INTRODUCTION
Young through middle-aged adults in high-poverty urban African
American populations have a high probability of dying or becoming
disabled long before they are old (Geronimus
2001; Geronimus et al., 2001). As
shown in Figure 1, in Harlem or
Chicago's South Side, one-third of African American girls and
two-thirds of boys who reach their fifteenth birthdays do not live to
celebrate their sixty-fifth. In contrast, only 10% of girls and about
25% of boys nationwide fail to live to age sixty-five. Indeed, African
American youth in some urban areas face lower probabilities of survival
to age forty-five than White youth nationwide face of survival to old
age (Geronimus et al., 1996, 2001).
Mortality calculations based on data from the 1990 U.S. Census
(adjusted for coverage error) and from death certificates for
1989–1991; Harlem refers to African American residents of the
Central Harlem Health Center District in New York City. Chicago refers
to the African American residents of South Side community areas of Near
South Side, Douglas, Oakland, Fuller Park, Grand Boulevard and
Washington Park in Chicago, Illinois. See Geronimus et al., 1999, for details of calculation
methods.
Stress-related chronic diseases are the primary reasons for this
excess mortality in urban, African American populations (Geronimus et
al., 1996, 1999).
Evidence indicates that their negative impact on life expectancy is
growing. For example, between 1980 and 1990 excess deaths attributed to
circulatory disease or cancer each doubled among young and
middle-aged men in Harlem (Geronimus et al.,
1999). In contrast, the more publicized homicide rates began to
decline. As a general rule, racial differences in health tend to widen
after age twenty-five and become most pronounced among those aged
thirty-five to sixty-four (Adler et al.,
1993; Elo and Preston, 1996; Geronimus 1994; Geronimus and
Bound, 1990; House et al., 1990).
Although racial differentials in infant health are also stark, these
often reflect differences in the health of reproductive-age women
(Geronimus 1996b). That is, substantial
percentages of African Americans in their twenties or early thirties
already suffer from stress-related diseases that can complicate
pregnancies (Geronimus 2001).
African American men and women in high-poverty, urban areas also have
rates of health-induced disabilities at ages thirty-five and fifty-five
that are comparable to the national averages for fifty-five and
seventy-five year olds, respectively (Geronimus et
al., 2001). These disabilities in young- and middle- adulthood
limit capacity to work, often necessitate caregiving, and lead to
premature death. Rates of death or disability are shown in Figure 2, illustrating stunning inequalities
between African American residents of Harlem or Chicago's South
Side, and Whites or Blacks nationwide. Only 30% of teenage girls and
20% of teenage boys residing in these urban areas can expect to be
alive and able-bodied at age sixty-five.
Mortality calculations as in Figure 1.
Disability calculations based on 1990 U.S. Census using Public Use
Microdata Areas ((PUMAs) that most closely approximate mortality areas
for Central Harlem Health Center District in New York City and
Chicago's South Side community areas of Near South Side, Douglas,
Oakland, Fuller Park, Grand Boulevard and Washington Park in Chicago,
Illinois. See Geronimus et al., Social Science and Medicine
1999; 49(12): 1623–1636 for details of
calculation methods.
Reducing the size of these and other racial inequalities in health
has been a high-priority, national public health policy objective for
well over two decades. Yet, racial disparities in important health
indicators have persisted and, in some cases, have grown (Pappas et al., 1993). This is true even for some
health disparities that have been energetically targeted for reduction,
such as infant mortality rates. This failure is notable and, we argue,
a major indictment of public policies aimed at African American
communities.
At least since 1971, when William Ryan coined the phrase
“blaming the victim,” a raft of literature has criticized
public policies that concentrate on encouraging individuals to change
their behavior, instead of on creating structural changes in the social
environment in which people live.1
Ryan
himself wrote mainly about education policies (Ryan
1971). Other scholars have criticized the individual focus in
policies on drunk driving (Gusfield 1981,
1988), environmental education (Bookchin
1974, 1990), water
pollution (Fitchen 1987), welfare (Rose 2000), disease prevention and risk-factor
epidemiology (Crawford 1977; Tesh 1988; Link and Phelan, 1995, 1996), and housing
policy (Saegert et al., 2003).
More
recently, Bruce Link and Jo Phelan (
1995,
1996) have argued that failures in eliminating social
disparities in health result from undue emphasis being placed on
ameliorative approaches that target the risk factors linking socioeconomic
position to health in a particular context, but do not alter the context
(or underlying inequalities) fundamentally.
From this “fundamental cause” perspective, the only
effective way to reduce or eliminate differentials in health is to
address the underlying “social inequalities that so reliably
produce them.” (Link and Phelan, 1996,
p. 472). This is a formidable challenge that, by definition, requires
going beyond the normal confines of public health policy discourse.
Toward this end, we start by noting that racial inequalities in health
are the predictable manifestation of linkages among:
- prevailing racialized ideologies;
- political and economic structural inequalities that follow;
- the personal and social coping mechanisms adopted to manage
dominant ideologies and structural inequalities; and
- the physiological effects of these coping efforts.
Thus, before classifying policies according to whether they emphasize
individual behavioral change or political-economic structural change,
we ask whether similar ideological and social premises that undergird
both perspectives misinterpret Black health problems, and whether they
are harmful to Black health. We illustrate below that current policy
ideas and proposals rely upon specific social and moral viewpoints that
are racially biased towards White norms and behavior and that these
viewpoints, in and of themselves, have negative implications for Black
health. They stimulate race-related stress that can
“weather” the cardiovascular, metabolic, and immune
systems, fueling the development or progression of disease.
I. RACIALIZED IDEOLOGIES: DEVELOPMENTALISM,
ECONOMISM, AND THE AMERICAN CREED
Racialized ideologies influence social science's interpretation
of Black health problems, and of Black subjects more generally. Here we
identify and then critique three central and mutually reinforcing
American ideologies that inform common understandings of the production
of health inequality: developmentalism, economism, and the
American Creed.
Developmentalism
Developmentalism is the most widely used model for interpreting the
relationships between age and health and among age, identity, and
social expectations in the United States. Linked to the acquisition of
abilities necessary to take personal responsibility, it is an
individualistic and economistic model. While a full accounting of
developmental theory is beyond the scope of this paper,2
in broad strokes, it assumes that
people's lives unfold in three biological and psychosocial stages.
The first stage, from birth through adolescence, is a process of
maturation. The second stage, extending for the next four or five
decades, is full maturity. The final stage is gradual senescence. In
this perspective, children, adolescents, and the elderly face fairly
predictable age-related health and mortality risks. Childhood risks
stem from biological and psychological immaturity, which, with proper
nurture, is generally outgrown. So too, adolescents are expected to
outgrow their psychosocial vulnerability to engage in risky behaviors
that may impair their health (
Burt 2002).
Such risk taking is understood to derive from their psychological
immaturity, rebellion against parental authority, susceptibility to
peer and pop cultural influences and, in a world where death appears a
predictable function of old age, their belief that they are invincible
(
Brown and Witherspoon, 2002;
Furstenberg 2000).
3 The elderly, again, face increased health
vulnerability due to the inevitable physiological deterioration
that culminates in death. In recent years, this final physiological
deterioration has been delayed to older ages and, for many
people—although not for many African Americans—compressed
into the very end of life (
Geronimus et al.,
2001;
Hayward and Heron, 1999;
Rowe and Kahn, 1998).
Economism
Economism is rooted in the assumption that all adult human beings
know their own needs and wants (they are internally centered), they are
essentially self-interested and competitive, and they are mainly
motivated by economic considerations. Economism elevates a particular
version of individual agency—or “personal
responsibility”—into a general social definition of what it
means to behave responsibly. In this view, markets are the arbiters of
social exchange; individuals can shape their placement in the social
hierarchy by choosing to invest in their human capital to best position
themselves to engage the market and fulfill their personal
responsibilities. Economism thus divorces material context from culture
(Goodwin and Emirbayer, 1994). It privileges
material well-being over other contributors to human health and
wholeness.
The American Creed
The American Creed combines the values of equality and personal
responsibility. Equality is expressed in the Creed's promise of
equal rights and equal opportunity for all citizens, but the Creed is
not an ideology of equal outcomes. Instead, individual outcomes depend
on personal responsibility. Thus, inequality is expected, and poverty
is considered a just consequence of poor effort.4
This view underlies the traditional distinction in the U.S.
between the deserving poor (e.g. widowed) and the undeserving poor
(e.g., malingerers) (Katz 1993).
The
American Creed has a strong transcendent quality to it that is firmly
rooted in the American psyche. It unites an imagined community of
virtuous seekers of the American Dream—people who work hard, play
by the rules, and stoically suffer the consequences if they do not. The
Creed is connected to what makes many White citizens believe that they
are good and decent people—and that many Blacks are not.
