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Editor's Note
In Focus Health Highlights
International Health

Fall 2002; Volume 3, Number 2
Features: Equality and Health Care

Eliminating African-American Health Disparity via History-based Policy
Karen Williams, MA, and Veronica W. Johnson, MA
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"Health is the place where all the social forces converge."
-Reed Tuckson, M.D., Vice President, American Medical Association

The legacy of racial and ethnic health disparities[1] suffered by African-Americans (the second largest minority group in the United States) consistently reminds patients, health practitioners and policymakers of the taint of America's "slave health deficit."[2] Infamous health scandals like the Tuskegee Syphilis Study affect the healthcare[3] choices of both Blacks and their providers, often against a backdrop of racist, classist and paternalist medical conduct.

Despite passage of the 1964 Civil Rights Act, numerous medical milestones, and the government's "Healthy People" initiative to eliminate minority health disparities by 2010, African-Americans still suffer much higher disease and excess death rates than other racial groups. Infant mortality, one of the nation's most critical gauges of maternal and societal health, is twice as common in Black communities than in white, and occurs across all socioeconomic ranges of the Black community.

In addition to such disparities in health, Blacks also report suffering from disparities in the care they receive. A 1999 study found that 80% percent of Blacks believe they receive different medical treatment and have different care options due to their race and ethnicity.[4] Findings from a 2001 study by The Kaiser Family Foundation's National Survey of Physicians corroborates Black patients' sentiments. The study's first part examines physicians' perceptions of disparities in medical care. Of the white physicians interviewed, 77% believed that disparities in how people are treated within the healthcare system "'rarely' or 'never' happen based on factors such as income, fluency in English, educational status, or racial or ethnic background." In the same survey, 8 out of 10 Black physicians reported that the "healthcare system at least 'somewhat often' treats people unfairly based on various characteristics, with differences particularly striking with regard to race and ethnicity."[5]

In the article, "The Meanings of 'Race' in the New Genomics: Implications of Health Disparities Research," investigators pose the question: "To what extent are health disparities the result of unequal distribution of resources, and thus a consequence of varied socioeconomic status (or racism), and to what extent are inequities in health status the result of inherent characteristics of individuals defined as ethnically or racially different?" [6] The historic conflicts and passionate opinions surrounding this question necessitate a commitment to social justice by both patient and provider to ensure the rights, equity, access and participation of African-Americans in health care. This commitment must constrain healthcare financiers, administrators, practitioners, researchers, academics and those working in related disciplines to acknowledge history and develop historically-accurate, evidence-based health policies examining: (1) why African-Americans have historically succumbed to poorer health faster and earlier than their non-Black counterparts; (2) how to close the disparity gap without blaming African-Americans for their historically sub-optimal health status; and (3) how to encourage American medicine to embrace more sociocultural (as opposed to strictly biomedical) care paradigms and mechanisms facilitating humane and non-prejudiced medical encounters.

Defining, Confronting and Treating "The Other"

Defining race and ethnicity

The confluence of race, genetics and disease in explaining African-American health status presents race as a central health culprit. The concept of "race" has been found to be largely psychological and sociopolitical, rather than biological, as human genome research indicates that all human beings carry 99.9 % of the same genetic material (DNA) regardless of race. False constructs of racial effects on health must be studied in order to eliminate health disparities that are largely psychosocially, historically and economically driven. University of Dayton Law Professor, Vernellia Randall, outlines nine factors through which the corolla of race affects healthcare training and delivery systems: (1) lack of economic access to health care; (2) barriers to hospitals and healthcare institutions; (3) barriers to physicians and other providers; (4) discriminatory policies and practices; (5) lack of language and culturally-competent care; (6) inadequate inclusion in healthcare research; (7) commercialization of healthcare; (8) disintegration of traditional medicine; and (9) disparities in medical treatment.[7]

To combat such factors, accurate conceptions of race must first be academically redefined, as suggested by the American Anthropological Association (AAA), the official professional organization of physical, biological, social and cultural archaeologists and anthropologists in the United States. The AAA states:

