Public Health
In 1990 a 15-year-old African-American male in Harlem had a 37 percent chance of surviving to age 65. The shorter life expectancy of this black child compared with his poor white neighbor on the Lower East Side--who had a 70 percent chance of survival to the same age--has traditionally been blamed on genetics and the effects of poverty.
But what if there were another player in the game? A character that stalks the health of African Americans no matter where they live, what their income or education levels are, or how many drinks or cigarettes they have. A character that wears many masks, including that of poverty. Researchers at the Harvard School of Public Health believe that such a beast exists. Its name is racism.
| Nancy Krieger, Camara Jones, and Lisa Berkman research the detrimental health effects of the many forms of racism. |
Camara Jones, assistant professor in the Department of Health and Social Behavior and in Epidemiology, Harvard School of Public Health, is a staunch believer that racism is bad for your health. But how can something that starts as an abstract attitude affect one's biology? To explain the connection, Jones uses allegories (see sidebar p. 8) to describe three levels of racism and how each is detrimental to health.
The most visible type of racism, encompassing prejudice and discrimination, is personally mediated racism, Jones says. The black man being beaten for the color of his skin is a victim of this kind of racism, and the effect on his health is easy to see.
When people who have been subjected to racial prejudice and discrimination begin to doubt their own worth and ability, Jones says, they become victims of internalized racism. "The stigmatized people become hopeless and helpless, and those things can impact on health."
Institutionalized racism, characterized by restricted access to well-paying jobs, safe housing, and high-quality health care, is the third classification, and potentially the most profound. "It's because of institutionalized racism that there is an association between social class and race in this country," says Jones.
It is too early to say how much of African Americans' poor health is attributable to institutionalized racism and how much is induced by prejudice and discrimination, but Lisa Berkman, chair of health and social behavior, believes that scientists are now at the brink of being able to look at this empirically.
Levels of Racism: A Gardener's Tale
The following allegory is used by Camara Jones in her class "Race and Racism."
A gardener has two kinds of seed, red and pink, and two flower boxes. One contains rich soil and one has poor, rocky soil. The gardener favors red flowers over pink, so she plants the red seed in the rich soil and the pink seed in the poor soil. Year after year, the rains water, the sun shines, and the gardener harvests the flowers. But she never changes the soil.
The red flowers flourish in the rich soil. But the pink flowers languish--the strongest make it to middling height, the weakest die. The gardener notices the difference, but soon forgets her original decision to put poor soil in one flower box and rich soil in the other. "It's really good that I liked red flowers because they're much prettier," she thinks.
The analogy to institutionalized racism arises from the flowers being contained in separate boxes, and it is perpetuated by the gardener failing to fertilize or mix the soil. An example of personally mediated racism would be if she purposefully removed a stray pink seed that found its way into the red flower box.
Internalized racism results when the pink flowers, realizing they are all scraggly, say to the bee, "Don't bring me any of that substandard pink pollen, bring me the high-quality red pollen," believing that there is something inherently bad about their own kind.
"It all goes back to institutionalized racism," says Jones, suggesting that if society addressed the institutionalized form--mix up the soil, mix up the seed, fertilize--then the personally mediated and the internalized forms would also disappear.
At the core of this area of investigation is the gradual acceptance that race is more a social construct than a biological reality. Epidemiologists and biomedical scientists are falling into line with modern population genetics in the recognition that race has no biological meaning. The outdated argument that blacks have higher morbidity and mortality rates solely as a result of inherited "black" genes is slowly being dismantled. Evidence has accumulated that there is more genetic variability among people within the same racial group than between different groups.
"Race in this country does not even tell you much about ancestry," says Jones. "Why is it such a good predictor of health outcome? Because it measures the social classification of people in a race-conscious society."
Factoring Out Risks
Without the genetic argument, researchers are now forced to confront other factors in their search for the causes of black-white inequality in health. Berkman's own research on health-promoting and health-damaging behaviors of older blacks and whites points the way forward.
