and norms: the unwritten how?
 Values: the why?


Beyond individual behaviors
 Address the social determinants of health,
including poverty, in order to achieve large and
sustained improvements in health outcomes

 Address the social determinants of equity,
including racism, in order to achieve social justice and
eliminate health disparities


Why racism?
 To eliminate racial disparities in health, need examine
fundamental causes
 “Race” is only a rough proxy for social class, culture, or genes
 “Race” captures the social classification of people in our “race”-
conscious society
 Hypothesize racism as a fundamental cause of racial
disparities in health

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

What is racism?
A system

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

What is racism?
A system of structuring opportunity and assigning
value


What is racism?
value based on the social interpretation of how we look
(which is what we call “race”)


What is racism?
(which is what we call “race”), that

 Disadvantages some individuals and communities


What is racism?

 Advantages other individuals and communities


What is racism?

 Saps the strength of the whole society through the waste of
human resources


Levels of Racism
 Institutionalized
 Personally-mediated
 Internalized

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

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 social class and “race”


Personally-mediated racism
 Differential assumptions about the abilities, motives,
and intents of others, by “race”
 Differential actions based on those assumptions

 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


Who is the gardener?

 Power to decide
 Power to act
 Control of resources

 Dangerous when
 Allied with one group
 Not concerned with equity


Measuring institutionalized racism
 Scan for evidence of “racial” disparities
 “Could racism be operating here?”
 Routinely monitor opportunities as well as outcomes by “race”

 Identify mechanisms
 “How is racism operating here?”
 Structures: the who?, what?, when?, and where?
of decision-making
 Policies: the written how?
 Practices and norms: the unwritten how?
 Values: the why?


“Reactions to Race” module
 Six-question optional module on the Behavioral Risk
Factor Surveillance System since 2002

 “How do other people usually classify you in this country?”
 “How often do you think about your race?”
 Perceptions of differential treatment at work or when seeking
health care
 Reports of physical symptoms or emotional upset as a result of
“race”-based treatment

States using the “Reactions to Race” module
2002 to 2011 BRFSS

Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Indiana,
Kentucky, Massachusetts, Michigan, Mississippi, Nebraska, New Hampshire, New Mexico, North Carolina,
Ohio, Rhode Island, South Carolina, Tennessee, Vermont, Virginia, Washington, Wisconsin

States using the “Reactions to Race” module
Arkansas 2004
California 2002
Colorado 2004
Connecticut 2010
Delaware 2002 2004 2005

DC 2004
Florida 2002
Georgia 2010
Indiana 2009
Kentucky 2010

Massachusetts 2006 2008
Michigan 2006
Mississippi 2004
Nebraska 2008 2009
New Hampshire 2002

New Mexico 2002
North Carolina 2002
Ohio 2003 2005 2011
Rhode Island 2004 2007 2010
South Carolina 2003 2004

Tennessee 2005
Vermont 2008
Virginia 2008
Washington 2004
Wisconsin 2004 2005 2006

Socially-assigned “race”
 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
 Some other group

Socially-assigned “race”
 On-the-street “race” quickly and routinely assigned
without benefit of queries about self-identification,
ancestry, culture, or genetic endowment

 Ad hoc racial classification, an influential basis for
interactions between individuals and institutions for
centuries

 Substrate upon which racism operates

Source: Jones CP, Truman BI, Elam-Evans LD, Jones CA, Jones CY, Jiles R, Rumisha SF, Perry GS. Using “socially assigned race”
to probe White advantages in health status. Ethn Dis 2008;18(4):496-504.

General health status
 Would you say that in general your health is:

 Excellent
 Very good
 Good
 Fair
 Poor

General health status by socially-assigned "race", 2004 BRFSS
100
80
60
percent of respondents
40
20

58.3 43.7 41.2 36.1
0

White Black Hispanic AIAN
Report excellent or very good health

General health status by socially-assigned "race", 2004 BRFSS

Report fair or poor health
100

13.9 21.5 20.9 22.1
80
60
40
20

58.3 43.7 41.2 36.1
0

White Black Hispanic AIAN

General health status and “race”
 Being perceived as White is associated with better
health

Self-identified ethnicity
 Are you Hispanic or Latino?

