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THE FOUNDATION OF MODERN RACIAL CATEGORIES AND IMPLICATIONS FOR RESEARCH ON BLACK/WHITE DISPARITIES IN HEALTH

The persistence of black/white disparities in Nina T. Harawa, PhD; Chandra L. Ford, PhD health outcomes has led some to question the approaches public health, biomedical and clinical researchers use to classify, describe, INTRODUCTION suspect, Dominican by an employer and analyze race. Although these fields appear ready for the emergence of new strategies for who subscribes to the belief that studying race, they must first develop a solid Inconsistent progress in narrowing Hispanics/Latinos possess a better understanding of the historical bases for the the black/white racial gap in health work ethic than do African Ameri- concept. This article adds to the health outcomes1,2 has led many to question cans, and simply Dominican by disparities discourse by explaining the origins how health researchers classify, describe, herself and her family. In other of the US race and ethnicity concepts and and analyze race in their efforts to words, the manner in which she self clarifying ways in which race is ‘real.’ The idea of distinct and hierarchically valued races is a understand racial disparities in health. identifies may rarely involve race, but dominant, though problematic paradigm for As Braun explains, ‘‘the notion of ideas about race and ethnicity may explaining . We propose that ‘inequality’ or ‘disparity’ implies group affect her likelihood of being subject- the construct of race is inseparable from the difference in the experience of health’’; ed to police surveillance or brutality, term’s origins and, in research must be treated therefore, ‘‘much of the debate over opportunities for employment, self- as such. Doing so appropriately may enhance cross-disciplinary efforts to target the funda- health disparities has necessarily cen- identity, cultural milieu, and associ- mental causes of racial disparities in health. tered on the issue of human classifica- ated stressors. We draw on multi-disciplinary research to tion.’’3 p. 557 Researchers have recom- As demonstrated by research on explain how race became fixed within the mended a focus on ethnic rather than social and contextual health influences, mind, describe how it racial variation,4,5 proposed alternative human interactions, and highlight limitations of all of these factors may affect her health terminology for racial and ethnic cate- the official racial/ethnic categories enumerated and life expectancy. Health investiga- gories,6–8 questioned the exchangeabil- by the US Office of Management and Budget. tions that seek to understand the (Ethn Dis. 2009;19:209–217) ity assumptions intrinsic to efforts to mechanisms through which racial and explain racial disparities,9 suggested ethnic factors operate must recognize Key Words: Characteristics, Pop- abandoning racial comparisons alto- ulation Groups, , Blacks, Race, Ethnic- and differentiate the various aspects of gether,4 and debated whether strong ity, Social Environment identity outlined in this example. associations between genetic markers, The inclusion of race/ethnicity in an continental ancestry, and standard ra- epidemiologic triad with age and sex has cial/ethnic categories validate the latter’s become routine.14–17 For example, from biologic relevance.3,10–12 Researchers 1996 through 1999, 77% of studies and the public, however, lack a uniform published in the American Journal of understanding about what the terms Epidemiology and the American Journal race and ethnicity refer to and how they of Public Health made some reference to should be categorized.6,10,13,14 Further- race or ethnicity.14 Race, sex and age, all more, despite the current national focus may be thought of as physical attributes on understanding and reducing health with social relevance. Race, however, disparities between racially designated differs conceptually from both sex and groups, terse attention is given to the age because it lacks agreed-upon criteria origins of racial terminology and classi- for classification16 or a direct biological fications. Advancing our ability to component. Because no set of biological address racial/ethnic disparities in health From the Department of Research, traits determines race18 and because requires an historically informed under- Charles Drew University (NTH) and Uni- racial/ethnic designations represent the versity of California Los Angeles, Los An- standing of these issues, including how needs of various stakeholders, racial geles, California (NTH and CLF); Depart- the notion of fixed and distinct races categories change over time19,20 and ment of Epidemiology, Columbia University, became fixed in the American mind. New York, New York (CLF) are used inconsistently and unreli- ably.14,21,22 Example Address correspondence and reprint There is no ‘gold standard’ for the requests to: Nina T. Harawa, PhD; Charles Drew University; 1731 East 120th St; Bldg A dark-skinned Dominican-Ameri- use of race in health research; however, N; Los Angeles, CA 90059; 323-563-5899; can woman may be viewed as black the Office of Management and Budget [email protected] by a police officer pursuing a black (OMB) establishes racial and ethnic

