Question

Consider the criteria of causality described by Hill. How would you use these criteria to determine whether the experience of racism causes higher rates of chronic illnesses?

Answer 1

Race is typically used in a mechanical and uncritical manner as a proxy for unmeasured biological, socioeconomic, and/or sociocultural factors. Future research should explore how clearly delineated environmental demands combine with genetic susceptibilities as well as with specified behavioral and physiological responses to increase the risk of illness for groups differentially exposed to psychosocial adversity.

Health inequity, categories and examples of which were discussed in the previous chapter, arises from social, economic, environmental, and structural disparities that contribute to intergroup differences in health outcomes both within and between societies. The report identifies two main clusters of root causes of health inequity. The first is the intrapersonal, interpersonal, institutional, and systemic mechanisms that organize the distribution of power and resources differentially across lines of race, gender, class, sexual orientation, gender expression, and other dimensions of individual and group identity (see the following section on such structural inequities for examples). The second, and more fundamental root cause of health inequity, is the unequal allocation of power and resources—including goods, services, and societal attention—which manifest in unequal social, economic, and environmental conditions, also called the social determinants of health. Box 3-1 includes the definitions of structural inequities and the social determinants of health.

The factors that make up the root causes of health inequity are diverse, complex, evolving, and interdependent in nature. It is important to understand the underlying causes and conditions of health inequities to inform equally complex and effective interventions to promote health equity.

The fields of public health and population health science have accumulated a robust body of literature over the past few decades that elucidates how social, political, economic, and environmental conditions

Large and persistent racial inequalities in mortality across the twentieth century and into the
twenty-first century give cause to expect that racism, like SES, may be a fundamental cause of
health inequalities. We have attempted to evaluate this question.
We developed and provided evidence consistent with a conceptual model that be-
gins with systemic racism , a fundamental cause that advantages white Americans
in terms of flexible resources including control of governmental and commercial institutions, dis-
proportionate possession of socioeconomic resources at the individual level, and an ideology of
white superiority that benefits whites socially and psychologically and that justifies
the more material and structural aspects of systemic racism. Systemic racism generates multiple
mechanisms that produce and maintain white advantage. Consistent with fundamental causality,
mechanisms have been replaced over time. At the level of structural and material discrimination,
slavery and disenfranchisement were replaced by racial violence, Jim Crow segregation laws, and
more recently by covert, illegal discrimination. Note that racial violence and legal discrimina-
tion and segregation persist but at more muted levels than in the past. At the ideological level,
overtly expressed stereotypes and differential appraisals of the value and worth of whites and
blacks have been substantially reduced but covertly expressed, and implicit stereotypes and dif-
ferential appraisals of worth remain quite strong. these mechanisms result
in the maintenance over time of racial differences in flexible resources of money,
knowledge, power, prestige, beneficial social connections, and freedom, which in turn are con-
nected by multiple replaceable mechanisms to racial differences in health and mortality. A subset
of these resources (money, occupational power and prestige, and knowledge as embodied by for-
mal education) strongly overlap with SES, which we have evidenced is a fundamental cause of
health inequalities. Thus, we see much of the enduring association between race and health in the
United States as resulting from two fundamental associations: one between systemic racism and
racial inequalities in SES and a second between SES and inequalities in health outcomes.
Nevertheless, not all flexible resources associated with race overlap with SES. We found several
important resources beyond the bounds of SES to differ between black and white Americans,
especially nonoccupational prestige and power, freedom (control of one’s own behavior and life circumstances), and beneficial social connections associated with residential segregation. These
were connected, independent of SES, to multiple health outcomes by multiple mechanisms.
Notable among these mechanisms are racial discrimination as a stressor; inequalities in health
care; and myriad neighborhood conditions, involving nutrition, protection and crime, exposure to
harmful substances, recreational opportunities, toxic environmental exposures, and medical care,
that affect blacks and whites very differently because of the extreme degree of racial residential
segregation and neighborhood inequality in the United States. We conclude that the connection
between race and health outcomes endures largely because racism is a fundamental cause of racial
differences in SES and because SES is a fundamental cause of health inequalities, but that racism
also has a fundamental association with health outcomes independent of SES.
If, as we suggest, the bulk of the effect of racism as a fundamental cause works though SES,
why do we care whether racism is a fundamental cause of health inequalities independent of SES?
The social and policy importance of a fundamental cause of health inequalities lie in the fact that
inequalities based on a fundamental cause cannot be eliminated by addressing the mechanisms
that currently link the fundamental cause to health. The fundamental cause must be addressed
directly. If the distinctive features of a fundamental cause that reproduce inequalities over time
characterize SES but not racism, then persistent racial differences in health should be addressed
by breaking the link between race and SES. If, however, racism has the distinctive features of
a fundamental cause independent of SES, then persistent racial differences in health cannot be
remedied solely by reducing socioeconomic differences between black and white Americans. Even
if such SES differences were eliminated, racial differences in health would persist. In this case,
racial differences in health would have to be addressed like a fundamental cause, reducing racism
itself. Our review suggests that such is the case.
Our findings suggest many avenues for addressing racial health inequalities in the short term:
reduce racial differences in SES, in neighborhoods, in freedom, in power and prestige, in health
care. Each of these is extremely important and should be vigorously pursued. At the same time,
by nature, a fundamental cause is expected to replace any of these mechanisms that might be
effectively blocked. We have previously identified two approaches to reducing the impact of SES
as a fundamental cause .One is to prioritize the development of health inter-
ventions that minimize the relevance of an individual’s level of resources, such as providing health
screenings in schools and other community settings rather than only through private physicians,
and the other is to develop interventions, such as drugs, that are relatively affordable and easy to
disseminate and use (beta-blockers) rather than those that are expensive and difficult to implement
(HAART treatment for HIV) Such
approaches should be pursued for race-related resources as well. However, we have argued that to permanently reduce SES inequalities in health requires reducing SES
inequalities themselves. By the same token, because of the reliable replacement of mechanisms
linking racism to health outcomes, we conclude that racism must be the ultimate target in attempts
to effectively and permanently reduce racial inequalities in health and mortality.

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