Race & Health: Under the skin

In this episode, Delan Devakumar and guests shed light on how the social construction of race and its operators take a physiological toll of chronic exposure to racism. They discuss maternal and child health, the concept of race and biology, and how constant microaggressions, systemic inequalities, and overt discrimination can lead to a sustained state of stress that goes far beyond mere emotional distress. There are also  recommendations for applying anti-racism in everyday life, and how we can strive for a future where everyone, regardless of their background, can live a healthy and fulfilling life.

Guests include Dr. Ndidiamaka Amutah-Onukagha, the Julia A. Okoro Professor of Black Maternal Health in the Department of Public Health and Community Medicine at Tufts University School of Medicine, Dr. Arline Geronimus, Professor of Health Behaviour and Health Education at the University of Michigan, and Dr. Jonathan Wells, Professor of Anthropology and Paediatric Nutrition at the Population, Policy & Practice Department at UCL.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Delan: Hi everyone, welcome to the third series of the race and health podcast. In this we're partnering with the Lancet Voice podcast to discuss issues raised in the recent Lancet series on racism, xenophobia, discrimination, and health published in December 22. My name is Delan Devakumar. I'm a professor of global child health in University College London and lead on the academic series.

Today's episode is focused on biology and the many ways in which racism can affect normal physiology. The ideas of race have been incorporated into modern medicine in many ways unquestioningly. This is despite the social construction and the often arbitrary way in which race is defined. In this episode, we'll have three wonderful guests to talk through these issues.

First we have Dr. Ndidiamaka Amutha Onukaga, who's the Julia A. Okoro Professor of Black Maternal Health and the Director of the Center for Black Maternal Health and Reproductive Justice. Thanks She's also an associate professor in the Department of Public Health and Community Medicine at Tufts University in the School of Medicine, where she leads the largest research lab in the United States dedicated to addressing maternal health inequities.

Next, we have Professor Arline Jeronymous, who's a professor at the University of Michigan School of Public Health and Institute for Social Research. She's a member of the National Academy of Medicine and author of the book Weathering the Extraordinary Stress of Ordinary Life in an Unjust Society. And finally, Professor Jonathan Wells, who is a Professor of Anthropology and Pediatric Nutrition at UCL Great Ormond Street Institute of Child Health, where he conducts research on a range of issues related to maternal and child health, using an anthropological and evolutionary perspective to support empirical research.

Ideas of race are commonly used in medicine and healthcare, and On an individual basis when deciding the treatment of a person, in deciding clinical guidelines, and also at a bigger scale when dealing with whole populations. And Didi Amaka, can I come to you first? Can you tell me what the term race means and how this has been applied to health?

Ndidiamaka: Thank you for this opportunity to be on the Race and Health podcast. So race at its core is a social construction based on people's phenotypical image in the history of medicine and the current practice of medicine across the world really has racial implications in a way that groups have prioritized or not.

Who has access to resources or not. We saw this most recently in the COVID 19 pandemic. There are certain groups received vaccines, or certain groups received medication or education more quickly and more efficiently than other populations based on racial stratification. Race is also quite problematic because we know that People that are of darker melanin, or black and brown, or other indigenous people are more likely to be discriminated against because of their race.

So this basis of race as a social construction based on someone's phenotypical appearance, is a made up construct. There is no real genetic difference between groups of people at the core level, at the DNA level. And so I think that's one thing to be really clear about is that this premise around a race and why we still continue to use it as a marker is quite problematic in the field of health.

Delan: And this goes back hundreds of years to sort of Carl Linnaeus Arlene, can I come to you? There's this idea of race, which is socially constructed, as Ndidi and Marco were saying, but racism is very real. Can you talk a little bit about that? 

Arline: I agree with all that's been said, and in fact, I'd like to expand on it, in saying that our exquisite ability to create and sustain Population health and equities, and by corollary, our colossal failure to achieve anything resembling health equity is the inevitable byproduct of the fact that race is not rooted in any meaningful biological categories.

Race is a biological fiction, an invention that keeps some people, those deemed by those in power, to fall on the wrong side of an arbitrary color line in their place. And it's associated with poor population health through racialization and racism and the way being classified as a threatening or undeserving or inferior social identity group member, in fact, links the faiths, opportunities, and sense of what gives life purpose and meaning among those classified into specific groups and into the dominant versus a marginalized and demigrated group with consequences for one's biology.

