The Evolution of Health Policy: Influences, Interpretations and Implications Confronting...

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, NWWashington, 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

– 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?


individuals and communities– Unfairly advantages other individuals

and communities

What is racism?


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

Module on Reactions to Race

Piloted on 2002 Behavioral Risk Factor Surveillance System by:

CaliforniaDelawareFloridaNew HampshireNew MexicoNorth 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

02

04

0

12.35

10.817.5

29.5

2.8

22.1

pe

rce

nt o

f re

spo

nd

en

ts

never 1/year 1/month 1/week 1/day 1/hour constantly

Black women (Black Women's Health Study, n = 49,709)

02

04

0

11.65.5

13.820.4

26.2

1.5

21

pe

rce

nt o

f re

spo

nd

en

ts


Black women (Nurses' Health Study II, n = 1,292)

02

04

0

50.2

17.4 19.39.6

3.1 0 0.3

pe

rce

nt o

f re

spo

nd

en

ts


White women (Nurses' Health Study II, n = 88,188)


02

04

0

24.9 20.5 23.715

7.80.2

8

pe

rce

nt o

f re

spo

nd

en

ts


Asian women (Nurses' Health Study II, n = 1,509)

02

04

0

25.818.1

24.917.5

9.70.2 3.7

pe

rce

nt o

f re

spo

nd

en

ts


Hispanic women (Nurses' Health Study II, n = 1,243)


020

60

12.5 5.419.6

31 24.4

1.2 6

perc

ent o

f re

spon

dent

s


Pakeha (n = 168)

020

60

1.9 1.9 0.9 4.7 9.3 4.7

76.6

perc

ent o

f re

spon

dent

s


Maori (n = 107)

020

60

3.7 0 3.7 9.322.2

7.4

53.7

perc

ent o

f re

spon

dent

s


Mixed Maori identity (n = 54)

New Zealand: How often do you think about your race?

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 creatinginherited 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 limitingself-determination

De jure limitations to voting rights

Limits to representation/participation

“Majority rules” when there is a fixed minority

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

[email protected]

The Evolution of Health Policy: Influences, Interpretations and Implications Confronting...

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