Ethnicity & Disease, Volume 19, Spring 2009 209 RACE ORIGINS AND HEALTH DISPARITIES - Harawa and Ford standards for census and other official the race variable. Many disparities re- present-day assumptions that the origins data collection and the NIH requires that searchers may lack training and expertise of race are genetic endeavors. investigators categorize clinical research in this area. To this end, we briefly The first known scientific descrip- study participants into the OMB-defined review the origins of the term and the tions of human ‘‘races’’ was published by racial/ethnic categories. These are as history of racial classification in the the French physician Francis Bernier in follows with the descriptions in paren- American context, focusing most of our 1684. It described four groups distin- theses referring to ‘‘a having attention on how race has been applied guished by geography but described by origins in the’’: American Indian or to of African and European phenotype.26 Numerous other racial Alaska Native (original peoples of North, descent because overall health disparities classification systems were published Central, and South America who main- are greatest between these groups. subsequently as the new discipline of tain tribal affiliation or evolved and colonial ex- attachment), Asian (original peoples of ploration expanded during the following the Far East, Southeast , or the RACE:ORIGINS OF THE TERM century. In 1735 the Swedish-American Indian subcontinent), Black or African naturalist and father of modern taxono- American (black racial groups of ), The precise origins of the term my, C. Linnaeus, first published System Native Hawaiian or other Pacific Island- ‘‘race’’ are obscure, but it appears that Naturae. In it, Linnaeus proposed four er (original peoples of Hawaii, , the word evolved in Romance distinct racial groups for human beings , or other Pacific Islands), or white during the Middle Ages and was used to that encompassed not only phenotype (original peoples of , the Middle describe distinct breeding lines of ani- and geographic origin but also personal- East, or North Africa), and Hispanic/ mals. The application of the English ity traits, skills, and abilities generally Latino (Cuban, Mexican, Puerto Rican, word race to classify of varying thought to be inherent to each group Cuban, South or Central American, or geographic origins and phenotypes like- (Figure 1).27,28 The categories in these other Spanish or origin, regard- ly stems from the Italian, razza or raza, early ‘‘scientific racial classifications’’ less of race) or not.23 This commentary’s a classificatory term for animals similar were often explicitly or implicitly or- uses of the terms race and ethnicity to type or species.24 As a taxonomic dered, with descriptions or rankings that follow these official designations. category, race falls below the level of regularly placed blacks (Africans) at the Efforts to explain racial disparities in species, implying biologically (and ge- bottom and whites (Europeans) at or health are expanding with increased netically) distinct that may near the top.27 Interestingly, the 1990 attention and funding for this area. We interbreed and produce viable off- US Census used essentially the same four suggest that the historical context in spring.25 The scientific and popular racial groupings – Indian (Amer.)/Eski- which racial categorization evolved in the North American versions of the modern mo/Aleut, Asian/ sub- provides the appropriate concept of human races and formal race groups, black or Negro, and white23 — starting point for conducting and cri- taxa for human populations emerged in demonstrating how relevant the history is tiquing research on race, ethnicity, and the 17th century, which precedes mod- to our current understandings and uses health, including proposals to abandon ern genetic theory and thus challenges of race.

