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Health begins where welive, learn, work, and play  Addressing racism as a threat  to the health and well-being          of...
Levels of health interventionSource: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Addressing the                                        Primary prevention         social determinants of health            ...
But how do disparities arise?    Differences in the quality of care received within the     health care system    Differ...
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Source: Jones CP et al. J Health Care Poor Underserved 2009.
Differences in                                                               Differences in access to care                ...
Addressing thesocial determinants of equity:Why are there differencesin resourcesalong the cliff face?Why are there differ...
3 dimensions of health interventionSource: Jones CP et al. J Health Care Poor Underserved 2009.
3 dimensions of health interventionHealth servicesSource: Jones CP et al. J Health Care Poor Underserved 2009.
3 dimensions of health interventionHealth servicesAddressing social determinants of healthSource: Jones CP et al. J Health...
3 dimensions of health interventionHealth servicesAddressing social determinants of healthAddressing social determinants o...
Determinants of health                                                         Individual                                 ...
Determinants of health                                                   Social determinants                              ...
Determinants of health  Determinants  of health and  illness that are                                                   So...
Determinants of health  Determinants                                                            The contexts in  of health...
Determinants of health  Individual  resources  Education,                                          Social determinants  oc...
Determinants of health  Individual  resources  Education,                                          Social determinants  oc...
Determinants of health  Individual                                                                                      Ha...
Determinants of health  Individual                                                                                      Ha...
Determinants of health                                            Structural determinants of context                      ...
Determinants of healthDetermine therange ofobserved contexts                                            Structural determi...
Determinants of healthDetermine therange ofobserved contexts                                            Structural determi...
Determinants of healthDetermine the                                                                    Include economicran...
Determinants of healthDetermine the                                                                    Include economicran...
Addressing the social determinants                               of HEALTH    Involves the medical care and public health...
Addressing the social determinants                               of EQUITY    Involves monitoring for inequities in expos...
Beyond individual behaviors    Address the social determinants of health,     including poverty, in order to achieve larg...
Why racism?    To eliminate racial disparities in health, need examine     fundamental causes        “Race” is only a ro...
What is racism?     A systemSource: Jones CP. Confronting Institutionalized Racism. Phylon 2003;50(1-2):7-22.
What is racism?     A system of structuring opportunity and assigning     valueSource: Jones CP. Confronting Institutional...
What is racism?     A system of structuring opportunity and assigning     value based on the social interpretation of how ...
What is racism?     A system of structuring opportunity and assigning     value based on the social interpretation of how ...
What is racism?     A system of structuring opportunity and assigning     value based on the social interpretation of how ...
What is racism?     A system of structuring opportunity and assigning     value based on the social interpretation of how ...
Levels of Racism    Institutionalized    Personally-mediated    InternalizedSource: Jones CP. Levels of Racism: A Theor...
Institutionalized racism    Differential access to the goods, services, and     opportunities of society, by “race”    E...
Personally-mediated racism    Differential assumptions about the abilities, motives,     and intents of others, by “race”...
Internalized racism    Acceptance by the stigmatized “races” of negative     messages about our own abilities and intrins...
Levels of Racism: A Gardener’s TaleSource: Jones CP. Levels of Racism: A Theoretic Framework and a Gardener’s Tale. Am J P...
Who is the gardener?                                                                            Power to decide          ...
Measuring institutionalized racism    Scan for evidence of “racial” disparities        “Could racism be operating here?”...
“Reactions to Race” module   Six-question optional module on the Behavioral Risk    Factor Surveillance System since 2002...
States using the “Reactions to Race” module                        2002 to 2011 BRFSSArkansas, California, Colorado, Conne...
States using the “Reactions to Race” moduleArkansas                       2004California       2002Colorado               ...
States using the “Reactions to Race” moduleArkansas                       2004California       2002Colorado               ...
Socially-assigned “race”   How do other people usually classify you in this    country? Would you say:       White     ...
Socially-assigned “race”    On-the-street “race” quickly and routinely assigned     without benefit of queries about self...
General health status   Would you say that in general your health is:       Excellent       Very good       Good     ...
General health status by socially-assigned "race", 2004 BRFSS                         100                         80      ...
General health status by socially-assigned "race", 2004 BRFSS                         100                         80      ...
General health status by socially-assigned "race", 2004 BRFSS                                                   Report fai...
General health status and “race”   Being perceived as White is associated with better    health
Self-identified ethnicity   Are you Hispanic or Latino?     Yes     No
Self-identified “race”   Which one or more of the following would you say is    your race?       White       Black or A...
Self-identified “race”/ethnicity   Hispanic     “Yes” to Hispanic/Latino ethnicity question     Any response to race qu...
Two measures of “race”                              How usually classified by others                             White    ...
Two measures of “race”                                How usually classified by others                               White...
Two measures of “race”                                How usually classified by others                               White...
General health status, by self-identified and socially-assigned "race", 2004                         100                  ...
General health status, by self-identified and socially-assigned "race", 2004                         100                  ...
General health status, by self-identified and socially-assigned "race", 2004                         100                  ...
General health status, by self-identified and socially-assigned "race", 2004                         100                  ...
Two measures of “race”                                How usually classified by others                               White...
Two measures of “race”                                How usually classified by others                               White...
General health status, by self-identified and socially-assigned "race", 2004                         100                  ...
General health status, by self-identified and socially-assigned "race", 2004                         100                  ...