The Creed underlies the universalism of the developmental view that
ignores fundamental differences in the life circumstances of Whites and
Blacks. The Creed underlies, as well, the decontextualized
individualism, i.e., the imaginary “level playing field” of
the economistic perspective. The “Creed” is not only a
dominant ideology; it is hegemonic. Martin Rein defines a dominant idea
as one that is “normatively secure as the accepted course of
action.” Hegemony is an extreme form of domination, implying,
“the dominant position of the paradigm is maintained, without
being engaged in a contest for dominance with other competing
paradigms” (Rein 2000, p. 215). As
Robert Dahl (1961, p. 317) wrote: “To
reject the American creed is in effect to refuse to be an American. As
a nation we have taken great pains to insure that few citizens will
ever want to do anything so rash, so preposterous—in fact, so
wholly un-American.”
The Effects of Prevailing Ideologies on
Interpretations of Black Health Problems
Developmentalism, economism, and the American Creed are all
racialized ideologies. They ignore or, worse, denigrate African
American historical, social, and moral perspectives, and in their
social impacts, they disrupt African American coping mechanisms. This,
in turn, induces poor health and exacerbates illness, once
developed.
Developmentalism frames health as a universal process of biological
unfolding that is only undone or impeded by accident or by poor
behavioral choices. On closer inspection, development actually reflects
biological potential nurtured through a combination of resources and
values that are largely restricted to members of the dominant group
(Whites). The developmental understanding of the relationship between
age and health expresses dominant cultural ideals, values, age-graded
social expectations, and the institutions that reinforce them.
Centrally, developmentalism and rigid cultural commitment to the
nuclear family ideal are mutually reinforcing. Healthy development can
proceed because parents are charged with supervising, supporting, and
protecting children and adolescents. Cultural and parenting competence
are measured by the extent to which young people can separate from
their parents and establish an independent identity at the appropriate
time: neither so old that they remain dependent on their parents at an
age when young adults are expected to be self-sufficient, nor so young
that they fall prey to the more subversive influences of their (not yet
fully responsible) peers. Newly emergent adults are expected to become
attached to the labor force and to marry members of their generation in
order to launch and support new nuclear families. They are expected to
break away from their primary reliance on parents for support and, for
their part, parents are expected to “let go.”
In these ways, the dominant cultural scenario for the life course
entrains the proper objects of attachment (first to parents and then to
spouse and other peers) and identity development (always as an
individual, first in the context of the nuclear family of origin and
later in the context of peers), and it outlines the cadence of
life-course demands along the axes of dependence and responsibility.
Dependents (youth and the elderly) are relatively free from family (or
“personal”) responsibility, while young through middle-aged
adults are expected to be both independent and highly responsible.5
One caveat to this scenario is that
“history” can affect life chances, but in a particular way.
The opportunities for health and well-being available to members of
specific generations are influenced by the general state of knowledge,
prosperity, and technology in the historical period in which they live,
and also by the advent of specific events (for example, wars), or
macroeconomic realities (recessions, depressions, or economic booms)
that occur during their lifetime. These all may affect health, but they
are seen as affecting the health of entire cohorts, and, thus, do not
violate the assumption of a level playing field.
Through the developmental prism, it is difficult to appreciate (1)
that some cultural groups may value collectivism over individualism (or
group self-sufficiency over individual self-sufficiency), or (2) that
family structure, itself, is historically and culturally variable. For
instance, African American urban populations often recognize an
extended and multigenerational definition of family. Here, families
comprise kin who may or may not be biologically related but,
regardless, who share a mutual understanding that they are part of a
familial network of reciprocal obligations, and who act consistently
with this perception to fulfill functions the dominant ideology would
reserve for nuclear families (Hicks-Bartlett
2000; Stack 1974, 1996; Stack and Burton,
1993). Indeed, the extreme economic need, experience with social
exclusion, and early health deterioration that characterize African
American families in high-poverty areas require a degree of
multigenerational connectedness and familial responsibility and
reliance throughout the life span that makes aspects of the dominant
developmental ideology untenable. In high-poverty Black communities,
children and youth, as well as adults, participate actively in
fulfilling domestic responsibilities; individuals hold allegiance to
multigenerational collectives (community or kin) rather than to
biological nuclear family members alone or same-aged peers, and salient
aspects of history are those that tie one to a people or community,
rather than only to discrete political or economic events.6
We are not implying that multigenerational
kin network systems are uniformly positive or without costs for their
participants, just as no type of social arrangement or family
organization is uniformly positive for all participants. The pertinent
question when discussing family arrangements in specific contexts is
whether the observed arrangements are, on balance, better or worse ways
of supporting and caring for people than would be the alternatives that
are realistic options.
In this context, the dominant cultural understanding of psychosocial
development is not sensible. Instead, maintaining active family ties,
cooperation, and support are especially salient to Blacks in
high-poverty areas, taking priority over self-reliance and
independence. African American adults often do not feel the same
responsibility as their White counterparts to “let go” of
youthful family members—both because they rely on their
cooperative efforts and because they view society as neither level nor
welcoming for African American youth. For their part, poor Black teens
cannot take a moratorium from family responsibility, nor, with death
and disability all around, are they likely to view themselves as
invincible. These teens have ample reason to protect the ties they have
to their elders because the intergenerational perspectives provided by
their parents help them to make sense of ongoing social, political, and
economic exclusion (Ward 2000).
Interconnections among members of social or kin networks help
participants feel valued and attended to, as well as providing
practical support, and through both routes can be health promoting. By
feeling part of a collective that stands in opposition to the dominant
culture and through the social ties that reinforce this feeling,
members of the collective are able to contest the dominant
culture's images of themselves as morally marred or culturally
deficient.7
We are distinguishing between
racist ideologies that promote racial subordination from the protective
and oppositional Black racial ideologies (such as most Black
nationalisms) formed in opposition to Black racial subordination.
Racial ideologies, like all beliefs, have to be put in context. It
makes as much sense to equate Black nationalism with White racism as it
does to equate feminism with patriarchy.
This ability has
positive health consequences.
8 The positive impact
of social integration and social support on health is said to rival in
strength the detrimental impact on health of such known biomedical risk
factors as cigarette smoking, obesity, and high blood pressure (
James, Schultz, and van Olphen, 2001). Social
support that serves as a buffer against race-related stress (
Williams 1999), stigmatization (
Jones 2000), lifestyle incongruity (Dressler
1995,
1996,
1999), or culturally incompetent medical care
(
James 1993;
Scribner and
Dwyer, 1989) reaps critical advantages for Black health. This is
especially true where residential and school segregation, although
tacit rather than legally proscribed, is an omnipresent physical
symbolic representation to both Blacks and Whites of norms of Black
inferiority.
Thus, the relatively longer, healthier lives of Whites are
conditioned not only on greater access to material resources, but also
on the psychic benefits of having their values honored in public
discourse and institutional structures and timetables. Explanations for
racial health inequality must encompass the impact of pervasive insults
to the personal and collective integrity of African Americans. We are
here suggesting that cultural oppression is as important a structuring
force in Black health as economic forces (Lamont
1997).
While material resources contribute to health in a critical way,
populations vary in their strategies for achieving economic security or
social mobility. The most promising avenues for any population are ones
that are environmentally adaptive, responsive to socioeconomic
opportunities and constraints, and culturally mediated (Geronimus 1987, 2000, 2003a). Moreover, health also comes from a sense of
rootedness in and affirmation of cultural values, practices, affective
ties, and beliefs that give life purpose and meaning (James 1993; James et al.,
2001). These psychosocial resources may be especially important
in averting stress-related disease (James
1993). The economistic assumption is problematic when
considering racial disparities in health, not only because it promotes
“victim blaming” or “ameliorative”
interventions but also because, at best, it ignores the culturally
mediated, psychosocial aspects of health. As we discuss later, this
perspective can even lead to policies that are counterproductive or to
structural interventions that have limited effect.
Even social epidemiologists and policy advocates who focus on
structural issues unduly limit their thinking to economic interventions
and metaphors. Few pay any attention to the impact of affective ties
and social identity on health. They see the ultimate goal of social
research and policy as providing access to material resources (e.g.,
income, health insurance, food stamps, good housing) or to other forms
of “capital” that are commutable in a market economy
(including human capital investment opportunities such as education or
social capital development). This reflects the large degree to which
economistic assumptions about human behavior have permeated cultural
discourse. For example, recent explication by Oakes and Rossi (2003) of the “essential nature of
social stratification” (emphasis added) with a view toward
determining “an ideal Socioeconomic Status (SES) measure for
public health research” offers insights into the rootedness of
the economistic assumption in the thinking of investigators interested
in the social determinants of health. Oakes and Rossi locate
the definition of SES, or social structure, in “differential
access (realized and potential) to desired resources.”9
Oakes and Rossi (2003)
elaborate that this is a common understanding among social researchers:
“Hauser and Warren (1997) think that SES is a shorthand
expression for variables that characterize the placement of persons,
families, or neighborhoods with respect to the capacity to consume
valued goods; Krieger et al. (1997) add that prestige or rank-related
characteristics pertain to relative position in socially ranked hierarchies
and chiefly concern status in relation to access to and consumption
of goods, services and knowledge; and Nock and Rossi (1979) state that
SES is that dimension of stratification which translates the objective
distribution of societal resources into meaningful perceptions of
relative desirability” (emphases added pp.
