1 From the Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
Imagine that you are an epidemiologist investigating the health status of the city Metropolis. You document that the east side of the city has twice the prevalence of disease X as the west side of the city. You become interested in the determinants of disease X. How will you proceed?
Most readers would agree that option 1 is the preferable response to the findings in Metropolis. That is because option 1 treats the large east-west difference as an important clue to understanding the etiology of disease X, and it attempts to vigorously explore the basis of that difference. Option 2, on the other hand, merely treats the east-west difference as a confounder in understanding other determinants of disease X. Under option 2, the basis of the large east-west difference goes unexamined and therefore is likely to remain unknown.
So consider now how we as epidemiologists typically deal with differences in health status observed by "race." Race-associated differences in health outcomes are routinely documented in this country (14
), yet for the most part their basis remains poorly explained. Instead of vigorously investigating the basis of these differences, we tend to simply adjust for race in our analyses or restrict our studies to a single "racial" group (5
).
In this issue of the Journal, Kaufman and Cooper (6) provide guidelines for the appropriate use of race and ethnicity in etiologic research. However, their discussion is limited in two important ways. First, even as Kaufman and Cooper admit that race is a social construct and not a biologic reality (7
, 8
), they still conceptualize race as an individual characteristic and a matter of self-identity akin to ethnicity. Second, even as they thoughtfully assess the potential validity of five different uses of race by epidemiologists, they do not discuss how two of these uses that they judge to have high validity may actually diminish our ability to understand root causes of racial disparities.
In this invited commentary, I discuss the meanings of race and make the case that race is a contextual variable, not a characteristic of the person. I also examine the practice of epidemiology with regard to the use of race and place the five uses of race discussed by Kaufman and Cooper in the larger context of the questions that we decide or neglect to ask. Finally, I urge epidemiologists to take an interest in elucidating the underlying causes of race-associated differences in health outcomes and conclude with eight recommendations for practice that will move us toward that goal.
WHAT DO WE MEASURE WHEN WE MEASURE RACE?
The variable race is generally thought to measure some combination of social class, culture, and genes (9). Yet race is only a rough proxy for each of these. Consider the following examples for those labeled "Black" in this country. With regard to social class, Black people in the United States are overrepresented in poverty, but the majority of poor people in this country are White and not all Black people are poor. Black race therefore serves as only a very rough proxy for poverty. With regard to culture, people who are labeled Black in this country may have just arrived from Ethiopia, recently immigrated from Haiti, or been raised in the rural South or the urban North and have very different cultures with regard to diet, physical activity, and other health-related practices. There is no single Black culture, just as there is no single White, Hispanic, or Asian cutlure. With regard to genes, it is clear that people who are labeled Black in this country represent a genetic admixture of geographic stocks from all over the world. (Indeed, people who are labeled White in this country also represent a genetic admixture from many parts of the world.) In addition, an Aboriginal person from Australia, a Zulu person from South Africa, and a Kikuyu person from Kenya are all labeled Black in this country, yet they arise from very different geographic genetic stocks. There is no denying that there is genetic variability on the planet. However, the pie slicer that we call race does not capture that genetic variability (10
).
ACKNOWLEDGING AND MEASURING RACISM
If race is only a rough proxy for social class, culture, and genes, why is it such a good predictor of health outcomes in the United States? It is because the race that we measure in our studies is the same race that is noted by a taxi driver, a police officer, a judge in a courtroom, or a teacher in a classroom. That is, race is a social classification in our race-conscious society that conditions most aspects of our daily life experiences and results in profound differences in life chances (11).
We are all born with a heritage. We have parents, grandparents, and great-grandparents behind us who give us both a genetic heritage and a cultural heritage (ethnicity), but we are assigned a race in this country. We learn our race in early childhood and it becomes part of our self-identity. However, it is clearly a contextual variable, not something inherent to the person.
This assigned race varies among countries. For example, in the United States I am clearly labeled Black, while in Brazil I would be just as clearly labeled White and in South Africa I would be clearly labeled "colored." It is likely that, if I stayed long enough in any one of these settings, my health profile would become that of the group to which I had been assigned, even though I would have the same genetic endowment in all three settings.
In addition, this assigned race may vary over time. It is instructive to examine the changing racial categories used in the United States decennial census from 1790 to the present (12). For example, in 1790 I would have been counted as a slave, in 1850 as either Black or "mulatto," in 1890 as one of Black, mulatto, "quadroon," or "octoroon" ancestry, in 1950 as "Negro," and in 2000 as "Black, African American, or Negro," plus "White" and "American Indian or Alaska Native" if I so chose. These and other changes on the census reflect changes in political climate and patterns of immigration. The only category that has remained constant over the history of the census is White, and even this is a constructed category that has had variable criteria for membership (13
).
Race is a social construct, a social classification based on phenotype, that governs the distribution of risks and opportunities in our race-conscious society. Although ethnicity reflects cultural heritage, race measures a societally imposed identity and consequent exposure to the societal constraints associated with that particular identity. That is, the race that an investigator notes or a study subject has learned to self-report is an excellent measure of exposure to racism. Perhaps it is this aspect of race that profoundly impacts health and results in race-associated differences in health outcomes that are large in magnitude, occur across the life span, and involve many different organ systems.