But it's the ways that race becomes biology, not that it's essential or genetically predisposed to be biology. And I think the concept of racialization is particularly important because it signals an active, historical, and dynamic social process that creates and maintains the possibility of racist actions.

and outcomes of all types and levels, whether we're talking historical, structural, systemic, interpersonal, explicit, or implicit. To understand racialization, I think we first have to understand the power differentials and psychosocial dynamics between members of the dominant culture and marginalized cultures in inequitable societies.

I think the practices, values, language, and common sense of a dominant group in a stratified society are often deemed to be authoritative knowledge, and this particularly applies in the medical situation where doctors are often viewed as very authoritative. I want to highlight that authoritative knowledge is not necessarily the knowledge that has been tested or is empirically true or universally applies to everybody.

Thank you. It's the knowledge that counts in that society. It's the knowledge that's taken as expert, whatever its truth value is. And the imposition of dominant values and practices and beliefs is maintained systemically by power historically derived through might and hubris. But maintained by institutional control and greater economic resources of the dominant group and propped up by the pervasive hegemonic narratives that become common sense for everyone.

Delan: Thank you. And those dominant groups can vary across the world, right? So the, this hierarchy can differ. Jonathan, can I come to you next? And this kind of idea of races being socially constructed, I guess there is genetic variation between populations, not very much in most cases, but how does that compare to racial categories?

Jonathan: Humans do vary genetically, as you say, but to an extraordinarily little degree. There's actually more genetic variability in the global population of chimpanzees than there is in the global population of humans. So humans have managed to colonize every continent apart from Antarctica without genetic specialization.

So what we see in terms of the human genome is Slow gradients of changes in the frequency of genes across geographical areas, but there are no hard edges. We can't say that here a population starts and another one ends. And as well as that, where we have alleles that are associated with health outcomes, they don't match on to alleles that are associated with physical characteristics.

We really can't say that. tell what's inside the body in terms of health from looking at people from the outside. And where we do know about alleles and health outcomes, they pretty much do the same thing, whatever population you're looking at. So biologically, we have one human population globally with very little genetic variability.

So racial categorizations are, as Darlene has said, are imposed and they don't have a biological reality. They may have a political purpose, but that's very different. So we have these two completely different things. Fluid genetic variability versus discontinuous categorizations that are socially constructed.

Ndidiamaka: Now, I would just echo what my colleagues here have said. I think the continued and intentional use of race is quite problematic, not only in health. and the way that resources are delivered or allocated or prioritized. But also in policies. There's a clear correlation between race and structural racism that really prioritizes unfair advantage for other people based on the backs of disadvantaged populations.

And so race and racism do not operate in silos. They operate as part of a system that includes structures and policies and procedures that reinforce this unfair and disadvantaged treatment. And so race is a conduit for how systems of oppression and racism operate, particularly in the healthcare space.

Race is so problematic and it's intentional, right? There's nothing unintentional about the stratification of different groups and marginalized populations. It's a very intentional system that is oppressive. We do have individual races who are individual actors, but the system overall The healthcare system and the way that we deliver health around the world is racist in the structure of it.

Delan: And that's important, so racism can act at all these levels, from the individual to this whole structure being structurally racist. Absolutely. Jonathan? 

Jonathan: Alongside structural racism and interpersonal racism, I think it's also important to remember internalized racism. And this is another way that experience, if you like, gets under the skin, where people internalize negative experience and see it as normal.

And that can lead to the self regulation of behavior, the fear of doing something or expressing something that other people to object to. It's like a third strand where people start to see as normal a system that's not normal. 

Delan: While racist is an arbitrary category, racism is very real. How does racism lead to adverse health outcomes?

Arlene, if I can come to you first. 

Arline: Yeah. I think a major mechanism that many people haven't recognized is that the chronic and in some cases, perpetual. Activation of the human physiological stress response in the daily rounds of denigrated, oppressed, exploited, and discriminated against social identity groups typically wears down their health across body systems.

down to the cellular level. This is a process I've called weathering. Being weathered leaves people vulnerable to a large range of diseases, health conditions, and disabilities, and in effect accelerates their aging, resulting in the early onset of chronic diseases of aging. Heightened susceptibility to the whole panoply of diseases that we see characterize inequities between social identity groups through public erasure of their lived experiences and their sources of meaning and purpose in the dominant narratives that inform actions and options at all levels.

As well as exposure to material, environmental, and psychosocial threats, members of denigrated social identity groups face structured and objective perils in their environments and circumstances. which I would call what we think of as the neon lights of structural racism. And as we've moved to a conversation about structural racism, I think more and more people are beginning to understand those neon lights and certainly medical underservice and the poorly informed actions of service providers are part of those neon lights and they're very important.