775–776).
They draw on Coleman's social theory,
which they note “is rooted in the
purposive action of an individual
agent,” (emphasis added) and can be summarized as being:
based on two kinds of elements and two ways in which they
are related: The elements are (1) actors and (2) resources, related
through (3) interests and (4) control … Since resources may take
the form of (1) material and monetary goods, (2) skills and
capabilities, and (3) the strengths of social relationships, three
dimensions may be defined. These three domains which we call material
capital, human capital, and social capital, respectively, uniquely
locate the status of individuals in the social structure.
Material features are central to each of these domains. Oakes and
Rossi note:
material capital is observable and tangible, or at least
easily convertible into such forms (e.g. stock options) … human
capital refers to fixed endowments of an actor. However, human capital
also refers to the education, skills, abilities, and knowledge one may
acquire. It is thus mutable through “investment” of time
and labor.
Furthermore, they assert: “Human capital is a critical
component of SES since it is a resource that may be used to acquire
socially valued goods. It is fungible in a market economy.” And
finally, even social capital is stripped of affective ties and social
identity:
[S]ocial capital stands for the ability of actors
to secure benefits by virtue of membership in social networks and other
social structures. Examples include increased educational achievement,
social mobility, employment opportunities, decreased welfare
dependency, and low levels of teenage pregnancy (p. 777).
Note that this highly individualistic, acquisitive, and materialistic
discussion is made not by researchers who primarily advocate individual
behavior change, but by those who are attempting to remedy limitations
in SES measurement for health researchers who “believe that a
narrow focus on individuals outside of historical, social, and
biophysical contexts limits the understanding of disease etiology,
health, and intervention modes” (p. 769).
Economism misunderstands Black health problems by ignoring cultural
oppression. Similarly, unequal racial opportunity is commonly defined
in narrow economistic terms as unequal access to the material resources
and social contacts needed for economic information and individual
advancement. The problem with racial segregation, in this view, is not
that it represents overwhelming negative cultural ostracism of Blacks,
and a colossal moral failure of the nation to rectify its horrendous
racial history, but simply that it limits Blacks' access to
contacts and resources or, in health terms, exposes Blacks to noxious
social and physical environments. This economistic understanding of
segregation skirts the moral and institutional implications of
America's racial history for its current social hierarchy,
imposing an individualistic and decontextualized viewpoint on Black
health problems that few African Americans share.
We believe that economism also leads to misunderstandings of the
Black middle class. The expansion of the Black middle class has been
identified as a solid sign of economic progress and as a precursor to
eventual widespread black social integration.10
The use of the term Black middle class should not be taken
to imply that Blacks and Whites in the middle class are on an equal
economic footing. Despite an expanded middle class as measured by
income in the period between the 1960s and late 1980s (Fainstein 1993; Hochschild
1995), Blacks trail Whites significantly (12:1 overall) in
wealth. Controlling for income, Blacks have only 0.57 as much wealth as
Whites (Shapiro 2001).
The dominant
view among whites is that although limited racial discrimination persists,
African Americans are on a steady path towards full integration and equality
with Whites (
Bobo and Kluegel, 2001;
Hochschild 1995;
Kluegel and
Bobo, 1997). However, the Black middle class does not define
itself solely by its ability to consume valued material goods; rather,
racial identity figures prominently in their view of middle-class social
status (
Dawson 1994). The economistic concept of
a nonracialized middle class treats African Americans as individuals
isolated from their extended family networks, group history, social context,
and social identity. It falsely assumes that, like middle-class Whites,
middle-class Blacks feel distanced from the suffering of poor Blacks.
Many middle-class Blacks are still morally allied and socially
associated with the defamed Black poor, and most are segregated in the
same or proximate neighborhoods (Charles
2003). Individual economic or educational success does not bring
the same rewards for African Americans as for Whites (Kaufman et al., 1997). As Sikes and Faegin wrote,
“African-Americans with income and occupational standing to be
considered middle class sooner or later comprehend that they can never
become truly middle class, or at least not in ways available to White
Americans” (Sikes and Faegin, 1994, p.
35). Crime victimization is a good example of this disproportion. With
Whites, crime victimization rates decline as income increases, with
Blacks victimization rates rise as income increases (Kennedy 2001).
Given this context, it is not surprising that the health of
middle-class Blacks and Whites differs greatly in many regards,
especially in prevalence of stress-related diseases (James et al., 1992; Light et
al., 1995; Williams 1999; Williams et al., 1997). Middle-class Black
populations have only modestly better functional health status than
high poverty Black populations (Geronimus et al.,
2001). This circumstance contrasts sharply with the steep
economic gradient in functional limitation prevalent among White
populations (Geronimus et al., 2001; Hayward and Heron, 1999; House et al., 1990, 1994).11
Speaking to both the benefits and
limitations of access to material resources for Blacks, more affluent
African Americans are less likely than poor African Americans to pay
the additional price of early mortality, although, unlike for more
affluent Whites, their longer lives show no reduction in the years
spent in poor health (Geronimus et al.,
2001). One explanation is that economically better-off African
Americans may have greater access to medical services and resources
that help them to avert premature death, despite high morbidity (Link et al., 1998). Another (perhaps,
complementary) explanation is that African Americans who enjoy
socioeconomic success in the face of race-based barriers to their
achievement might also be a population singularly determined to cope
effectively with chronic disease, among other stressors (James 1994).
It also indicates that
interventions addressing the acquisition of education, income, or
material goods alone will be insufficient to eliminate racial health
inequality.
The third ideology, the American Creed, asserts the essential
fairness of U.S. institutions. In so doing, it wipes away consideration
of fundamental structural inequalities and cultural oppressions. The
American Creed is basically a White point of view. Belief in the Creed
prevails among Whites, but a large majority of Blacks hold an opposite
view (Dawson 1996). This difference in group
perspective reflects the continuing absence of deep public
consideration of slavery, Jim Crow laws, and subsequent forms of racial
discrimination in the U.S. Slavery and Jim Crow laws undermined the
foundation of morality and of shared humanity in the United States. The
U.S. government never instituted a national anti-racist educational
program after slavery (Feagin 2000). Nor did
the government institute a full employment “Marshall Plan”
in the 1960s, despite Black demands for such a program to counter the
effects of centuries of slavery and segregation (Hamilton and Hamilton, 1997). In thinly coded
racial language, Republican Party leaders from Goldwater to Reagan to
Bush attacked the 1960s Great Society programs as an unwarranted tax
burden on hardworking (White) Americans for (poor Black) people who do
not want to work (Edsall and Edsall,
1991).
Allowing human monstrosities of the scale of slavery and legal
segregation to pass without deep ethical consideration conceals the
questionable legitimacy of today's racially segregated communities
and institutions. White Americans evaluate African American demands for
justice from the standpoint of the Creed morality. Their belief in the
essential fairness of U.S. institutions and in the equality of
opportunity in social structures leads many Whites to the racially
prejudiced stereotype that Blacks are lazy and culturally disposed
toward poverty. Martin Gilens (1999), in his
study of White opposition to welfare, argued that while some Whites may
harbor general antipathy for Blacks,
… for many whites the stereotype of blacks as lazy
grows out of the belief that the American economic system is
essentially fair, and that blacks remain mired in poverty despite the
ample opportunities available to them. These perceptions in turn are
fed by media distortions that neglect the “deserving poor”
in general and portray poor blacks in a particularly unsympathetic
light (p. 173).
Thus, as Jennifer Hochschild (1995, p. xi)
writes: “[M]any whites see middle-class blacks as
making excessive demands and blaming their personal failures on a
convenient but nonexistent enemy. Even more whites see poor blacks as
menacing, degraded strangers.”12
In
contrast, one of the damaging effects of this interpretation is the
development of White racial “innocence.” This is the widely
held view of many Whites that their current social status has nothing
to do with past slavery and segregation, but is instead simply a result
of their individual pursuit of the American Dream (Harris 1993; Waters
1990). This notion of White innocence can also lead to
intellectual hubris—the view that Blacks do not yet know how to
think properly, and that their interests need to be calculated for
them.
Of note, in a race-conscious society, internalizing Creed ideology
can be harmful to the health of Blacks who “play by the
rules.” For example, Sherman James (1994) has suggested and found evidence of a
predisposition among most African Americans to engage in persistent
high-effort coping with social and economic adversity (“John
Henryism”). In low-income African American populations,
individuals who exhibit high levels of John Henryism are the ones most
apt to be hypertensive (James 1994), a
circumstance that directly contradicts notions that fatalism or
indolence precipitate cardiovascular disease among low-income African
Americans.13
Put another way, the
empirical evidence on John Henryism suggests that low-income African
Americans who work hard to mobilize their internal resources to cope
with or surmount structural barriers to their achievement express
values and take actions that are in sync with the greater American
ideological emphasis on having an internal locus of control and strong
work ethic. Yet, whether or not these actions are successful in
producing social mobility, they can exact a profound physical toll
manifested in the high prevalence of stress-related disease among young
through middle-aged African American adults.