 Yes
 No

Self-identified “race”
 Which one or more of the following would you say is
your race?

 White
 Black or African-American
 Asian
 Native Hawaiian or Other Pacific Islander
 American Indian or Alaska Native
 Other

 Which one of these groups would you say best
represents your race?

Self-identified “race”/ethnicity
 Hispanic
 “Yes” to Hispanic/Latino ethnicity question
 Any response to race question
 White
 “No” to Hispanic/Latino ethnicity question
 Only one response to race question, “White”
 Black
 Only one response to race question, “Black”
 American Indian/Alaska Native
 Only one response to race question, “AI/AN”

Two measures of “race”
How usually classified by others
White Black Hispanic AIAN ...
White
98.4 0.1 0.3 0.1 1.1
26,373
How self-identify

Black
0.4 96.3 0.8 0.3 2.2
5,246

White
98.4 0.1 0.3 0.1 1.1
26,373
How self-identify

Black
0.4 96.3 0.8 0.3 2.2
5,246
Hispanic
26.8 3.5 63.0 1.2 5.5
1,528

General health status, by self-identified and socially-assigned "race", 2004
100
80
60

58.6
53.7

39.8
40
20
0

Hispanic-Hispanic Hispanic-White White-White

100

Test of H0: That there is no difference in proportions
reporting excellent or very good health
80

Hispanic-Hispanic versus White-White
p < 0.0001
60

58.6

39.8
40
20
0

Hispanic-Hispanic White-White

100

80

Hispanic-Hispanic versus Hispanic-White
p = 0.0019
60

53.7

39.8
40
20
0

Hispanic-Hispanic Hispanic-White

100

80

Hispanic-White versus White-White
p = 0.1895
60

58.6
53.7
40
20
0

Hispanic-White White-White

White
98.4 0.1 0.3 0.1 1.1
26,373
How self-identify

Black
0.4 96.3 0.8 0.3 2.2
5,246
Hispanic
26.8 3.5 63.0 1.2 5.5
1,528
AIAN
47.6 3.4 7.3 35.9 5.8
321

100
80
60

58.6
52.6
40

32
20
0

AIAN-AIAN AIAN-White White-White

100

80

AIAN-AIAN versus White-White
p < 0.0001
60

58.6
40

32
20
0

AIAN-AIAN White-White

100

80

AIAN-AIAN versus AIAN-White
p = 0.0122
60

52.6
40

32
20
0

AIAN-AIAN AIAN-White

100

80

AIAN-White versus White-White
p = 0.3070
60

58.6
52.6
40
20
0

AIAN-White White-White

White
98.4 0.1 0.3 0.1 1.1
26,373
How self-identify

Black
0.4 96.3 0.8 0.3 2.2
5,246
Hispanic
26.8 3.5 63.0 1.2 5.5
1,528
AIAN
47.6 3.4 7.3 35.9 5.8
321
> 1 race
59.5 22.5 3.8 5.3 8.9
406

health
 Even within non-White self-identified “race”/ethnic groups

health
 Even within the same educational level

health

 Being perceived as White is associated with higher
education

Key questions
 Why is socially-assigned “race” associated with self-
rated general health status?

 Why is socially-assigned “race” associated with
educational level?

Racism

human resources


Source: Jones CP, Truman BI, Elam-Evans LD, Jones CA, Jones CY, Jiles R, Rumisha SF, Perry GS. Using “socially assigned race” to probe
White advantages in health status. Ethn Dis 2008;18(4):496-504.

What is [inequity] ?
value based on [fill in the blank]

What is [inequity] ?
value based on [fill in the blank], that

human resources

Many possible axes of inequity
 “Race”
 Gender
 Ethnicity
 Labor roles and social class markers
 Nationality, language, and legal status
 Sexual orientation
 Disability status
 Geography
 Religion

These are risk markers

ICERD: International Convention on the
Elimination of all forms of Racial Discrimination
 International anti-racism treaty adopted by the UN
General Assembly in 1965
http://www2.ohchr.org/english/law/cerd.htm

