May 20, 2022 – Nancy Kriegerprofessor of social epidemiology, reflects on the still topical themes of a paper of which she was the first author three decades ago for the American Journal of Preventive Medicine. The newspaper reprinted the article on May 18, 2022, along with a new remark by Krieger and another remark by epidemiologist Ana Diez Roux of Drexel University.
Q: How did the diary come about and what is its significance?
A: The article focused on the implications of racism, sexism, and social class for studies of health, disease, and well-being. It was developed for a CDC conference focusing on poor birth outcomes among black American women. A key group of black women researchers led by Dr Diane Rowley at the CDC said the data did not support the widespread view that it was solely because of poverty – or ‘race’ being mistreated as a innate biological characteristic – that there were worse birth outcomes in black women. This is because there were racial differences in health status, comparing birth outcomes between black American and white women, which differed across and within various income categories and education levels.
Diane Rowley and others wanted to be on the agenda, for the very first time at the CDC, a conference that began to openly and publicly address racism as a determinant of health inequities, and which was not aimed not to see racism as something by itself, but as interdependent of class and gender inequalities.
The conference organizers have solicited a wide range of papers. What prompted me to be lead author on the recently reprinted article was my 1989 thesis research on the impact of race, social class and health on breast cancer and hypertension .
In our 1993 article, we reviewed the evidence that existed in the literature, considered what all the gaps were, and helped establish a research agenda that some of us have been busy with – not just out of intellectual curiosity, but to inform action and advocacy for health equity — ever since. This is why our newly reprinted article continues to be a touchstone and continues to be cited to this day.
I think the document is as timely today as it was then. In my new commentary, I write about how science and the world have changed, but there’s a distinction between having scientific advances and understanding and having that translate into real life, politically and socially, with real advances for health equity.
Q: Can you give examples of how research 30 years ago was limited in how it looked at health inequalities?
A: Thirty years ago, there was still virtually no research that even asked about self-reported experiences of racial discrimination. We also said in our article that it was important to examine not only what people self-reported about their interactions with other people, but also to examine how racism, in conjunction with class and gender relations and inequalities, shapes the context. where people live and work.
For example, in the literature on racialized residential segregation, it is important to examine not only the composition of neighborhoods, but also the policies that made it so, in particular historical redlining – the US federal policies of the 1930s that deepened and propagated racial discrimination. nationwide segregation. This is work that has taken off in the last five years or so.
We similarly said at the time that there was incredibly little work on sexism and health issues, and that continues to be the case. Much research on “women’s health” focuses on sex-related biology and issues with the assumption of a “male” biological reference point for research. But this is not about gendered experiences across diverse gender identities. For example, there are still remarkably few studies that have looked at the impact of explicit exposures to sexual harassment on cardiometabolic disease, or the impact of gender-based violence on cardiometabolic disease or the onset of dementia. .
Thirty years ago, there was also a real lack of attention to how issues of social class relations shape population health. There is still a reluctance to talk about this and the power issues involved. The dominant tendency is to focus on individual characteristics. For example, a question about why you have a particular health problem might focus on your level of education, rather than the forces that determine who gets a particular level of education in that country, and the quality of this education.
Q: What inspires you and what is your hope for research in the future?
A: There have certainly been advances. The CDC now has a website on racism as a key social determinant of health. Many people have been calling for this for years, and the effort was further galvanized by the brutal police killing of George Floyd in 2020. It is now better understood that scientific rigor demands attention to issues of structural racism. . The NIH also now has an initiative to eliminate structural racism in biomedical research. And the WHO organized a huge global commission on the social determinants of health in 2008, followed a decade later by the PAHO Commission on Equity report in 2018, which highlighted the continuing effects of systems of slavery and colonization on contemporary health inequalities.
Going forward, researchers need to – and indeed can – think about issues of racism, class and gender simultaneously. It is important to use a tiered approach not only in designing studies, but in the data itself. It’s about getting not only what people report about themselves in terms of factors like their education, income, gender identity, but also the context in which they live. What are the policies of the city, state, country they live in, past and present, that affect their well-being?
A very disturbing point to note, with which I conclude my new commentary, is that at the time we wrote our article 30 years ago, the black/white ratio for infant mortality in the United States was 2 for 1. We wrote that if things don’t change, it will stay that way. And guess what? It stayed that way, otherwise it got a little worse.
So we still have work to do. Scientifically understanding the problem is not the same as knowing how to fix things. Even if we know how to fix things, in terms of proposing social priorities, policies and resource allocation, there are serious political and societal obstacles. We need to understand what power relations are holding us back, those of us in public health and in society at large, who value and strive for health equity, from achieving these goals.
– Karen Feldscher