Discrimination Can Make You Sick

There’s a growing body of evidence that links the experience of racism with poor health and illness.  Recent, ground-breaking research further confirms this.

Any type of stress can impact health, but none may be quite as toxic as the tension and anxiety people experience when they fear that they will be discriminated against, reveals a groundbreaking new study led by Margaret Hicken, PhD, a Robert Wood Johnson (RWJF) Health & Society Scholar (2010-2012).

Working with a team that included David R. Williams, PhD, a veteran disparities researcher and head of the RWJF Commission on Building a Healthier America, and RWJF Health & Society Scholars Hedwig Lee, PhD, and Sarah Burgard, PhD, Hicken worked across disciplines to uncover several of the many ways that racism gets under the skin. “This research grew out of conversations with other Robert Wood Johnson Foundation scholars with backgrounds in sociology and epidemiology,” explains Hicken, who focuses on social demography and public health.

“Sociologists have a different way of looking at how people respond to discrimination on a personal level and what it’s like to live in a country where the media portrays your group in a certain way. Even policy-makers in the United States sometimes speak in code because ours is a racialized society,” Hicken says.

Using survey results from the Chicago Adult Community Health Study, a population-representative sample of 3,105 people, the team conducted two studies that measured the possible health effects of remaining hypervigilant about encountering racism when engaging in simple, everyday activities.

Health and the Stress Response

The first study was “‘Every Shut Eye, Ain’t Sleep’: The Role of Racism-Related Vigilance in Racial/Ethnic Disparities in Sleep Difficulty,” published in the June 2013 issue of Race and Social Problems. The results suggested that Black, but not Hispanic, adults were most likely to maintain high levels of racism-related hypervigilance (also called anticipatory stress), and toss and turn during the night. The Black adults reported 15 percent more hypervigilance-related sleep problems than the White adults.

The second study revealed far more striking differences among racial groups. In the article, “Racial/Ethnic Disparities in Hypertension Prevalence: Reconsidering the Role of Chronic Stress,” published online November 18 in the American Journal of Public Health, the team reported large differences in rates of hypervigilance and hypertension between Black and White study participants, and only a small difference among Hispanics.

Not only were the Blacks surveyed more likely to be hypervigilant about experiencing discrimination, that hypervigilance may have contributed to significantly higher levels of hypertension in them. At the lowest levels of hypervigilance, Black and White study participants had similar levels of hypertension. However, at the highest levels of hypervigilance, 55 percent of Black study participants had hypertension while 20 percent of the White study participants had hypertension.

The study findings may contribute greatly to the understanding of differences in health between racial groups, because disparities in hypertension are considered a significant contributor to health disparities in America.

Discrimination Can Make You Sick

(Download the PDF here.)


The Racism/Hypertension Link

“We think that the chronic activation of the biological stress response system that takes place when a person anticipates a negative event like encountering discrimination is what contributes to the higher rates of hypertension among the Blacks in our study,” Hicken says.

After controlling for variables such as income, gender, age, and socioeconomic status, study respondents’ feelings were measured through questions that included:

  • In your day-to-day life, how often do you do the following things: (a) try to prepare for possible insults from other people before leaving home; (b) feel that you always have to be very careful about your appearance to get good service or avoid being harassed; and (c) try to avoid certain social situations and places.

The researchers wrote, “the anticipatory nature of vigilance sets it apart from traditional notions of perceived racial discrimination. For decades, a large body of scientific and lay literature has provided evidence of the pervasive consequences of interpersonal and societal discrimination. In qualitative studies, social scientists often report on the way Blacks continually think about the potential for discrimination.”

“Overall, the work shows that in cases where racism-related vigilance is low or absent, Blacks and Whites have similar levels of hypertension. But when people report chronic vigilance, the rates in Blacks rise significantly. They rise a little in Hispanics, but not at all in Whites,” Hicken explains.

“For our next study,” she adds, “we are going to expand the questionnaire to gather better data and explore how or if the impact of hypervigilance can be mitigated.”

Originally posted at Robert Johnson Wood Foundation. 

Sleeping Problems Linked to Racism

Have a racist encounter during the day? Chances are, if you were on the receiving end of that encounter, you’re not sleeping well tonight. New research suggests that experiences of racial discrimination are associated with an increased risk of problems sleeping. These problems may in turn have a negative impact on mental and physical health.

My sleeping Angel
(Creative Commons License photo credit:Michael Brindley

The study involved an analysis of data from the 2006 Behavioral Risk Factor Surveillance System (BRFSS), which is administered by the CDC. The BRFSS is the largest, ongoing telephone health survey of American adults, administered annually to people selected by states and random-digit-dialing. Researchers analyzed responses from 7,093 people in Michigan and Wisconsin, which were the only states to collect data on both sleep and racism.

