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‘Health inequalities are the systematic, avoidable and unfair differences in health outcomes that can be observed between populations, between social groups within the same population or as a gradient across a population ranked by social position.’ (McCartney et al, 2019)
Health inequities, however, are differences in health that are judged to be avoidable, unfair, and unjust. (Sudana and Blas, 2013)
Asking “Is X racist?” is the wrong question to ask. If X is factual, then making the claim cannot be racist (facts themselves cannot be racist). But, one can perform a racist action—either consciously or subconsciously—on the basis of a fact. Facts themselves cannot be racist, but one can use facts to be racist. One can hold a belief and the belief can be racist (X group is better than Y group at Z), but systemic racism would be the result (the outcome) of holding said belief. (Some examples of systemic racism can be found in Gee and Ford, 2011.) Someone who holds the belief that, say, whites are more “intelligent” than blacks or Jews are more “intelligent” than whites could be said to be racist—they hold a racist belief and are making an invalid inference based on a fact (blacks score 15 points lower in IQ tests compared to whites so blacks are less intelligent). Truth cannot be racist, but truth can be used to attempt to justify certain policies.
I have argued that we should ban IQ tests on the basis that, if we believe that the hereditarian hypothesis is true and it is false, then we can enact policies on the basis of false information. If we enact policies on the basis of false information, then certain groups may be harmed. If certain groups may be harmed, then we should ban whatever led to the policy in question. If the policy in question is derived from IQ tests, then IQ tests must be banned. This is one example on how we can use a fact (like the IQ gap between blacks and whites) and use that fact for a racist action (to shuttle those who perform under a certain expectation into certain remedial classes based on the fact that they score lower than some average value). Believing that X group has a higher quality of life, educational achievement, and life outcomes on the basis of IQ scores—or their genes—is a racist belief but this racist belief can then be used to perform a racist action.
I have also discussed different definitions of “racism.” Each definition discussed can be construed as having a possible action attached to it. Racism is an action—something that we perform on the basis of certain beliefs, motivated by “what can be” possible in the future. Beliefs can be racist; we can say that it is an ideology that one acts on that has real causes/consequences to people. Truth can’t be racist; people can can use the truth to perform and justify certain actions. Racism, though, can be said to be a “cultural and structural system” that assigns value based on race; further, actions and intent of individuals are not necessary for structural mechanisms of racism (e.g., Bonilla-Silva, 1997).
We can, furthermore, use facts about differences between races in health outcomes and say that certain rationalizations of certain outcomes can be construed as racist. “It’s in the genes!” or similar statements could be construed as racist, since it implies that certain inequalities would be “immutable” on the basis of a strong genetic determination of disease.
Racism is indeed a public health issue. For instance, physicians can hold biases on race—just like the average person. For instance, differences in healthcare between majority and minority populations can said to be systemic in nature (Reschovsky and O’Malley, 2008). This needs to be talked about since racism can and is a determinant of health—as many places in the country are beginning to recognize. Racism is rightly noted as a public health crisis because it leads to disparate outcomes between whites and blacks based on certain assumptions on the ancestral background of both groups.
Quach et al (2012) showed that not receiving referrals to a specialist is discriminatory—Asians, too were also exposed to medical discrimination, along with blacks. Such discrimination can also lead to accelerated cellular aging (on the basis of measured telomere lengths where shorter telomeres indicate a higher biological compared to chronological age; Shammas et al, 2012) in black men and women (Geronimus et al, 2006; 2011; Schrock et al, 2017; Forrester et al, 2019). We understand the reasons why such discrimination on the basis of race happens, and we understand the mechanism by which it leads to adverse health outcomes between races (chronic elevation in allostatic load leading to higher than normal levels of certain stress hormones which will, eventually, lead to differences in health outcomes).
The idea that genes or behavior lead to differences in health outcomes is racist (Bassett and Graves, 2018). This can then lead to racist actions—that their genetic constitution impedes them from being “near-par” with whites, or that their behavior is the cause of the health disparities (sans context). Valles (2018: 186) writes:
…racism is a cause with devastating health effects, but it manifests via many intermediary mechanisms ranging from physician implicit biases leading to over-treatment, under-treatment and other clinical errors (Chapman et al. 2013; Paradies et al. 2015) to exposing minority communities to waterborne contaminants because of racist political disenfranchisement and neglect of community infrastructure (e.g., the infamous Flint Water Crisis afflicting my Michigan neighbors) (Krieger 2016; Sherwin 2017; Michigan Civil Rights Commission 2017).
There is a distinction between “equity” and “equality.” For instance, to continue with the public health example, take public health equality and public health equity. In this instance, “equality” means giving everyone the same thing whereas “equity” means giving individuals what they need to be the healthiest individual they can possibly be. “Strong equality of health” is “where every person or group has equal health“, while weak health equity “states that every person or group should have equal health except when: (a) health equality is only possible by making someone less healthy, or (b) there are technological limitations on further health improvement” (Norheim and Asada, 2009). But we should not attempt to “level-down” people’s health to achieve equity; we should attempt to “level up” people’s health, though. That is, it is impossible to reach a strong health equality (making all groups equal), but we should—and indeed, have a moral responsibility to—attempt to lift up those who are worse-off. Poverty is what is objectionable, inequality is not. It is impossible to achieve true equality between groups, but we can—and indeed we have a moral obligation to—lift up those who are in poverty, which is, also a social determinant of health (Braveman and Gottlieb, 2014; Frankfurt, 2015; Islam, 2019).
We achieve health equity when all individuals have the same access to be the healthiest individuals they can be; we achieve health equality when all health outcomes are the same for all groups. Health equity is, further, the absence of avoidable differences between different groups (Evans, 2020). One of these is feasible, the other is not. But racism does not allow us to achieve health equity.
The moral foundation for public health thus rests on general obligations in beneficence to promote good health. (Powers and Faden, 2006: 24)
Social justice is not only a matter of how individuals fare, but also about how groups fare relative to one another whenever systemic racism is linked to group membership. (Powers and Faden, 2006: 103)
…inequalities in well-being associated with severe poverty are inequalities of the highest moral urgency. (Powers and Faden, 2006: 114)
Public health is directly a matter of social justice. If public health is directly a matter of social justice, and if health outcomes due to discrimination are caused by social injustice, then we need to address the causes of such inequalities, which would be for example, conscious or unconscious prejudice against certain groups.
Certain inequalities between groups are, therefore, due to systemic racism which is an action which can be conscious or unconscious. But which inequalities matter most? In my view, the inequalities that matter most are inequalities that impede an individual or a group from having a certain quality of life. Racism can and does lead to health inequalities and by addressing the causes for such actions, we can then begin to ameliorate the causes of structural racism. This is more evidence that the social can indeed manifest in biology.
Holding certain beliefs can lead to certain actions that can be construed as racist and negatively impact health outcomes for certain groups. By committing ourselves to a framework of social just and health, we can then attempt to ameliorate inequities between social class/races, etc. that have plagued us for decades. We should strive for equity in health, which is a goal of social justice. We should not believe that such differences are “innate” and that there is nothing that we can do about group differences (some of which are no doubt caused by systemically racist policies). Health equity is something we should strive to do and we have a moral obligation to do so; health equality is not obligatory and it is not even a feasible idea.
If we can avoid health certain outcomes for certain groups on the basis of beliefs that we hold, then we should do so.