Inequality and African-American Health

How Racial Disparities Create Sickness

Hill, Shirley A., Shirley A. Hill

• Publisher: Policy Press
• Year: 2016
• Print ISBN: 9781447322825
• eBook ISBN: 9781447322856
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

This book shows how living in a highly racialized society affects health through multiple social contexts, including neighborhoods, personal and family relationships, and the medical system.

Black-white disparities in health, illness, and mortality have been widely documented, but most research has focused on single factors that produce and perpetuate those disparities, such as individual health behaviors and access to medical care.

This is the first book to offer a comprehensive perspective on health and sickness among African Americans, starting with an examination of how race has been historically constructed in the US and in the medical system and the resilience of racial ideologies and practices. Racial disparities in health reflect racial inequalities in living conditions, incarceration rates, family systems, and opportunities. These racial disparities often cut across social class boundaries and have gender-specific consequences.

Bringing together data from existing quantitative and qualitative research with new archival and interview data, this book advances research in the fields of families, race-ethnicity, and medical sociology.

Part One

Theorizing social inequalities in health

The more than 40 million African Americans who live in the US carry a disproportionate share of the nation’s sickness burden. Sociologist David R. Williams, who has written extensively about the black-white health disparity, has repeatedly shown that African Americans not only have higher rates of sickness than Whites, but they also get sick earlier, have more severe diseases, and are more likely to die from their diseases (Williams and Sternthal, 2010; Williams, 2012; Williams and Mohammed, 2013). Black people have higher rates of death than Whites for 13 of the 15 leading causes of death, and they have more nonfatal diseases (Hayward et al, 2000). Heart disease and cancer, the two leading causes of death, strike African Americans at an earlier age and result in more premature deaths. These racial disparities in health start at the moment of birth: black infants are more likely than white infants to be born preterm and underweight, to have more developmental problems, and to die in infancy (Rosenthal and Lobel 2011). The health disadvantages of early childhood persist throughout life, leading to poor health, more functional limitations, and earlier death among African Americans; they also curtail educational attainment and career mobility (Garbarski, 2014; Umberson et al, 2014; Rossin-Slater, 2015).

The earliest systematic data available on race and health date back to the 1800s, and consistently document the black health deficit. Sickness and early death, however, were common during that era, and the fact that African Americans were sicker and died earlier supported theories of their innate, biological inferiority. Sociology emerged during that time as the study of modernity with a focus on how social environmental forces transformed societies, but early theorists expressed little interest in how those forces affected health (Gerhardt, 1989). Many were concerned about the transformations caused by industrialization, such as increases in family and community instability and socially deviant behaviors, but gradually came to understand modernity as evolution toward a more highly developed society. Structural-functionalism became and remained the dominant theoretical paradigm among US sociologists until the late 1950s, focusing on how macro level forces were modernizing societies, institutions, and cultural values. Structural functionalism resonated with the “American Dream” ideology of upward mobility for everyone who worked hard to achieve it, but it also held essentialist notions of race and gender that led to virtually ignoring people of color and women.

Sharply contrasting this perspective was the work of Karl Marx and Friedrich Engels, who offered scathing critiques of how industrial capitalism was undermining the health of the working-classes (Engels, 1892). The mass of industrial workers lived in ever-deepening poverty and misery and suffered from high rates of infectious diseases and premature death due to the inhumane living and working conditions that were forced upon them—for example, high levels of air pollution, inadequate ventilation in factories, and poor sanitation. These theorists argued that industrial Western nations were dominating the global economy because they benefited immensely from slavery and exploiting the labor and resources of people in poor nations. This critique of industrial capitalism never gained much traction in the US, however, although the public health movements of the late 1800s at least tacitly recognized the link between social environmental conditions and health. That focus waned, however, with the discovery of the germ theory of disease and, by the 1950s, the booming post-war economy that created more social class equality (House, 2001).

Medical sociology originated during this era and, like much of the discipline, did not offer a strong critique of structural inequalities in health. Some medical sociologists acknowledged social class-based disparities in health and health behaviors, but their work often focused on white ethnic groups and sought to understand how they responded to symptoms of illness (Zborowski, 1952; Zola, 1966). Their work was insightful, but far from a critique of structural inequalities in health or access to health care. Not until the 1960s did a more critical perspective emerge among medical sociologists, and it primarily challenged the organization and power of the medical system.

