Breaking Through and Backlash: Advancing Awareness About Racism, Sexism, Social Class, and the People's Health

  • Nancy Krieger
    Address correspondence to: Nancy Krieger, PhD, Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Kresge 717, Boston MA 02115.
    Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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      Thirty years ago, the U.S. Centers for Disease Control and Prevention (CDC) held a truly pathbreaking 3-day symposium, by invitation only, that explicitly focused on racism, sexism, social class, and health.
      • Rowley DL
      • Hogue CJ
      • Blackmore CA
      • et al.
      Preterm delivery among African-American women: a research strategy.
      Titled “Preterm delivery among Black women: The symposium on psychosocial factors” (December 2–5, 1991), this meeting was organized by a visionary group of African American women researchers, led by Diane Rowley, who were based in the Pregnancy and Infant Health Branch in the Division of Reproductive Health in CDC's National Center for Chronic Disease Prevention and Health Promotion (Table 1).
      • Rowley DL
      • Hogue CJ
      • Blackmore CA
      • et al.
      Preterm delivery among African-American women: a research strategy.
      A central goal was to expand the dominant poverty paradigm for explaining U.S. racialized inequities in infant mortality by explicitly addressing the additional and interacting adverse impacts of racism and sexism, within and across social class strata. To this end, the organizers solicited a wide range of articles (Table 2). Contributors included, in intersecting permutations, professionals across numerous public health, medical, and social science disciplines and Black women whose lived experiences were at the heart of the matter: the excess risk of preterm delivery and infant mortality long afflicting Black Americans.
      Table 1Reflections of Original Coauthors Diane L. Rowley, Byllye Avery, and Mona T. Phillips on the Preparation and Significance of Our 1993 Article
      Co-author Reflection
      Diane L. Rowley, MD, MPH, Emeritus Professor of the Practice of Public Health, Department of Maternal and Child Health, and Senior Researcher, Sheps Center for Health Services Research, UNC Gillings School of Public Health (Chapel Hill, North Carolina) The 1985 “Report of the Secretary's Task Force on Black and Minority Health” revealed the staggering health disparities among populations of color in the U.S. Infant mortality was one of the major contributors to excess deaths. However, 5 years after its publication, no new approaches to understanding and reducing the infant mortality disparity had emerged. In 1990, I directed a group at the CDC that embarked on a year-long multidisciplinary review of factors that potentially contributed to the disparity. The year culminated in an invited conference that called for a new prevention research strategy on preterm delivery as a major contributor to the disparity in infant mortality. A companion publication to the conference was published in 1993 as we began funding components of the research strategy. The research strategy embraced an interdisciplinary conceptual framework that would potentially result in a broad spectrum of interventions. We called for studying "the environmental stressors" and protective factors associated with being African American in the U.S. as important contributors to the high risk of very low birth weight and preterm delivery. We declared racism, sexism, and classism as environmental factors that interfere with a woman's ability to achieve optimal health. We required collaboration with African American families on what should be studied, how to design studies, and what study benefits should go to participants. (Rowley DL, Hogue CJ, Blackmore CA, Ferre CD, Hatfield-Timajchy K, Branch P, Atrash HK. Preterm delivery among African-American women: a research strategy. Am J Prev Med. 19,931; 9(6):1–6; Rowley DL. Research issues in the study of very low birthweight and preterm delivery among African-American women. J Natl Med Assoc. 1994; 86[10]761–764.)

      Some colleagues at the CDC warned me that the journal supplement would not get through the CDC clearance for publication process because of the controversial article that explicitly referred to racism as a contributor to health outcomes, a first for a CDC publication. Fortunately, I persevered, and we made it through.
      Bylley Avery, founder of the Black Women's Health Imperative, formerly the National Black Women's Health Project, and the Avery Institute for Social Change Reflections 30 years later:

      As I reflect on my participation in the writing of this article over 30 years ago, I realize the special space we occupied and the bravery in introducing the idea that racism has a negative impact on our health. For 10 years, women at the National Black Women's Health Project voiced their lived experiences that clearly showed the way our health is shaped by a lack of access to health care; how racial discrimination shaped their lives. Participation in this article and conference gave me a place to make their voices heard and recorded. Black women also emphasized the importance of addressing physical, emotional, and spiritual health, well-being.

