An invisible evil

{***Music***}

{***Amie Montemurro***}

Coming up on Harvard Chan: This Week in Health…

Structural racism and health.

{***Zinzi Bailey Soundbite***}

(Structural racism has been called an invisible evil because it’s so pervasive.)

This week we examine how long-standing institutions and policies affect health disparities—and what can be done to change this.

{***Music***}

{***Amie Montemurro***}

Hello and welcome to Harvard Chan: This Week in Health. It’s Thursday, May 4, 2017…I’m Amie Montemurro.

{***Noah Leavitt***}

And I’m Noah Leavitt.

{***Amie Montemurro***}

Noah, A black mother in New York City is four times more likely to die during childbirth than a white mother. And nationally the infant mortality rate for non-Latino blacks is more than two* times the rate for white infants.

{***Noah Leavitt***}

Those are just two of the many stark examples of the very real racial health disparities in the United States.

The list goes on: For example, diabetes and heart disease are more prevalent among Latinos or blacks than other groups

{***Amie Montemurro***}

The evidence is clear: marginalized racial groups are more likely to experience worse health outcomes.

{***Noah Leavitt***}

But what’s less clear is what exactly is driving these disparities.

And that’s what we’re focusing on today.

{***Amie Montemurro***}

You’ll be hearing from Zinzi Bailey, who we spoke to via Skype.

She graduated from the Harvard Chan School in 2014, and is now director of research and evaluation in the Center for Health Equity at the New York City Department of Health and Mental Hygiene.

{***Noah Leavitt***}

Bailey was recently first author on a paper in the Lancet which examined structural racism and health inequities in the U.S.

{***Amie Montemurro***}

And structural racism is different than interpersonal racism, which you may be more familiar with.

Interpersonal racism occurs between people or groups—and can take the form of verbal harassment or even police violence.

It’s visble and easier to recognize.

{***Noah Leavitt***}

Structural racism is harder to recognize because it occurs in connected institutions and policies—things like housing or education.

And Bailey says that unlike interpersonal racism you don’t have to recognize it to be affected.

{***Zinzi Bailey Soundbite***}

(Structural racism has been called an invisible evil because it’s so pervasive, not only affecting sectors and systems, but also making us colorblind to white supremacy in various forms. So it’s invisible because we are socialized to be blind to it. So in essence, structural racism involves interconnected institutions whose linkages are historically rooted and culturally reinforced. It encompasses all the ways, all the mutually reinforcing ways, that different systems in housing, education, employment credit, media, health care, criminal justice, foster discrimination by a racialized group. These systems reinforce discriminatory beliefs, values, and distribution of resources, whether it’s on the institutional or individual levels. So together, these impact life chances, environment, exposures, and ultimately, the risk of health outcomes.)

{***Noah Leavitt***}

Because it is so pervasive and hidden, structural racism is incredibly difficult for public health practitioners to research.

{***Amie Montemurro***}

Structural racism is different from Jim Crow Laws which were on the books for decades in the United States.

They used clear racist language—so it was possible to analyze their impact.

{***Noah Leavitt***}

Structural racism on the other hand is built into our society. It’s harder to identify yet its effects are wide-ranging: from the distribution of financial resources, to the quality of schools in certain neighborhoods versus others, and even the quality of health care services

{***Amie Montemurro***}

And it affects people differently than interpersonal racism—which affects health mostly through stress and psychological factors.

With institutional racism the effects can be varied—and often run deeper, through generations.

{***Noah Leavitt***}

This is all part of the growing recognition of what researchers like Bailey call the social determinants of health.

{***Zinzi Bailey Soundbite***}

(So it’s really thinking about the living conditions under which people eat, live, pray, play, all of those things. So that list expands as we go along. But those conditions of daily life impact every part of us. So while we can think about things that are more proximal and modifiable on an individual level– like diet or exercise, things like that– thinking about social structures will have an impact on those downstream factors.)

{***Noah Leavitt***}

So how does this manifest itself?

Let’s say you live in a neighborhood that isn’t safe—there’s violence or drug deals—you’ll be less likely to go to your park to exercise or play with your children

This changes how you live your life—and this lack of exercise could make you more susceptible to type 2 diabetes or heart disease.

Or the violence in the neighborhood could deter stores selling healthier foods.

{***Amie Montemurro***}

In the Lancet paper, Bailey and fellow researchers outline several ways that structural racism manifests itself, and one of the strongest is racial and economic segregation.

