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
–
–
–
–
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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, selfemployed, 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
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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 groupdisadvantage
• 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
cdj9@cdc.gov