Confronting Institutionalized Racism The Evolution of Health Policy: Influences, Interpretations and Implications Confronting Institutionalized Racism

Advancing health policy Setting the agenda Collecting data Coordinating action

The current agenda Initiative to Eliminate Racial and Ethnic Disparities in Health by the Year 2010 Healthy People 2010 Overarching goal to eliminate health disparities

How do disparities arise? Differences in the quality of care received within the health care delivery system Differences in access to health care including preventive and curative services Differences in social, political, economic, or environmental exposures which result in differences in underlying health status

Institute of Medicine Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care 2101 Constitution Avenue, NW Washington, DC 20418 http://www.nap.edu

Differences in exposures American Journal of Public Health February 2003 issue on Racism and Health Levels of racism Global definition of racism

Levels of racism Institutionalized Personally-mediated Internalized

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 SES and “race”

Personally-mediated racism Differential assumptions about the abilities, motives, and intents of others, by “race” 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 But there is a very important question that I have not raised so far. Who is the gardener? It is the one with agency and the control of resources, and in this country that is the government. It is particularly dangerous when the gardener is allied with one group over others (you see I have colored the gardener red, explaining the preference for red flowers). It is also dangerous when the gardener is not concerned with equity. If she had been, she would have asked the question why the pink flowers were not faring so well. Just asking the question would have led her to seek solutions. So that is the end of my story on levels of racism. The story was meant to illustrate the different levels of racism and how they are related, and to highlight that institutionalized racism is the most fundamental level. If you want to make real change in the garden, you have to at least deal with the institutionalized racism, even as you might also want to address the other two levels. Also, when you do address the institutionalized racism, the other levels will fix themselves over time.

What is racism? A system

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

What is racism? A system of structuring opportunity and assigning value based on phenotype (“race”)

What is racism? A system of structuring opportunity and assigning value based on phenotype (“race”), that Unfairly disadvantages some individuals and communities

What is racism? A system of structuring opportunity and assigning value based on phenotype (“race”), that Unfairly disadvantages some individuals and communities Unfairly advantages other individuals and communities

What is racism? A system of structuring opportunity and assigning value based on phenotype (“race”), that Unfairly disadvantages some individuals and communities Unfairly advantages other individuals and communities Undermines the potential of the whole society

Racism is a conveyor belt Don’t get carried away!

Debates Focus on racism versus focus on health disparities Political climate for acknowledging racism Perceived feasibility of interventions “Race” and racism in relation to social class Interactions Primacy Structural determinants

Advancing health policy Setting the agenda Collecting data Coordinating action

Module on Reactions to Race Piloted on 2002 Behavioral Risk Factor Surveillance System by: California Delaware Florida New Hampshire New Mexico North Carolina

Earlier you told me your race. Now I will ask you some questions about reactions to your race.

Question 1 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, or some other group?

Question 2 How often do you think about your race? Would you say never, once a year, once a month, once a week, once a day, once an hour, or constantly?

Question 3 [For those who are employed for wages, self-employed, or out of work for less than one year] Within the past 12 months at work, do you feel you were treated worse than, the same as, or better than people of other races?

Question 4 Within the past 12 months when seeking health care, do you feel your experiences were worse than, the same as, or better than for people of other races?

Question 5 Within the past 30 days, have you felt emotionally upset, for example angry, sad, or frustrated, as a result of how you were treated based on your race?

Question 6 Within the past 30 days, have you experienced any physical symptoms, for example a headache, an upset stomach, tensing of your muscles, or a pounding heart, as a result of how you were treated based on your race? We will not only be analyzing responses to these questions stratified by race, but will also be looking at the relation between responses to these questions and engagement in preventive as well as risky health behaviors, health care utilization, chronic disease outcomes, and overall quality of life measures using other data on the BRFSS. We hope that results from this module will start discussions at state health departments, raising questions that start with “Could racism be operating here in our state or in our program?”, and then move to “How is racism operating here in our state or in our program?”. We also expect that the results can be used in surveillance to judge the impacts of changes in programs and policies, as well as in the general racial climate.

How often do you think about your race? Never Once a year Once a month Once a week Once a day Once an hour Constantly Before I present the data on the question “How often do you think about your race?” from the earlier surveys, I would like us to answer that question in this audience. So who would say that they never think about their race? Please raise your hand. How about those who think about think their race once a year? . . . What usually surprises most people when I do this exercise is that not everyone says the same thing that they did. And it is especially surprising for those who say never that some people think about their race constantly, although it is less surprising for those who think about their race constantly that some people say never. It is also interesting that as you look around the room, there is a color gradient to the responses. So now lets look at some data on responses to this question from earlier surveys.

So now I show you data from New Zealand So now I show you data from New Zealand. These responses come from people who have come to hear me speak. The first group includes people who are usually classified as Päkehä and also classify themselves as Päkehä. The second group includes people who are usually classified as Mäori and classify themselves as Mäori. The third group may be sometimes classified as Päkehä but classify themselves as Mäori, or otherwise have some sort of mixed Mäori identity. So let’s look at the results. More that 75% of the Mäori-Mäori group reports thinking about their race constantly. That is much more frequently than was reported by the black women in the United States. The mixed Mäori identity group has a distribution quite similar to the Mäori-Mäori group. The Päkehä group has quite a different distribution from the Mäori group, but it is also markedly different from the white women in the United States. Note that only roughly ten percent report that they never think about their race, and the modal response is once a week. I think the difference between those of European descent in New Zealand and those of European descent in the United States is that Päkehä in New Zealand have a label applied to them that they did not chose themselves. That is, they have been named by others. Many white people in the United States do not even consider that they have a race. They consider themselves “normal”, “human”, “universal”. In fact, one white respondent to the Nurses’ Health Study II sent in a note saying “I don’t run.”

Racial climate Pertinence of “race” as a basis for classification Rules for racial classification Number and names of categories Sorting rules Opportunities and value accorded the different racial groups Measured by pertinence of racial assignment

Measuring institutionalized racism Scan for evidence of “racial” disparities Routinely monitor outcomes by “race” “Could racism be operating here?” Identify mechanisms Examine written policies Query unwritten norms and practices “How is racism operating here?”

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 There are four classes of policies that we have so far identified as being of interest. They are: . . .

Policies allowing segregation of resources and risks Redlining, zoning, toxic dump siting Use of local property taxes to fund public education

Policies creating inherited group disadvantage Estate inheritance Lack of social security for children 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 limitations to voting rights Limits to representation/participation “Majority rules” when there is a fixed minority

Advancing health policy Setting the agenda Collecting data Coordinating action

Quality of care Promulgate treatment protocols Implement reminder systems Monitor provider practice Train a diverse workforce Provide anti-racism training Train and deploy translators Ensure community oversight

Access to care Make health care a right Implement a national health system Provide universal health care coverage Train a diverse workforce Assure the appropriate geographic distribution of providers Implement Community Oriented Primary Care

Differences in exposures National conversation on racism Name racism Acknowledge impacts on health Acknowledge waste to the nation National campaign against racism

Confronting institutionalized racism Put racism on the agenda Ask, “How is racism operating here?” Organize and strategize to act Dismantle, remodel, or create a structure Eliminate, revise, or implement a policy Identify and challenge or promote a practice Identify and challenge or promote a norm

Register your efforts Document your strategies and successes with the Measures of Racism Working Group cdj9@cdc.gov