      It has become more apparent that racism based in the institution of slavery continues to influence the health of Black people. Brutality forced on enslaved people passed through DNA to future generations contributes to vast inequalities despite advances in education and social class as evidenced by increasing Black infant and maternal mortality.

      It is imperative that the American healthcare system deal effectively with structural racism, implicit racial bias, and a lack of access to quality health care; the health of future generations will be a mirror of the past.
      Mona T. Phillips, PhD, cochair of Sociology and Anthropology, Professor of Sociology & Anthropology, Spellman College (Atlanta, Georgia) Like most of the country and the world, I have been consumed these past 2 years (has it been that long?) by the most up-to-date news of COVID-19 variants and vaccination rates, and I have been struck by the fact that social media and television coverage has been shaped by 1 assumption:

      That this country cannot even begin to grapple with health, death, and access to care without careful consideration of race, ethnicity, gender, sexuality, social class/precarity, and the geography of inequality.

      The mainstreaming of intersectionality—and intersectionality's embodiment in public health experts and community health workers on cable and network television—has been gratifying.

      When I tell my students that we live inside history, I am primarily alerting them to the signs of a second post-Reconstruction era in the U.S. and a transnational far-right movement fueled by vaccine disinformation and discourses of individual rights.

      I tell them the world has been here before.

      But while rethinking and rereading “Racism, Sexism, and Social Class: implications for Studies of Health, Disease, and Well-Being,” I am reminded of what it is to live inside history on a personal level and be a part of an intellectual and (dare I say?) political partnership with the other people whose names are on this publication. I had not been a part of a team such as this before, and the conversations and ideas and commitment to social justice shaped my own work and future partnerships, including the community-based research on Black women's preterm delivery (Fleda Mask Jackson, Diane L. Rowley, Carol J. Hogue, Tracey Curry Owens).

      I am grateful.
      CDC, Centers for Disease Control and Prevention.
      Table 2Table of Contents for the Articles Prepared for the 1991 CDC Conference on “Racial Differences in Preterm Delivery: Developing a New Research Paradigm”
      Sections and subsections
       Racial Differences in Preterm Delivery – Sherman A. James (pp. v–vi)
       Preterm Delivery Among African-American Women: A Research Strategy – Diane L. Rowley, Carol J.R. Hogue, Cheryl A. Blackmore, Cynthia D. Ferre, Kendra Hatfield-Timajchy, Priscilla Branch, and Hani K. Atrash (pp. 1–6)
       Infant Mortality and Health Policy
        Confronting Racial Disparities in Infant Mortality: Reconciling Science and Politics – Paul. H. Wise (pp. 7–16)
        Infant Mortality: Its History and Social Construction – Martha Hargraves and Richard W. Thomas (pp. 17–26)
       Research Within the Black Community
        Community Research: Partnership in Black Communities – John Hatch, Nancy Moss, Ama Saran, Letitia Presley-Cantrell, and Carol Mallory (pp. 27–31)
        Commentary on “Community Research: Partnership in Black Communities” – William W. Dressler (pp. 32–34)
        A Legacy of Distrust: African Americans and Medical Research – Vanessa Northington Gamble (pp. 35–38)
       Psychosocial Measurement: Implications for the Study of Preterm Delivery in Black Women – Diane E. McLean, Kendra Hatfield-Timajchy, Phyllis A. Wingo, and R. Louise Floyd (pp. 39–81)
       Racism, Sexism, and Social Class: Implications for Studies of Health, Disease, and Well-Being – Nancy Krieger, Diane L. Rowley, Allen A. Herman, Byllye Avery, and Mona T. Phillips (pp. 82–122)
      The article “Racial Differences in Preterm Delivery: Developing a New Research Paradigm,” was published in the American Journal of Preventive Medicine, 1993; 9 (Suppl 6), November/December 1993.
      CDC, Centers for Disease Control and Prevention.
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