Fig 1. Racial classification scheme by Linneaus (as summarized from Systemae Naturae25 p. 164)

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EVOLUTION OF THE out the second half of the 1600s, white servants for their labor.28,36 RACE CONCEPT however, social, economic, and legisla- Although many non-English European The concept of inherently distinct tive changes altered the character of immigrants (particularly the Irish) were and unequal subpopulations of human forced servitude in the colonies, making initially seen as inferior to the English beings termed ‘‘races’’ continued to it a permanent status for African and even depicted as subhuman, savage, evolve during the period of Spanish servants and eventually reserving this or animal in scientific writings, printed and British colonial expansion, the slavery solely for Africans and their advertisements, and popular culture,37 extermination and removal of various descendants: the rigid boundaries among European American Indian , and the massive groups blurred, disappeared, or became ‘‘There is, or should be, no doubt enslavement of Africans on American non-divisive over time38,39 and the that the Africans’ physical differences shores.28–30 We and others propose disparaging notions eventually came to facilitated their reduction to the kind that, over time, these beliefs about race be largely reserved for African Ameri- of servitude that the English had long coalesced into an ‘‘ideology,’’ or sys- cans and American Indians.28 wanted and that agricultural circum- tematic body of ideas31 that reflected Through legislative and social pro- stances demanded. The visibility of the social and economic needs and cesses, race in the North American Africans made it possible to aspirations of the dominant classes and context, evolved into a rigidly hierar- the demarcation point of permanent (in this case) the emerging United States chical framework for jointly conceptu- slavery solely on the basis of color. government.32,33 Ideologies shape the alizing human differences and labor Captured Africans, removed from organizing principles by which divisions, with white relative to non- anypossiblesourceofaidand operate and help establish how individ- white, and ultimately black, forming the comfort, thrown together with others uals understand themselves in relation- major dividing line.36 Although frame- who did not share their , ship to others and the world around works existed differentiating Europeans culture, or , were the most them.34 The birth of racial categories according to nativity, class, and pheno- vulnerable of all of the subordinate was the product of these sociopolitical type, Indians according to , and populations, …’’28p. 107 organizing principles: ‘‘ appeared Africans according to tribe and , and gained currency with the beginning Increasingly, only members of one these were slowly superseded by an of ‘modern science’ which coincided group were both born into slavery and ideology promoting white/non-white with the development of one of the died as slaves: Africans with dark skins. distinctions as more fundamental than ideological systems that gave legitimacy Scientific and religious theories that any other.19 The phenotypic variation to the bourgeoisie who was then blacks were of a separate and inferior that existed among the different peoples acceding to political and economic race flourished and served to both who populated the during the power.’’35 p. 291 justify slavery’s institutionalization and colonial period was real25;however, In the United States, early racial reinforce the idea of distinct and ‘‘race,’’ the means used to understand classifications and descriptions (ie, labels distinctly inferior human races. it, was an ideology. This race ideology such as ‘white,’ ‘red,’ and ‘black’) As black slavery became institution- supported the survival and aspirations of reflected the striking skin color differ- alized, distinctions between blacks and British settlers by legitimating the ences that distinguished European set- whites were coded into legislation, such perpetual ownership and mistreatment tlers, American Indians, and West as post-1650 colonial laws that allowed of some human beings, the violent quest Africans. As populations representing white indentured servants to marry with for land already inhabited by others, the full skin color continuum between their masters’ permission, earn their and the enactment of laws to prevent these groups (ie, the ‘shades of grey’ freedom, and even carry weapons.36 by poor whites and blacks between black and white) were not Eventually, none of these rights were who, despite their shared experiences of present, the phenotypic distinctions afforded to black slaves. Moreover, mistreatment and desperate economic between them seemed discrete. These became secondary conditions,28,36 were largely kept apart striking phenotypic differences helped to the dictates of race laws, such that by racial classifications. In other words, shape North America’s particular man- even free blacks were not permitted racism, defined by Merriam-Webster as ifestation of slavery.28,32 For example, rights and privileges afforded whites of ‘‘a belief that race is the primary European indentured servants originally similar classes. As the threat of rebel- determinant of human traits and capac- held a somewhat similar status to lions from unified poor whites and ities and that racial differences produce African servants and composed the blacks grew, laws were passed to prevent an inherent superiority of a particular major portion of the free labor pool in fraternization between white servants race’’ was encoded in the modern idea the first half of the 1600s.28 Through- and black slaves and to better reward of race itself.31

