This month Camara Jones visited our school to deliver the Jonathan Mann Health and Human Rights Memorial Lecture and eloquently spoke about racism and the multifaceted ways in which racism can affect health. When we think about the impact of racism on health one of the first things that comes to mind is what Dr. Jones refers to as “personally-mediated” racism. Personally mediated racism results in a collection of often subtle but pervasive and persistent daily experiences that can set off the body’s “fight or flight” responses leading to a cascade of physiologic effects that can trigger things like deposition of body fat, diabetes, and elevations of blood pressure. Dr. Jones also spoke about the role of internalized racism, in her words “the acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth”. Internalized racism can also have subtle yet important effects on health.
But perhaps the most profound way in which racism affects health has to do with institutionalized racism. Institutionalized racism limits access to power and material resources. It constrains the economic, educational and employment opportunities of discriminated groups and shapes the environments in which these groups live with profound consequences for health over the lifecourse and even across generations. Institutionalized racism is thus a fundamental cause of a constellation of other “downstream” factors that impact health. In public health we are very accustomed to thinking about these fundamental “upstream” causes. Intervening on these causes through policy is a defining feature of the public health approach.
The very same day of the Jonathan Mann Memorial lecture a front page article in the New York Times reported on remarkable gains in life expectancy in black Americans over the past 15 years and a striking narrowing of the life expectancy gap between black and white Americans from 7 years in 1990 to 3.4 years in 2014. Why did this happen? How does this favorable evolution of mortality fit in with the persistence of racism in our society? An audience member at the Jonathan Mann lecture asked us to reflect on precisely this question.
The hallmark of a good public health approach is to take a good look at the data in order to precisely describe the patterns and also search for clues of what might explain what we see. The reduction in the life expectancy gap appears to be attributable to reductions in death rates from a range of causes including heart disease, HIV, cancer, unintentional injuries and homicide (especially in men). Infant mortality has also dropped proportionately more in blacks than in whites.
But the picture is not as rosy as it may first appear. A closer examination of the actual values of life expectancy for blacks and whites in 1990 shows that blacks started out much lower (only 69.1 years compared to 76.1 years). It is not unexpected that gains would occur more easily (and more rapidly) when life expectancy starts at lower values than when it is already high to begin with.
Indeed between the early 1980s and the mid 1990s US blacks experienced not only stalling but also unprecedented declines in life expectancy largely attributable HIV, homicides, and the crack epidemic. Hence the more rapid increases in life expectancy occurred right after a period during which life expectancy had been evolving much more unfavorably in blacks than in whites. In addition, part of the reduction in the life expectancy gap is attributable to unfavorable trends in life expectancy in some groups of whites (primarily whites with low education) linked to the opioid epidemic, although this appears to explain only a small proportion of the reduction.
Of course these summary numbers hide important heterogeneity within both blacks and whites associated with socioeconomic factors. For example, a 2012 study reported that white men with 16 or more years of schooling can expect to live an average of 14 years longer than black men with fewer than 12 years of education. Race and class thus need to be considered jointly as they affect health through interrelated pathways.
A critical fact is that despite reductions in the life expectancy gap between blacks and whites, blacks continue to experience substantially higher death rates due to heart disease, cancer, homicide, diabetes, and perinatal conditions, with these conditions accounting for 60 percent of the black-white gap. As noted by the CDC report, the gap would be even larger "if not for the lower death rates for the black population for suicide, unintentional injuries, and chronic lower respiratory diseases."
Certainly the favorable evolution of life expectancy among blacks over recent years is very good news. It is important to identify the key drivers of this improvement. But the stark reality is that there is still much to be done to eliminate the disparities in health by race, ethnicity, and social class that plague our societies. According to the Philadelphia Department of Public Health 2015 Community Needs Assessment, life expectancy was only 69 years for black men compared to 74.9 years for white men, and 77.4 years in black women compared to 80.5 years in white women. Differences in premature mortality are especially striking: the years of potential life lost before age 75 were close to 11,800 years per 100,000 persons for blacks but only about 7,400 years per 100,000 persons for whites.
Dr. Jones challenged us to think broadly about the impact of racism on health. Despite progress made, the persistence of stark differences in health by race highlights that eliminating racism at all levels, taking action to redress its historical effects, and acting broadly on the social determinants of health remain key strategies to improving population health.