The impact goes beyond the physical separation of people into different areas says bailey—it makes discriminatory distribution of resources easier or more likely to happen.

{***Noah Leavitt***}

An example of this is something called redlining—which is when services are denied to residents of certain areas based on their ethnic or racial composition.

This could take the form of making mortgages or insurance unobtainable…or raising prices so those in the area can’t afford a service.

{***Amie Montemurro***}

These segregated neighborhoods become “disinvested” says Bailey—bringing up the parks example again.

{***Zinzi Bailey Soundbite***}

(When we’re talking about disinvested neighborhoods, oftentimes, the parks have less resources. In similar patterns, the schools have less resources, hospitals have less resources, the businesses have less reinforced key actors. Oftentimes, people say that your zip code has more impact on your health than your genetic code. And in many ways, that’s right, but I think it’s also a false distinction, because a lot of what we’re living with and the living conditions that we have inherited as well, they are embodied in our physical forms and impacts how our bodies function.)

{***Amie Montemurro***}

The key point, Bailey, says it that even if we’ve eliminated Jim Crow Laws in name—other policies can still have the same effect, whether it’s health care policy or drug policy.

{***Noah Leavitt***}

She says that addressing structural racism is an issue of health equity—and that it can only begin by fixing the underlying societal structures that lead to health disparities

Bailey says the best solutions will likely be ones that affect a number of areas and are localized and place-based—in other words they recognize that structural racism may manifest itself differently depending on the area.

The goal is to correct that unbalanced distribution of resources we talked about earlier—and then document it in a scientific way so that other communities can follow suit.

{***Amie Montemurro***}

Examples of this are the Choice and Promise Neighborhoods programs from the federal Department of Housing and Urban Development and the Department of Education

The Choice program aims to help transform high-poverty, distressed neighborhoods into communities with healthy, affordable housing, safe streets, and access to quality educational opportunities.

The strategy involves investing in improvements at community facilities, parks, gardens, and in economic development, job creation, and asset building, while also boosting support services for residents.

The Promise program focuses on schools—with the goal of improving educational and developmental outcomes for children by investing in schools and support services for students.

{***Noah Leavitt***}

The key says Bailey is not just identifying success stories, but figuring out why they worked and what the long-term impact will be.

She points to efforts in California to reform drug policy and address prison overcrowding.

{***Amie Montemurro***}

But the challenge is programs like this may be affected by budget cuts and politics at the federal or state level.

So Bailey says a strong starting point is internal reform of institutions—which is already underway in New York City.

{***Zinzi Bailey Soundbite***}

(While there might be all sorts of things happening on a federal level, there’s opportunities on a local level to, for example, reform health departments. We’re here at the New York City Department of Health and Mental Hygiene embarking on an internal reform process whereby we recognize key ways that the city has played a role in structural racism in the past but how we can start to undo that and be a part of the change that we want to see. And those are things that we can do on a city level. We can try to emphasize health equity all across the city. We’re trying to invest in neighborhood health action centers, which are seeking to be working across sectors but focusing on a local level. And this doesn’t just happen with government institutions, but we can also think about our medical schools and schools of public health where we are training the next generation of health professionals. And we can all always see anti-racism as a professional competency that can be emphasized during training and reemphasized during work. So I think we have that opportunity that’s provided to us right now, and we can really make strides there.)

{***Amie Montemurro***}

And Bailey says each of us can all take a look internally in our lives to address our own implicit biases—and how they affect how we view others.

{***Noah Leavitt***}

Doing this can actually slow down our brains so we recognize when our biases are affecting our actions. It’s a tactic that’s actually now being used by police departments in the U.S. to address the complexities of race and policing

{***Amie Montemurro***}

If you want to learn more about structural racism and Bailey’s work to address it, you can visit our website, hsph.me/thisweekinhealth. We’ll have a link to her Lancet paper.

{***Noah Leavitt***}

And coming up next week: a conversation with Gina McCarthy, former administrator of the Environmental Protection Agency. We spoke to her about the history of the EPA and why it’s one of our country’s most important public health institutions. Plus, McCarthy weighs in on how we can combat climate change denial.

{***Amie Montemurro***}

Until then: you can subscribe to this podcast on iTunes and Stitcher…or listen any time at soundcloud.com/harvardpublichealth.