In a recent study published by the National Academy Press, Berkman and her coauthor Jewel Mullen, of Yale University, were unable to identify high-risk practices that could account for the higher death rate among African Americans. The accusation that has been leveled at black communities in the past--that their higher rates of sickness and death are a direct result of their indulgence in high-risk behaviors such as alcohol consumption and cigarette smoking--was not borne out in the study. Rather, the inconsistent patterns in the data provided fodder for the argument that socioeconomic factors and stressful experiences related to discrimination were worthy of serious investigation.
The type of analyses that Berkman's paper hinted at was exactly what Jones was working on. As a doctoral student at Johns Hopkins University, Jones analyzed blood pressure measurements from black and white women and hit upon what may be the most tangible and best-substantiated example yet to support the racism/health hypothesis. Jones found that the blood pressure of all women increased with age, as expected. But the blood pressure of the black women was rising earlier and faster.
Using new statistical methods that she developed for the purpose, Jones showed that black women had an accelerated increase in blood pressure above and beyond the usual age-related increase. By the time she reached her thirties, and for the rest of her life, the average black woman had the same blood pressure reading as a white woman 10 years older (see figure).
The graph shows that the blood pressure of black women rises earlier and faster than that of white women. Black women from age 30 onwards have systolic blood pressure values equal to those of white women 10 years older.
In ongoing research, Jones continues to explore the cause of this blood pressure difference. She hypothesizes that black women's accelerated increase in blood pressure is a result of the stress of racism. She now plans to correlate blood pressure data with how often each woman thinks about her race. Her preliminary data suggest that race is a constant thought nagging many black women. "White people by virtue of their white privilege don't even have to think about themselves as having a race," she says. "But blacks are thinking about their race 24 hours a day, and it's basically wearing their body down."
A Toll on the Heart
The link between racial discrimination and hypertension also concerns assistant professor Nancy Krieger, who two years ago conducted one of the first studies in this area, the largest so far. "There has been only a handful of studies, mine included, that have tried to relate experiences of discrimination to outcomes such as blood pressure, or other aspects of somatic health," says Krieger. "It is too early to say that there are any clear trends, but I think we're now at a point in the research where it is becoming possible to ask these kinds of questions rigorously." These initial studies sparked further inquiry in the field.
More recently, Krieger has been investigating cancer rates in whites, blacks, and other ethnic groups. Using data collected from the San Francisco Bay area, she is attempting to correlate socioeconomic position with incidence of five different types of cancer: breast, lung, colon, prostate, and cervical. She is also busy preparing a grant to continue her research on questions of racial discrimination and cardiovascular health.
Lest one believe that racism is an issue that only affects minority populations, Bruce Kennedy, director of the public health practice initiative, and Ichiro Kawachi, associate professor of health and social behavior both at HSPH, have found that racism is everybody's problem. In a study published in the Autumn 1997 issue of Ethnicity and Disease, Kennedy and Kawachi report that racism strongly correlates with increased black mortality, but also higher white mortality. "The point is that inequality affects everybody's health," says Kennedy.
The other researchers agree. "If I could get any message out to the general public, it would be that racism is a threat to the public's health. It's not just threatening the health of the people of color, it's also threatening the health of white people," says Jones.
--Kristin Weidenbach
Reducing racial and ethnic differences in health is one of the three founding areas of the recently established Harvard Center for Society and Health. The center aims to investigate health issues on a societal level and identify social and economic policies that may affect national health. It is a University-wide initiative that will foster interdisciplinary research and integrate members of diverse areas, such as the John F. Kennedy School of Government and the Departments of Social Medicine and Ambulatory Care and Prevention at HMS.
The center evolved from research programs within the Department of Health and Social Behavior that relate to the changing demographics of the U.S. population. Healthy aging and improving work conditions will be targeted, in addition to racial inequalities in health.
"This research is necessary if we are going to address the major question of how to improve the health of the public," says Lisa Berkman.