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July 15, 2021
Health disparities Racism
Paula M. Lantz
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Critical Race Theory (CRT) has recently become the focus of conservative pundits’ vitriol and Republican lawmakers’ knee-jerk policy action. As of early July 2021, legislation prohibiting the discussion of CRT in K-12 public schools has been introduced in Congress and 22 state legislatures, passing into law in 6 states. In most policy discussions, CRT is used as a catchphrase or label for any type of pedagogy or training that attempts to elucidate institutional or systemic discrimination, implicit bias, colonialism, and other terms related to racial inequality. Policy rhetoric also shallowly misrepresents these frameworks and concepts as harmful to children by teaching divisiveness, prejudice, collective guilt, and racial segregation.1
CRT was coined and grew within academic legal studies in the 1970s-1980s by scholar-advocates who were interested in exploring how law and other forms of public policy could secure/protect civil rights, yet also serve to reproduce and codify racial hierarchy and discrimination.2 Importantly, CRT was not created de novo. Rather it is a bundling of tenets or suppositions that have a longer history in scholarship attempting to understand persistent racial disparities in economic, political, and social experiences and outcomes, including outcomes related to health. Taken alone or combined as CRT, these tenets are widely used in the humanities and myriad sciences, including the social and population sciences. Thus, CRT is a framework for a critical (i.e., deep, historical, complex) analysis of what drives ongoing racial inequality that builds upon long-standing scientific theories and concepts, and is supported by decades of multidisciplinary scholarship.
Any pundit, person, or group criticizing or defending CRT should understand its main tenets. This is especially important for the field of population health, broadly defined as science and practice related to the geospatial and social distribution of health-related exposures, risks, resources, and outcomes within and across populations. There can be no objective or effective teaching, research, or practice addressing population health disparities by race that does not implicitly or explicitly incorporate the tenets of CRT. Summarized below are four main tenets of CRT and how they are fundamental to understanding and addressing the significant racial inequities in population health in the United States.
Starting Point—Racial Inequality Exists: In CRT, the starting point is the actual existence of racial inequality. A vast amount of research documents significant and persistent racial/ethnic disparities in almost every key health metric in the United States, including life expectancy, infant and maternal mortality, cardiovascular disease incidence and mortality, homicide, and COVID-19.3 Furthermore, it has long been recognized that racial inequities in the upstream socioeconomic determinants of health are the primary drivers of downstream inequities in health outcomes, and that the experiences of racial minorities over the life course confer added cumulative exposures, risks, and burdens on health beyond socioeconomic status.3, 4
Building upon the evidence-based understanding of racial disparities in important social outcomes, including myriad health outcomes, the main tenets of CRT provide a useful framework for understanding the existence and persistence of these racial inequities and identifying key intervention points.2
Tenet 1: Race is a social construction – the way that race is defined and experienced is the result of social and political thought and actions that change over time. This tenet is built upon the fact that “race”—as a way to categorize or classify humans—is defined, measured, and experienced in demonstrably different ways both across and within societies over time. As Camara Jones explains: “Race is a social construct, a social classification based on phenotype, that governs the distribution of risks and opportunities in our race-conscious society… (it) measures a societally imposed identity and consequent exposure to the societal constraints associated with that particular identity.”5 Thus, it is racism—not race—that drives and explains racial differences in almost every health and social outcome.
A basic premise of population health science is that “race” is not a biological imperative driving disease processes and longevity, but rather a marker for how individuals within populations experience physical and social exposures, risks, facilitators, and burdens that matter for health over the life course. As Nancy Krieger explains, individuals’ “chances” for good or bad health outcomes are largely determined by social differences in exposures, risks, opportunities, resources, etc.; and it is this “structured chance” that drives racial and other forms of social inequality in the distributions of health and illness within populations.6
Tenet 2: Although individuals can indeed be racist, racism and its outcomes are perpetuated in society through social processes above and beyond individual actions including through cultural norms, institutional rules, and laws and regulations. Camara Jones has defined how racism operates at three different levels: 1) institutional and structural racism that differentially influences access to the goods, services, and opportunities of society by race; 2) personally mediated racism between individuals, which includes intentional and unintentional prejudice (differential assumptions about the abilities, motives, and worth of others by race) and discrimination (differential actions toward others by race); and 3) internalized racism or the acceptance of negative messages by members of a stigmatized race about their worth, deservedness, or abilities.5
CRT emphasizes the need to avoid the conflation of “racism” and “racists.” Rather than focus on racism as primarily being a problem of personally mediated racism—or individual “bad apples” on the police force, in hospitals/clinics, in schools, in banks, or in neighborhoods—CRT elucidates how institutions, systems, and policies can be designed in ways that reinforce, codify, and perpetuate exposures, risks and opportunities that differ across socioeconomic and racial groups. And because racism at all three levels contributes to racial inequality, policy action and intervention is necessary at all levels as well.
Tenet 3: Because the differential treatment of individuals based upon racial classification is embedded within social systems and institutions—including public policy and law—racism is commonplace rather than rare and aberrant. As such, racism is omnipresent in society, which CRT refers to as “normal.” This is sometimes misinterpreted to mean that CRT purports it is “normal” or expected for white people to be racist. The point here is that because differential access by race to resources, opportunities, benefits, and burdens is embedded within many aspects of our institutions and legal/policy systems, racial inequality continues to be reproduced outside of acts of personally mediated racism. Understanding structural racism within our systems and polices related to education, income, housing, food, criminal justice, the environment, and health care matters greatly for addressing population health inequities.3
Tenet 4: While racism is perpetuated at the structural/macro level in society, listening to and understanding the lived experiences of individuals is essential for understanding how racism works to create inequities in individual outcomes, including health. A main question for population health is how does living within institutions and systems that differentially structure exposures, experiences, and opportunities based on race/ethnicity get “under the skin” and produce health inequities?3-6 Moving beyond descriptive research that simply documents racial disparities in health outcomes, CRT rightly asserts that there is a need to better represent in research, the media, and policy advocacy and reform work how racism in all of its manifestations is experienced by people in ways that matter, including for physical and mental health.
In sum, CRT provides a framework for unpacking and understanding the fact that racial differences in important social outcomes, including morbidity, mortality, and other health indicators, exist and persist in the United States and other societies despite advances in civil rights. Population health scientists of all political persuasions should be deeply concerned about the current movement to ban the use of the tenets and concepts of CRT, as they are fundamental to a scientific understanding of racial inequality in every type of social, economic, and health outcome. Beyond banning the tenets of CRT in K-12 public schools, there is discourse regarding the need to ban such teaching and application in public universities, in publicly funded research, and in government-sponsored communication and education. Even if such actions are unsuccessful, the chilling effect on population health teaching, science, and policy work could be profound.
Given the misinformation and misguided political actions underway, it is incumbent upon those committed to health equity through population health science to publicly defend the tenets of CRT and their long-standing contributions to population health. The stakes—the ability for education, research, community-based efforts, and policy reform to improve the health and well-being of all—are incredibly high.
Paula Lantz, PhD, MS, MA, is the associate dean for academic affairs and a professor of public policy at the Ford School of Public Policy at the University of Michigan. She also holds an appointment as professor of health management and policy in the School of Public Health. Lantz teaches and conducts research regarding the role of social policy in improving population health and reducing health inequities. She is currently leading a project regarding the potential for and challenges associated with using social impact bonds to finance interventions aimed at upstream social determinants of health. An elected member of the National Academy of Social Insurance and the National Academy of Medicine, Lantz received an MA in sociology from Washington University, St. Louis, and an MS in epidemiology and PhD in social demography from the University of Wisconsin.
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