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The pre-17th century uses of the pete with Whites in the emerging migrants and interracial parents have word ‘‘race’’ referred, in a sometimes- industrial sector. The reclassification of found race notions ill-fitting to how they neutral fashion, to national groups, these Eastern and Southern European perceive themselves or their chil- generations, or types and not to classi- ethnic groups occurred as whites forti- dren.39,49 born to different race fications so broad that they subsumed fied their while under- parents have agitated for a multiracial entire continents of or predeter- mining black efforts to access institu- category23 and questioned the paradigms mined individuals’ inherent capacities.33 tions, such as labor unions and home of white purity and non-white pollution Similar to the modern-day notions of ownership, that would improve their implied in the one-drop rule that asked ethnicity, European explorers and schol- own.38,42 Racial reclassification process- them to choose one race. Those from ars once used race as a means to refer to es continue to unfold with various East India and Middle East have resisted different tribes, , language groups, implications for the growing popula- being classified as Asian and white, and ,28,40 as these were the tions of non-European people in the respectively.23 Hispanics/Latinos, whose primary bases for group identification, United States.43 In some instances, native ideas of race and color differ conflict, and . Lumping very however, they may reflect and reinforce markedly from U.S. ideas,50,51 have diverse peoples together, by, for exam- perceptions of white and black as polar widely resisted racial categorization, with ple, stripping enslaved Africans of their opposites on an American racial contin- 42% selecting ‘‘other’’ race in the 2000 tribal identities and race-ing them as uum as the quote below suggests. Census.52 Asian American organizations black, ultimately facilitated the domi- have also pushed for more detailed ‘‘Are Lebanese ?’’ we of these populations for their information on their subpopulations19 asked a 71-year-old Ned Holder, a land, their labor, and their bodies. whose SES and differ markedly former sheriff [in Sunflower County, Religious and pseudoscientific theories by national origin.46 It is for these groups MI]. ‘‘Yes,’’ he said, ‘‘although they’re linking mental and physical inferiority – those in between the of black and real dark.’’ How about Italian Catho- and superiority to newly formed racial white – that the notions of separate and lics; are they white? Sure. And ? categories served to legitimize this distinct races most consistently break ‘‘Yes,’’ he said, ‘‘they go to the white oppression.28 For example, the exploi- down, as evident from inconsistent racial schools.’’ And Mexicans? ‘‘They’re tation of minority females in the slavery codings on birth and death certifi- becoming more white. More of them area was justified by notions regarding cates,21,53 in multiple wave of follow- are getting an education.’’ Then the untouchable and pure nature of up surveys,54 or between respondents what’s a white person, we asked? After white female bodies vs the crude, public, and interviewers.54 some confusion over the meaning of and inherently violable nature of black The 1990 and 2000 Census ques- the question, he concluded that it was and other female bodies. It included the tions on race and ethnicity show a probably anybody ‘‘who isn’t rape of slaves by slaveholders and the substantial move from an inflexible race black.’’44 —Rodriguez G. ‘‘Defini- perfection of surgical techniques, with- based on phenotype or supposed tions of Whiteness and the Delta out consent or anesthesia, on enslaved quantum to a more flexible notion that Blues,’’ LA Times,1/14/2007. black women and on Eastern European captures ancestry or . For immigrant women, who were not yet The apparent physical reality of race example, the 2000 Census categorizes considered white.41 has become rooted in our collective Hispanics, Asians, and Pacific Islanders consciousness even though it is not by national ancestry and American difficult today to find individuals Indians and Alaska Natives by tribal RACE:MODERN USES whose phenotype is not consistent with affiliation. Conversely, although non- his or her racial identity. Since 1970, Hispanic whites and blacks together The early post-slavery period, 1870– those who fill out the phenotypic compose about 80% of the US popu- 1930, saw large in-migrations of non- continuum between white and black lation, the Census does not further Anglo Saxon Europeans such as Euro- have been at the forefront of challeng- categorize these two racial groups.23 pean Jews and Italians. Most were not ing official race categories and popular Hence, while recognizing that a com- initially classified as white but, within a notions about race. During the inter- plex and inherently fluid heritage exists few generations, became white through vening nearly 40 years, the foreign- and should be distinguished among processes heavily influenced by labor, born population has doubled – primar- some peoples, the questions continue housing segregation, and the ‘‘Great ily through immigration from non- to reinforce fixed and distinct notions of Migration’’ of African from European areas.45,46 Interracial couples, black and white races, the new ‘‘select the rural South to Northern urban and offspring have also all’’ option for multiracial individuals, centers where they threatened to com- increased dramatically.47,48 Many im- notwithstanding.