Those hoping to
eliminate racial health inequality must be responsive to the evidence
that African Americans of
all social classes pay a
disproportionately high price in stress-related disease for their
membership in American society.
Without basic reconstruction of widespread racist stereotypes and
essentialist myths regarding the virtues of American democracy, there
is little intellectual foundation for scientific investigations of
Black health problems that take structural and cultural aspects of
racism seriously. The Creed blames Blacks for their condition, and in
this way blocks understandings of broader structural and cultural
causes for racial differences as well as broader social
responsibilities for persistent racial inequality. Meanwhile, Blacks
undergo harmful stress from powerful ideological forces valued by
Whites as common sense (Geronimus 2000, 2003a).
Racial Ideologies and Black Health
Whether health is construed narrowly or broadly, developmentalism,
economism, and the Creed are of limited value to public health policy
advocates working to eliminate racial health inequality. Regarding
developmentalism, the problem of racial health inequality leads us to
ask: How do we reconcile the notion that modern Americans have the
developmental potential to be healthy at least through middle age with
the stark evidence that many young and middle-aged African Americans
are not? Adhering to the developmental model limits our perspective,
reducing instances of poor health and mortality among relatively young
adults to exceptions. Calling such group-wide experiences exceptions to
the rule of a long, healthy, life is an inadequate explanation. It
offers little to help explain the rapid health decline of African
Americans that becomes detectable in their twenties, even among the
middle class (Geronimus 1996b).
As an alternative, Geronimus (1994, 2001) conceptualizes aging as a process of
weathering. That is, people's health reflects the
cumulative impact of their experiences from conception to their current
age (Kline et al., 1989). The older they are,
the more time they have had to have health-impacting experiences, and
the greater the opportunity for these experiences to express any (even
lagged) health effects or to accumulate or interact with others.
Weathering posits that African Americans experience early health
deterioration because, relative to Whites, they have much greater and
more frequent experiences with social and economic adversity. On a
physiological level, persistent, high-effort coping with acute and
chronic stressors has a profound effect on health and disease. While
the body's ability to respond to acute stress (the “fight or
flight” response) is protective in certain threatening
situations, under other circumstances, the physiologic systems
activated by stress (the allostatic systems) can damage the body (Sapolsky 1998). Allostatic systems enable people to
respond to changing physical states and to cope with ambient stressors
such as noise and crowding, as well as extremes of temperature, hunger,
danger, or infection. As Bruce McEwen (1998)
notes, the body's response to a stress-inducing challenge is
twofold: turning on an allostatic response that introduces a complex
cascade of stress hormones into the body, and then shutting off this
response when the threat has receded. However, when the allostatic
system is not completely deactivated, the body experiences overexposure
to stress hormones. Long periods of overexposure result in
“allostatic load,” which can cause wear and tear on the
cardiovascular, metabolic, and immune systems.
Allostatic load may result from exposure to a series of acute
short-term stressors (for example, life traumas such as job loss,
eviction, or the death of a loved one), or from long-term exposure to
chronic stress (such as that associated with social stigmas or
persistent economic adversity).14
There
is also evidence that allostatic load may result from post-traumatic
stress disorder, and some evidence from animal studies that the
allostatic systems of infants subjected to stress become set to
overreact, increasing the probability of allostatic load throughout
their lifetime. In light of this evolving evidence, it is possible that
children in urban ghettos begin to experience allostatic load and its
negative health impacts at a young age, due to chronically stressful
living conditions or traumatic events.
Beginning in utero,
Black residents of high-poverty, urban areas are subjected to
environmental and psychosocial stressors, both acute and chronic. As
they move through young and middle adulthood, urban African Americans
suffer many health-harmful burdens that persist, accumulate, and
interact with one another to exacerbate weathering and increase
allostatic load. Examples include:
- persistent material hardship;
- repeated exposure to environmental hazards and ambient or social
stressors in residential and work environments;
- high psychosocial stress and high-effort coping that increase in
young to middle adulthood as family leadership roles are assumed and
obligations expand and compete;
- pressure to adopt unhealthy behaviors as a means to cope with
growing stress, uncertainty, or persistent material hardship;
- the early development of chronic conditions and the practical,
financial, and emotional difficulties associated with these;
- medical underservice or differential treatment by health care
providers; and
- feelings of stigma, frustration, or anger at racial
injustice.
Over the life course, weathering and allostatic load can cause the
allostatic systems to wear out or become exhausted, leading to
cardiovascular disease, obesity, diabetes, increased susceptibility to
infection, and accelerated aging. African Americans suffer from these
stress-related conditions at greater rates, at earlier ages, and with a
higher probability of early death than do Whites. They are prominent
contributors to racial health inequality.
Individuals can make changes in their lives to mitigate weathering
and reduce allostatic load, but likely only to a small degree. The
weathering model suggests that behaviors such as smoking, poor diets,
and sedentary lifestyle may be secondary to the constraints or stresses
of everyday life, or may interact with allostatic load to produce
adverse health outcomes. Significant changes in the social, political,
and physical environments are required to substantially reduce or
eliminate weathering and allostatic load among the Black population.
II. IMPLICATIONS FOR PUBLIC POLICY
New public health and social policy discussions must embrace the
dynamic relationship between population health and the needs of family
economies and caretaking systems in high-poverty African American
communities. Weathering and the pervasive health uncertainty in
adulthood it implies have local social consequences as they enlarge the
scope of caretaking needs in a community while simultaneously depleting
the pool of caretakers and economic providers. Analysts' casual
disregard of the responsiveness of local institutions, such as kin
networks, and their critical function in promoting health and
well-being creates racial barriers between public health professionals
and those with indigenous knowledge. This disregard is, itself, a form
of racism (Geronimus 2000).
An implication of the weathering framework is that policies likely to
fragment or impose new obligations on already overburdened networks,
that disregard the local cadence of life-course demands or norms of
care across and within generations, or that rely upon or legitimize
demeaning stereotypes will increase allostatic load for the urban poor,
and, ultimately, further imperil their health. Policies that are
logically informed by uncritical acceptance of developmentalism,
economism, and the Creed are likely to have such impacts. In this
section, we show that policy discourse concerning Black health outcomes
is steeped in dominant ideological perspectives that valorize existing
social inequalities and undermine the recognition of social and
cultural strengths in Black communities.
The government's insistence on the value of low-paying work,
regardless of social context is an example of the harmful effects of
these racialized ideologies on Black communities. Policy makers tend to
perceive unemployed young and middle-aged adults as socially atomized
individuals rather than active participants in family economies and
caretaking systems strained by persistent poverty and pervasive health
uncertainty. Whether unemployment is viewed as malingering or as
resulting from labor market discrimination, the perceived remedies
revolve around getting the unemployed working, with little concern for
ripple effects through kin networks or the impact of increased stress
on the health of these “working age” adults.
According to our analysis, low rates of labor force participation in
high-poverty, urban, African American communities represent a
combination of structural barriers to employment (Wilson 1996), high rates of health-induced
disability (Bound et al., 1996), and
collective strategies for seeing to the considerable caretaking needs
of multigenerational kin networks (Stack and Burton,
1993; Geronimus 1987, 1992, 1997). In the
context of Black communities, where death and infirmity are erratically
scattered across the lifespan, men and women cannot easily maintain
secure positions in the workforce. Bound, Schoenbaum, and Waidmann
(1996) find that health differences between
Blacks and Whites can account for most of the racial gap in labor force
attachment for men. They find that Black women would be substantially
more likely to work than White women were it not for the
marked health differences. In subsequent work, Bound et al. (2003) document that working people with health
limitations typically earn between 20 and 40% less than people without
such limitations. Finally, they find that health disparities can
account for a significant part of the higher participation rates in
public assistance programs among Blacks (and Native Americans) relative
to Whites.
Additionally, practical challenges for the members of family or
social networks who care for the disabled can undermine their efforts
to fulfill competing obligations to family and work. In these
circumstances, multigenerational families may divide kin network
responsibilities among young and middle-aged adults so that some
provide economically by participating in the work force, whereas others
focus their energies on the caretaking and other domestic needs of the
extended family (Stack and Burton, 1993).
Indeed, a pervasive theme in recent research on welfare reform is
that most recipients of welfare assistance share the dominant cultural
belief in the dignity of paid work, but that the jobs available to them
both fail to improve their economic situation, and put great strains on
their ability to fulfill responsibilities for their extended families
(Edin 1995). A general conclusion of recent
research is that welfare policy requiring poor people to get paid jobs
does little to ease poverty. Meanwhile, Sharon Hicks-Bartlett (2000), for example, shows that African Americans in
poor communities are so interdependent that when one person gets
full-time employment, a cascade of social problems for others may be
set in motion. Katherine Newman (2001)
observes that, given the general level of poverty in Harlem, it is hard
for those not on welfare to hold down jobs or go to school unless some
family members stay on the welfare rolls. Ariel Kalil and her colleagues
(2000) describe how requiring young Black mothers
to take paying jobs puts new strains on their relationship with family
members and the fathers of their children. Earlier researchers of Black
family structure report findings that are consistent with and would presage
such findings (Billingsley 1992; Geronimus 1992; McAdoo
1980; Hogan et al., 1990; Stack 1974; Stack and Burton,
1993).
