Race is a figment of the imagination.1 Racism, on the other hand, is real. The problem in America is not that people look different from each other. The problem is that people are treated differently because of how they look. Racism is a pervasive force that produces differences in health and socioeconomic status. Yet, historically, the field has focused on race rather than on addressing racism. This has helped to reify the notion of race and obscure the underlying role of racism in producing the patterns of health inequities that persist in our society.
The concept of race pervading the United States today originated in 15th century Europe and was used to justify the colonization and exploitation of non-European peoples.1,2
In the Americas, racism—the idea that some groups of people are inherently inferior to others—was used to justify the near extermination of the first Americans and the enslavement of millions of Africans.3,4 It justified systems of segregation. The logic of racial thinking continues to be used to justify many forms of differential treatment of groups with respect to immigration, policing, taxation, voting, education, health, and social services.
This important book builds on the work public health advocates and others have been doing for decades, that of trying to achieve racial health equity. Public health advocates and others have documented the existence of health inequities and have fought against the health inequities stemming from racism. In the United States, the 1950s initially saw a substantial increase in Civil Rights efforts and the reduction of overt forms of racism. By 1960, efforts included health-specific activities such as expanding access to quality medical care as a solution to health inequities. By the 1970s, it was clear that medical interventions alone would not reduce health inequities. In the 1980s, health equity champions undertook new efforts to solve them through social interventions, some of which helped improve access to medical care. During this period, substantial research was undertaken to document racial and ethnic health disparities and to identify specific causes for these, particularly as reported in The Heckler Report.5
By 1990, it was clear that data alone would not produce the research, policy, and community action needed to eliminate health disparities. However, it was also clear to those working on the front lines that disparities, along with the tepid institutional responses to these, persisted not because of biological or cultural deficiencies tied to race; rather, there was growing acknowledgment that the underlying barrier to effecting change was racism.
In 1991, a scientific meeting was held to discuss what later came to be called “health disparities”; the meeting was the first of its kind. Its purpose was to focus not on documenting group differences based on the flawed understanding of “race” but rather to focus on the true factors causing the gaps in health status. Emerging from this meeting, the Society for the Analysis of African American Public Health Issues (SAAPHI) was formed to advance the science, education, and advocacy needed to eliminate the stark health disparities burdening African American populations. Several organizations—including the American Public Health Association, the American College of Epidemiology, and the American Statistical Association—developed policies to focus on reducing health disparities. Also in 1991, we saw the first articles focusing on health disparities. In addition, government and foundation funding was obtained to develop new approaches to health disparities.
Since 1991, research has been more focused. Unfortunately, to a large extent, it continues to focus on race rather than racism. As a result, we have learned a lot about the shortcomings of African Americans in preserving their health but very little about the conditions under which they are forced to choose the lesser of multiple unhealthy options. For example, many people talk about the communities in which many African Americans live as food deserts, when the appropriate analogy might be “food swamps” or—to bring attention to the structural forces driving the food situation—sites of “food apartheid.”
Many policies have helped to bring attention to health disparities, but they have not resulted in the kind of research and activities that would be most effective. For example, many of the policies still focus on race, but many of the observed differences in health status occur among ethnic groups. African Americans can be better defined in terms of their culture and behavior rather than the fact that they have more melanin in their skin. Another deficit in the approach to health disparities has been the tendency of researchers and policymakers to focus on what a community lacks rather than on ways to draw out the community’s strengths in order to shift structures to improve health.
Improvements have been made regarding attempts to understand and document the activities that work well in racial/ethnic minority communities; however, the potential effectiveness of some of these activities has, in some cases, been stymied. Even with efforts like these, policymakers and public health professionals have also faced cultural beliefs or practices that have been in conflict with the overall aims for improved health status. For instance, during the AIDS epidemic, the widely believed idea that AIDS was a conspiracy to exterminate Black Americans was an unfortunate one. It obstructed HIV prevention efforts and likely increased the spread of HIV in the community.
Racism is still present in 2018.6,7 The field of public health must continue to remain on the front lines of the fight because racism contributes to health inequities. Researchers, practitioners, and community members will all need to build on the field’s history of fighting racism and its health effects if health disparities are to be eliminated. Historically, advocates were not able to use the term “racism” to describe the focus of their efforts. This book, which targets racism directly and includes the word squarely in its title, marks an important shift in the field’s antiracism struggle for racial health equity.