General health status, by self-identified and socially-assigned "race", 2004                         100                  ...
General health status, by self-identified and socially-assigned "race", 2004                         100                  ...
Two measures of “race”                                How usually classified by others                               White...
Two measures of “race”                                How usually classified by others                               White...
General health status and “race”   Being perceived as White is associated with better    health     Even within non-Whit...
General health status and “race”   Being perceived as White is associated with better    health     Even within non-Whit...
General health status and “race”   Being perceived as White is associated with better    health     Even within non-Whit...
Key questions   Why is socially-assigned “race” associated with self-    rated general health status?     Even within no...
Racism     A system of structuring opportunity and assigning     value based on the social interpretation of how we look  ...
What is [inequity] ?A system of structuring opportunity and assigningvalue based on [fill in the blank]
What is [inequity] ?A system of structuring opportunity and assigningvalue based on [fill in the blank], that Disadvantag...
Many possible axes of inequity   “Race”   Gender   Ethnicity   Labor roles and social class markers   Nationality, la...
ICERD: International Convention on the    Elimination of all forms of Racial Discrimination   International anti-racism t...
CERD Concluding Observations   14-page document (8 May 2008) available online    http://www.state.gov/documents/organizat...
Our goal: To expand the conversationHealth services
Our goal: To expand the conversationHealth servicesSocial determinantsof health
Our goal: To expand the conversationHealth servicesSocial determinantsof healthSocial determinantsof equitySource: Jones C...
Camara Phyllis Jones, MD, MPH, PhD(404) 374-3198 cell(404) 498-1128 workcamara99@bellsouth.net
Barriers in moving the nation                  to care about social justice   A-historical culture     The present as di...
Moving the nation   Changing opportunity structures       Understand the importance of history       Challenge the narr...
Unpublished allegories    Dual Reality: A Restaurant Saga    Conveyor Belt: Stages of Anti-racism    Japanese Lanterns:...
Resources   National Partnership for Action to End Health    Disparities    Office of Minority Health, US Department of H...
Resources   Healthy People 2020    http://www.healthypeople.gov/2020/default.aspx    Overarching goals:     Attain high-...
Resources   National Prevention Strategy    National Prevention, Health Promotion, and Public Health Council    http://ww...
Resources   US-Brazil Joint Action Plan to Eliminate Racial and    Ethnic Discrimination and Promote Equality    Five-yea...
Resources   CDC Racism and Health Workgroup    rahw@cdc.gov    Communications and Dissemination    Education and Developm...
Resources   Race: The Power of an Illusion    California Newsreel    http://www.pbs.org/race    http://newsreel.org/video...
Resources   3rd World Conference Against Racism, Racial    Discrimination, Xenophobia and Related Intolerance    Convened...
Resources   Unnatural Causes: Is Inequality Making Us Sick?    California Newsreel    http://www.unnaturalcauses.org   C...
Resources   World Conference on Social Determinants of Health    Convened by the World Health Organization in Rio de Jane...
Resources   International Convention on the Elimination of all    forms of Racial Discrimination (ICERD)    Adopted by th...
Resources   2007 USA State Department report to the CERD    http://www2.ohchr.org/english/bodies/cerd/docs/AdvanceVersion...
Resources   Report of the Secretary’s Task Force on Black and    Minority Health    Margaret M. Heckler, Secretary    U.S...
Resources   The Gardener’s Tale podcast    CityMatCH Health Equity and Social Justice Action Group    http://www.citymatc...
Camara Phyllis Jones, MD, MPH, PhD(404) 374-3198 cell(404) 498-1128 workcamara99@bellsouth.net
Policies of interest    Policies allowing segregation of resources and risks    Policies creating inherited group disadv...
Policies allowing segregation ofresources and risksRedlining, municipal zoning, toxic dump sitingUse of local property tax...
Policies creating inherited groupdisadvantageLack of social security for childrenEstate inheritanceLack of reparations for...
Policies favoring the differentialvaluation of human life by “race”CurriculumMedia invisibility / hypervisibilityMyth of m...
Policies limiting self-determinationDe jure and de facto limitations to voting rights“Majority rules” when there is a fixe...
Camara Phyllis Jones, MD, MPH, PhD(404) 374-3198 cell(404) 498-1128 workcamara99@bellsouth.net
Achieving health equity    “Health equity” is assurance of the conditions for     optimal health for all people    Achie...
Our tasks   Put racism on the agenda     Name racism as a force determining the other social determinants      of health...
Our tasks   Ask , “How is racism operating here?”     Identify mechanisms in structures, policies, practices, norms, and...
Our tasks   Organize and strategize to act     Join in grassroots organizing around the conditions of people’s      live...
Camara Phyllis Jones, MD, MPH, PhD(404) 374-3198 cell(404) 498-1128 workcamara99@bellsouth.net
What is racism?“Racism includes racist ideologies, prejudiced attitudes,  discriminatory behavior, structural arrangements...
What is racism?“it hinders the development of its victims, perverts those   who practice it, divides nations internally, i...