Symbolic interactionism has roots as deep as structural functionalism but focuses more on micro-level human interactions and processes. From this perspective human beings have agency in defining and creating reality, and those realities have important consequences for shaping societies and the experiences of individuals. Drawing on this perspective medical sociologists challenged the idea that the biomedical model of illness was based on objectivity and scientific neutrality, arguing instead that medical knowledge and diagnoses were as much a matter of social construction as a biological fact (Gerhardt, 1989). Theorists contended that in its effort to find and eradicate disease, medical science often constructed conditions that did not formerly exist (Freidson, 1970), and they pointed to the growing medicalization of social life and problems (Conrad and Schneider, 1980). Sociologists also became more likely to embrace conflict theory, especially in criticizing the existence of a profit-driven, capitalist medical system that defined health as a commodity to be purchased rather than a right of citizenship.

The women’s health care movement emerged in this era of protest and drew on symbolic interactionism and conflict theory to criticize gender inequities in health and the organization of the health care system. Its key premise was that gender is socially constructed in a way that adversely affects women, their health, and their participation in the medical system. Although the higher rates of sickness that women experience may have some basis in biology, they argued that gender norms and stereotypes adversely affected women’s health by constraining their full participation in society (Bird and Rieker, 2008). Moreover, medical knowledge about women’s health was saturated with sexist and essentialist theories that ignored the link between their life experiences and their health and medicalized female functions such as childbirth (Ehrenreich and English, 1978). The problem also reflected the gender hierarchy in medicine, where physicians were overwhelmingly white men from privileged backgrounds (Zimmerman and Hill, 2000).

The feminist critique of the health care system was pivotal in generating a discussion of the impact of social inequalities on health, but it was evident that the experiences of middle-class white women were different from those of low-income and women of color. The latter experienced issues such as the lack of access to adequate medical care, disrespect from health care professionals, and violations of their reproductive rights. These class and racial inequities had already propelled black female activism, which started in the early decades of the 20th century and promoted individual and social interventions to improve black health (Smith, 1995). In the 1970s, Byllye Avery, an African-American health activist, founded a clinic in Gainsville, Florida devoted to addressing black women’s health issues. The National Black Women’s Health Project officially started in 1984, with the goal of empowering women with control over their lives and health (Morgen, 2002). Social class and racial differences in health issues pointed to the need for an intersectionality perspective that theorized race, class, sexuality, and gender intersecting inequalities in the production of health inequalities (Collins, 1990). Still, “gender” typically centered only on women and ignored male experiences and perspectives.

Social inequalities in health have now become a major focus in medical sociology, and social conditions as the fundamental cause of sickness and death has become the major theory in the field (Link and Phelan, 1995; Phelan et al, 2010). This theory is especially applicable in advanced societies where improved sanitation and modern health services, and even universal health care, have not eliminated racial and social class disparities in morbidity and mortality. That social conditions are the fundamental cause of sickness had become so irrefutable that a 1995 edition of the Journal of Health and Social Behavior, celebrating 40 years of medical sociology, was devoted to the topic. Link and Phelan have argued that medical sociology has devoted too much attention to identifying individual risk factors that affect health, such as smoking, diet, and exercise, but far too little to understanding how social conditions affect health and health behaviors. Moreover, they pointed out that although the link between social conditions and class is apparent, much more research needs to be done to show how social conditions affect gender and racial health inequalities (quoted in Masters et al, 2015).

Research in medical sociology on racial inequalities and health, in fact, remains in its nascent stages, despite the revolutions of the 1960s, changing racial ideologies and the fact that the black-white color line essentially defined racial boundaries. James House pointed out that the first edition of the popular Handbook of medical sociology (published in 1963) did not even list the words “poverty,” “black,” or “Negro” in its index (House, 2001). Not until 2000 did this often-updated and popular textbook include a chapter that explicitly dealt with racial and social class disparities in health. In his examination of the contributions of medical sociology to understanding racial disparities in health, D. R. Williams also found that prior to 1990, major sociological journals had at best only a handful of articles about race and health (Williams and Sternthal 2010). The health experiences of African Americans are also missing from theories and concepts generated by medical sociologists, such as the sick role concept and medicalization. The next two chapters advance the study of race and health by examining how social definitions of race create disadvantage and influence health, thus placing the health deficit of African Americans in historic perspective.