 US signed in 1966
 US ratified in 1994

 2nd US report submitted to the UN Committee on the
Elimination of Racial Discrimination (CERD) in 2007
http://www2.ohchr.org/english/bodies/cerd/docs/AdvanceVersion
/cerd_c_usa6.doc

CERD Concluding Observations
 14-page document (8 May 2008) available online
http://www.state.gov/documents/organization/107361.pdf

 Concerns and recommendations
 Racial profiling (para 14)
 Residential segregation (para 16)
 Disproportionate incarceration (para 20)
 Differential access to health care (para 32)
 Achievement gap in education (para 34)

Our goal: To expand the conversation
Health services

Health services

Social determinants
of health

Health services

Social determinants
of health

Social determinants
of equity


Camara Phyllis Jones, MD, MPH, PhD

(404) 374-3198 cell
(404) 498-1128 work

camara99@bellsouth.net

Barriers in moving the nation
to care about social justice
 A-historical culture
 The present as disconnected from the past
 Current distribution of advantage/disadvantage as happenstance
 Systems and structures as givens and immutable
 Narrow focus on the individual
 Self-interest narrowly defined
 Limited sense of interdependence
 Limited sense of collective efficacy
 Systems and structures as invisible or irrelevant
 “Myth of meritocracy”
 Role of hard work
 Denial of racism
 Two babies: Equal potential or equal opportunity?

Moving the nation
 Changing opportunity structures
 Understand the importance of history
 Challenge the narrow focus on the individual
 Expose the “myth of meritocracy”
 Acknowledge existence of systems and structures
 View systems and structures as modifiable
 Break down barriers to opportunity
 Build bridges to opportunity
 Transform consumers to citizens
 Intervene on decision-making processes
 Valuing all people equally
 Break out of bubbles to experience our common humanity
 Embrace ALL children as OUR children

Unpublished allegories
 Dual Reality: A Restaurant Saga
 Conveyor Belt: Stages of Anti-racism
 Japanese Lanterns: Colored Perceptions
 Understanding This Bus We Are On
 Bicycles on a Hill: Equal Opportunity?
 Bus Seating: The Permanence of Privilege
 Bus Survey: Who Counts?
 Airplane Seating: Invisible Tether

Source: Jones CP, unpublished allegories developed for course “Race” and Racism, Harvard School of Public Health, 1994 to 2000.

Resources
 National Partnership for Action to End Health
Disparities
Office of Minority Health, US Department of Health and Human
Services
http://www.minorityhealth.hhs.gov/npa/

 National Stakeholder Strategy for Achieving Health Equity
 HHS Action Plan to Reduce Racial and Ethnic Health Disparities

Regional Health Equity Councils
http://minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=1&
lvlid=42#1

Resources
 Healthy People 2020
http://www.healthypeople.gov/2020/default.aspx

Overarching goals:
 Attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death.
 Achieve health equity, eliminate disparities, and improve the
health of all groups.
 Create social and physical environments that promote good
health for all.
 Promote quality of life, healthy development, and healthy
behaviors across all life stages.
42 topic areas, including 13 new ones

Resources
 National Prevention Strategy
National Prevention, Health Promotion, and Public Health Council
http://www.healthcare.gov/prevention/nphpphc

Resources
 US-Brazil Joint Action Plan to Eliminate Racial and
Ethnic Discrimination and Promote Equality
Five-year bilateral agreement signed in 2008
http://www.state.gov/p/wha/rls/2008/111446.htm
http://www.state.gov/p/wha/rt/social/brazil/index.htm

Areas of focus
 Civil society engagement
 Economic opportunities and labor
 Education
 Environmental justice
 Health
 Justice

Resources
 CDC Racism and Health Workgroup
rahw@cdc.gov

Communications and Dissemination
Education and Development
Global Matters
Liaison and Partnership
Organizational Excellence
Policy and Legislation
Science and Publications

Resources
 Race: The Power of an Illusion
California Newsreel
http://www.pbs.org/race
http://newsreel.org/video/RACE-THE-POWER-OF-AN-ILLUSION

 RACE – Are We So Different?
American Anthropological Association
http://www.understandingrace.org/home.html

Resources
 3rd World Conference Against Racism, Racial
Discrimination, Xenophobia and Related Intolerance
Convened by the United Nations in Durban, South Africa in 2001
http://www.un.org/WCAR/