Camara Phyllis Jones, MD, MPH, PhD(404) 374-3198 cell(404) 498-1128 workcamara99@bellsouth.net
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Addressing Racism as a Threat to the Health and Well-Being of Our Nation

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Addressing Racism as a Threat to the Health and Well-Being of Our Nation

Camara Phyllis Jones, MD, MPH, PhD
Social Determinants of Health and Equity

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Transcript of "Addressing Racism as a Threat to the Health and Well-Being of Our Nation"

  1. 1. Health begins where welive, learn, work, and play Addressing racism as a threat to the health and well-being of our nation Camara Phyllis Jones, MD, MPH, PhD Social Determinants of Health and Equity Leadership Challenge Fairfax, Virginia September 17, 2012
  2. 2. Levels of health interventionSource: Jones CP et al. J Health Care Poor Underserved 2009.
  3. 3. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  4. 4. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  5. 5. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  6. 6. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  7. 7. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  8. 8. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  9. 9. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  10. 10. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  11. 11. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  12. 12. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  13. 13. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  14. 14. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  15. 15. Addressing the Primary prevention social determinants of health Safety net programs and secondary prevention Medical care and tertiary preventionSource: Jones CP et al. J Health Care Poor Underserved 2009.
  16. 16. But how do disparities arise? Differences in the quality of care received within the health care system Differences in access to health care, including preventive and curative services Differences in life opportunities, exposures, and stresses that result in differences in underlying health statusSource: Smedley BD, Stith AY, Nelson AR (editors). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.Washington, DC: The National Academies Press, 2002.Source: Byrd WM, Clayton LA. An American Health Dilemma: Race, Medicine, and Health Care in the United States, 1900-2000.New York, NY: Routledge, 2002.Source: Phelan JC, Link BG, Tehranifar P. Social Conditions as Fundamental Causes of Health Inequalities. J Health Soc Behav2010;51(S):S28-S40.
  17. 17. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  18. 18. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  19. 19. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  20. 20. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  21. 21. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  22. 22. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  23. 23. Source: Jones CP et al. J Health Care Poor Underserved 2009.
  24. 24. Differences in Differences in access to care exposures and opportunities Differences in quality of care (ambulance slow or goes the wrong way)Source: Jones CP et al. J Health Care Poor Underserved 2009.
  25. 25. Addressing thesocial determinants of equity:Why are there differencesin resourcesalong the cliff face?Why are there differencesin who is foundat different parts of the cliff?Source: Jones CP et al. J Health Care Poor Underserved 2009.
  26. 26. 3 dimensions of health interventionSource: Jones CP et al. J Health Care Poor Underserved 2009.
  27. 27. 3 dimensions of health interventionHealth servicesSource: Jones CP et al. J Health Care Poor Underserved 2009.
  28. 28. 3 dimensions of health interventionHealth servicesAddressing social determinants of healthSource: Jones CP et al. J Health Care Poor Underserved 2009.
  29. 29. 3 dimensions of health interventionHealth servicesAddressing social determinants of healthAddressing social determinants of equitySource: Jones CP et al. J Health Care Poor Underserved 2009.
  30. 30. Determinants of health Individual behaviorsSource: Jones CP et al. J Health Care Poor Underserved 2009.
  31. 31. Determinants of health Social determinants of health (contexts) Individual behaviorsSource: Jones CP et al. J Health Care Poor Underserved 2009.
  32. 32. Determinants of health Determinants of health and illness that are Social determinants outside of the of health (contexts) individual Individual Beyond genetic behaviors predispositions Beyond individual behaviorsSource: Jones CP et al. J Health Care Poor Underserved 2009.
  33. 33. Determinants of health Determinants The contexts in of health and which illness that are individual Social determinants outside of the of health (contexts) behaviors arise individual Individual Beyond genetic behaviors predispositions Beyond individual behaviorsSource: Jones CP et al. J Health Care Poor Underserved 2009.
  34. 34. Determinants of health Individual resources Education, Social determinants occupation, of health (contexts) income, wealth Individual behaviorsSource: CSDH. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of theCommission on Social Determinants of Health. Geneva: World Health Organization, 2008.Source: Jones CP et al. J Health Care Poor Underserved 2009.
  35. 35. Determinants of health Individual resources Education, Social determinants occupation, of health (contexts) income, wealth Neighborhood Individual resources behaviors Housing, food choices, public safety, transportation, parks and recreation, political cloutSource: CSDH. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of theCommission on Social Determinants of Health. Geneva: World Health Organization, 2008.Source: Jones CP et al. J Health Care Poor Underserved 2009.
  36. 36. Determinants of health Individual Hazards and resources toxic exposures Education, Social determinants Pesticides, lead, occupation, of health (contexts) reservoirs of income, wealth infection Neighborhood Individual resources behaviors Housing, food choices, public safety, transportation, parks and recreation, political cloutSource: CSDH. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of theCommission on Social Determinants of Health. Geneva: World Health Organization, 2008.Source: Jones CP et al. J Health Care Poor Underserved 2009.
  37. 37. Determinants of health Individual Hazards and resources toxic exposures Education, Social determinants Pesticides, lead, occupation, of health (contexts) reservoirs of income, wealth infection Neighborhood Opportunity Individual resources behaviors structures Housing, food Schools, jobs, choices, public justice safety, transportation, parks and recreation, political cloutSource: CSDH. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of theCommission on Social Determinants of Health. Geneva: World Health Organization, 2008.Source: Jones CP et al. J Health Care Poor Underserved 2009.
  38. 38. Determinants of health Structural determinants of context Social determinants of health (contexts) Individual behaviorsSource: Jones CP et al. J Health Care Poor Underserved 2009.
