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

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

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?

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

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

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