But I also want to add That members of integrated groups also face reasons to remain alert and vigilant to potential dangers in all their settings, environments, and interactions. Not talking about people who are overreacting but based on their lived experiences and the kind of probabilistic calculation debated to be possible perils, and how they read cues, which all human beings, as a way to protect ourselves, are exquisite cue readers, they imagine the possibility of a peril that Even if it doesn't exist.

So for instance, if a person of color is stopped by a police person for either nothing, or maybe a very minor traffic violation, this will send the stress response is a high alert and in all probability, there's a very low statistical chance that police officer is going to harm that person. But there's every reason given.

To how often it even result, those interactions even result in death. For that person to be alarmed and to set off the biological responses to that level of threat. And the vigilance of denigrated groups maintains their physiological stress response. somewhat on speed dial. There are expressions in the United States like having your head on a swivel, for example.

And if you add to that the practical strategies they must follow and coordinate with their families and networks to survive or overcome their challenging circumstances, all of which involve active, effortful coping, just withstanding the adverse exposure adds to weathering itself. So even the strategies to overcome or withstand are both shelter and storm.

Delan: Thank you, Jonathan. 

Jonathan: We can think of the body as having two sets of defenses and one medicine has made huge progress in which is immune defense, which tackles pathogens. And mostly we can't see pathogens. We just get symptoms when we get them, but there are other stresses or threats that come from other organisms that the brain perceives, and that might be a predator, but it can also be other humans and humans can actually impose a lot of stress on each other.

And that also has negative health effects. So when we. perceived threat, we activate a whole series of biological systems, which are commonly known as the fight or flight response. And in the short term, you can think of that as offering a survival advantage. You prepare the body to respond to the threat.

And that's, that can be useful. But if people are activate the stress response chronically over long periods, unsurprisingly, it's not very healthy to keep on having your defenses of the ready for threats. We actually damage the body by maintaining our defenses, the stress response. And we also use up a lot of energy.

So from an evolutionary perspective, we only have metabolic resources for a set of four functions, maintaining the body in a healthy condition, growing, reproducing, and defense. So if they're allocating a lot of metabolic resources to defense, unsurprisingly, there are fewer metabolic resources for other biological functions, most obviously at maintaining good health, maintaining homeostasis, maintaining cellular health, but also you can think of this for reproduction.

That's why maternal stress contributes to less investment in the next generation, which we see as low birth weight. So maintaining a stress response is very harmful for health, both of the individual and across generations as well. And we see this in physical characteristics such as insulin resistance, high blood pressure, high heart rate and so on.

And over time that can lead to excess body weight, high levels of abdominal fat. And so it's a cardiometabolic disease. 

Delan: Thank you. And Dede, Marka, can you talk about the sort of clinical implications of this, maybe in relation to maternal health that you've worked on? 

Ndidiamaka: Yeah, so the way that racism shows up in health outcomes, particularly in the delivery of care and treatment, is through what for a long time were known as algorithms.

These clinical decision making was based on race. The reliance on race as a determiner in clinical diagnoses exacerbates existing racial inequities in health and healthcare based on racial distinction. For an example, the use of the vaginal birth after cesarean calculator is called a VBAC calculator.

This is a clear illustration of the use of race in clinical algorithms. It estimates the likelihood of success or the probability of a successful delivery after a prior c section. Clinicians use this estimate to counsel people who have to decide whether to attempt a trial of labor or should they undergo a repeat caesarean section.

Why is this problematic? The use of race when you include African American and Hispanic correction it subtracts your likelihood of success for anyone that identifies as Black or Hispanic. And his VBAC score, or his algorithm formula, predicts a lower chance of success for these racial groups, which may dissuade clinicians from offering trials of labor to people.

This is problematic because we know that C sections are a major surgery. We know that unnecessary C section increases the likelihood of death. infection such as sepsis, increases complications, hemorrhage. And so when you have this addition of this insertion of race, it reduces the likelihood of success based on your Black or Hispanic origin.

It doesn't really take into account the likelihood of success based on your physiologic ability to have another vaginal delivery. And so that's just one example of how this insertion of race into the clinical decision making. really can impact populations, which is further problematic thinking about it in the maternal health space because we know that black and brown birthing people are more likely to have complications, are more likely to be disregarded by their clinicians.

And so you exacerbate that with the c section that they may not even need solely based on their race. And you can see why we have the maternal mortality rates we have here in the United States. That's a very Abbreviated version of it, the other many other things that have exacerbated our maternal mortality rates and our maternal morbidity rates, but certainly the insertion of race into decision making does not help black and brown patients in this space.

Delan: And we see the consequences of maternal mortality amongst black women is about double that of white women in the U. S. 