  39. 39. Determinants of healthDetermine therange ofobserved contexts Structural determinants of context Social determinants of health (contexts) Individual behaviorsSource: Jones CP et al. J Health Care Poor Underserved 2009.
  40. 40. Determinants of healthDetermine therange ofobserved contexts Structural determinants of context Social determinants of health (contexts) Individual behaviorsDetermine thedistribution ofdifferent populationsinto those contextsSource: Jones CP et al. J Health Care Poor Underserved 2009.
  41. 41. Determinants of healthDetermine the Include economicrange of systems, racism,observed contexts and other systems Structural determinants of context of power Social determinants of health (contexts) Individual behaviorsDetermine thedistribution ofdifferent populationsinto those contextsSource: Jones CP et al. J Health Care Poor Underserved 2009.
  42. 42. Determinants of healthDetermine the Include economicrange of systems, racism,observed contexts and other systems Structural determinants of context of power Social determinants of health (contexts) Individual behaviorsDetermine the The socialdistribution of determinants ofdifferent populations equityinto those contextsSource: Jones CP et al. J Health Care Poor Underserved 2009.
  43. 43. Addressing the social determinants of HEALTH Involves the medical care and public health systems, but clearly extends beyond these Requires collaboration with multiple sectors outside of health, including education, housing, labor, justice, transportation, agriculture, immigration, and environmentSource: National Prevention Council. National Prevention Strategy. Washington, DC: U.S. Department of Health and HumanServices, Office of the Surgeon General, 2011.Source: Jones CP, Jones CY, Perry GS, Barclay G. Addressing the Social Determinants of Children’s Health: A Cliff Analogy.J Health Care Poor Underserved 2009;20(4)Suppl:1-12.
  44. 44. Addressing the social determinants of EQUITY Involves monitoring for inequities in exposures and opportunities, as well as for disparities in outcomes Involves examination of and intervention on the mechanisms of power  Structures: the who?, what?, when?, and where? of decision-making  Policies: the written how?  Practices and norms: the unwritten how?  Values: the why?Source: Jones CP, Jones CY, Perry GS, Barclay G. Addressing the Social Determinants of Children’s Health: A Cliff Analogy.J Health Care Poor Underserved 2009;20(4)Suppl:1-12.
  45. 45. Beyond individual behaviors Address the social determinants of health, including poverty, in order to achieve large and sustained improvements in health outcomes Address the social determinants of equity, including racism, in order to achieve social justice and eliminate health disparitiesSource: Jones CP, Jones CY, Perry GS, Barclay G. Addressing the Social Determinants of Children’s Health: A Cliff Analogy.J Health Care Poor Underserved 2009;20(4)Suppl:1-12.
  46. 46. Why racism? To eliminate racial disparities in health, need examine fundamental causes  “Race” is only a rough proxy for social class, culture, or genes  “Race” captures the social classification of people in our “race”- conscious society Hypothesize racism as a fundamental cause of racial disparities in healthSource: Jones CP. “Race”, Racism, and the Practice of Epidemiology. Am J Epidemiol 2001;154(4):299-304.
  47. 47. What is racism? A systemSource: Jones CP. Confronting Institutionalized Racism. Phylon 2003;50(1-2):7-22.
  48. 48. What is racism? A system of structuring opportunity and assigning valueSource: Jones CP. Confronting Institutionalized Racism. Phylon 2003;50(1-2):7-22.
  49. 49. What is racism? A system of structuring opportunity and assigning value based on the social interpretation of how we look (which is what we call “race”)Source: Jones CP. Confronting Institutionalized Racism. Phylon 2003;50(1-2):7-22.
  50. 50. What is racism? A system of structuring opportunity and assigning value based on the social interpretation of how we look (which is what we call “race”), that  Disadvantages some individuals and communitiesSource: Jones CP. Confronting Institutionalized Racism. Phylon 2003;50(1-2):7-22.
  51. 51. What is racism? A system of structuring opportunity and assigning value based on the social interpretation of how we look (which is what we call “race”), that  Disadvantages some individuals and communities  Advantages other individuals and communitiesSource: Jones CP. Confronting Institutionalized Racism. Phylon 2003;50(1-2):7-22.
  52. 52. What is racism? A system of structuring opportunity and assigning value based on the social interpretation of how we look (which is what we call “race”), that  Disadvantages some individuals and communities  Advantages other individuals and communities  Saps the strength of the whole society through the waste of human resourcesSource: Jones CP. Confronting Institutionalized Racism. Phylon 2003;50(1-2):7-22.
  53. 53. Levels of Racism Institutionalized Personally-mediated InternalizedSource: Jones CP. Levels of Racism: A Theoretic Framework and a Gardener’s Tale. Am J Public Health 2000;90(8):1212-1215.
  54. 54. 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 social class and “race”Source: Jones CP. Levels of Racism: A Theoretic Framework and a Gardener’s Tale. Am J Public Health 2000;90(8):1212-1215.
  55. 55. Personally-mediated racism Differential assumptions about the abilities, motives, and intents of others, by “race” Differential actions based on those assumptions Prejudice and discrimination Examples  Police brutality  Physician disrespect  Shopkeeper vigilance  Waiter indifference  Teacher devaluationSource: Jones CP. Levels of Racism: A Theoretic Framework and a Gardener’s Tale. Am J Public Health 2000;90(8):1212-1215.
