Racism, Whiteness and the Health Disparities Industry

There’s a growing body of evidence that implicates racism in a variety of negative health consequences.  Yet, the research on ‘health disparities and race’ neither focuses on whiteness nor on the ways that racism plays a role in health.

( Creative Commons License photo credit: rwdownes )

The Health Disparities Industry. Much of public health is driven by a concern with, and research on, ‘health disparities.’   If you’re not familiar with this field (or, subfield), it works like this:

“The literature on racial disparities in health by definition involves comparisons across groups defined by some racial classification system.  Perhaps the most common of these comparisons take the form of the following general proposition: [Black/Hispanic/Native American] [children or adults] have higher rates of [the condition, disease, or ‘disability’ under investigation] than whites, primarily because of [explanatory variable]” (Daniels and Schultz, 2006, p.97).

There is a vast amount of scientific literature, and a number of federal agencies, built on this formulation.  The equation is always the same: measure some health outcome (rates of heart disease, diabetes, HIV/AIDS) in “minority” populations and compare it to the rates in the white population.   Don’t misunderstand me.  I think it’s a good thing, indeed an important thing, to focus on the health of folks who are black and brown because they carry a disproportionate burden when it comes to health.  And, black and brown folks endure less than equal care when they encounter the health care system.  Both these – health and health care – deserve attention from scholars, activists and those in public policy.

In a recent article critical of the health disparities industry, Shaw-Ridley and Ridley chart the scope of this industry and question the ethics of it.  The problem is that there’s a lot that remains unexamined in the ‘health disparities’ framework.

Whiteness & The White Racial Frame in Health Disparities. Defining whiteness has been a central project of the construction of what it means to be American.   What it means to be “white” is built into the U.S. Census. This history is the subject of a recent book by Nell Irvin Painter, The History of White People.  She observes that:

“Until the 1960′s, there were two racial dialogues going on the United States. One was more or less Southern, and that was black-white. The other had to do with various kinds of white people.”

The fact that white people have dominated the U.S. since its founding has also meant that they (we) have shaped the very way that we view reality (e.g., everything from laws, relationships, media, discourse,) in the U.S.  This shaping of how we ‘frame’ things is referred to by Joe Feagin as ‘the white racial frame.’ The basic idea of the white racial frame is as follows:

The North American system of racial oppression grew out of extensive European exploitation of indigenous peoples and African Americans. It has long encompassed these dimensions: (1) a white racial framing of society with its racist ideology, stereotypes, and emotions; (2) whites’ discriminatory actions and an enduring racial hierarchy; and (3) pervasively racist institutions maintained by discriminatory whites over centuries. White-generated oppression is far more than individual bigotry, for it has from the beginning been a material, social, and ideological reality. For four centuries North American racism has been systemic–that is, it has been manifested in all major societal institutions.

Even though as Painter and Feagin note that whiteness and the white racial frame are central to the the American social and political context, these are little remarked upon within the literature on racial disparities in health outcomes.   Indeed, the white racial frame permeates the research on race and health, and in particular, the research on ‘health disparities.’

The usual construction of ‘health disparities’ research constructs whiteness in two ways:

“First, it establishes a comparison between whites as a referent group and some ‘other’ group whose health is evaluated in comparison to that of whites.  In an Ideal world, such comparisons may demonstrate arenas in which health outcomes do not differ by race, challenging ideas of racial group difference.  If, however, funders are less likely to support research in which susbstantial racial differences are not apparent, or if publishers are less likely to publish articles that find no statistically significant differences….the literature will reinforce racial health differences while minimizing similarities…  (Daniels and Schultz, 2006, p.97).

The comparison group in this research is always whites, which puts those who are not white in a “one down” position.  The question as it’s framed in this research is always “What’s wrong with this [non-white] group? What’s happening that their health outcomes are ‘disparate from’ [not as good as] the health outcomes of whites?”   The second way that that health disparities research constructs whiteness is through:

“….the use of racial categories and comparisons with no consistent foundation fo rthe theorizing, understanding, or interpreting observed racial differences (or their absence) in health outcomes provides space for a wide range of potential explanations.  Each of these ‘explanations’ implicity or explicitly constructs both race and whiteness.  ”  (Daniels and Schultz, 2006, pp.97-8)

The overwhelming majority of research on ‘health disparities’ never examines whiteness nor implicates the actions of white people in this equation.   This may be changing, however.  Very recent research by Blodorn and O’Brien (of Tulane University, “Perceptions of Racism in Hurricane Katrina-Related Events: Implications for Collective Guilt and Mental Health Among White Americans) examines the implications of health disparities on whites.   This is a rare focus in this research.

Racism. Contrary to the passive voice construction of most ‘health disparities’ literature, there are indications in the literature that there are actors responsible for at least some of the racial inequality contributing to the racial inequality in health outcomes.   As I mentioned at the beginning of this post, there’s an increasing amount of evidence in the scientific literature that supports the claim that racism is a contributing factor to ill health.  The pernicious sleight-of-hand in the ‘health disparities’ literature is that most of this research focuses on “perceptions” of racism among black and brown folks, but none of this research (at least none that I’ve found) acknowledges the reality of racism nor does it address those who are the perpetrators of racism in contemporary American society.

What Needs to Change. Clearly, there are unequal health outcomes that need to be addressed (see for example, Glady Budrys, Unequal Health: How Inequality Contributes to Health or Illness).  On almost every measure, those in our society who are Black, Latino or Native American will die sooner than those who are white.   For almost every disease, such as cancer and diabetes, those who are Black, Latino or Native American are more likely to contract the disease than whites, and once the disease is contracted, more likely to die from it.

This is one of the many costs of racism in our society and it must change.

However, looking only at those who must pay these costs as the source for changing these mechanisms of inequality is misguided.   We need to begin to critically examine those who hold the most power and resources in society, that is at white people, for the ways that they contribute to and benefit from the inequality in health outcomes.