A second example is the policy pressure for marital childbearing,
which is the logical extension of developmentalism and its ties to the
nuclear family ideal. Through these lenses, policy advocates see
unmarried mothers as lone mothers rather than as participants in kin
networks. They focus on policy remedies that encourage marital
childbearing or, at least, paternity support, unaware that such
remedies are meager, at best, or that they undermine complex systems
for caretaking and economic provision worked out through kin networks,
not nuclear families. Even some who recognize the functional, economic,
importance of kin network participation often interpret tight social
networks as ones that restrain people in poor African American
communities, selectively highlighting Carol Stack's (1974) original observation that participation in
these networks can make it hard for individuals or married couples to
make and save money or get very far ahead financially as nuclear
households. Overshadowed by the concern over nonmarital
childbearing, the importance to health and well-being of caretaking,
risk pooling, or the transmission of shared values is missed. Few
people in positions to inform or make public policy see these positive
contributions of Black norms and social bonds.
Yet, Tom DeLeire and Ariel Kalil (2002) found
critical exceptions to the shibboleth that children raised in married
families fare better than others. While teens in single-parent divorced,
widowed, and step families were disadvantaged, teens with divorced mothers
in multigenerational families fared no differently than those in married
families. Moreover, youths living with their never-married mothers in
multigenerational households—most often Black teens whose young
mothers had low education and income—had social and academic
outcomes that were better than those in married families.
These positive child outcomes are consistent with our thesis that
nonmarital childbearing as part of an extended kin network is adaptive
in this population.
A third example is fertility timing. Public policy to prevent teen
childbearing was both prompted and legitimated by ideas embedded in
racialized perspectives of developmentalism and economism. Through the
prism of developmentalism, teen mothers are perceived to be lone and
immature adolescents, rather than young adult members of
multigenerational kin networks. They are judged as individuals who made
wrong choices with grave personal and social consequences. An
additional presumption is that simply by postponing childbirth until
they are past their teen years would have allowed them to be better
mothers, and to accumulate sufficient “human capital” to be
successful in the labor market. Although its scientific basis is open
to question, this view has gathered great political momentum. It has
served as a basis for important policies, including key aspects of
national welfare policy (Geronimus 1997).
Despite dramatic reductions in U.S. rates of teen childbearing over
the past fifty years, teen childbearing continues to occur
disproportionately among low-income African Americans. Indeed, in
high-poverty, urban, African American populations, such as in Detroit,
Watts, or Chicago's South Side, the modal age for first childbirth
is in the teenage years (Geronimus 2003a).
According to our analysis, this is because early fertility remains in
sync with the needs of local family economies and caretaking systems in
high-poverty Black communities. Weathering challenges, even threatens,
family economies and caretaking systems as it increases the probability
of widowhood or orphanhood and prolonged disability in the family
(Geronimus, Bound, and Waidmann, 1999). These
risks and their adverse effects are reduced when childbearing occurs
early and childrearing is seen as the obligation of a multigenerational
kin network, rather than a biological nuclear family.
Children may fare best if their birth and pre-school years coincide
with their mother's peak health and access to social and practical
support provided by relatively healthy kin. This period occurs at a
younger age for African American than for White women. In fact, in
Harlem, infant mortality rates for teen mothers in 1990 were
half those for older mothers, even though the preponderance of
“older” first-time mothers in Harlem were only in their
twenties (Geronimus 2001). Nor do empirical
findings related to child development and school achievement provide
consistent endorsement for the political viewpoint that teen
childbearing harms children. For example, Moore et al. (1997) found that among Black children in their
national sample of four to fourteen-year olds, those whose mothers were
eighteen or nineteen at their birth performed better in reading and
math than those whose mothers were in their early twenties. Geronimus,
Korenman, and Hillemeier (1994) studied the
performance of preschool and elementary school age children of a
national sample of sisters who experienced their first births at
different ages. They found evidence that children of teenage mothers in
high-poverty Black populations fare as well or better on standard
measures of socioemotional development, cognitive development, and
school performance than children of older mothers. Although these
findings on infant health and child development are consistent with
others in a methodologically diverse literature that spans two
decades,15
On maternal age and infant
health outcomes, see, for example, Geronimus 1986, 1987, 1994, 1996b, 2003b; Geronimus and Korenman,
1993; Kline et al., 1989; McCarthy and Hardy, 1993; Rauh
et al., 2001; Rich-Edwards et al., 2002.
On early child development see, for example, Geronimus
et al., 1994; Levine et al., 2001; Moore et al., 1997; Moore and Snyder,
1991; Rothenberg and Varga, 1981.
few in the broader public seem aware of them, nor have such findings informed
interventions to reduce the Black-White gap in infant mortality or to
improve the school performance or well-being of urban Black children
(
Geronimus 2003a).
In contrast, qualitative evidence from ethnographies and in-depth
interviews suggests that African American residents of high-poverty
urban areas have socially situated knowledge of the benefits to child
and family health and well-being of early childbearing, childrearing in
multigenerational families, and parental respite from the labor force
(Burton and Whitfield, 2003; Edin 1995; Geronimus
1996b; Hicks-Bartlett 2000; Stack
1974, 1996; Stack and Burton, 1993). The mismatch between
indigenous and authoritative knowledge has made low-income African
Americans appear lazy, unable to take personal responsibility, and
impervious to sex education and family planning measures, as their
rates of unemployment and nonmarital and/or teen childbearing
continue to be what the larger public views as alarming. This alarmist
interpretation has fueled public contempt for teen or nonmarital
childbearing, including resentment of teen mothers, new theories that
question the morality of residents of urban Black communities, and
corresponding new, more punitive ideas about how to solve the
“problem that hasn't gone away.”
Following developmentalist logic, policy makers discredit Black
elders in high-poverty urban communities as good parents because of
their seeming failure at their supervisory function. Policy makers feel
entitled to act in loco parentis to entire communities, in
effect, discrediting adults in these communities while meting out
paternalistic and punitive policies aimed to encourage urban youth to
tow the line.16
For example, reducing
teenage childbearing has officially become a measure of moral
renaissance. Remedies include punitive measures—such as denial of
welfare benefits and reinvigoration of statutory rape laws—and
national discussion of religion, culture, and public values. The
premature consensus that teenage childbearing is a major social ill is
now exploited to legislate abstinence education programs, while
mandated support for family planning programs and abortion has eroded.
Social policy (e.g. welfare policy) and health education (e.g.
abstinence education) are now seen as a legitimate means to encourage,
cajole, even coerce, these uneducated or “recalcitrant”
individuals to assume greater “personal responsibility”
(Geronimus 1997).
The dominant
reaction against unmarried parents, teenage mothers, or the unemployed,
has introduced new and highly publicized sources of stigmas for young
parents, their children, and their elders. Such stigmas, themselves,
can contribute to weathering. The policies and programs that follow
effect perturbations in their protective networks, with the potential
to inflict further health harm on African Americans. This
developmentalist consensus has been effectively used to undercut
support for social safety nets and other antipoverty programs (
O'Connor 2001). Meanwhile, through the Family
Support Act of 1988 and then the 1996 Personal Responsibility and Work
Opportunity Reconciliation Act (PRWORA), this consensus resulted in
legislation that placed barriers, even barricades, in the way of urban
teen mothers who hoped to pursue educational or career opportunities.
Bush administration proposals to reauthorize PRWORA's time limit
provisions, while increasing the number of hours mothers on welfare are
required to work, and expending resources to roll out pro-marriage
policies and increase abstinence programs, would exacerbate this trend
in the wrong direction. But these approaches are logical results of
uncritical acceptance of developmentalism, economism, and the
Creed.
17 To make progress in this domain
of public policy discussion, the social goal of enabling teens to avoid
unwanted pregnancies needs to be de-coupled from welfare reform
activism and abortion rights activism. Although for pro-choice
advocates, abortion rights are an essential part of teen childbearing
prevention, it is reductionist and unnecessarily divisive to reducing
the profound goal of enlarging options for disadvantaged youth to
abortion rights. And tying the two issues together so closely consigns
this broader goal to being endlessly stuck in a tug of war between
moral conservatives and social liberals. In its own way it adheres to
the stereotypic view that the most threatening challenge to the
socioeconomic success of young African American women is their
sexuality and reproductive capacity.
Our analysis also has implications for policy interventions that are
perceived as “structural.” So-called
“structural” interventions are usually conceived in ways
that do not challenge the boundaries of larger
political-economic-spatial structures, and they tend to ignore
fundamental issues of racial identity and Black marginalization. One
example is the policy focus of many liberals and progressives on
increasing the minimum wage. Arguments for and against increasing the
minimum wage, including arguments for a “living wage,” are
usually debated in social management terms. The main dispute in the
scholarly economic literature focuses on whether increasing the minimum
wage reduces poverty and encourages workers to enter the market who
would otherwise shun it (because work does not pay), or whether it
inadvertently increases unemployment among the very groups a minimum
wage increase intends to help (Ellwood and Bane,
1994; Sessions and Stevans, 2001).