The results of the study show that there was a link between experiences with racism and self-reported problems with sleeping. Experiences of racism – which the health disparities literature insists on referring to as “perceived racism,” as if the problem is with perception – is assessed with the question: sorted into two cateogires as either “worse” or “same or better.” Respondents were classified as having problems with sleep if they reported having difficulty sleeping at least 6 nights in the past 2 weeks. Lead researcher and author Michael A. Grandner, PhD, Postdoctoral Fellow at the Center for Sleep and Circadian Neurobiology at the University of Pennsylvania, is quoted in an interview saying:

“This study found that an environmental stressor that exists purely at the social level—perceived racial discrimination—had a hand in how likely a person was to experience disturbed sleep. The most surprising finding in this study was that individuals who perceived racial discrimination were more likely to experience sleep difficulties, and it did not matter if they were black or white, men or women, rich or poor, or even if they were otherwise depressed or not, since these were adjusted for in the statistical analysis.”

There are a couple of things to note about this research. First and foremost is the somatic, bodily impact of racism on those who experience it.  Second, the overly cautious academic language of “perceived racism” undermines the voices and experiences of those in the studies who shared their experiences with researchers, relegating them to the realm of “perception,” the truth of which is to be determined later and by someone else, more removed, objective, and whiter.

Finally, what struck me about this research was that it’s framed within the language of health disparities in which the focus is always on African American, Latino, Asian and Native American folk. This is fine as far as it goes, as when it highlights the unequal burden placed on some when it comes to health.

What’s missing from this analysis is the unequal benefit that white people reap in all this. Encounters with racism are sometimes structural, sometimes personal. Over and over again in research like Living with Racism and The Myth of the Model Minority and Racism without Racists and Everyday Injustice and Racism in Indian Country, scholars have documented the experiences of Black, Asian, Latina/o and Native Americans with racist whites and with white power structures. Yet, the health disparities literature still frames these experiences as “perceptions” and white actors are rendered invisible through the academic use of the passive voice.

My guess is that most white folk are not losing sleep at night because of racism, and as a result of that, get an unearned benefit of greater physical and mental health.

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.

Racism and Racial Inequality in Health: Re-Thinking Health Care Reform as Social Justice

I’m gearing up for teaching this fall in an Urban Public Health program; part of what I like about the field is that it requires a very practical application of what can seem like abstractions in the field of sociology.  So, to talk about racism and racial inequality in public health means to talk about how these affect people’s bodies, health and illness.  Most eloquent on this subject recently is Marion Wright Edelman who has written about the impact of racial inequality on the health of children, she writes:

Right now, we live in a nation where children of color experience significant health disparities that begin before birth and follow them throughout their lives. Black infants are more than twice as likely as white infants to die before their first birthday and have higher infant mortality rates than children in 62 nations including Barbados, Malaysia and Thailand. One in every seven babies born to black mothers is born at low birthweight, a core risk factor for infant mortality and childhood developmental disorders. The rate of black infants born at low birthweight in the United States is worse than the rate of low birthweight in more than 100 nations including Algeria, Botswana and Panama.

Not surprisingly, black and Latino children also have higher incidences of childhood illnesses than white children. For example, one out of eight black children has asthma — one of the most common illnesses in children — compared to one in 12 white children. One out of every four black two-year-olds and one out of every five Latino two-year-olds is not fully immunized, although we know that every dollar spent vaccinating children against measles, mumps and rubella saves $16 in future costs. More than 30 percent of black children and about 40 percent of Latino children report not receiving dental care. Minority children are more likely to be living in poverty. However, racial disparities aren’t just about socio-economic status, although more than three-quarters of uninsured black children have a working parent, and more than half have a parent who works full-time throughout the year.

Edelman, a long-time defender of children’s rights, emphasizes “It doesn’t have to be this way,” and urges for reform on health care which would help address these persistent inequalities. Yet, even as much of the national public debate right now is focused on “health care reform” and that discussion has been derailed by racism.


Some anti-health care protesters, like the one in this photo (from here), cast their objections to health care reform in rather explicitly racist terms.  As Maggie Mahar writes, the health care reform effort has reignited what she refers to as the “Culture Wars,” a familiar story in the American political landscape. When viewed in terms of Edelman’s point about the impact of racial inequality on children’s health, these kinds of battle lines seem even more cruel.