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RACE:DEFINITIONS cial forms), active cultural identification Several studies,60–62 including random- AND IMPLICATIONS (in the case of Native Americans) , ized controlled trials with video pseu- mother’s race (birth certificates), geo- dopatients,63 have documented differ- Races are not defined consistently graphic origin (Census), and phenotype ential treatment by patient race. This on the basis of specific combinations of (death certificates).21,59 Individuals, research allows us to discuss race in a physical or cultural criteria; rather, the however, still regularly group others causal, counterfactual sense – similar concept of race, derives its meaning into racial categories based on their patients of white rather than black race within societal contexts.55 Phenotypic phenotypes without any knowledge of would have been more likely to receive differences, sometimes striking ones, their ancestral origins, cultural identifi- aggressive care.64 However, the actual exist across racially designated groups, cation, or parents’ race. Furthermore, causal mechanism – the so-called ‘‘race but these are described in some coun- the white and black race categories effect’’– relates not to personal race tries without referring to the same rigid persist and many disparities in the attributes but to the relative positions and finite racial classification system.28 health and of these groups these pseudopatients occupy within the For example, in , individuals are have remained constant or worsened racial hierarchy of the physicians’ soci- categorized primarily according to skin over the past century.1 ety. In other words, racial hierarchies color and class,22 with those with some Approaches to presenting racial establish value systems and in African ancestry classified as white if health disparities that are not historical- individual’s minds that can lead them to they have light skin or large bank ly informed have the potential to differentially react to others’ pheno- accounts.56 A few other societies (eg, reinforce racial ideologies that assume types. As no feasible interventions can ) operate under different, the inferiority or superiority of racially change a patient’s race, interventionists but still rigid and hierarchical racial designated groups. Acknowledging that must target interpersonal factors (eg, the schemata.56 Many others focus on race is a worldview whose current conscious or subconscious racial ideol- ethnic or religious, rather than racial, meanings cannot be separated from its ogy of healthcare providers) and struc- divisions.57 historical origins enables health re- tural factors (eg, the institutional sys- In the United States, race was searchers to develop solid foundations tems in which clinicians operate) to historically classified according to an- for understanding and eliminating ex- insure equitable care.65 cestry and blood quantum in official isting racial disparities in health and The manifestation of racial ideolo- statistics and popular opinion (eg, healthcare delivery (Figure 2). This gies in the structural features of institu- origins of the infamous ‘one-drop rule’ includes the behaviors of healthcare tions can lead them to operate in ways are laid out in 1870, 1880, and 1890 providers who may not consciously that can create or reinforce racial instructions for Census takers).49,58 subscribe to prejudiced ideas against inequalities without any intentionality Official racial designations are now minorities but whose practice of med- on the part of those involved (ie, based on self-identification (many offi- icine is differential by patient race.24 institutionalized racism).66,67 Structural

Fig 2. Examples of macrolevel forces leading to and influencing the historical and contemporary understandings of race in the United States of America

Ethnicity & Disease, Volume 19, Spring 2009 213 RACE ORIGINS AND HEALTH DISPARITIES - Harawa and Ford racism, together with sexism and class- this generates – including who has the strengthened by the false notion that ism, may thus be a fundamental cause of opportunity to become a physician – hierarchical racial categories reflected health disparities68–70 and limit the requires this shift in focus to institu- biological realities. Finally, the ongoing effectiveness of public health interven- tionalized racism. debate about whether race is a social or tions that do not acknowledge and Second,evenwhenverystrong biological category is unlikely to be address it.66 The following examples evidence indicates that discriminatory resolved if race continues to be con- are just a few of many that indicate the practices may be at work, scholarly ceived of as solely an attribute of importance of contextualizing dispari- discourse tends to avoid describing individuals because it does not address ties research given the implications of them as racist or reacts negatively to why race seems to be a scientific fact.55 such structural inequalities: 1) black such descriptions. This presents chal- We argue that race is a social patients’ adherence to prescribed treat- lenges for publication of research that category with some relevant biologic ment regimens may be hampered by might