ONE

Race, racism, and health outcomes

That patterns of health, sickness, and mortality vary on the basis of race is irrefutable, and this has made race a major ‘variable’ in research in the medical and health sciences. Cross-national data reveal that in every race-conscious nation in the world, racially dominant groups are healthier and live longer than racially subordinate groups (Williams, 2012). But what is race? And through what mechanisms does it affect health? Definitions of race have shifted in recent decades, and it is now seen as more of a socially defined category than a biological fact. That race is a social construct has been widely—although not universally—accepted among scholars, and this has offered new possibilities for rethinking the meaning of skin color and phenotype. However, it has neither erased damaging racial stereotypes about African Americans nor has it eliminated racial discrimination. Although the majority of Americans today endorse racial equality and equal opportunity, black people encounter race-based disadvantages over the course of their lifespans and in multiple settings. In the pervasively racialized social system of the US, whiteness still symbolizes goodness, morality, intelligence, and attractiveness, and blackness is seen as the absence of those attributes.

Research has shown that despite widespread support for racial equality, many white people still hold a spate of racial stereotypes about black people (for example, they are lazy, prone to violence, immoral). They may be less likely to explain their beliefs in terms of biological factors, but equating blackness with inherently flawed social and cultural values is no less damaging. An example of this is found in a quote from a white male asked to explain racial inequality:

I think the majority [of black people] aren’t enthused, not motivated, and don’t care. The opportunity is there if they want to take advantage. I don’t think most Blacks want to work for anything. (quoted in Kwate and Meyer, 2010: 1833)

African Americans are intensely aware of racism and racial stereotypes, and more than 90 percent report that they have experienced racial discrimination (compared to 10 percent of Whites) (Bratter and Gorman, 2011). History reveals a continuous struggle by African Americans to resist oppression and discrimination, yet pervasive racism still fosters psychological and physical violence; it does so even more insidiously when it is institutionalized into social policies that adversely affect the life chances of black people. Racism is a chronic stressor for African Americans, whether it is ignored, challenged, or internalized, and it poses significant barriers to their ability to achieve socioeconomic success or to abide by dominant cultural values. Social class and racial inequalities, in fact, have been pivotal in developing the stress paradigm in medical sociology (House, 2001). Theorists have documented a direct link between social stress and sickness, with stressful life events predicting illnesses as serious as heart disease. They have also pointed out that chronic life strains diminish feelings of self-esteem, self-worth, and the sense of mastery over life, and thus have a detrimental impact on health. Life strains that are deeply entrenched in the social and economic organization of life are often impervious to individual coping efforts. They confront people with “dogged evidence of their failures,” according to Pearlin, “and inescapable proof of their inability to alter unwanted circumstances in their lives” (Pearlin et al, 1981: 340).

This chapter begins with a discussion of the origins of race as a biological concept and the emergence of a sociological perspective that defined race as a socially constructed category, but one with immense social and political consequences. Much evidence supports the socially constructed nature of racial categories, including the growing racial diversity of the black population, which has reshaped the relationship between race and health. This growing diversity has further challenged the notion of biological race, but has not eliminated the racialized social system that is rooted in notions of black inferiority. I examine how this racialized social system fosters social class disadvantage and promotes structural violence against African Americans. The persistent relegation of black people to the economic and social margins of society strengthens racist ideologies and, for African Americans, elevates the fears, uncertainties, and racial injustices that create stress and the social conditions that adversely affect health.

Race: historical foundation

Social scientists associate race with physical characteristics (for example, skin color, hair texture) that stem from national origins and biological ancestry and ethnicity with cultural characteristics. The two concepts often, but not always, overlap. The focus in early sociological research was mostly on ethnicity and was driven by the stream of white ethnic immigrants from southeastern Europe who came to the US during the early 20th century. They were racially and culturally distinct from the earlier English settlers in many ways, but especially language and religion, and were expected to undergo a process of assimilation to take on the dominant American culture. Studies of ethnic assimilation were popular in sociology during the early to mid-20th century; however, they were largely inapplicable to African Americans who were involuntary immigrants and expected to “stay in their place” rather than assimilate. Slavery and racial segregation were justified by theories of black racial inferiority, and penalties for transgressing rigid racial codes and boundaries were often severe.

The concept of race has its origins in 15th-century exploration, when European Whites first encountered people of color across the globe—the “cultural other”—and judged them as inferior to themselves. People of color became objects of scientific inquiry and exploitation, with ethnocentric Whites theorizing themselves and their culture as racially superior to others. This paved the way for the racial and economic domination of people of color, which intensified when industrial capitalism expanded and required cheap labor. For Africans, this meant centuries of slavery and virulent forms of racism and oppression that denied their humanity and defined every aspect of their lives. Being defined as black, which meant having any African ancestry, became a master status, despite social and economic distinctions among African Americans, and the black-white color line the most rigidly enforced of all racial distinctions.