The 'racial' worldview was invented to assign some groups to perpetual low status, while others were permitted access to privilege, power and wealth. The tragedy in the U.S. has been that the policies and practices stemming from this worldview succeeded all too well in constructing unequal populations among Europeans, Native Americans, and peoples of African descent. Given what we know about the capacity of normal humans to achieve and function within any culture, we conclude that present-day inequalities between so-called 'racial' groups are not consequences of their biological inheritance, but products of historical and contemporary social, economic, educational and political circumstances.[8]

Although many members of the medical community recognize these aspects of race, certain circles use race as a scientific variable in research, to explain disease, and as a proxy for socioeconomic class when it should be used for accurate distinctions between biomedical and sociocultural causes of illness, disease and death. If such distinctions are not made, health practitioners may continue to associate patient race and income with the practitioner's appraisal of the patient's intelligence, feelings of affiliation toward the patient, and beliefs about the patient's propensity to engage in risky behaviors and noncompliance. [9]

Constructing whiteness

"[Whiteness] inhabits the tiny spaces of social structure and social microstructures - the tiny habits, the little presumptions, the seemingly innocent perceptions, the taken-for-granted norms governing bureaucracy from top to bottom..."
-Jim Perkinson, Professor/ Ethicist, Ecumenical Theological Seminary

An honest and critical review of "whiteness constructs" as they relate to race, ethnicity and health can enrich the study of health disparities suffered by African-Americans. Consider the following question: If you needed to purchase a "flesh-colored" bandage, could you be reasonably assured that your local pharmacy would carry a bandage in the right shade? In an essay entitled "Unpacking the Invisible Knapsack of White Privilege," Peggy McIntosh, Associate Director for the Wellesley College Center for Research on Women, investigates such questions and concludes:

As a white person, I realized I had been taught about racism as something that puts others at a disadvantage, but had been taught not to see one of its corollary aspects, white privilege, which puts me at an advantage... I have come to see white privilege as an invisible package of unearned assets that I can count on cashing in each day, but about which I was 'meant' to remain oblivious. White privilege is like an invisible weightless knapsack of special provisions, maps, passports, code books, visas, clothes, tools and blankchecks.[10]

McIntosh and others who share her sentiments recognize the privilege structure that pervades American politics, media, current events, popular culture, and medical culture. Although dialogues of such racial constructs may be inflammatory in some circles, a recent study by researchers at the University of Maryland-Baltimore found that non-Blacks' beliefs about Blacks' health disparities have a profound impact on framing contemporary epidemiology, health policy development and public health research questions.[11] The researchers assert that most contemporary, middle-class, white citizens believe that race is a biological construct and health status is negotiated by self-determination, choice, and individual responsibility - assumptions that can falsely substantiate and justify health disparities while intensifying racist medical practices and erroneous assumptions about Black health.

Studying critical race theory (an analytical framework arguing need for the novel, interdisciplinary methods and arguments to address pervading racial inequalities) illuminates whiteness constructions that may perpetuate Blacks' health disparities. Constructions detailed by the James Jones article, "Psychological Knowledge and the New American Dilemma of Race," suggest that: (1) racism and racist behavior toward the African-American are "normal," spontaneous phenomena borne of the human need to categorize things and people into de facto or de jure hierarchies of inferiority, superiority or mediocrity; (2) racism and racist behavior are sustained by pervasive, consensual, learned cultural mythologies that perpetuate strong stereotypes and influence perceptions, judgments and behaviors; (3) the majority of institutions and power brokers will tolerate or encourage strategies promoting piecemeal advancement of the African-American only if it serves majority self-interest; and (4) the daily subtleties of racism and racist behaviors are often ignored or unconsciously not "seen" as racist because of both the aforementioned need to categorize, and a phenomenon termed "unconscious" or "unthinking" discrimination.[12] Only by studying constructions of whiteness can health practitioners, administrators and policymakers understand how notions of white identity and privilege affect the health and medical arenas, often to the detriment of Black patients, their families and their communities.

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Karen Williams, MA, is a minority health programs manager at the Wayne County (MI) Department of Public Health. Veronica Johnson, MA, is Director of the University of Michigan Lansing Service Center and Co-Chair of the Health Policy Advisory Committee. Ms. Johnson and Ms. Williams are both chief consultants to Senator Raymond Murphy's African-American Health Institute and co-authored the Policy Brief 2001 referenced in this article.

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