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UNC-Chapel Hill School of Public Health –

5th Annual William T. Small, Jr. Keynote Lecture –

Confronting Institutionalized Racism

February 28, 2003

KAMILAH THOMAS: Hello and welcome to the Satellite and Internet Broadcast of the Keynote Lecture from the 25th Annual School of Public Health Minority Health Conference. My name is KAMILAH Thomas, and I’m a Master’s student in the Department of Health Behavior and Health Education, and also Secretary of the School’s Minority Student Caucus. The Minority Student Caucus was founded in the early 1970s as a vehicle for bringing the concerns of minority students to the attention of the School’s administration and for working to attract more students of color to the School. The Minority Student Caucus founded the Minority Health Conference in 1977, and has conducted it since then. The Caucus also sponsors many community service and professional development events throughout the school year. You can learn more about the Caucus and the Conference at www.minority.unc.edu.

This year’s Minority Health Conference is entitled, “The Evolution of Health Policies: Influences, Interpretations, and Implications”. Earlier today, we had the pleasure of hearing this year’s William T. Small, Jr Keynote Lecturer, Dr. Camara Jones, on the topic of “Confronting Institutionalized Racism”. Dr. Jones is a family physician and epidemiologist, whose work focuses on the impact of racism and on the health and well-being of the nation. As an epidemiologist, she studies the nature and mechanisms of race-associated differences in health outcomes. As a teacher, she has a gift for illuminating topics that are otherwise difficult for many Americans to discuss. She hopes through her work to initiate a national conversation on racism that will eventually lead to a national campaign against racism. Dr. Jones currently serves on the Board of Directors of the National Black Women’s Health Project, the Executive Board of the American Public Health Association and the Board of Directors of the American College of Epidemiology. Dr. Jones is a public health leader who is helping to bring about the elimination of racial and ethnic health disparities. And now we will view the videotape of Dr. Jones’s keynote lecture. As soon as the lecture finishes, you will be able to post questions to her live in our studio by calling us at 1-877-869-7811, faxing your question to 1-919-966-7141, or by sending an e-mail to question@unc.edu. You can also visit our website at www.minority.unc.edu. This information will appear on the screne periodically during the broadcast. And now we begin the videotape from the 25th Annual Minority Health Conference Keynote Lecture by Dr. Camara Jones.



DR. CAMARA JONES: Thank you so much for inviting me to be the William T. Small Keynote Speaker. I feel like I’m at home here at UNC Chapel Hill. I’ve been greeted so warmly, and it’s such an honor to be here, so thank you all.

Today, the whole conference is around the evolution of health policy, influences, interpretations, and implications, and I want to focus us on confronting institutionalized racism, as a potential health policy. I’m not a health policy expert, but in terms of advancing health policy, there are three things that I know. First of all, it’s important who is setting the agenda and what’s on the agenda. The second thing is that we often look to data to help guide our policy. Not always – sometimes politics guide our policy more than data do – but it’s important to collect data, so that we can potentially guide our policy. And then, finally, policy is for nothing if not to help us coordinate action. So, I’m going to use this framework of setting the agenda, collecting data, and coordinating action, to talk about confronting institutionalized racism, for these next 40-minutes or so.

Our current health agenda is thankfully focused on eliminating racial and ethnic health disparities, thanks to the excellent work and efforts of our 16th Surgeon General, David Satcher. He and former President Bill Clinton announced, in February of 1999, the initiative to eliminate racial and ethnic health disparities by the year 2010, and then they formalized that initiative in our country’s National Health Plan, Healthy People 2010, where the second of two overarching goals is to eliminate health disparities. And of course, the current Administration has continued to embrace this as a very important aspect of our National Health Plan. So, if we are going to be serious about this effort to eliminate health disparities, we are going to have to get some understanding of how health disparities arise.

I want to offer to you a framework of thinking of how health disparities arise, how racial and ethnic health disparities arise, in particular, on three levels, and this is – I mean a lot of people talk about this. I think it’s useful for us to think about how these disparities arise because that’s how we can intervene.

First of all, people have looked at differences in the quality of health care, differences – [the AV technician came on stage to suggest that she use the podium microphone, because the wireless microphone that she was wearing was picking up noise from her necklace] what do you want me to do with this? Okay, you know what I’m going to do? I’m going to take it [the microphone] off, but you know what it means? I’m going to go out a few times to tell different stories, and so I’m just hoping – maybe I can just pick it up, don’t take it too far. And then I’ll carry it over there. Okay, sorry for that. The other thing I want to do is for the AV person, can you tell me, because I’m having to look over here to see my pictures are not very big here on the screen. Can you tell me or help me with that? And I’ll continue talking while he comes around and helps me with that. – So differences in the quality of care and differences in the health care delivery system is where people go first. I mean that seems, sort of, the easiest thing for people to think about, but of course health disparities arise not just within the care people get once they’ve made it into the system, because there are so many who don’t even have access to the health care system. So you have differences in access to health care, including both preventative and curative services and then, of course, before you even need to access health care, you have differences in how sick different populations are, because of differences in social, political, economic, or environmental exposures that result in differences in underlying health status, and I think that instead of being stuck in what we can do within the medical care system, or even more broadly, within the medical and public health system, we need to think about intervening at all of these levels, which includes having partners that are not within health – partners that are in justice, partners that are in economics and business and all of that – in order to understand how to intervene on health disparities.

