Go to this issue's Table of Contents.
J A N U A R Y 2 0 0 1
by Sally Satel
• An article in The New England Journal of Medicine in February of 1999 reported that white men get the best treatment for heart disease. Other experts have cited discrimination in patient care as a cause of disparities in the health of blacks and whites.
• The 1998 President's Initiative on Race stated, "Research suggests that discrimination and racism create stress leading to poorer health among members of racial minority groups." Some public-health experts who advance this claim have used it to rebut physicians who urge people to take responsibility for protecting their own health.
| Discuss this article in the Politics &
Society conference of Post & Riposte.
More on politics and society in The Atlantic Monthly and Atlantic Unbound.
See a collection of Atlantic articles on health care.
From the archives:
"Does Civilization Cause Asthma?" by Ellen Ruppel Shell (May 2000)
"What Nurses Stand For," by
Suzanne Gordon (February 1997)
"The Sex-Bias Myth in Medicine," by Andrew G. Kadar, M.D. (August 1994)
From Atlantic Unbound:
Interviews: "A Doctor's Stories," (March 8, 2000)
"Can Racism Make You Sick?" by Sally L. Satel, M.D.
MacArthur Network on Socioeconomic Status and Health
"Death by Discrimination?" by Joe Feagin (1998)
• Women's-health advocates often contend that the male-dominated medical establishment has kept women from participating as subjects in research studies, thus depriving them of the benefits of medical breakthroughs. Some nurses say that they are oppressed by the hierarchical nature of that medical establishment and thus prevented from giving the best care to patients.
• Former psychiatric patients, calling themselves "consumer-survivors," condemn the health-care system for violating their human rights. They are on a crusade to "limit the powers of psychiatry by making consumers full partners in diagnosis and treatment."
The common theme here is the failure of the medical system to make a connection between illness and oppression. This is not a dry academic debate with purely abstract consequences. The critics are beginning to fashion a world of politically correct medicine. I began to worry about this in 1995, when I learned that some of my fellow psychiatrists at San Francisco General Hospital were grouping inpatients according to race and sexual orientation so that they could organize treatment around psychological needs supposedly specific to those groups.
Though activists believe they are fighting for better health through social justice, their actions do not necessarily prevent disease, treat symptoms, or improve clinical methods. At best they create distractions and waste money; at worst they interfere with effective treatment. In either case, they undermine the Hippocratic ideal, which puts the patient first.
How did these activists -- I call them "indoctrinologists," because their diagnosis is oppression and their prescription is social reform -- manage to gain their foothold? Larger social trends supply part of the answer: for several decades a range of institutions, such as universities, courts, and workplaces, have been under assault by people claiming oppression of one sort or another. Another part of the answer resides in well-earned feelings of guilt that afflict the medical profession. The reputation of the U.S. Public Health Service is still tarnished by revelations about the notorious syphilis study in Tuskegee, Alabama. For years women were expected to submit without question to radical mastectomies and hysterectomies simply because their (male) doctors recommended them. Psychiatry has its own embarrassments, such as the dismal back wards of state mental hospitals in the 1930s, 1940s, and 1950s.
When the control of communicable diseases was the primary focus of public health, the profession's tasks were well defined -- tracking disease and ensuring the purity of food and water supplies -- and its victories were often dramatic. Today public health is still very much concerned with epidemiology (the study of diseases in populations) and the control of infections, but over the past century its scope has expanded, legitimately so, to include such activities as monitoring air quality, administering vaccination programs and community-based clinics, and combating asthma, diabetes, heart disease, and other chronic conditions.
Not surprisingly, public health has inevitably overlapped with public policy. After all, many diseases and afflictions are directly related to living and working conditions. In Colonial times, for example, local governments passed sanitation laws and imposed fines for selling putrid meat or failing to drain swamps. In the early part of the twentieth century the "industrial hygiene" movement played an important role in public health by condemning the needlessly hazardous working conditions of coal miners, factory hands, and other laborers, which could result in severe injuries, lung disease, or poisoning from mercury, radium, or solvents. The movement recalled the spirit of the nineteenth-century German pathologist, physician, and statesman Rudolf Virchow, who had spoken eloquently about the effects of social conditions such as poverty and squalor on fitness and health. He called physicians the "natural attorneys of the poor."
Documenting the unhealthful effects of social conditions and calling them to the attention of civic leaders is one thing -- but some contemporary public-health experts have gone much further.
N the early 1990s a new academic enterprise, "social production theory," was born. Many scholars consider Richard G. Wilkinson, a professor of social epidemiology at the University of Sussex, in England, to be the father of this school of thought, which considers how social variables -- among them classism, racism, and sexism -- may contribute to disease. Wilkinson published an article on the relationship between income and health in 1992, and numerous studies followed. Social productionism posits two general ways in which social disenfranchisement can lead to infirmity and a shortened life expectancy: through the stress of oppression, and through relative material disadvantage and inferior access to health care, which take the greatest toll on minorities and the poor.