I want to suggest that we re-frame the current health care reform debate in terms of social justice.   In my view, supporting universal health care for everyone in the U.S. is an important step toward re-dressing the persistent racial inequality that is endemic in our society.

Racism: The Impact on Health

A recent article in the American Journal of Public Health presents findings on experiences of everyday racism and HIV testing which are consistent with those from two other studies examining experiences of everyday racism’s relationship to preventive behaviors (condom use behaviors & mammography screening).  The greater the level of everyday racism, the less likely people are to engage in health prevention behaviors.   (Full citation for the article, which is behind a paywall: Ford CL, Daniel M, Earp JL, Kaufman JS, Golin CE, Miller WC. Perceived Everyday Racism, Residential Segregation and HIV Testing in an STD Clinic Sample. American Journal of Public Health Apr 2009 99;(Supp 1):S137-S143.)

The fact that racism takes a toll on the lives of people of color, and in particular on African Americans, is not especially new information.   There’s a literature on this that’s been growing for some years.  For example, Joe’s book with Karyn McKinney, The Many Costs of Racism, details the physical and psychological toll of racism on African American’s health.

What seems to be new here is that scholars in public health are increasingly documenting racism as an important underlying factor, if not a causal variable, in creating a number of specific health hazards and pathways to disease and mortality.   In the past, public health – like many other fields – had attributed racial inequality to the vagueness of social determinants phrased in the passive voice.   A research agenda that now explicitly includes racism is a step forward.

However, researchers are still overly cautious in their use of the term “perceived” as an ubiquitous qualifier to “everyday racism.”   Calling the experiences of everyday racism “perceived” leaves open the possibility that these experiences were not, in fact, racism but instead, a misundertanding of the actual situation.  If there is a “perception” of racism, then perhaps there is room for “misperception.”

Why does this matter?  It leaves unsettled then what the root cause is:  is it white racism that’s inflicting real harm on real people?  Or, is it the “perceptions” of black folks and other people of color that need to be adjusted?

Make no mistake, this burgeoning field of studying the impact on health of racism is important.  Yet, still largely missing here is a robust analysis of the cost of racism to whites.  A colleague of mine, Amy J. Schultz and I wrote a book chapter on this “Whiteness and the Construction of Health Disparities,” (Jessie Daniels and  Amy J. Schulz, pp. 89-127,  in Gender, Race, Class, and Health, (Jossey-Bass, 2006), Leith Mullings and Amy J. Schulz, Eds.).  Also missing here is what might be effective interventions, to use the public health language, to reduce the level of racism so that black and brown people might live longer, healthier lives.

Updated 6/26 to add: There’s an important piece on Racism’ Health Toll at Miller-McCune (from 6/15) that I should have referenced here.   Highly recommended.

Racism and Health Disparities

In a report just released from the NIH, as many as 1 in 100 black men and women develop heart failure before the age of 50, which is 20 times the rate in whites in the same age group.  In public health terms, these racial differences in health are referred to as “health the human heartdisparities,” and the newly released report from the NIH raises questions about why there are such stark disparities across racial groups (Creative Commons License photo credit: derek*b).

According to the NIH, this sharp rise in heart failure is directly related to the increased levels of hypertension (aka, high blood pressure) for blacks.    There’s a growing body of scientific literature which points to the experience of racism as a major factor in elevated blood pressure, one of the leading risk factors for early heart failure.   David Williams was a pioneer in this field with his 2001 article, “Racism, discrimination and hypertension: evidence and needed research,” (Ethn Dis. 2001 Fall;11(4):800-16).  That piece spawned a bunch of others, including an excellent piece by Wyatt and colleagues entitled, “Racism and cardiovascular disease in African Americans,” (Am J Med Sci. 2003 Jun;325(6):315-31), which posits that there are three levels of racism that affect the cardiovascular disease (CVD) of African Americans, namely:

First, institutional racism can lead to limited opportunities for socioeconomic mobility, differential access to goods and resources, and poor living conditions that can adversely affect cardiovascular health. Second, perceived/personally mediated racism acts as a stressor and can induce psychophysiological reactions that negatively affect cardiovascular health. Third, in race-conscious societies, such as the United States, the negative self-evaluations of accepting negative cultural stereotypes as true (internalized racism) can have deleterious effects on cardiovascular health.

And, in a recent cross-sectional study that included African American men  (n = 393) and women (n = 717), researchers at the University of North Carolina Chapel Hill found that the likelihood of hypertension significantly increased with higher levels of perceived stress following racism from non-African-Americans.

While many people contend that racism is no longer a relevant or life-threatening issue,  this kind of evidence persuades me that addressing racism is more crucial than ever.