Now I’m happy to say that last year, the Institute of Medicine released a very, very important report, called “Unequal Treatment – Confronting Racial and Ethnic Disparities in Health Care”, and I’ve given you an address here (www.nap.edu) in case you want to get the summary, which you can write and get a free little, you know, like 30-page summary, and also there’s a website there that you can go to and actually look at the whole report on-line. This report reviewed all the data that are now out there about differential care by race and ethnicity within the health care system and came out and basically said that there is evidence for bias in the system, and they made some very important recommendations that included systemic recommendations as well as retraining of health providers and all of that.

But even the people who were on that IOM committee were frustrated by the fact that they were constrained to only think about what happened once people were in health care. They were specifically told not to consider issues of access to care and then beyond that, of course, what makes certain populations sicker in the first place. So this is very important work, and some people have even suggested that the IOM be commissioned to take a close look at these other two levels of how health disparities arise. Wouldn’t it be interesting if the IOM did a report on differential access to care by race and ethnicity, or did a report on diffential life experiences and life opportunities by race in this country.

Looking at that third level of how disparities arise, differences in exposures, and social, and political, and environmental influences– I’m happy to say that this is on the scientific agenda and, especially now with the publication, in this month, February 2003, the American Journal of Public Health published an issue devoted to issues of racism in health. These are papers that were presented last year in April of 2002 at a meeting convened by the National Institutes of Health, and if you haven’t read this issue, you need to read it.

What this is doing is – there have been people working on these issues now for a while – but this is allowing us to discuss. It’s putting on the scientific agenda and making legitimate discussion of issues of racism. So now, we are going to be able to more easily engage in discussions of some of the fundamental causes of racial disparities. Because of course, that’s what we think is happening.

In order to have that kind of discussion, you have to have some kind of common language or whatever, so what I’m going to do is present to you all, a framework for understanding racism on three levels that some of you will be familiar with. But because not everybody is familiar with it, I’m going to present it again briefly. I’m going to tell a story that illustrates these three levels of racism that will help us understand how can racism turn into health impact, and then I’m going to provide something new that nobody here has ever seen before, which is my global definition of racism, which I think can move us forward toward action.

I think about racism on three levels, institutionalized, personally-mediated and internalized. So I’m going to quickly define each of these levels and give you examples of how they can impact on health. The first level, institutionalized racism, I define as the system that results in differential access to the goods, services and opportunities of society, by “race”. And this is the kind of racism that often doesn’t have an identifiable perpetrator. You can’t point and say so-and-so did something to me. It’s often manifest as inherited disadvantage, and it’s invisible because it’s institutionalized in our laws and in our policies and customs and norms, and in our values. Yet, it would be apparent to a Martian who could land here in Chapel Hill or in almost any other city in the United States and look at the way things are distributed, for example, housing. And that Martian would say, there is something systematic going on here by race.

Institutionalized racism manifests itself in terms of access to material conditions, like housing, education, employment, income, medical facilities, access to a clean environment including the location of toxic dump sites, and all of those examples have direct impacts on health. Institutionalized racism also manifests in terms of access to power. Power is information, which could be health information or information about your own history. Access to power is resources, material resources, organizational resources, political resources, or access to power as a voice, representation on school boards, representation in our Congress, representation on the media, control of the media.

Now sometimes when I present this kind of definition and examples of institutionalized racism, people say, “well, why are you calling that racism, when you clearly have up there housing, education, occupation, income? Those are how we measure social class. What are you talking about really? Are you talking about racism or are you talking about social class.” So I’d like to address that point by saying that it doesn’t just so happen that certain groups in this country, for example, black folks, are overrepresented in poverty, while other groups, especially white folks, are overrepresented in wealth. That’s not a happenstance or a fluke. That situation is present today because of the initial historical injustice of the enslavement of West African people. You know our kidnapping and importation across the Atlantic, and then the use of our coerced, unpaid labor to build this country for centuries.

But then, you know you’ll say, “Well okay, but that was a long time ago, you know. Enslaved people were emancipated in 1865. Come on, it’s 137 years”. And all else being equal, we would expect that things would have evened out. But the key phrase there is “all else being equal”, and all else has not been equal, and all else still is not equal in this country. [applause]

There are contemporary structural factors that are perpetuating that initial historical injustice for Africans of our enslavement, for Native Americans of the taking of the land. You know, each group has it’s own history, but there are contemporary structural factors that are perpetuating those initial historical injustices. And it is those contemporary structural factors – the laws and the practices when we remove the laws – that I’m calling part of institutionalized racism. And so when I’m asked, am I talking about racism or am I talking about social class, I say that it is institutionalized racism that explains the fact that we see an association between social class and “race” in this country. Before I get off of institutionalized racism, I just want to say that it can be through acts of omission, not doing, as well as acts of commission, doing, and institutionalized racism is very, very often manifest as inaction in the face of need.