  56. 56. 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 humanitySource: Jones CP. Levels of Racism: A Theoretic Framework and a Gardener’s Tale. Am J Public Health 2000;90(8):1212-1215.
  57. 57. Levels of Racism: A Gardener’s TaleSource: Jones CP. Levels of Racism: A Theoretic Framework and a Gardener’s Tale. Am J Public Health 2000;90(8):1212-1215.
  58. 58. Who is the gardener?  Power to decide  Power to act  Control of resources  Dangerous when  Allied with one group  Not concerned with equitySource: Jones CP. Levels of Racism: A Theoretic Framework and a Gardener’s Tale. Am J Public Health 2000;90(8):1212-1215.
  59. 59. Measuring institutionalized racism Scan for evidence of “racial” disparities  “Could racism be operating here?”  Routinely monitor opportunities as well as outcomes by “race” Identify mechanisms  “How is racism operating here?”  Structures: the who?, what?, when?, and where? of decision-making  Policies: the written how?  Practices and norms: the unwritten how?  Values: the why?Source: Jones CP. Confronting Institutionalized Racism. Phylon 2003;50(1-2):7-22.
  60. 60. “Reactions to Race” module Six-question optional module on the Behavioral Risk Factor Surveillance System since 2002  “How do other people usually classify you in this country?”  “How often do you think about your race?”  Perceptions of differential treatment at work or when seeking health care  Reports of physical symptoms or emotional upset as a result of “race”-based treatment
  61. 61. States using the “Reactions to Race” module 2002 to 2011 BRFSSArkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Indiana,Kentucky, Massachusetts, Michigan, Mississippi, Nebraska, New Hampshire, New Mexico, North Carolina,Ohio, Rhode Island, South Carolina, Tennessee, Vermont, Virginia, Washington, Wisconsin
  62. 62. States using the “Reactions to Race” moduleArkansas 2004California 2002Colorado 2004Connecticut 2010Delaware 2002 2004 2005DC 2004Florida 2002Georgia 2010Indiana 2009Kentucky 2010Massachusetts 2006 2008Michigan 2006Mississippi 2004Nebraska 2008 2009New Hampshire 2002New Mexico 2002North Carolina 2002Ohio 2003 2005 2011Rhode Island 2004 2007 2010South Carolina 2003 2004Tennessee 2005Vermont 2008Virginia 2008Washington 2004Wisconsin 2004 2005 2006
  63. 63. States using the “Reactions to Race” moduleArkansas 2004California 2002Colorado 2004Connecticut 2010Delaware 2002 2004 2005DC 2004Florida 2002Georgia 2010Indiana 2009Kentucky 2010Massachusetts 2006 2008Michigan 2006Mississippi 2004Nebraska 2008 2009New Hampshire 2002New Mexico 2002North Carolina 2002Ohio 2003 2005 2011Rhode Island 2004 2007 2010South Carolina 2003 2004Tennessee 2005Vermont 2008Virginia 2008Washington 2004Wisconsin 2004 2005 2006
  64. 64. Socially-assigned “race” 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  Some other group
  65. 65. Socially-assigned “race” On-the-street “race” quickly and routinely assigned without benefit of queries about self-identification, ancestry, culture, or genetic endowment Ad hoc racial classification, an influential basis for interactions between individuals and institutions for centuries Substrate upon which racism operatesSource: Jones CP, Truman BI, Elam-Evans LD, Jones CA, Jones CY, Jiles R, Rumisha SF, Perry GS. Using “socially assigned race”to probe White advantages in health status. Ethn Dis 2008;18(4):496-504.
  66. 66. General health status Would you say that in general your health is:  Excellent  Very good  Good  Fair  Poor
  67. 67. General health status by socially-assigned "race", 2004 BRFSS 100 80 60percent of respondents 40 20 58.3 43.7 41.2 36.1 0 White Black Hispanic AIAN Report excellent or very good health
  68. 68. General health status by socially-assigned "race", 2004 BRFSS 100 80 60percent of respondents 40 20 58.3 43.7 41.2 36.1 0 White Black Hispanic AIAN Report excellent or very good health
  69. 69. General health status by socially-assigned "race", 2004 BRFSS Report fair or poor health 100 13.9 21.5 20.9 22.1 80 60percent of respondents 40 20 58.3 43.7 41.2 36.1 0 White Black Hispanic AIAN Report excellent or very good health
  70. 70. General health status and “race” Being perceived as White is associated with better health
  71. 71. Self-identified ethnicity Are you Hispanic or Latino?  Yes  No
  72. 72. Self-identified “race” Which one or more of the following would you say is your race?  White  Black or African-American  Asian  Native Hawaiian or Other Pacific Islander  American Indian or Alaska Native  Other Which one of these groups would you say best represents your race?