This debate is technical and inconclusive. What is of interest here are
the contours of the debate. It is framed in the economistic and
utilitarian terms of whether raising the minimum wage will help more
people than it harms in terms of income (Levin-Waldman 2000). However, the debate over the
minimum wage is just as much a collective moral and political debate
over the kind of society that the U.S. should be. That is, should
employment policy be guided by an overarching goal of achieving a more
economically and racially equal society?18
Sabel and Piore (1984) noted two
decades ago that employment policy is not decided by technical
calculation, but depends on social vision. They posited a choice
between a “low road” economy based on cheap, low-skilled,
and easily outsourced labor versus a “high road” economy
with a well paid, highly skilled, and flexible workforce.
Is
it morally and socially acceptable if most Blacks are not trained to
occupy high-end service jobs and Blacks' labor is allowed to
become obsolete in the face of globalization?
19 Historian Thomas Holt (2000)
divides U.S. history into the pre-Fordist era of slavery and Jim Crow
that launched modern society; Fordism that corresponds to Blacks'
escape from rural areas for industrial jobs and unionization in the
city (a promising period in retrospect); and the contemporary
post-Fordist consumer oriented society in which Black labor is obsolete
and Black demands are potentially anachronistic. See also Jones 1998.
The prevalent economistic
orientation of most structuralist approaches leaves them unable to
address the bedrock issue of Whites' lack of emotional attachment
to Blacks. Being a racial minority in a racially hostile majoritarian
democracy, Blacks are left without political safeguard in the midst of
a potentially devastating economic transformation. Black interests are
essentially up for grabs in the political and economic marketplace.
This cultural-political condition of racial isolation and economic
marginalization creates greater uncertainty about the future and
harmful stress in Black communities, and it increases the importance of
Black communities as a countering source of positive self-identity and
support.
Another example is the widespread perception that universal health
insurance will go a long way toward the elimination of health
disparities. Leading political advocates still portray universal health
insurance as a rallying cry for all uninsured persons (Reich 2001). Blacks are more skeptical as health
insurance proposals fall short of addressing fundamental health
problems in Black communities connected to broader forces of racial
subordination.20
African Americans tend
to live in segregated communities with poor housing, relatively high
exposure to toxic environmental hazards, high levels of violent crime,
and inadequate access to healthy foods. Poor housing can contribute to
infectious disease transmission, injuries, asthma symptoms, lead
poisoning, and mental health problems—both directly (e.g.,
because of environmental hazards) and indirectly (e.g., by contributing
to psychological stress that exacerbates illness). Blacks not only tend
to face higher levels of pollution, crowding, inadequate housing, and
inadequate community infrastructure, but, “they also frequently
experience these social and environmental demands in concert”
(Saegert et al., 2003).
Leading
proposals for universal health insurance continue to ration health care
according to ability to pay, providing incentives to health practitioners
and insurers to discriminate against low-income Blacks (
Stone forthcoming). Moreover, few health care
providers locate their practices in central cities. In fact, Fossett and
Perloff et al. (
1990,
1995) suggest that access to care in high poverty urban
areas is constrained more by the lack of accessible physicians than by the
lack of insurance. Thus, while White policy advocates view universal health
insurance proposals as a call for major structural change, for Blacks they
represent a minimum ameliorative policy that leaves basic structures of
racial subordination intact.
Another example is the call for housing vouchers and other programs
that enable some African Americans to move out of urban ghettos. The
premise underlying such programs is that if individual Black families
are freed of the environmental hazards, ambient stressors, and social
and economic constraints imposed by life in racially segregated
ghettos, they will find more opportunities to invest in their human
capital, find jobs, and avoid stress. Certainly, several researchers
have examined the relationship between residential segregation and
health outcomes and found evidence that segregation is a factor above
and beyond the effects of poverty, per se, or individual demographic
characteristics (LaVeist 1989; Polednak 1991; Williams and
Collins, 2001). Among African Americans, segregation is also
positively associated with increased rates of all-cause mortality
(Cooper et al., 2001; Jackson et al., 2000), chronic conditions such as
cardiovascular disease (Cooper 2001), and
infectious diseases such as tuberculosis (Acevedo-Garcia 2001). However, current approaches
to enable the movement of ghetto residents into more affluent areas are
small in scale and politically fragile.
The major program in this vein is the Moving to Opportunity Program
(MTO), a national demonstration program that has been operated by the
U.S. Department of Housing and Urban Development since 1994 at five
sites: Baltimore, Chicago, Boston, Los Angeles, and New York. MTO
involves about 4600 families nationally and has a complex design. The
families were assigned by a computerized lottery system to three
groups. One group of families was assigned to an experimental group
that received Section 8 housing subsidies as well as additional
support, and were required (for the first year of their participation)
to find housing in neighborhoods with a 1990 poverty rate below 10%. A
second treatment group received only a Section 8 subsidy, and a control
group received no tenant-based assistance (Kling et
al., 2004).
Reports on the health impacts of MTO are mixed. Early reports
suggested that members of those Black households that moved out of high
poverty ghettos showed signs of responding to their improved physical
environments. For example, children in the experimental group had fewer
asthma attacks or injuries requiring medical attention (Goering et al., 2002). Feelings of safety increased
and fewer depressive/anxiety problems were reported among adults
and some children (Leventhal and Brooks-Gunn,
2003). Reports based on longer-term follow-up are less
clear-cut. Net positive impacts appear to be more modest as some
negative health impacts have emerged. For example, while female youth
appear to have benefited from the move in terms of their mental health,
male youth who moved were found to engage in more risky behaviors and
to experience more physical and mental health problems than those who
did not (Kling and Liebman, 2004). Adults
experienced a positive mental health impact and, at least, a temporary
reduction in obesity, but showed no significant effects on four other
aspects of physical health—general health, asthma, physical
limitations, or hypertension (Kling et al.,
2004).
The original program was intended to involve substantially more
families, but it was scaled back after strong White suburban resistance
in Baltimore, the initial program site. This gets to the heart of our
critique of the MTO intervention. In so far as it is meant to inform
policies aimed at desegregation of large numbers of families, it is
politically naive. Previous survey research and numerous historical
accounts have shown strong White resistance to living in neighborhoods
that are “overly” Black (Zubrinksky and
Bobo, 1996). A recent study has shown that housing “loses
at least 16% of its value when located in neighborhoods that are more
than 10% black” (Harris 1999, p. 476).
This suggests that if sizable numbers of Blacks were to move to White
neighborhoods, those Whites who could afford to leave would do so.
Interestingly in this regard, the neighborhoods that MTO experimental
families moved into experienced sharply increasing poverty (Kling and Liebman, 2004, footnote #21).
The MTO program skirts the basic and fundamental political issue of
persistent popular racism that thwarts elevating desegregation programs
to meaningful levels. Such housing programs also ignore the social and
cultural strengths of urban Black communities (Bennett and Reed, 1999). These programs are usually
premised either on the defaming idea that concentrating poor Blacks
together leads to social pathology—and that it is in
society's interest for poor Blacks to be dispersed—or that
the problem of the urban, racially segregated ghetto is that it effects
a spatial mismatch between poor Blacks and job or educational
opportunities. Both premises fall short of addressing the racism that
led to Black urban ghettos, still maintains Black ghettos, and that
will likely turn Black suburban destination points into new racial
ghettos (Thompson 1998).21
Black single mothers are significantly more likely than
non-Black single mothers to move from a prosperous neighborhood to a
poor neighborhood. In any case, “even when Black single mothers
do escape poor neighborhoods, their tenure in wealthier areas is
unusually tenuous” (South and Crowder,
1998).
They also do nothing to address the psychic pain
and anger of ostracized African Americans that can be health harmful,
nor do they ensure a continued commitment to integration on the part of
Whites.
Another concern is that the MTO evaluation findings that health
problems were not consistently or significantly improved—nor were
educational or employment outcomes, for that matter (Kling et al., 2004)—might be interpreted by
some as support for policies of neglect, containment, or punishment
rather than truly structural interventions. In the absence of
alternative prisms through which to interpret such findings, most
people are left to draw on prevailing racialized ideologies, leading
some to reach the defaming conclusion that “you can take the
resident out of the ghetto, but you can't take the ghetto out of
the resident.” Similarly, those interested in the health impacts
of housing voucher experiments are likely a priori to take an
economistic perspective on the impact of ghetto residence on health.
This limits their ability to hypothesize that important health costs
may accrue from moving through voucher programs or that enduring health
benefits may be more modest than anticipated. These possibilities would
be clearer if a weathering perspective were taken. It would allow
investigators to consider that some health problems may be exacerbated
as kin networks are dispersed, fragmented, and their work disrupted;
that facing interactions with Whites on a regular basis can be
stressful in ways that harm Black health (Light et
al., 1995), or that little, if any, health benefit accrues to
ghetto residents left behind, impacting even those who move and
highlighting the severe limits of such interventions.