The second level of racism that I describe is personallymediated racism, and my kind of quick definition is differential assumptions about the abilities, motives and intents of others, by “race”, and then differential actions based on those assumptions. So that’s what most people think of when they hear the word “racism”. You know, somebody did something to somebody. It’s the prejudice, the different idea, and then the discrimination, the different action. And, of course, personally-mediated racism can also impact your health, examples include:



  • Police brutality – You know, if you are pulled over for driving while black, and then a police officer interprets that you are resisting arrest and then hits you upside the head, that’s going to impact your health. And there are too many men, especially, in too many cities around this country, that if I started telling you, you know, they were interpreted as pulling up a gun, or having a gun. I could be talking about any number of people. It’s not just one situation. It’s not just Amadou Diallo, who was thought to be pulling out his gun when he was pulling out his wallet and was shot 43 times or some outrageous number. It’s happening too many times, too many days in this country.

  • Physician disrespect, which can be as subtle as a physician’s not giving a patient the full range of treatment options, because they figure the patient can’t afford, wouldn’t understand, wouldn’t comply, you know. Or it can be as blatant as sterilization abuse, which still goes on.

  • Shopkeeper vigilance – you know, some people in this audience know what I’m talking about. I don’t even have to explain it. You walk into a store and then, you know, the clerk is shelving right next to you and then you move over and then, all of a sudden, they’ve got to shelve the next place, and they aren’t asking may I help you? You know, they are just right on you. That’s part of one of the stresses of everyday racism in this country.

  • Waiter indifference –, not getting respectful treatment

  • Teacher devaluation – This is very important. When a teacher looks at a young child and thinks that that young child can’t learn, or interprets that child’s question at a low level of sophistication as opposed to a high level of sophistication, and then starts tracking that child at a whole wrong trajectory, that impacts all of their life opportunities and chances and their health into the future, and it affects the children of that child.

Just like for institutionalized racism, personally-mediated racism can be through acts of omission, not doing, as well as acts of commission, doing. And also – very, very importantly – personally-mediated racism can be unintentional, as well as intentional. You do not need to have intended to do something racist to have it have a racist impact.

The third level of racism I describe is internalized racism, which I define as acceptance by members of the stigmatized races of negative messages about our own abilities and intrinsic worth. That impacts our health through self-devaluation. Feeling less than …[members of other groups], which not only is not good for you and maybe limits your life opportunities, but I think it also turns into fratricide, for example, black-on-black crime. Because if you don’t value yourself and you may not value that brother that looks like you and you may just as well off him as not.

The white man’s “ice is colder” syndrome – that phraseology comes from my parents generation, but it’s still true to some extent today at that time, if you were black and you wanted a lawyer, you might go and look out for the white lawyer, get the white lawyer as opposed to the black lawyer, or if you needed a doctor, you go and get a white doctor, as opposed to a black doctor, and if you needed ice, you go down the street and get the white man’s ice over the black man’s ice because the white man’s ice is colder. Right? It’s deeply believing in the superiority of white folk, internalizing that message that is out there.

Resignation, helplessness and hopelessness, I think not only turn into lack of registering to vote or voting, but also turn into destructive health behaviors, and so impact on health. I would summarize internalized racism as accepting the limitations to our own full humanity of the box into which we’ve been placed. And so, maybe a young black girl saying I won’t do ballet or violin because that’s not a black thing to do, or I’m not going to try to be valedictorian of my class because then my friends will say I am trying to be white. Right, since when do white folks own excellence? So –[laughs] I heard a little murmur “and it’s true” [laughter].

So what I’d like to do now is tell a story that illustrates these three levels of racism and their relationships to one another and helps guide us in our action, and there are some of you who have read this story before or have heard me tell it before, and so I started feeling uncomfortable about telling this story again and again and again, but people say to me that I need to keep telling it until people can tell it back to me, so that’s your challenge. [laughter and applause] That’s your challenge. If you’ve heard it before then get it so you can tell it to your neighbors and tell it back to me.

This story, like a number – I have about 14 teaching stories or allegories that I’ve developed in my teaching on race and racism, and this one like all of them was based on a real-life experience – so the real life experience was that when I moved to Baltimore, my husband and I bought a house, and we had flower boxes on our porch and we wanted to plant flowers in our flower boxes, so when spring came, because we bought the house in October, so we had to wait a while so we were really anticipating …… when spring came, my husband said, “Well, you know, we don’t have, we have some dirt in some of the boxes, but some of the boxes are empty, so let me go on down to the garden store and bring back a bag of potting soil”. So he did that, and he filled up the empty boxes. Then we got our flower seed, and we sprinkled the same number of seed in all of the boxes and, you know, watered them and waited for them to grow.

Now I’m not a gardener, so I was kind of sitting back, laid back, so when I came out of the house about three weeks later and looked at the flower boxes – this is true – there was an amazing difference in yield and in the way the boxes looked, between the boxes that had the potting soil, which turned out to be rich fertile soil, and the boxes that had the old soil, which turned out to be poor rocky soil. Because in the boxes with the rich fertile soil, it looked like every single seed had sprouted. You know some of them were very tall and vigorous, some of them were just making it, but it looked like all of them had sprouted, as compared to in the box with the poor rocky soil, which had just half as many plants. I guess the weak seeds had died and even the strongest seed among them were just struggling to make it to a middling height.