Theories of racial inferiority stigmatized and stereotyped African Americans and were almost universally accepted, resulting in laws that severely restricted every aspect of their lives. Most people, including social scientists, accepted race as a biological category and rarely challenged essentialist notions of black racial inferiority. Although Africans came to the US from multiple countries and had a variety of skills, slavery and racial oppression had a homogenizing effect on them as it made blackness their most important characteristic. Even as African Americans moved from slavery to freedom, and from being defined as “property” to second-class citizens in a racially segregated society, they continued to be viewed as intellectually and morally inferior to Whites. Legalized segregation and “Jim Crow” rules reinforced racial inequality and the economic marginalization of African Americans. Racial violence against black people was common, including untold numbers of rapes and beatings, and the documented lynching of more than 6,000 people, few if any of which were effectively addressed by the criminal justice system (Evans and Feagin, 2015).

Social construction of race

The latter half of the 20th century witnessed a seismic shift in our thinking about race and racism, especially as it pertains to African Americans. For a number of reasons—for example, the long history of black resistance to oppression, the racial genocide that occurred during the Second World War in Nazi Germany, and the civil rights movement of the 1960s—scholars began to rethink notions of race, especially the belief that it was based on biological differences. Most scholars came to see race as a social construct, or more of a product of social definitions than biological features. There is little evidence of significant biological or genetic differences between people, but significant support for the social constructionist view of race. From a biological standpoint, there are no “pure races” in the sense of genetically homogeneous populations; in fact, there is little evidence in recorded history that racially pure groups have ever existed.

The social constructionist framework theorizes racial groups as socially created through processes of racialization, or assigning meaning to real, perceived, or ascribed differences between groups, and then making those differences the basis for distributing power and prestige (Burton et al, 2010). People of color in the US have primarily been defined as racial groups—for example, surveys and censuses usually ask people to self-identify based on racial categories. These racial categories do not, however, reflect the level of racial diversity that exists among Americans—for example, people from the Middle East (for example, Arabs, Jews, Iranians), and some Hispanics, are categorized as “White.” The racial category “Mexican” was used only in the 1930 federal census, dropped amid protest, and reinstituted in 1970 as Hispanic. Panethnic categories like Asian American also include people from several countries and cultures. And while Jews are usually categorized racially as White, they are in reality an ethnic group that can be composed of various races. Anyone with African ancestry was legally categorized as Negro, Black, or African American.

The social construction of racial categories is seen in shifting definitions of whiteness and even more so in determined efforts to delineate the black-white color line. The rule of hypodescent, also known as the “one drop rule,” held that children born of mixed racial unions had to be assigned the race of the racially subordinate parent. The dominant racial hierarchy placed African Americans as subordinate to all other racial groups, and anyone with any known African ancestry was legally categorized as Black. That rule is still commonly applied—for example, Barack Obama, the son of a white mother and black African father, is considered the first black president of the US, despite his mixed racial heritage. Still, African ancestry is not always evident in one’s phenotype, and numerous people legally defined as Black have passed for White.

Growing complexity of defining race

The social construction of racial categories has become even more difficult with the growing diversity in the black population. Scholars have noted that since race is socially constructed, the identities and rules associated with it are fluid and subject to change (Burton et al, 2010). This has become more apparent for African Americans in the post-civil rights era because of greater social class diversity, an increase in interracial unions and biracial children, and a growing population of black immigrants from Africa and the Caribbean. Although there has always been some social class diversity among African Americans, being black was once almost synonymous with being poor. In 1940, about 80 percent of black people worked in the three lowest occupational categories (farming, service workers, and laborers), and the majority lived in poverty (Gilbert, 2011). Black people are still overrepresented among the poor—in 2013, nearly 28 percent were poor, compared to 9.8 percent of Whites, but the majority are in the working and middle classes.

Another dimension of intraracial diversity among black people that might affect health is the growth of interracial unions, multiracial people,...

Table of contents

• Coverpage
• Title page
• Copyright
• Contents
• Preface
• Introduction
• Part One: Theorizing social inequalities in health
• Part Two: Health and medicine
• Part Three: Health and families
• Conclusion
• References