All of these examples imply that understanding what factors shape
public sentiment on race and how they might be influenced are critical
public health and social policy objectives. Embedded racial biases
reinforce the urban ghettoization that limits access to municipal
services, health care, healthy environments, and educational and
employment opportunities (Kelley 1997; Newman 1999; Wallace and
Wallace, 1997); supports discriminatory hiring practices (Wilson 1996); and reduces the availability of
welfare and other social insurance benefits (Bound
1989). Racialized ideologies not only affect clinical judgments
to the detriment of Black patients (Chasnoff et al.,
1990; Schulman et al., 1999), and fuel
distrust of health care professionals and public health initiatives on
the part of Blacks (Dalton 1989; LaVeist et al., 2000), but also weaken public
support for initiatives to improve the health of poor Black (and other
minority) populations by framing their problems as self-inflicted. This
view opens the door for industries to target marginal communities for
environmental hazards or unhealthy consumer products (Davis 1987; LaVeist and Wallace,
2000; Mohai and Bryant, 1992; US DHHS 2000), and it creates a mismatch between
dominant cultural expectations for acting “responsibly,” and
family or local community needs (Geronimus 1997,
2003a). These conditions induce race-related stress
that causes wear and tear on the cardiovascular, metabolic, and immune
systems, fueling the development or progression of disease. Without
neutralizing pervasive racial prejudices embedded in dominant
ideologies, sustaining health-enhancing political successes will be
difficult, and the biological potential of African Americans to lead
long, healthy, lives will continue to be subverted.
III. BUILDING A MOVEMENT FOR POLICY REFORM
We agree with analysts who argue that a broad social movement is
needed to enact significant health reforms (Kilbreth
and Marone, 2003). However, it is far from clear how to
construct such a movement (Nathanson 2003).
No doubt, numerous scholars will disagree with our support for
considerations of racial difference. One familiar critique has been
that emphasizing racial (and other) differences leads to divisive and
counter-productive identity movements (Fainstein
1999). Critics have argued that movements for community
empowerment and demands for the recognition of racial difference are
largely discursive initiatives in practice, and that they have
displaced a focus on structural economic inequalities at the heart of
problems in marginalized communities. Moreover, some say that community
empowerment often amounts to little more than formal inclusion of local
groups in discussions over priorities. Such “empowerment”
often occurs in concert with budget cuts and centralization of
authority at broader levels of government that effectively undermine
local empowerment gains.
These critics seem discomforted and frustrated by advocacy for
greater community empowerment and racial representation. Such advocacy
is, indeed, often polarizing and it may divert attention and resources
away from efforts to unify movements of low-income groups against
powerful economic and political elites. However, the critiques
discussed above seem to ignore the seriousness of problems motivating
Black and other identity advocates in the first place. Black advocates
argue that White-led organizations—such as the Democratic Party
and labor unions—continue to promote policies that,
however salutary for Whites, seem unjust and of marginal benefit for
Blacks, Latinos, and others.22
For
example, because there are higher proportions of uninsured people among
racial and ethnic minorities, universal insurance is often presented as
an especially favorable approach for uniting groups across race. The
Clinton administration included minorities among those who would be
excited by their universal health security proposals [Peterson 1998, pp. 191–192]. However, there
are strong doubts about this approach among African American community
health advocates, for reasons described in an earlier endnote #
20.
Critics of identity movements make the economistic assumption that
poor Whites and Blacks share common grievances—always defined in
economistic terms—that White leaders of broad-based organizations
understand and capably represent. The Black struggle, however, is only
partially directed against White elites. That is, Black struggles are
only partially about class issues, and they are not just a misdirected
expression of class grievances. The essence of Blacks'
race struggle is not against White elites; it is directed
against the racism—intentional or institutional—that
non-elite and elite Whites share.23
This
is a controversial point, and we cannot fully defend it here. Suffice
it to say that Black advocacy and criticism, when directed towards
Whites, has historically been aimed at breaking the social and
political bonds that non-elite Whites feel towards White elites. As the
historian Robin D. G. Kelley (2002) put it,
“White progressives have not been radical enough for Black
activists.”
A proper analogy to today's race
relations between Blacks and Whites is not the relationship between
slave and slave-owner, or laborer and employer; it is more like the
relationship between an overburdened and angry wife and an abusive and
cheating husband. Just as conservative cries for women to strengthen
families by rallying behind their husbands seem counterproductive to
abused spouses, calls from politicians for a “dampening of
sentiments based on group identity” (
Fainstein
1999, p. 267) are likely to seem self-serving and undermining
to Blacks and other marginalized groups. As women's advocates
do not place much confidence in movements for family unity that do
not address serious issues of spousal abuse, Black advocates are
intensely resistant to movements that emphasize moderation in racial
advocacy for the sake of cross-racial unity.
Black activist discourse has long recognized the potential benefits
of solidarity with non-elite Whites, and that there are limits to
Blacks' capacity to address major social problems on their own.
This is why Black advocates bother to engage in racial criticism rather
than turn entirely inward. Yet interracial solidarity is only a
potential, and a long-awaited one at that. Whites' willingness to
accommodate racial difference signals a stronger commitment to building
interracial solidarity than appeals for Blacks to join interracial
coalitions based on short-term economic interests to secure marginal
benefits. Black advocates have long and unsuccessfully appealed to
Whites to acknowledge and legitimize struggle against racial
subordination, rather than merely asking Blacks to join what are
essentially White interest-based, inter-racial economic coalitions. The
surest means of reducing divisiveness within movements is to provide
marginalized groups with a sense that their well-being is safeguarded
by other groups (Pettit 1993).
The Politics of Building Solidarity
The Creed, we have argued, is based on belief in the essential
fairness of current economic and political arrangements in American
society. The Creed relegates Black experiences, demands, and criticisms
to the periphery of politics, and actually cultivates racial prejudice
by blaming Black poverty on a lack of personal responsibility. While
American pluralism is tolerant of diversity in certain private
moralities such as religious faith, it is fundamentalist with regard to
defense of the basic legitimacy of political and economic structures.
For example, many Blacks have argued to no avail that through the
definition and enforcement of inheritance laws and property rights, the
government has legitimized ill-gotten wealth from slavery and Jim Crow
laws, while simultaneously perpetuating a false explanation for Black
economic inequality (Dawson and Popoff,
2004). Blacks' formal right of dissent has little practical
value in challenging such government-, corporate- and mass media-backed
social structures. The economistic view undergirds this kind of shallow
pluralism, where individuals and groups compete for audiences and
resources within the context of unquestioned government rules and
affirmative ontological boundaries. Economism discourages reforming
these rules and boundaries, and in so doing it reduces interracial
trust and the potential for cross-racial political solidarity.
Just as alternative explanations for Black health problems are
precluded in dominant research paradigms, and just as alternative
perspectives on American society are marginalized by beliefs in the
American Dream, there are alternative possibilities for building a
movement around public health issues that are constrained by norms
restricting political participation. Rather than accepting rules
governing participation and struggling for a redistribution of goods
and services within these limits, an alternative is to build a movement
for democracy that contests the boundaries of political discourse and
the rules determining which groups get to participate in the political
arena.
A political argument for accepting the procedural status quo is that
there is little broad political support for revamping existing rules
regarding political participation, and rethinking conventional policy
paradigms, particularly within the White middle class. Radical demands
attract narrow political constituencies, and even if they are intensely
mobilized, such movements have little hope of passing legislation.
Black health advocates are, therefore, encouraged to tailor their
health demands to what is acceptable to the White middle class, and
thereby to reforms that will be taken seriously during major
political-cultural conflicts. This kind of pragmatic realism is
politically shortsighted. It has produced policy ineffectiveness, and
maintained racial tensions in the ghetto handled by an ever expanding
criminal justice system. Narrow framing of health problems—within
the normal boundaries of political and policy discourse—is likely
to lose the mobilizing energies of Black activists. In addition, a
victory using such an approach will likely leave Blacks'
particularly severe community health problems unaddressed.
Bringing about fundamental policy reform requires imagining (within
the realm of the possible) ways to bring about a movement for democracy
that is both broadly appealing and intense.24
Gerald Torres and Lani Guinier (2002)
write that, “Magical realists infuse ordinary situations with an
enchanted quality that distorts both physical and temporal reality. This
allows the narrative to take paths that would ordinarily fall outside the
range of acceptable accounts.
We will approach this task in
two steps. First we will discuss what it means to challenge the
boundaries of everyday discourse on issues of Black poverty and
community participation so that more Whites may come to believe that
there are valid reasons for sharp racial dissent within society. We
think this is an important step both in reducing White resentment of
Black criticism and in redefining the social problems that government
must solve. Then, we will propose changing the rules governing
electoral participation as a possible approach for a democracy-oriented
movement for health reform.
A key aspect of racial difference is that Blacks tend to have a much
broader view of the legitimate bounds of political reform than Whites.
From the Black ideological perspective, their health problems are
rooted in the economy, in racial segregation, in a racist political
culture, and in Black political powerlessness. Healthy Black
communities, from this point of view, would require fundamental
restructured housing and environmental conditions, good jobs, political
reform, and preceding all of this, major changes in racial
discourse.