Ndidiamaka: It's three to four times higher. Three to four times. Yeah. The latest data we have that was released in February of this year has a non Hispanic Black maternal mortality of 69. 9, which is a 40 percent increase of where it was in 2020.

That's 2021 data. In 2020, it was 55. 3. And so you see this dramatic increase in just one year, Black women are three to four times more likely to die from complication, including. From C section, from hemorrhage, from sepsis, it's disregarded by the healthcare system, which is predicated on their race. 

Delan: What can we do to reduce the impact of racism in kind of modern medicine and health care more generally?

Ndidiamaka: I think there are a couple of things we can do. One, we can be more intentional about diversifying our clinical workforce and making sure we have more clinicians, obstetric providers, maternal fetal medicine, nurses. doulas of color working in spaces to reduce maternal health inequities. I think when we think about the way that healthcare is delivered and who healthcare is frankly prioritized for and who healthcare has been built around, it's not minoritized populations.

And so if we have more clinicians of color, we can combat some of the racism that will inevitably occur at the hands of their colleagues to the detriment of their patient population. I think another thing we can do is to continue to invest in students, scholars, trainees of color such as the work we're doing here in my mother lab.

I work with 35 students from undergrad, master's, PhD, MDs, residencies, postdocs. I think we also need to think about policy. Who are we putting in elected positions of power, and what are they doing with that privilege and the power. So here in Massachusetts, I'm working with some state senators who are introducing a suite of bills called a mom the bus, which is a package of bills that will be bundled to reduce and that please.

in the space of birthing justice, in the space of reimbursement for doulas, and trying to put together a package of bills and legislation that will be beneficial to not only minoritized birthing people, but all birthing people. So when you think about what we can do, I think it's to invest in innovative models that work.

that are really framed around reducing inequities, framed around being actively anti racist in very white spaces, and really being intentional about prioritizing sustainability for these models that are not traditional, but really work. I think when you talk about maternal health in particular, this is a nice opportunity to look at the intersection and reimagine how we deliver care.

And then the last thing I'll say is that I think we have a particular moment in time now. Before the pandemic, and before the deaths and the murders, at least here in the United States, of George Floyd and Breonna Taylor, I think that really woke everyone up. And so we're seeing a lot of things happening now in medical schools.

Even here at my own medical school, some of my colleagues and I put together a curriculum on anti racism to train our clinicians, particularly our white students, on how to be actively anti racist as they continue their medical education. 

Delan: Thank you. Jonathan? 

Jonathan: Being a researcher, the issue that comes to my mind is what we need to do more research on.

And I think one thing we really need to know more about is identity. So we know a lot about how racism can target people's identities and cause negative health effects. But I don't think we know nearly as much about the identity of dominant groups and why we're finding it so hard to challenge different forms of racism that appears through both institutions and interpersonal relationships.

Like many aspects of biology, we now we know that many things start early in life. Identity starts early in life. How does the identity of dominant and privileged groups form and why do they end up whether consciously or unconsciously perpetuating systems of inequality and inequity? So I think that itself is something that we need to know more about in order to find additional types of solution to this problem.

Delan: Thank you. And finally, Arlene. 

Arline: I think whether it's in the. Actual types of programs that we should be relying more on and instituting and training our medical and policy professionals in, or whether it's the extra research we absolutely need to keep doing. I think one important aspect, based on what I had said before, of whether those will be effective or give us the answers we need, is if we start to view our understanding of health inequities.

To a more what I would call weathering lens, in other words, to transform our understanding of the relationship of age and health to be contingent on social identity and the pattern of lived experience says that social and identity and dreams, rather than we tend to see it. In the biomedical world and in just the lay world, that the relationship of age and health is really some, is based primarily for some people, even exclusively on a universal developmental process from immaturity to maturity to senescence.

And I think we need to realize that 20 doesn't equal 20, 30 is even less likely to equal 30. When we're thinking about the relationship of age to health in different, in, in dominant versus marginalized groups, I think it's a particularly important for issues like maternal health where we're talking about the sort of reproductive and working ages and have this lay folk notion that those are the prime healthy ages and that they're, that's true for everybody unless they engage in bad behavior, but rather that, that the condition, the varying conditions of life.

will affect how fast you age and how quickly you become weathered or your body systems are worn down. Bearing that in mind, I think in addition to all the things that have been mentioned, we need to change cues and settings that activate stress responses across all settings, in schools, on TV, in algorithms.