  73. 73. Self-identified “race”/ethnicity Hispanic  “Yes” to Hispanic/Latino ethnicity question  Any response to race question White  “No” to Hispanic/Latino ethnicity question  Only one response to race question, “White” Black  “No” to Hispanic/Latino ethnicity question  Only one response to race question, “Black” American Indian/Alaska Native  “No” to Hispanic/Latino ethnicity question  Only one response to race question, “AI/AN”
  74. 74. Two measures of “race” How usually classified by others White Black Hispanic AIAN ... White 98.4 0.1 0.3 0.1 1.1 26,373How self-identify Black 0.4 96.3 0.8 0.3 2.2 5,246
  75. 75. Two measures of “race” How usually classified by others White Black Hispanic AIAN ... White 98.4 0.1 0.3 0.1 1.1 26,373How self-identify Black 0.4 96.3 0.8 0.3 2.2 5,246 Hispanic 26.8 3.5 63.0 1.2 5.5 1,528
  76. 76. Two measures of “race” How usually classified by others White Black Hispanic AIAN ... White 98.4 0.1 0.3 0.1 1.1 26,373How self-identify Black 0.4 96.3 0.8 0.3 2.2 5,246 Hispanic 26.8 3.5 63.0 1.2 5.5 1,528
  77. 77. General health status, by self-identified and socially-assigned "race", 2004 100 80percent of respondents 60 58.6 53.7 39.8 40 20 0 Hispanic-Hispanic Hispanic-White White-White Report excellent or very good health
  78. 78. General health status, by self-identified and socially-assigned "race", 2004 100 Test of H0: That there is no difference in proportions reporting excellent or very good health 80 Hispanic-Hispanic versus White-White p < 0.0001percent of respondents 60 58.6 39.8 40 20 0 Hispanic-Hispanic White-White Report excellent or very good health
  79. 79. General health status, by self-identified and socially-assigned "race", 2004 100 Test of H0: That there is no difference in proportions reporting excellent or very good health 80 Hispanic-Hispanic versus Hispanic-White p = 0.0019percent of respondents 60 53.7 39.8 40 20 0 Hispanic-Hispanic Hispanic-White Report excellent or very good health
  80. 80. General health status, by self-identified and socially-assigned "race", 2004 100 Test of H0: That there is no difference in proportions reporting excellent or very good health 80 Hispanic-White versus White-White p = 0.1895percent of respondents 60 58.6 53.7 40 20 0 Hispanic-White White-White Report excellent or very good health
  81. 81. Two measures of “race” How usually classified by others White Black Hispanic AIAN ... White 98.4 0.1 0.3 0.1 1.1 26,373How self-identify Black 0.4 96.3 0.8 0.3 2.2 5,246 Hispanic 26.8 3.5 63.0 1.2 5.5 1,528 AIAN 47.6 3.4 7.3 35.9 5.8 321
  82. 82. Two measures of “race” How usually classified by others White Black Hispanic AIAN ... White 98.4 0.1 0.3 0.1 1.1 26,373How self-identify Black 0.4 96.3 0.8 0.3 2.2 5,246 Hispanic 26.8 3.5 63.0 1.2 5.5 1,528 AIAN 47.6 3.4 7.3 35.9 5.8 321
  83. 83. General health status, by self-identified and socially-assigned "race", 2004 100 80percent of respondents 60 58.6 52.6 40 32 20 0 AIAN-AIAN AIAN-White White-White Report excellent or very good health
  84. 84. General health status, by self-identified and socially-assigned "race", 2004 100 Test of H0: That there is no difference in proportions reporting excellent or very good health 80 AIAN-AIAN versus White-White p < 0.0001percent of respondents 60 58.6 40 32 20 0 AIAN-AIAN White-White Report excellent or very good health
  85. 85. General health status, by self-identified and socially-assigned "race", 2004 100 Test of H0: That there is no difference in proportions reporting excellent or very good health 80 AIAN-AIAN versus AIAN-White p = 0.0122percent of respondents 60 52.6 40 32 20 0 AIAN-AIAN AIAN-White Report excellent or very good health
  86. 86. General health status, by self-identified and socially-assigned "race", 2004 100 Test of H0: That there is no difference in proportions reporting excellent or very good health 80 AIAN-White versus White-White p = 0.3070percent of respondents 60 58.6 52.6 40 20 0 AIAN-White White-White Report excellent or very good health
  87. 87. Two measures of “race” How usually classified by others White Black Hispanic AIAN ... White 98.4 0.1 0.3 0.1 1.1 26,373How self-identify Black 0.4 96.3 0.8 0.3 2.2 5,246 Hispanic 26.8 3.5 63.0 1.2 5.5 1,528 AIAN 47.6 3.4 7.3 35.9 5.8 321 > 1 race 59.5 22.5 3.8 5.3 8.9 406
  88. 88. Two measures of “race” How usually classified by others White Black Hispanic AIAN ... White 98.4 0.1 0.3 0.1 1.1 26,373How self-identify Black 0.4 96.3 0.8 0.3 2.2 5,246 Hispanic 26.8 3.5 63.0 1.2 5.5 1,528 AIAN 47.6 3.4 7.3 35.9 5.8 321 > 1 race 59.5 22.5 3.8 5.3 8.9 406
  89. 89. General health status and “race” Being perceived as White is associated with better health  Even within non-White self-identified “race”/ethnic groups
  90. 90. General health status and “race” Being perceived as White is associated with better health  Even within non-White self-identified “race”/ethnic groups  Even within the same educational level
  91. 91. General health status and “race” Being perceived as White is associated with better health  Even within non-White self-identified “race”/ethnic groups  Even within the same educational level Being perceived as White is associated with higher education
  92. 92. Key questions Why is socially-assigned “race” associated with self- rated general health status?  Even within non-White self-identified “race”/ethnic groups  Even within the same educational level Why is socially-assigned “race” associated with educational level?