LEVELS OF RACISM
If, indeed, racism is a root cause of observed race-associated differences in health outcomes, it is vitally important that we develop a detailed understanding of the characteristics and manifestations of racism. I describe three levels of racism, institutionalized, personally mediated, and internalized, each of which can have an impact on health (14). Understanding these three levels is useful to epidemiologists and other public health practitioners for generating hypotheses about the basis of race-associated differences in health outcomes, as well as for designing interventions to eliminate those differences.
Institutionalized racism is defined as differential access to the goods, services, and opportunities of society by race (14). It is structural, having been codified in our institutions of custom, practice, and law so there need not be an identifiable perpetrator. Indeed, institutionalized racism is often evident as inaction in the face of need. Institutionalized racism manifests itself both in material conditions and in access to power. With regard to material conditions, examples include differential access to quality education, sound housing, gainful employment, appropriate medical facilities, and a clean environment. With regard to access to power, examples include differential access to information, resources, and voice.
It is important to note that the association between socio-economic status and race in the United States has its origins in discrete historical events but persists because of contemporary structural factors that perpetuate those historical injustices. In other words, it is because of institutionalized racism that there is an association between socioeconomic status and race in this country. Pathways through which institutionalized racism impacts health include socioeconomic status and access to health care.
Personally mediated racism is defined as prejudice and discrimination, where prejudice is differential assumptions about the abilities, motives, and intents of others by race, and discrimination is differential actions toward others by race (14). This is what most people think of when they hear the word, racism. Personally mediated racism can be intentional as well as unintentional, and it includes acts of commission as well as acts of omission. It manifests as lack of respect, suspicion, devaluation, scapegoating, and dehumanization. Pathways through which personally mediated racism impacts health include the stresses of everyday racism (15
) and differential treatment within the health care system.
Internalized racism is defined as acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth (14). It involves accepting limitations to one's own full humanity, including one's spectrum of dreams, one's right to self-determination, and one's range of allowable self-expression. It manifests as an embracing of "whiteness," self-devaluation, and resignation, helplessness, and hopelessness. Pathways through which internalized racism impacts health include fratricide and adoption of risky health behaviors.
The relations of institutionalized racism, personally mediated racism, and internalized racism (which taken together produce the racial climate) to health outcomes are illustrated in figure 1.
|
Figure 2 diagrams the practice of epidemiology with regard to the use of race. The first decision we make is whether or not to collect data by race. Many investigators make the decision, "yes." I speculate that epidemiologists in the United States routinely collect data by race for the following reasons:
|
The second decision we make is whether or not to try to understand the basis of the observed race-associated differences. Many investigators make the decision, "no." I speculate that we do not vigorously investigate the basis of race-associated differences in health outcomes for the following reasons:
Our common practice of routinely documenting race-associated differences in health outcomes but leaving the basis of those differences poorly explained is not benign but has at least three dangerous consequences (23). It impedes the advance of scientific knowledge, limits efforts at primary prevention, and contributes to ideas of biologic determinism. Scientific understanding is robbed when clues embedded in large group differences are not mined. Efforts at primary prevention are stymied when one can only screen and treat populations defined by race rather than prevent the onset of disease by addressing root causes. The ideology of race as a biologic determinant is bolstered when scientists fail to probe the basis of race-associated differences as though this basis were already completely understood.
DESIGN AND ANALYTICAL STRATEGIES
Three strategies derive from a decision not to vigorously investigate the basis of observed race-associated differences in health outcomes (see figure 2):
Three other strategies derive from a decision to actively investigate the basis of observed race-associated differences (see figure 2):
Of the five research approaches discussed by Kaufman and Cooper, three were found to have high potential validity, and two of these are included among the strategies of researchers who document race-associated differences but are not interested in investigating the basis of those differences. I do not believe that these authors are calling for epidemiologists to document differences by race without further analysis, nor do I believe that they are they condoning the practice of adjusting for race without taking an interest in the existence and underlying causes of race-associated differences. However, the commentary by Kaufman and Cooper highlights the need for epidemiologists to understand our work in a larger social context. It is just as important to be sure of the validity of our research approaches in a narrow sense as it is to consider the kinds of questions that we are trying to answer and the ones we are neglecting.
RECOMMENDATIONS FOR PRACTICE
I make the following recommendations based on the preceding discussion of race, racism, and the practice of epidemiology:
The distribution of risks and protective factors that are differentially distributed by side of the city in Metropolis can be identified and addressed. In the same way, the structures that govern the distribution of risks and protective factors by race must be identified and addressed. I urge our profession to pay focused attention to understanding the root causes of race-associated differences in health outcomes. We will need to raise new questions with renewed energy. We will need to understand that these racial disparities represent opportunities to increase our scientific understanding of many disease processes, to succeed in primary prevention rather than just screening and treating vulnerable populations, and to combat ideas of biologic determinism that shape public attitudes about the possibility of change. We need to participate in a growing national conversation on racism and to provide the scientific basis for truly understanding how to eliminate racial and ethnic disparities in health by the year 2010 (27, 28
).
NOTES
Reprint requests to Dr. Camara Phyllis Jones, 4770 Buford Highway, N.E., Mailstop K-45, Atlanta, GA 30341 (e-mail: cdj9{at}cdc.gov).
REFERENCES