We need to think about how these different cues act, can activate stress responses in members of denigrated groups to the detriment of their performance in that setting, but also to their long term health. And I think we need to reorient ourselves to the idea of pervasive health vulnerability and accelerated aging, and the likelihood that there are multiple morbidities in the same person and among their family members.

rather than a disease by disease, risk factor by risk factor approach, and that the fundamental cause of that vulnerability is historical and ongoing racialization and the structural and interpersonal racism that it permits or even fuels. 

Delan: Do you think that message is getting through? 

Arline: Yes and no. I think part of structural racism is that it's very hard for that message to permeate our beliefs.

We really do believe that age and health are a development, a purely developmental process. I'm not suggesting there's no developmental aspects to it. And we think that development is a purely biological process as opposed to related to the resources, opportunities, and values and power that you have depending on your positionality in society.

But I, I wrote the book you mentioned in hoping to get a broader audience. I think certainly scientists who have peer reviewed my articles or my grant proposals seem to value this perspective and get it and more and more. people, whether in policy or health professions, are beginning to draw on it. But this needs to be a broad society wide kind of shift in how we look at race, racism, racialization, and how that affects people cumulatively by age in ways that affect their ability not only to be healthy or to have long, healthy lives.

But also, their ability to interact with our various age, grade, and social institutions that also then set them up, better or worse, for economic success or educational success. So I think this is a very broad rearrangement of how we think about age. 

Jonathan: I think reflecting what the other speakers have described very elegantly, it's, I still think we probably have a challenge in biomedicine in accepting that humans are often the source of disease.

We know that for a long time for physical injury, warfare, and so on, but psychologically create. The idea that the source of the disease lies in the interactions of society. I think we're still coming to terms with that and trying to identify appropriate strategies. And it's incredibly complex. It's easy to say that how society is organized is something for political science.

It's not for biomedicine. But once you understand the health effects of societies that are not fair, it's fundamentally an issue relating to health. And I still think we're on the path to learning how to address that. 

Ndidiamaka: I would just say, I think oftentimes people get so overwhelmed with trying to ameliorate racial disparities or trying to address it.

And I think one thing I say for listeners of this podcast or anyone in general is that when you see racism operating you call it out. That's the only way to dismantle the system is to actively address it. There is no standing on the sideline. I would even push people to be co conspirators as opposed to allies.

I think people who are white need to understand and unpack and acknowledge their white privilege. I think once we can start to have really candid conversations about how racism operates in healthcare, how racism operates in all of our lives, how implicit bias shows up, what does it mean for delayed treatment, what does it mean for dismissiveness, what does it mean for a lack of urgency to people's health and people's needs based on their racial categorization, I think then we can start to have the conversations that need to be had and work towards solutions.

But that's it. If we really want to be actively anti racist and you're not a person of color, then you need to unpack, sit in, and use your privilege for the good of other people. And until we can have that conversation on a very candid level, we're not going to be able to prevent unnecessary death. We're not going to be able to save very meaningful lives.

We're going to continue to see how the healthcare system fails minoritized populations around the world. And so we have to be very intentional, aggressive, and direct about trying to unpack. Racism, particularly when it shows up in delivery of health care. 

Arline: I just endorse both sets of comments that have been made already.

And I want to add to it a fear I have that while we're all see this historical moment is one where more and more people are actively concerned about racism and want to be anti racist and where we're seeing that racism matters to health and therefore to everything else. And the most fundamental inequity is not having the health you should be able to have at your historical moment.

I'm very worried that this will all, not fizzle, but turn into performative actions. People will have trainings, one day trainings or one hour trainings. Believe on a superficial level, they're being anti-racist. I hope we can all dedicate ourselves and help people see that just going to a training isn't gonna make a difference.

It may be a first step. It, I'm not saying it's worthless, but that we have to be sure that we're really dealing with substance and not just performance. We can sincerely want to change things and sincerely try to be anti racist and still proliferate racism and its impacts on health. Precisely because this is a daunting challenge in some ways, and it's pervasive, it also means in every single, every day setting, there's some action you can do.

Even if you're, it's not literally that you're calling out racism, if you understand, for instance, the importance of cues in a setting, you can. Be sure the settings you're responsible for. are not filled with racist cubes that will activate stress responses. I remain hopeful in the face of that. It's not just the big things.

It's in everything we do. 

Delan: Thank you very much. And thank you to all of you. It's been fantastic conversations, delving deep into the biology and then pulling back into the socio political. So thank you all for joining me today. This episode was produced by Mita Hawke, Sophia Lobanov Rostovsky and myself, editing by Gavin Cleaver and music by Mita Hawke.

Do visit the race and health website on www. raceandhealth. org for more information about our academic work and to sign up for our newsletter.