Although the Black perspective poses strategies and demands that are
far removed from mainstream White opinion, political advantages exist
to taking such a broad view. One is that the broad approach is highly
motivating for many Blacks; it connects with their sense of justice,
history, and deeply felt aspirations in a way that a narrow economistic
framing of Black health problems does not. It also brings the power of
intense protest. This is a power that, for example, the Clinton health
initiative sorely lacked.25
Theodore
Marmor (1994) wrote, “compulsory health
insurance—whatever the details—is an ideologically
controversial matter that involves enormous symbolic, financial, and
professional stakes. Such legislation does not emerge quietly or with
broad bi-partisan support, either here or elsewhere.”
Protest is a part of deepening pluralism—making it more inclusive
of marginalized groups. Despite the discomfort it may cause, it
encourages social learning and moral repositioning by groups unfamiliar
with radically different perspectives on U.S. history and public
policies. In so doing it opens up political space for broader reform.
Such space is desperately needed.
Second, as mentioned previously, we believe that a logical and
promising strategy for building a movement for progressive health
reform would be to focus on changing the rules governing political
participation to include excluded groups likely to support radical
health reforms. For example, both immigrant groups and citizen slum
dwellers are frequently discounted in political calculations because
most immigrants cannot vote, and because many slum dwellers are former
felons and cannot vote. This disfranchisement is the result of state
laws restricting immigrant and ex-felon voting in state and local
elections. Although immigrants had voting rights in parts of the United
States from the Colonial Era until the 1920s, and although legal
immigrants pay taxes and many serve in the U.S. military, they cannot
vote in most states (Shin and Harper-Ho,
2000; Tienda 2002). Because immigrants
tend to be poor and live in cities and inner-ring suburbs with native
poor people, these areas lose voting power in relation to wealthy areas
having fewer immigrants. In short, immigrant disenfranchisement weakens
the capacity of the native-born poor to secure support for their
schools and neighborhoods in state and local budget contests. The
immigrant vote could aide low-income citizens in poor communities to
win many state and local political contests and to fund needed health
and social services in their neighborhoods. While enfranchising
immigrants may seem like an impossibility in the present political
climate, it may become more attractive as their numbers continue to
swell, and as municipal leaders consider the implications of having
huge numbers of poor city residents with no representation in the
normal political process.26
The mayor of
Washington, D.C. has recently come out in favor of immigrant voting in
local elections. In New York, there is currently strong debate on the
issue between the mayor and leading members of the City Council. San
Francisco immigrant groups are also beginning a grass-roots campaign
for the local franchise. For public discussion of this issue see, for
example, “A Citizen's Right,” editorial, New York
Times, April 19, 2004; Cobb 2004; Marks 2004.
A second means of expanding suffrage would be to expand the vote to
ex-felons. An estimated 3.9 million U.S. citizens are disfranchised,
including 1 million who have fully completed their sentences. The large
scale of felony disfranchisement among the Black population is mainly
the result of state drug laws and harsh sentencing policies that have
been disproportionately imposed on Blacks. In the U.S., about 1.4
million African American men are disfranchised. In Alabama and Florida,
more than 30% of African American men are permanently
disfranchised. In Mississippi and Virginia, one in four Black men is
permanently disfranchised (Project 2003).
This restricted franchise reflects the view that democracy is a
privilege rewarded to noble citizens having an orientation toward
moderation and consensus.27
J. A.
Schumpeter's influential Capitalism, Socialism and
Democracy (1943) argued that “all
the interests that matter” in democracy should have strong
allegiance to the “structural principles of existing
society.” Schumpeter therefore argued that racial, religious, or
property (class) restrictions on voting are not incompatible with
democracy. While more recent consensus theorists do not defend these
restrictions, they do defend his earlier thesis and use it to justify
other restrictions.
Ironically, this view of democracy
excludes those who need the power of representation the most, and it
disarms democracy as a means of preventing potentially explosive social
conflicts. If not through participating in politics with their
neighbors, how will excluded persons identify themselves or be
identified as part of their community?
28 As Leslie Thiele (1999, p. 8)
writes, “The quandaries of moral life are seldom if ever resolved
by deduction. They are negotiated by way of reflective mythologizing.
We find out what is right to do by discovering what our proper roles
are in a story that concretely situates us in the world. The struggle
for contextual meaning and identity is thus the end for which the
rational derivation of principles serves only as a means.” Being
in a participatory political process enables participants to learn new
stories that help them identify themselves as part of a
community.
This question becomes pointed and poignant when
applied to specific health problems, for example HIV/AIDS, that are
increasingly concentrated, but not contained (
Wallace and Wallace, 1997), among persons excluded
from political participation. How can communities work cooperatively
with ex-felons and immigrants to generate greater awareness and public
support for combating HIV/AIDS when the latter cannot participate
in local politics? Rather than leaving immigrants and ex-felons out of
the political picture, health advocates could support political reform
efforts to enable their political participation. History has shown that
extending voting rights to Blacks, for example, was crucial for
strengthening other movements of marginalized groups, as well as the
responsiveness of political structures to poverty and discrimination
more generally. Adopting progressive social policies to eliminate the
political exclusion of immigrant non-citizen taxpayers and ex-felons
could have similarly beneficial impacts today.
Because trying to work within the constraints of the Creed has been
disadvantageous and misleading to both mainstream and marginalized
groups, it has fueled intolerance between these populations. It is an
important development, for example, that in recent decades Black
demands are increasingly viewed as unjust to many low-income and
middle-class Whites (Kinder and Sanders,
1995). How did that happen? When Black civil rights advocates
moved from demands affecting Southern Whites to demands affecting
Northern White liberals, such as the desegregation of schools in the
North and demands for full employment (regardless of race), they lost
much of their White liberal political support. Rather than engage in
contentious political argument with their liberal White allies,
frustrated civil rights groups and Black political leaders settled for
partial concessions, such as affirmative action, as a pragmatic
accommodation to White mainstream opinion (Skrentny
1996). However, because these programs provided limited help for
the Black poor, Black leaders and organizations lost much of their
Black grassroots support, intensity, and mobilization capacity. In
their weakened state, Black civil rights advocates were unable to
successfully challenge a subsequent conservative movement that attacked
even minimal affirmative action programs as discriminatory against
Whites. As a consequence, Black leaders are today faced with a
demobilized Black public still saddled with the problems of slums and a
more hostile White public. Their defense of even the minimal
compensatory reforms they settled for in the past are now denounced by
some White liberals as divisive and morally repugnant. By agreeing to a
shallow pluralist approach rather than sticking with their broadly
framed, more contentious agenda more than thirty years ago, Black
advocates now find themselves in a much weaker position.29
For a history of social democratic
aspirations underlying Black political movements, see Hamilton and
Hamilton (1997).
After decades of avoiding the central problem of ideological and
political disputes over the nature of Black poverty in favor of
narrowly framed ameliorative programs, we have seen some clear results
in public health. Dramatic improvements in Black health outcomes became
evident during the highly contested era of the late 1960s (Almond, Chay, and Greenstone, 2003). A decade later
and to the present day, progress in reducing racial disparities in
health have stalled. The absence since the 1960s of vigorous
contestation of the defamation of Black ghetto communities has resulted
in increasing vilification, making even ameliorative interventions more
stingy.
We have argued that public health failures to date stem, in part,
from ideologically driven and poorly informed policy discussion about
the lives of the African American poor. Given the context in which they
find themselves, to accept the values or roles of economistic
individuals would be self-defeating for many African Americans. The rub
is that, increasingly, public policy is uncharitable to those who do
not accept economistic values or roles. This results in a disconnect
between larger societal expectations, policies, programs, or laws on
one hand, and family or local community needs on the other. This
disconnect feeds health-threatening stigmas against urban African
Americans and intensifies their material hardship by leading to
policies, programs, and laws that, in effect, undermine the work of
social and kin networks. As we have shown, these approaches leave poor
Black urbanites with fewer resources to meet increasing needs while
also undermining their efforts to provide social support, identity
affirmation, or pool economic risk to avert the worst consequences of
material hardship (Geronimus 2000; Mayer and Jencks, 1988; Ward
2000). All of this has the potential to increase allostatic load
and exacerbate weathering, leading to chronic or infectious disease,
co-morbidity, and death.
With a fundamentally new type of policy discussion, not only within
the public health community, but also within the broader social welfare
and anti-poverty policy communities, we can lift the veil over
taken-for-granted cultural processes that shape policies and programs
in ways that harm African Americans.30
This point is developed in more general form by Arthur
Kleinman and Joan Kleinman (1997).
Without a new type of policy discussion that questions rules of exclusion
and raises unpopular racial criticisms, we have little hope of generating
the power, intensity, or deep interracial solidarity needed to produce
fundamental health reform.
Thus, a similar choice confronts Black health analysts and advocates
today as was faced by Black social advocates in the mid to late
twentieth century. Should they pursue an incremental, shallowly
pluralist approach that will be more popular and more easily winnable
within confines of existing White middle-class opinion? Or should they
encourage substantive reform and intense political and policy debate,
engaging in the risky work on the edges of our weakly pluralist
democracy?