  93. 93. Racism A system of structuring opportunity and assigning value based on the social interpretation of how we look (which is what we call “race”), that  Disadvantages some individuals and communities  Advantages other individuals and communities  Saps the strength of the whole society through the waste of human resourcesSource: Jones CP. Confronting Institutionalized Racism. Phylon 2003;50(1-2):7-22.Source: Jones CP, Truman BI, Elam-Evans LD, Jones CA, Jones CY, Jiles R, Rumisha SF, Perry GS. Using “socially assigned race” to probeWhite advantages in health status. Ethn Dis 2008;18(4):496-504.
  94. 94. What is [inequity] ?A system of structuring opportunity and assigningvalue based on [fill in the blank]
  95. 95. What is [inequity] ?A system of structuring opportunity and assigningvalue based on [fill in the blank], that Disadvantages some individuals and communities Advantages other individuals and communities Saps the strength of the whole society through the waste of human resources
  96. 96. Many possible axes of inequity “Race” Gender Ethnicity Labor roles and social class markers Nationality, language, and legal status Sexual orientation Disability status Geography ReligionThese are risk markers
  97. 97. ICERD: International Convention on the Elimination of all forms of Racial Discrimination International anti-racism treaty adopted by the UN General Assembly in 1965 http://www2.ohchr.org/english/law/cerd.htm US signed in 1966 US ratified in 1994 2nd US report submitted to the UN Committee on the Elimination of Racial Discrimination (CERD) in 2007 http://www2.ohchr.org/english/bodies/cerd/docs/AdvanceVersion /cerd_c_usa6.doc
  98. 98. CERD Concluding Observations 14-page document (8 May 2008) available online http://www.state.gov/documents/organization/107361.pdf Concerns and recommendations  Racial profiling (para 14)  Residential segregation (para 16)  Disproportionate incarceration (para 20)  Differential access to health care (para 32)  Achievement gap in education (para 34)
  99. 99. Our goal: To expand the conversationHealth services
  100. 100. Our goal: To expand the conversationHealth servicesSocial determinantsof health
  101. 101. Our goal: To expand the conversationHealth servicesSocial determinantsof healthSocial determinantsof equitySource: Jones CP et al. J Health Care Poor Underserved 2009.
  102. 102. Camara Phyllis Jones, MD, MPH, PhD(404) 374-3198 cell(404) 498-1128 workcamara99@bellsouth.net
  103. 103. Barriers in moving the nation to care about social justice A-historical culture  The present as disconnected from the past  Current distribution of advantage/disadvantage as happenstance  Systems and structures as givens and immutable Narrow focus on the individual  Self-interest narrowly defined  Limited sense of interdependence  Limited sense of collective efficacy  Systems and structures as invisible or irrelevant “Myth of meritocracy”  Role of hard work  Denial of racism  Two babies: Equal potential or equal opportunity?
  104. 104. Moving the nation Changing opportunity structures  Understand the importance of history  Challenge the narrow focus on the individual  Expose the “myth of meritocracy”  Acknowledge existence of systems and structures  View systems and structures as modifiable  Break down barriers to opportunity  Build bridges to opportunity  Transform consumers to citizens  Intervene on decision-making processes Valuing all people equally  Break out of bubbles to experience our common humanity  Embrace ALL children as OUR children
  105. 105. Unpublished allegories Dual Reality: A Restaurant Saga Conveyor Belt: Stages of Anti-racism Japanese Lanterns: Colored Perceptions Understanding This Bus We Are On Bicycles on a Hill: Equal Opportunity? Bus Seating: The Permanence of Privilege Bus Survey: Who Counts? Airplane Seating: Invisible TetherSource: Jones CP, unpublished allegories developed for course “Race” and Racism, Harvard School of Public Health, 1994 to 2000.
  106. 106. Resources National Partnership for Action to End Health Disparities Office of Minority Health, US Department of Health and Human Services http://www.minorityhealth.hhs.gov/npa/  National Stakeholder Strategy for Achieving Health Equity  HHS Action Plan to Reduce Racial and Ethnic Health Disparities Regional Health Equity Councils http://minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=1& lvlid=42#1
  107. 107. Resources Healthy People 2020 http://www.healthypeople.gov/2020/default.aspx Overarching goals:  Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.  Achieve health equity, eliminate disparities, and improve the health of all groups.  Create social and physical environments that promote good health for all.  Promote quality of life, healthy development, and healthy behaviors across all life stages. 42 topic areas, including 13 new ones
  108. 108. Resources National Prevention Strategy National Prevention, Health Promotion, and Public Health Council http://www.healthcare.gov/prevention/nphpphc
  109. 109. Resources US-Brazil Joint Action Plan to Eliminate Racial and Ethnic Discrimination and Promote Equality Five-year bilateral agreement signed in 2008 http://www.state.gov/p/wha/rls/2008/111446.htm http://www.state.gov/p/wha/rt/social/brazil/index.htm Areas of focus  Civil society engagement  Economic opportunities and labor  Education  Environmental justice  Health  Justice
  110. 110. Resources CDC Racism and Health Workgroup rahw@cdc.gov Communications and Dissemination Education and Development Global Matters Liaison and Partnership Organizational Excellence Policy and Legislation Science and Publications
  111. 111. Resources Race: The Power of an Illusion California Newsreel http://www.pbs.org/race http://newsreel.org/video/RACE-THE-POWER-OF-AN-ILLUSION RACE – Are We So Different? American Anthropological Association http://www.understandingrace.org/home.html