Now, I saw that with my own eyes, and those of you who are gardeners may have seen something like that with your own eyes if, you know, you compost half of your garden or something like that, and what that image is about is the importance of environment. But now I’m going to take that image and turn it into a story about racism, by introducing a gardener. And this gardener has two flower boxes, one which he knows to have poor rocky soil and one which he knows to have rich, fertile soil. And she has seed for flowers, the same kind of flower, except some of the seed is going to produce pink blossoms, and some of the seed is going to produce red blossoms. And, the gardener prefers red over pink. So the gardener puts the red seed in the rich, fertile soil, and she puts the pink seed in the poor, rocky soil. And, you know, three weeks later in her garden, the same thing happens that happened in my garden. All of the red seed sprouted, and some of them were tall and vigorous. But even the weak ones were making it up to a middling height, which we actually see, you know, in our system. And in the poor, rocky soil, it looked like half of the seed had died and the strongest ones were making it just to middling height. But then what happens is those flowers go to seed, and then the next year, the same thing happened, and those flowers go to seed. And year after year, the same thing happens, and then finally 10 years later, the gardener comes back and she’s looking at her garden, and she says, “You know, I was right to prefer red over pink” – right?

I’m going to interrupt the story there to say that the first part is about institutionalized racism. You have the initial historical insult of the separation of the seed into the two types of soil. You have the contemporary structural barriers of the flower boxes keeping the soil separate and then, because of inaction in the face of need, the perpetuation of that situation. Now I’m going to pick the story back up and say “well where would personally-mediated racism be in this garden?” That’s when the gardener’s looking at the flowers, and she’s just beaming at the red flowers. They look so good. And then she looks over at the pink flowers, and she says, “they sure look ugly and scrawny”, and she plucks off the blossoms before they can even go to seed – Or she notices that a pink seed has blown into the rich, fertile soil, so she plucks it out before it can establish itself.

And then where would internalized racism be in this garden? Well, that’s when the pink flowers are standing in their box, looking over at red, and red is all flourishing. And here come the bees. And the bees are just in there, you know, collecting nectar and pollinating as they go. And so they’re over in the red, and here comes a bee. And it’s over in the pink, and here it comes to one flower that says – a pink flower says – “Stop bee. Don’t bring me any of the pink pollen., I prefer the red”. Because the pink flowers have internalized by looking over there, and everything red is better than pink. So the question arises, “how do you set things right in the garden?” Well, you could start by addressing the internalized racism. So you could go over to the pink flowers, and you could say, “Pink is beautiful. Power to the pink!” [laughter] And that’s good. The pink flowers will feel better. But if that’s all that happens, that in and of itself will not change the situation in which they find themselves.

Or you could say, “Well no, I can understand that; let me address the personally-mediated racism”, right? Let me go talk to the gardener, or better still, we won’t even just talk to the gardener, we’re going to hold a multi-cultural workplace workshop for the gardener. [laughter] Which is good, right? And you are going to say to the gardener, “Would you please stop plucking those pink blossoms?” Well, maybe she will and maybe she won’t. But even if she does, that’s not going to change the situation in which the pink flowers find themselves. What you have to do, if you are really going to set things right in this garden, is address the institutionalized racism, right? So you’re either going to have to break down the boxes and mix up the soil or, if you want to keep separate boxes – which is okay, too; although, I think that makes it easier to segregate resources but if you want to keep separate boxes, that’s good, then you enrich the poor rocky soil until it’s as rich as the rich, fertile soil. And when you do that, the pink flowers will flourish, they will look beautiful. They might even look better then the red, because they have been selected for survival and strength. And that is a very interesting notion. And when you have fertilized the pink flowers with equal soil to what the red have, then they will no longer – you will have addressed the internalized racism, because they won’t be looking over to red, wanting to be red or thinking that red is better because they will see how beautiful they are. So you have addressed the internalized racism, and you may even be able through that one intervention to address the personally-mediated racism. Now the original gardener may have to go to her grave preferring red over pink, but her children growing up, you know, seeing the flowers equally beautiful, but be less likely to hold on to that attitude, okay?

So this story has been to illustrate these three levels of racism, the relationship between them and to very strongly suggest that if you want to set things right in the garden, if we want to eliminate racial disparities, you want to make things right, in this country, we must at least address the institutionalized racism. You can address the other levels at the same time, but you must at least address the institutionalized racism and when you do that the other levels may take care of themselves.

Now because I have so much more to share with you, I’m not going to share all the pictures that I have with that, but there is one picture that I share about this story, which is a very important question, “Who is the gardener?” After all, in my story, I painted the gardener as the one with the power to decide, the power to act and the control of resources, so you know is it our government, where is that, okay? But wherever you think the gardener is, it’s especially dangerous when the gardener is allied with one group. Here, I painted her red. That’s why she preferred the red over pink. And it’s especially dangerous when the gardener is not concerned with equity. I mean, what can this gardener be thinking about? She’s not looking at the garden, is she? She’s only looking at the red flowers. How can she be happy like this? But its as if the pink box is not part of her garden. Well at least in this country, as I say, on our health policy agenda, we do have now a commitment to equity, an explicit commitment to equity. And this is the first time, actually, because of course, in the first Healthy People in 1990, and in Healthy People 2000, there were separate race-specific goals, say for infant mortality rate. You would want to reduce the black rate from here to here and the white rate from here to here, right? Now, at least, we have equity as the goal, and that’s very important.

