The Evolution of Health Policy: Influences, Interpretations and Implications

2. The Evolution of Health Policy:Influences, Interpretations and Implications Confronting Institutionalized Racism

3. Advancing health policy • Setting the agenda • Collecting data • Coordinating action

4. The current agenda • Initiative to Eliminate Racial and Ethnic Disparities in Health by the Year 2010 • Healthy People 2010 • Overarching goal to eliminate health disparities

5. How do disparities arise? • Differences in the quality of care received within the health care delivery system • Differences in access to health care including preventive and curative services • Differences in social, political, economic, or environmental exposures which result in differences in underlying health status

6. Institute of Medicine Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care 2101 Constitution Avenue, NW Washington, DC 20418 http://www.nap.edu

7. Differences in exposures • American Journal of Public Health • February 2003 issue on Racism and Health • Levels of racism • Global definition of racism

8. Levels of racism • Institutionalized • Personally-mediated • Internalized

9. 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 SES and “race”

10. Personally-mediated racism • Differential assumptions about the abilities, motives, and intents of others, by “race” • Prejudice and discrimination • Examples • Police brutality • Physician disrespect • Shopkeeper vigilance • Waiter indifference • Teacher devaluation

11. 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 humanity

12. Levels of Racism: A Gardener’s Tale

13. Who is the gardener? • Power to decide • Power to act • Control of resources Dangerous when • Allied with one group • Not concerned with equity

14. What is racism? A system

15. What is racism? A system of structuring opportunity and assigning value

16. What is racism? A system of structuring opportunity and assigning value based on phenotype (“race”)

17. What is racism? A system of structuring opportunity and assigning value based on phenotype (“race”), that • Unfairly disadvantages some individuals and communities

18. What is racism? A system of structuring opportunity and assigning value based on phenotype (“race”), that • Unfairly disadvantages some individuals and communities • Unfairly advantages other individuals and communities

19. What is racism? A system of structuring opportunity and assigning value based on phenotype (“race”), that • Unfairly disadvantages some individuals and communities • Unfairly advantages other individuals and communities • Undermines the potential of the whole society

20. Racism is a conveyor belt Don’t get carried away!

21. Debates • Focus on racism versus focus on health disparities • Political climate for acknowledging racism • Perceived feasibility of interventions • “Race” and racism in relation to social class • Interactions • Primacy • Structural determinants

22. Advancing health policy • Setting the agenda • Collecting data • Coordinating action

23. Module on Reactions to Race Piloted on 2002 Behavioral Risk Factor Surveillance System by: California Delaware Florida New Hampshire New Mexico North Carolina

24. Earlier you told me your race. Now I will ask you some questions about reactions to your race.

25. Question 1 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, or some other group?

26. Question 2 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?

27. Question 3 [For those who are employed for wages, self-employed, or out of work for less than one 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?

28. Question 4 Within the past 12 months when seeking health care, do you feel your experiences were worse than, the same as, or better than for people of other races?

29. 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?

30. Question 6 Within the past 30 days, have you experienced any physical symptoms, 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?

31. How often do you think about your race? • Never • Once a year • Once a month • Once a week • Once a day • Once an hour • Constantly

35. Racial climate • Pertinence of “race” as a basis for classification • Rules for racial classification • Number and names of categories • Sorting rules • Opportunities and value accorded the different racial groups • Measured by pertinence of racial assignment

36. Measuring institutionalized racism • Scan for evidence of “racial” disparities • Routinely monitor outcomes by “race” • “Could racism be operating here?” • Identify mechanisms • Examine written policies • Query unwritten norms and practices • “How is racism operating here?”

37. 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-determination

38. Policies allowing segregation of resources and risks Redlining, zoning, toxic dump siting Use of local property taxes to fund public education

39. Policies creatinginherited group disadvantage Estate inheritance Lack of social security for children Lack of reparations for historical injustices

40. Policies favoring the differential valuation of human life by “race” Curriculum Media invisibility/hypervisibility Myth of meritocracy and denial of racism

41. Policies limitingself-determination De jure limitations to voting rights Limits to representation/participation “Majority rules” when there is a fixed minority

42. Advancing health policy • Setting the agenda • Collecting data • Coordinating action

43. Quality of care • Promulgate treatment protocols • Implement reminder systems • Monitor provider practice • Train a diverse workforce • Provide anti-racism training • Train and deploy translators • Ensure community oversight

44. Access to care • Make health care a right • Implement a national health system • Provide universal health care coverage • Train a diverse workforce • Assure the appropriate geographic distribution of providers • Implement Community Oriented Primary Care

45. Differences in exposures • National conversation on racism • Name racism • Acknowledge impacts on health • Acknowledge waste to the nation • National campaign against racism

46. Confronting institutionalized racism • Put racism on the agenda • Ask, “How is racism operating here?” • Organize and strategize to act • Dismantle, remodel, or create a structure • Eliminate, revise, or implement a policy • Identify and challenge or promote a practice • Identify and challenge or promote a norm

47. Register your efforts Document your strategies and successes with the Measures of Racism Working Group cdj9@cdc.gov