Durban Declaration and Programme of Action
http://www.un.org/WCAR/durban.pdf

Resources
 Unnatural Causes: Is Inequality Making Us Sick?
California Newsreel
http://www.unnaturalcauses.org

 Closing the gap in a generation: Health equity through
action on the social determinants of health
WHO Commission on Social Determinants of Health
http://www.who.int/social_determinants/thecommission/finalrep
ort/en/index.html

Resources
 World Conference on Social Determinants of Health
Convened by the World Health Organization in Rio de Janeiro,
Brasil in 2011
http://www.who.int/sdhconference/en/

Rio Political Declaration on Social Determinants of
Health
http://www.who.int/sdhconference/declaration/en/

Resources
 International Convention on the Elimination of all
forms of Racial Discrimination (ICERD)
Adopted by the United Nations General Assembly in 1965
http://www2.ohchr.org/english/law/cerd.htm

 Committee to Eliminate Racial Discrimination (CERD)
Office of the United Nations High Commissioner for Human Rights
http://www2.ohchr.org/english/bodies/cerd/

Resources
 2007 USA State Department report to the CERD
http://www2.ohchr.org/english/bodies/cerd/docs/AdvanceVersion
/cerd_c_usa6.doc

 2007 NGO shadow reports to the CERD
http://www2.ohchr.org/english/bodies/cerd/cerds72-ngos-
usa.htm

 2008 CERD Concluding Observations to the USA
http://www.state.gov/documents/organization/107361.pdf

Resources
 Report of the Secretary’s Task Force on Black and
Minority Health
Margaret M. Heckler, Secretary
U.S. Department of Health and Human Services
http://collections.nlm.nih.gov/ext/heckler/8602912V1/PDF/86029
12V1.pdf

 Unequal Treatment: Confronting Racial and Ethnic
Disparities in Health Care
Brian D. Smedley, Adrienne Y. Stith, Alan R. Nelson, Editors
Institute of Medicine of the National Academies
http://www.nap.edu/openbook.php?isbn=030908265X

Resources
 The Gardener’s Tale podcast
CityMatCH Health Equity and Social Justice Action Group
http://www.citymatch.org/UR_tale.php

 International Coalition of Cities Against Racism
United Nations Educational, Scientific and Cultural Organization
http://www.unesco.org/new/en/social-and-human-
sciences/themes/human-rights/fight-against-
discrimination/coalition-of-cities/

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


Policies allowing segregation of
resources and risks

Redlining, municipal zoning, toxic dump siting

Use of local property taxes to fund public education

Policies creating inherited group
disadvantage

Lack of social security for children

Estate inheritance

Lack of reparations for historical injustices

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

Curriculum

Media invisibility / hypervisibility

Myth of meritocracy and denial of racism

Policies limiting self-determination

De jure and de facto limitations to voting rights

“Majority rules” when there is a fixed minority

Achieving health equity
 “Health equity” is assurance of the conditions for
optimal health for all people

 Achieving health equity requires
 Valuing all individuals and populations equally
 Recognizing and rectifying historical injustices
 Providing resources according to need

 Health disparities will be eliminated when health
equity is achieved

Source: Jones CP 2010, adapted from the National Partnership for Action to End Health Disparities

Our tasks
 Put racism on the agenda
 Name racism as a force determining the 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, norms, and
values
 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

What is racism?
“Racism includes racist ideologies, prejudiced attitudes,
discriminatory behavior, structural arrangements and
institutionalized practices resulting in racial inequality
as well as the fallacious notion that discriminatory
relations between groups are morally and scientifically
justifiable;

“it is reflected in discriminatory provisions in legislation
or regulations and discriminatory practices as well as in
anti-social beliefs and acts;

Source: United Nations Educational, Cultural, and Scientific Organization, 1978.

What is racism?
“it hinders the development of its victims, perverts those
who practice it, divides nations internally, impedes
international co-operation and gives rise to political
tensions between peoples;

“it is contrary to the fundamental principles of
international law and, consequently, seriously disturbs
international peace and security.”

Source: United Nations Educational, Cultural, and Scientific Organization, 1978.

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