But this question, “who is the gardener?”, is also important in terms of thinking about interventions. What does the pink flower population have to do? Do they have to wait for the red gardener to become striped? I don’t know, you know, or are there ways that they can recruit or grow their own gardener? And these are questions that I really don’t have answers to. I mean they’ve been posed to me in past talks, and I don’t have those answers. But this whole situation, “who is the gardener?”, “where did the initial preference for red over pink come from?” – you know, all of that stuff has led me to this kind of global definition of racism that I’m going to share with you now. And you are the first large audience to see this, so you can help me with this. I mean it’s not finished, but here it is.

What is racism? Well first of all, I start by saying that racism is a system, it’s not an individual psychiatric illness of white people.[laughter] For example, it’s not a moral failing, it’s not a character flaw, it’s not an individual thing. It’s a system. And what is this system doing? It’s a system of structuring opportunity and a system of assigning value. Now how is this opportunity structured? How is the value assigned? What is it based on? It’s based on phenotype, how people look, which is what we call race, okay?

Now what is this system doing? This is a system that unfairly disadvantages some individuals and communities, and we think about it a lot like that. But is a system that at the same time is unfairly advantaging other individuals and communities, and we don’t often think about it like that. I mean, you know the whole issue of white privilege and kind of a sense of white entitlement doesn’t very often come up in public discourse, and while it is doing these things to individuals and communities, what is it doing to the whole society? It is undermining the realization of the potential of the whole society, because we are wasting the human potential. We are discarding all the genius in certain populations. We are not investing in all of our people and all of our genius, and that is making us a sick and weak society. So even if you are one of the individuals orcommunities that’s being unfairly advantaged as an individual, the society in which you live is still be adversely impacted by racism.

And that’s so… I like this definition because it helps us to start understanding that first of all the interventions don’t need to stay at an individual level of cultural competency, which is very important, antiracism… all that is very important, It’s important because we have to have people open their eyes and acknowledge that racism exists, but then really what we need to do is start attacking the system. The system, which is the institutionalized aspect of racism. We need to confront institutionalized racism.

Now I’m going to share with you another story. And this story is … it started out with Beverly Daniel Tatum’s book, Why Are All the Black Kids Sitting Together in the Cafeteria and Other Conversations about Race. If you haven’t read that book, you have to read that book. It’s excellent. It’s a book that you can read and share with your neighbors and your colleagues. Dr. Beverly Daniel Tatum is now the President of Spelman College, and in that book she talks about racism as a conveyor belt. And I have to just admit to people now it’s been so long since I’ve read the book, that I don’t know where the analogy that she tells ends and where I pick up begins. So read the book, and then you’ll be able to tell me, you know, how much of this is her story and how much I’ve added on. But she talks about racism as a conveyor belt. So you don’t have to do anything to be racist in this country. You’re just standing there, and it’s a people mover. We’re all on it, okay? And it’s taking us toward racism. But what you do have to do, – if you understand it where it’s taking us and it’s taking us toward racism and you don’t want to go there – what do you have to do, you have to turn around, right? And you have to walk. And you can’t even walk just a little bit. You have to walk at least as fast as the conveyor belt is going, and faster if you really want to go in the opposite direction.

Well, what’s going to happen when you turn around and start walking. There are all these people standing on the conveyor belt just there, right? Well, you’re going to be bumping into people, right? And people are going to say, “Hey, watch out. Hey, buddy”, you know, “Hey what are you doing?”, right? But what you have to do is not just turn around by yourself and say, “Well look, don’t you see where we are going, don’t you see the racist direction where we are, where we are being taken? Do you want to go there?” So you talk to people, and maybe the person you bumped into says, “Well no, I don’t want to go there”, so they turn around with you. So now you have two people, and then you are bumping into people, and you pick up more people and you say, “Why are you walking in the opposite direction?”. And eventually, if we can name racism and everybody sees where we are going, and everybody decides, we don’t want to go there, and we all turn around, maybe we can all turn back and get to the motor of the conveyor belt and turn it off. [Applause]

That’s what I’m talking about in confronting institutionalized racism. That is our goal. Okay? Now there are debates – I’m still in the setting agenda section of my talk, but I’m going to move on very quickly. There are debates about whether attention to racism should be the agenda. Because right now, we have an excellent agenda. I mean attention to health disparities, I mean that is so important. This is the first time, I’ve said, that we have been committed to equity. But what I’m suggesting is that if you’re attending to health disparities, racial and ethnic health disparities, are based not on biology, but on our different life experiences in this country on racism. So if you want to attend to racial and ethnic health disparities, you have to deal with the fundamental causes. You have to name racism and deal with that.