We know that, on average, people who are low on the socioeconomic ladder are less healthy and do not live as long as those above them. But is a person's health largely at the mercy of social forces? Some public-health experts come close to saying yes. Rodney Clark, a psychologist at Wayne State University, asserts that emphasizing the role of personal responsibility in various areas, including health, constitutes "subtler forms of racism" than overt discrimination. Richard S. Cooper, a physician at Loyola University Medical School, near Chicago, holds a similar view. "For all intents and purposes," he writes, "black people in this society are imprisoned by institutional racism; this is the attribute of blackness which at bottom determines their health status."
Hypertension, or high blood pressure, is more likely to afflict black Americans than white, even when factors such as income and salt intake are taken into account. Several explanations have been offered -- chief among them diet and genetic predisposition -- but the issue has continued to perplex medical researchers.
In the fall of 1996 Nancy Krieger, of Harvard University's School of Public Health, and her colleague Stephen Sidney, a physician at the Kaiser Foundation Research Institute, in Oakland, California, claimed to have new insight into the blood-pressure puzzle: that blacks are often victims of racial bias, they said, could explain their higher levels of hypertension. Krieger and Sidney's study, "Racial Discrimination and Blood Pressure," appeared in the American Journal of Public Health, and it made news instantly.
"Discrimination May Cause Hypertension in Blacks," a headline in The Washington Post for October 24, 1996, declared. On the same day National Public Radio broadcast a report in which one psychologist interviewed about the study said, "We're having more hard, concrete data that what society does to you can affect your health." Brent Staples, of The New York Times, wrote an editorial the following month titled "Death by Discrimination?" A couple of years later, still mindful of the study, Staples wrote, "The medical profession has yet to list 'racism' as a cause of death. But some social scientists now see tension related to discrimination as a health hazard on par with smoking and a high-fat diet." Krieger and Sidney's study was included in the 1998 report from President Clinton's Initiative on Race.
It is not unreasonable to think that the stress of being a victim of discrimination could produce certain kinds of illnesses. After all, we know that many physiological processes are influenced by psychological stress. For example, the immune and hormonal systems and cardiovascular functioning can be affected by emotional states.
In their study Krieger and Sidney collected information on 4,086 black and white men and women aged twenty-five to thirty-seven, who were questioned about their "experiences of racial discrimination and unfair treatment." The researchers asked whether the subjects had ever "been prevented from doing something [for example, getting a job or securing housing] or been hassled or made to feel inferior" because of any of a number of social variables, including sex and race. They divided the subjects into male and female, black and white, working-class and professional, and also into three groups according to the number of episodes of racial discrimination each had experienced: none, one or two, or three or more. Risk factors for high blood pressure such as obesity and smoking were taken into account. (The researchers did not factor in salt intake, however, which is a major determinant of blood-pressure levels, particularly in African-Americans.)
Krieger and Sidney looked at blood-pressure readings to see if a correlation could be found with the subjects' experiences of bias. They assumed that incidents the subjects perceived as discriminatory produced equal amounts of stress on all of them.
The results did not seem to follow any obvious pattern. Black working-class men and black working-class women who had reported no episodes of discrimination had higher blood-pressure readings than those who had reported one or more. Black professional women who had reported one or two episodes of discrimination had lower blood-pressure readings than those who had reported none or three or more, and black professional men who had reported one or two episodes of discrimination had higher readings than those reporting none or three or more.
Krieger and Sidney also asked their subjects how they had responded to being treated unfairly. Again, the findings seemed to show no consistent pattern. The highest blood-pressure readings among black working-class women were found in those who accepted unfair treatment as a fact of life and did not talk about it. Among black professional men, those who accepted unfairness as a fact and kept their experiences to themselves had lower blood pressure than those who did something about it and talked to others. As an explanation for the varying results, Krieger and Sidney considered the possibility that "some people who experience discrimination may not acknowledge or report it as such" or "may find it painful to admit that they have experienced discrimination." They also considered the idea that the subjects felt they deserved to be discriminated against, owing to their race -- a process called internalized oppression.
Thus any finding that did not fit the expected direction of the data could be explained away. It is a standard rule of research that hypotheses must survive attempts to falsify them before they can be regarded as true -- or, more precisely, as highly probable. But internalized oppression, by its very nature, is difficult to falsify -- and the researchers seemed to make no attempt to test this hypothesis. Nonetheless, they confidently concluded, "Our results indicate that racial discrimination shapes patterns of blood pressure among the U.S. Black population."
(The online version of this article appears in two parts. Click here to go to part two.)
Copyright © 2001 by The Atlantic Monthly Company. All rights reserved.
Copyright © 2001 by The Atlantic Monthly Company. All rights reserved.