  112. 112. Resources 3rd World Conference Against Racism, Racial Discrimination, Xenophobia and Related Intolerance Convened by the United Nations in Durban, South Africa in 2001 http://www.un.org/WCAR/ Durban Declaration and Programme of Action http://www.un.org/WCAR/durban.pdf
  113. 113. Resources Unnatural Causes: Is Inequality Making Us Sick? California Newsreel http://www.unnaturalcauses.org Closing the gap in a generation: Health equity through action on the social determinants of health WHO Commission on Social Determinants of Health http://www.who.int/social_determinants/thecommission/finalrep ort/en/index.html
  114. 114. Resources World Conference on Social Determinants of Health Convened by the World Health Organization in Rio de Janeiro, Brasil in 2011 http://www.who.int/sdhconference/en/ Rio Political Declaration on Social Determinants of Health http://www.who.int/sdhconference/declaration/en/
  115. 115. Resources International Convention on the Elimination of all forms of Racial Discrimination (ICERD) Adopted by the United Nations General Assembly in 1965 http://www2.ohchr.org/english/law/cerd.htm Committee to Eliminate Racial Discrimination (CERD) Office of the United Nations High Commissioner for Human Rights http://www2.ohchr.org/english/bodies/cerd/
  116. 116. Resources 2007 USA State Department report to the CERD http://www2.ohchr.org/english/bodies/cerd/docs/AdvanceVersion /cerd_c_usa6.doc 2007 NGO shadow reports to the CERD http://www2.ohchr.org/english/bodies/cerd/cerds72-ngos- usa.htm 2008 CERD Concluding Observations to the USA http://www.state.gov/documents/organization/107361.pdf
  117. 117. Resources Report of the Secretary’s Task Force on Black and Minority Health Margaret M. Heckler, Secretary U.S. Department of Health and Human Services http://collections.nlm.nih.gov/ext/heckler/8602912V1/PDF/86029 12V1.pdf Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care Brian D. Smedley, Adrienne Y. Stith, Alan R. Nelson, Editors Institute of Medicine of the National Academies http://www.nap.edu/openbook.php?isbn=030908265X
  118. 118. Resources The Gardener’s Tale podcast CityMatCH Health Equity and Social Justice Action Group http://www.citymatch.org/UR_tale.php International Coalition of Cities Against Racism United Nations Educational, Scientific and Cultural Organization http://www.unesco.org/new/en/social-and-human- sciences/themes/human-rights/fight-against- discrimination/coalition-of-cities/
  119. 119. Camara Phyllis Jones, MD, MPH, PhD(404) 374-3198 cell(404) 498-1128 workcamara99@bellsouth.net
  120. 120. 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-determinationSource: Jones CP. Confronting Institutionalized Racism. Phylon 2003;50(1-2):7-22.
  121. 121. Policies allowing segregation ofresources and risksRedlining, municipal zoning, toxic dump sitingUse of local property taxes to fund public education
  122. 122. Policies creating inherited groupdisadvantageLack of social security for childrenEstate inheritanceLack of reparations for historical injustices
  123. 123. Policies favoring the differentialvaluation of human life by “race”CurriculumMedia invisibility / hypervisibilityMyth of meritocracy and denial of racism
  124. 124. Policies limiting self-determinationDe jure and de facto limitations to voting rights“Majority rules” when there is a fixed minority
  125. 125. Camara Phyllis Jones, MD, MPH, PhD(404) 374-3198 cell(404) 498-1128 workcamara99@bellsouth.net
  126. 126. Achieving health equity “Health equity” is assurance of the conditions for optimal health for all people Achieving health equity requires  Valuing all individuals and populations equally  Recognizing and rectifying historical injustices  Providing resources according to need Health disparities will be eliminated when health equity is achievedSource: Jones CP 2010, adapted from the National Partnership for Action to End Health Disparities
  127. 127. Our tasks Put racism on the agenda  Name racism as a force determining the other social determinants of health  Routinely monitor for differential exposures, opportunities, and outcomes by “race”
  128. 128. Our tasks Ask , “How is racism operating here?”  Identify mechanisms in structures, policies, practices, norms, and values  Attend to both what exists and what is lacking
  129. 129. Our tasks Organize and strategize to act  Join in grassroots organizing around the conditions of people’s lives  Identify the structural factors creating and perpetuating those conditions  Link with similar efforts across the country and around the world
  130. 130. Camara Phyllis Jones, MD, MPH, PhD(404) 374-3198 cell(404) 498-1128 workcamara99@bellsouth.net
  131. 131. What is racism?“Racism includes racist ideologies, prejudiced attitudes, discriminatory behavior, structural arrangements and institutionalized practices resulting in racial inequality as well as the fallacious notion that discriminatory relations between groups are morally and scientifically justifiable;“it is reflected in discriminatory provisions in legislation or regulations and discriminatory practices as well as in anti-social beliefs and acts;Source: United Nations Educational, Cultural, and Scientific Organization, 1978.
  132. 132. What is racism?“it hinders the development of its victims, perverts those who practice it, divides nations internally, impedes international co-operation and gives rise to political tensions between peoples;“it is contrary to the fundamental principles of international law and, consequently, seriously disturbs international peace and security.”Source: United Nations Educational, Cultural, and Scientific Organization, 1978.
  133. 133. Camara Phyllis Jones, MD, MPH, PhD(404) 374-3198 cell(404) 498-1128 workcamara99@bellsouth.net
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