But there are people who are saying that this focus on racism vs. focus on health disparities might be premature or untimely. And some of the discussions have been that are we really in the political climate right now where we can acknowledge racism, where people can acknowledge racism? Or maybe people will feel like, if you talk about racism, they’ll throw up their hands, because they perceive that it’s not feasible to intervene when racism is such a big problem. I’m not going to go into all of these debates and questions and all, but that’s something that I think during our discussion period, we may want to take up with one another. I would just say that, yes, it’s a big problem, but there are mechanisms by which it’s being perpetuated, and if we identify those mechanisms that I think that we can start dismantling the system bit by bit.

Another debate, when you talk about racism is attention to race and racism vs. attention to social class. And, you know, where are we supposed to be on that. Certainly there are interactions and individual people and people who have lived experiences, it’s all of what they are, their class, gender, race and all that, and certain people feel that one thing is promising in their lives over others, and I think that even if, if I were to ask a poor, black women, what would you rather be, rich and black or poor and white, she would probably say rich and black, right? But then if I ask her further, she might say that class is more important in her life. But then if I ask her further, “well, why do you think it is that you’re poor, you’re parents were poor and that you’re children are likely to be poor, what are the structural factors that are conditioning the fact that you are poor in the first place?”, then we get attention to the causes, the underlying causes, the racism and that, so that again, this is another debate that we are actively involved in at CDC and trying to get the intersections right and all of that, and so that’s something else we can discuss as a group when I finish.

So now I’m going to move on to the second, though we were talking about setting agenda, how we have the health disparities agenda, which is a very important agenda, and how I’d like to introduce racism as a part of that because that’s addressing the fundamental causes of health disparities. Now what about collecting data to help forward this aspect of advancing health policy. And I’m going to just share with you two efforts that are coming out of the Measures for Racism Working Group at the Centers for Disease Control and Prevention.

The first is a module, a six-question module, that we call the Reactions to Race Module that was piloted on the 2002 Behavioral Risk Factor Surveillance System by six states. California, Delaware, Florida, New Hampshire, New Mexico, and North Carolina, and the data collection ended in December of 2002. The states actually have their data and are working with it already. CDC doesn’t have the clean data sets for all the states yet. Those data sets will be cleaned by April, so I was at first hoping to share with you some of the data from this module, but I’m not going to be able to that at this time. But I will share with you what the questions are and encourage you to follow-up.

The module starts out, “earlier you told me your race”. It starts out that way because the module was put at the very end of the survey, in the state-added question section, and people had been asked earlier about their ethnicity – Hispanic, yes or no, and then their race – you know, the usual Office of Management and Budget question. So, “earlier you told me your race. Now I will ask you some questions about reactions to your race. 1. How do other people usually classify you in this country?” It’s not asking for self-identified race. I t’s asking exclusively about race as a social classification, and the categories are all the OMB categories plus Hispanic or Latino, because of course there’s an artificial distinction between race and ethnicity, and in people’s lived experience, they’re classified like this. I won’t have time to talk about how we are analyzing all these studies, these questions, but you can ask me in the question and answer period.

The second question: “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?”, and I’ll actually, although I don’t have the data from BRFSS to show you, I’m going to show you some data from two other mail surveys where we do have responses to this question.

The third question, which was for people who have worked within the past 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?” This is explicitly a question about perception. This is not documenting the level of work-related discrimination. In order to do that, you have to actually go to the workplace and monitor behaviors and things over time. You can’t even go and do a survey among individuals that say “have you been respected at work or not?”, because people will always underestimate discrimination that is directed at them. I mean, there have been social/psychology experiments that show that. But this is talking about perceptions, which are important things. And it also allows, explicitly, allows for people to acknowledge “better than” treatment. Now of course if “worse than” treatment is going on in the world, then “better than” treatment is going on in the world. But not everybody recognizes – it will be interesting to see who acknowledges “better than” treatment.

The fourth question: “Within the past 12 months, when seeking health care, do you feel your experiences were worse than, better than, or the same as for people of other races?” Again this is not to document the level of discrimination in health care, because you need to look at prescribing practices, and like that, of physicians. But it is talking about how people feel…

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?” It is time to now make an explicit link between race-based treatment and stress. And the sixth question: “Within the past 30 days, have you experienced any physical symptom, 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?”

Now two weeks ago, at the Behavioral Risk Factor Surveillance Survey Annual Conference, the BRFSS coordinators from California and from North Carolina presented some early analyses of their data, and they are very interesting. And for those of you who are here in North Carolina, Dr. Ziya Gizlice , who is the BRFSS coordinator, has the data. He’s so excited about it, and I’m sure that if any of you all were interested in helping him with analyses, or suggesting analyses or working with the data, or anything, he would welcome your input. And, by the way, for you all who are in the video audience, or any of you, this module will be available for use on the 2004 BRFSS by any state that wants to use it. And now is the time when states are making these decisions. So if you think that these are interesting questionsthen you might want to contact your state health department and talk to their BRFSS coordinator and also contact your Minority Health Officer and express your interest in these questions. They represent an early attempt. This is not measuring the end all and be all of racism. As you can see, it’s not measuring institutionalized racism at all, but it is an acknowledgement of the impacts of reactions to race as an important factor to look at and have under surveillance in our society.