advance this line of inquiry and linkages; however, these can often be pharmacies’ refusal to dispense narcotic ultimately reduce disparities.28 Finally, more precisely described by other vari- pain medications in some predominate- posing questions like, ‘‘Is it race or ables. For example, a recent San ly black neighborhoods,70 2) HIV/STD racism?’’78 can inadvertently suggest Francisco Chronicle article describing a prevention approaches that fail to that there exists a neutral ‘race’ that is newly discovered genetic variant that acknowledge the influence of sexual neither a product of nor affected by may help explain elevated HIV rates network characteristics on risk71–74 racial stratification. We contend that among blacks contained the following may be ineffective and reinforce nega- there is an effect of being racially statement, tive stereotypes about the sexuality of categorized that reflects the experience Certain species of malaria parasites men and ,75,76 and 3) in of living in a where one’s latch on to the Duffy protein and use addition to contributing to access issues racialized phenotype influences one’s 79 it as a gateway to enter red blood and risky sexual networks, steering and social status. This effect can be cells. Africans overwhelmingly carry a redlining in real estate (ie, withholding blunted or compounded by whether gene that disables this gateway - and home-loan funds or insurance from and how an individual identifies with Weiss believes this may have been the neighborhoods considered poor-eco- his or her racial designation, internalizes result of an evolutionary battle be- nomic risks) may limit opportunities society’s ideas about his or her racial 80,81 tween humans and malaria. The for affected minority groups to reside in group, and copes with racism. genetic trait is also prevalent among areas that are low in pollutants and , who typically supportive of physical activity.70 carry a mixture of African and Some describe the resulting impact ONCLUSIONS C European bloodlines.82 of differential treatment on health as ‘‘the effect of racism’’ not ‘‘the effect of Although immigration, multiracial The use here of African, African race’’ itself.4,64 This framing of the issue offspring and social movements for American, and European provides read- helps to shift research away from racial and equality have radically ers a clear understanding of whom this attributes commonly associated with changed the racial landscape and dia- gene most affects and its evolutionary race and toward those forces differen- logue in the United States, the origins of etiology. Replacing African and African tially impacting racially defined groups, the modern American race concept American with black and European but it can be problematic, too. First, like continue to have important implications with white would obfuscate the infor- race, racism continues to be conceived for our contemporary ideas about race mation, failing to clarify that some of erroneously as an individual-level and its relevance to health. These ideas blacks are less likely to have this gene characteristic or as interpersonal dis- reflect perceptions about the sharp than others and implying that the gene’s criminatory treatment; therefore, re- phenotypic differences observed during distribution in non-European whites searchers may infer that unfair or the initial contacts between British (some of whom come from areas differential treatment occurs solely as a colonists, various American Indian peo- affected by malaria) is similar to that result of specific individuals’ (eg, physi- ples, and enslaved Africans in what is of European whites. Adding the term cians’) attitudes or behaviors. In truth, now the United States. The import black in front of ‘‘African’’ and white in racism is an integral feature of society. It awarded to skin color in determining front of ‘‘European’’ might further is not merely an individual attribute but race fostered the acquisition of land by clarify that the terms refer to people of a fundamental system attribute.41,77 whites and the perpetuation of chattel African and European descent rather Counteracting the inequality built into slavery for free labor. These processes than, for example, the white and Indian systems and the multiple inequalities and institutions strengthened and were populations of sub-Saharan Africa.

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psychosocial critique. Ann Epidemiol. 1993; 83. Braun L, Fausto-Sterling A, Fullwiley D, AUTHOR CONTRIBUTIONS 3(2):130–6. et al. Racial categories in medical practice: Design concept of study: Harawa 81. James SA. John Henryism and the health of how useful are they? PLoS Med. 2007; Manuscript draft: Harawa, Ford African-Americans. Cult Med Psychiatry. 4(9):e271. Statistical expertise: Harawa 1994;18(2):163–82. 84. Mackenzie S. Scientific silence: AIDS Acquisition of funding: Harawa, Ford 82. Russell S. Newfound genetic clue to HIV rate and African Americans in the medical lit- Administrative, technical, or material assis- in blacks. San Francisco Chronicle. 2008 July erature. Am J Public Health. 2000;90(7): tance: Harawa, Ford 17, 2008. 1145–6. Supervision: Harawa

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