Now I told you I’d show you some data on this question, “How often do you think about your race?” I’m interested in this audience – we have a very nice full audience here – and I’d be interested in having you answer this question for yourself. And then I’m going to ask for a show of hands. And then I’m going to say, you know, call out frequencies, and then I’m going to ask you to, not only answer when your frequency is called, but also look around in this audience and just see what we see.

How many of you say that you never think about your race? Please hold your hands up. Okay, what about once a year? once a month? once a week? once a day? once an hour? or constantly? Now for those in the video audience, I don’t think you got to see that, but first of all for those of you all here, aren’t you surprised that not everybody said what you said? [Laughter] You know what I’m saying, like it’s sort of surprising that there are some people who said “once a year”. I didn’t see anybody who said “never” in this audience, but there’s some people who said “once a year” and there’s some people who said “constantly”. And very frequently the people who said “never” or “once a year” are astounded that there are people who say “constantly”, although the people who say “constantly” aren’t so surprised that there are people who say “never” or “once a year”. [Laughter] But that’s an interesting thing, there’s … and the other thing that you notice, or that you could have noticed, is that there is kind of a little color wave going on.

Well, I’m going to show you some responses to this question from the Black Women’s Health Study. This question was put on that mail survey which went out to readers of Essence Magazine and their contacts in 1997, and to black women and white women who were in the Nurse’s Health Study. It was put on that questionnaire in 1995. And these are registered nurses in 10 states in a continuing bi-ennial survey. I don’t know if you can see in the back, but I’m trying to use this thing as a pointer. We have, “How often do you think about your race?”, from “never” to “constantly”. About 50,000 black women in the Black Women’s Health Study, more than a thousand black women and nurses and almost 90,000 white women and nurses. Aand the most astounding thing – just from the back, you can see there’s a pattern of it. It looks like the black women from Black Women’s Health Study and the Black women from Black Women nurses have almost identical distributions. It’s really astounding, although they’re different groups of Black women, different years, whole different populations. Furthermore, it looks like the black distribution is very different from the white distribution, even though, those Black women in the second row and those white women are all nurses in the same study, same year, everything. Okay?

So let’s take a look at some of the numbers now. More than 50% of the white women and nurses said that they never think about their race, down to 0.3% who said they constantly think about their race. Now that 0.3% – many of them sent in letters explaining why they constantly think about their race, even though this was on an eight-page survey about oral contraceptives and diet and all this stuff, and there’s this one little question – they were sending in letters with their survey saying, “I adopted a child from Bolivia”, or “I married a Black man”, or something like that, explaining why they constantly think about their race. In contrast, for the Black women, more than 20% said they constantly think about their race, and we didn’t get letters from any of the Black nurses [Laughter] explaining why.

I was actually surprised at the 11% who said that they never think about their race, because when I do this in audiences like this, I’ve never had a Black person raise their hand and say they never think about their race, and here I have more than 10%. And I think this is reflecting the fact that probably these women are living in segregated situations, which in this country unfortunately, for the most part are also impoverished situations, so my initial idea for this question had been on an individual level, you know, the more frequently that you think about your race, good, bad or indifferent, whether you are thinking I’m black and I’m proud or I just wish these people would get off my back. I was hypothesizing – and I still have to test this – I have to get access to these data again. I was hypothesizing that there was a monotonic relationship between adverse health outcomes and frequency of thinking about your race, and I think that is still true from probably about once a month and more frequency of thinking about your race. But I think that these data are more interesting in distribution, because look at that. Look at the constancy of the distribution from 1997 and 1995. Look at that. Look at the differences between those distributions.

Now hold these in your mind, because I’m going to show you the Asian and Hispanic women from Nurses for the same year.. Here’s the Asian distribution and the Hispanic. It’s kind of intermediate between the black and white, and I think it’s very interesting that for the “constantly”, 8% of the Asian women said they constantly think about their race. About 4% of the Hispanic women did. And I think that might not be an issue by identifiablility.

I’m going to show you some data from New Zealand, “How often do you think about your race?” Pakeha – that’s white folks. Maori – those are the indigenous Polynesian people. And here I have two Maori groups, because I asked two questions. I asked everybody how do other people usually classify you in this country, and then I asked how do you classify yourself, because in New Zealand, self identity is more pertinent than it is right now in this country, so that Maori is people who are usually classified as Maori by others and also self-identified as Maori, mixed Maori were usually classified as Pakeha, or white by others, but self-identified as Maori – but look at those distributions. Those aren’t anything like what we saw in any of the US groups because it’s a different what I’m calling “racial climate” there.

So, now I’m going to introduce this concept. This is kind of a second new thing that people haven’t heard before, okay? So here you are, so you can reflect back to me on what you think of this. This notion of racial climate, because I think that this question, “How often do you think about your race?”, is not reflecting something innate. People aren’t born thinking about their race frequently or not, but it’s something that reflects the environment. I It’s a contextual measure. So what am I going to talk about with racial climate?

Well before I define racial climate to you, I’m going to ask each of you to consider this question, “How often do you think about your caste?” So you say “What, how often do I think about my caste?” That question doesn’t make a lot of sense in this context, but if I were to ask that question in India, everybody would instantly be able to give me an answer. It might not be the same answer, and the Brahmans might say “never”, and the Dalits, or the untouchables, might say “constantly”. But it would make sense there because there they have a caste conscious society, whereas here we have a race conscious society.

So when I describe racial climate, I’m going to talk about those aspects of a society that are race conscious and the whole classification thing. So the first aspect of racial climate is the pertinence of this notion of race. That is how you look, putting you in a certain category, as a basis for classification. How pertinent is it in this society? That’s one aspect of the racial climate of a given society at a certain place in time. Then what are the rules for racial classification? You know, what are the number of categories? What are the names of categories?

For example, here, I’m Black in the United States, it’s so clear. I’m told that if I went to Brazil, I would be clearly white. I’ve never been to Brazil. I sometimes joke that I would like to go and try it out, for a little while.[Laughter] In South Africa, I would be clearly colored. So what are the rules for the classifications? And then what are the sorting rules, what are the names of the categories, number of categories, what is it all about? Because people come here from Brazil and don’t have a clue how to classify people, from most of South America don’t have a clue about our racial classification system. It’s something that’s learned. It seems so clear to us. But it’s something that’s learned and little kids don’t know it. Those of you who have kids know that they make all kinds of mistakes until they get it right.

The third aspect of racial climate, which is kind of the operationalizing of it, is how, what are the rules for distributing opportunities and value to the different racial groups? How are the goodie’s distributed? Because if there’s not a lot of difference, then maybe race won’t be so pertinent. Even if you are calling me something different, if everybody gets the same thing, then well that’s okay. And I think that this racial climate is measured by the pertinence to you of your racial assignment.

That is why I think the question, “How often do you think about your race?” is an important first measure of understanding the racial climate in a given place and time. I’m spending so much time on this because sometimes people wonder “Why would you ask that question?, what does that have to do with health? what does that have to do, why is that on the BRFSS, for example? So I’m telling you that I am trying to now tell us that there is a climate out there that we aren’t even measuring that we could measure. I think that this racial climate affects infant mortality rates. I think this racial climate affects everything. I think this racial climate causes accelerated aging of Black folks compared to white folks. So I think we need to start measuring, that this is another social and environmental measure that we need to put on the map. Now this question, “How often do you think about your race?” may not be the end-all, be-all question, but I think that it’s getting there.

The other aspect of data collection or measurement I wanted to get into is very important. That’s measuring institutionalized racism. And that’s hard to do especially, on the individual level. Here’s what we are thinking about in the Measures of Racism Working Group. [Moderator gives Dr. Jones a time cue] I think first of all that measuring institutionalized racism, we need to scan the environment for evidence of racial disparities, which means we need to routinely monitor outcomes by race in this country as long as we have a notion that there’s stuff going on. You know before people were monitoring cardiac procedures by race, nobody would have believed that Black folks got CABGs [coronary artery bypass grafts] at a much lower frequency than the white folks. I mean you have to start asking the question and looking places first. I mean that’s basically asking “couldn’t racism be operating here?”, and because we live in a race-conscious society, then, racism could probably be operating anywhere. But you should start looking a lot of places.

And then once you identify where there seems to be evidence of differential outcome it’s not good enough to say, “okay, we’ve documented institutionalized racism. Look at how income is distributed in this country by race. Okay, there it is”. That’s not good enough, because what we need are measures that can identify mechanisms that can tell us then where do we intervene how do we act. So we have started thinking about examining written policies. It’s not a survey question, it’s more qualitative research. But examining written policies and also examining areas where there are no policies in place, where there might be policies. Querying unwritten norms and practices and all of these things and asking the question how is racism operating here. Not “is” – we already asked “could racism be operating here?”. The question is how is it operating here, what are the mechanisms, what are the structures, what are the policies, what are the practices, what are the norms?

So I’m going to show you four areas of policies of interest, and this isn’t an exhaustive list of policies we might look at, but this is what we are thinking right now:



  • Policies that allow the segregation of resources and risks – let’s look for those kinds of policies, or

  • Policies that create inherited group advantage or disadvantage – let’s look for those policies,

  • Policies that favor the differential valuation of human life by race, and ,

  • Policies that limit self-determination.

    I’m going to give you some examples of policies in each of these areas, and I just want to be so clear now, that I’m not advocating either we keep these policies or we remove these policies. I have to make this especially clear because I am a government employee. This is not CDC. I am making a list of policies that fall into these different categories.

    So what are some examples of policies that allow segregation of resources and risks? Well, red-lining policies, zoning policies in terms of industrial regions, toxic dumping siting and all of the determinations that determine where these things are placed. These all affect the segregation of residential resources and risks. The use of public local property taxes to fund our public schools. Think about that. When you use local property taxes then when you have a poor community then you have poorly funded schools, which often result in poor educational outcomes. And so those children will have poor life chances, life trajectories and you will be perpetuating poverty over and over and over again. Now especially if you notice that this perpetuation of poor public education is affecting communities of color differentially, then it’s actually evidence again of institutionalized racism. This inaction in the face of need, we need to do something about that. [Moderator signals to Dr. Jones] I beg your indulgence, may I go for about five-minutes?




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