02/08/2017 04:36 pm ET

Dr. Mary Bassett: We Must 'Name Racism' As A Cause of Poor Health

Racism is messy. But acknowledging its effects is a key part of improving public health.

Thomas Barwick via Getty Images
"It is important to name racism as something more than poverty concentrated in communities of color," NYC Department of Health and Mental Hygiene Commissioner Dr. Mary Bassett said during her acceptance speech for the Frank A. Calderone Prize in Public Health in October.

The following is excerpted from Dr. Mary Bassett’s October 2016 acceptance speech, ‘Public Health Meets the ‘Problem of the Color Line,’ for Columbia University’s Frank A. Calderone Prize in Public Health. Bassett is the commissioner of New York City’s department of health and mental hygiene. 

Before Hillary secured the nomination, before many “felt the Bern,” and indeed, even before there was change we could believe in, there was a presidential candidate of several firsts running to represent a major party ticket who broke the mold in more ways than many could comprehend, let alone support. I am speaking of Shirley Chisholm.

There’s so much to learn from, but what I want to focus on today is her bold, unapologetic, and explicit commitment to naming racism. In her memoirs, she wrote: “Racism is so universal in this country, so widespread, and deep-seated, that it is invisible because it is so normal.” If you think the conversation on race in our country is just getting legs now, can you imagine a presidential candidate saying this in 1972? And still, nearly 45 years later, her analysis stands.

Congresswoman Chisholm has us consider how we lose sight of what’s right in front of us.

This is a consideration that has woven its way throughout my working life. A little over 30 years ago, Nancy Krieger and I published an article in the Monthly Review titled “The Health of Black Folk.” In it, we wrote about the normalization of poor health among black people – how the status quo of poorer health and shorter lives comes to pass as one the “facts of being black.” The following passage begins this essay:

What is it about being black that causes such miserable odds? One answer is the patently racist view that blacks are inherently more susceptible to disease, the genetic model. In contrast, environmental models depict blacks as victims of factors ranging from poor nutrition and germs to lack of education and crowded housing. Instead of blaming the victims’ genes, both liberals and conservatives blame black lifestyle choices as the source of the racial gap in health.

The “facts of being black” are not, as these models suggest, a genetically determined shade of skin color, or individual deprived living conditions, or ill-informed lifestyle choices. The facts of being black derive from the joint social relations of race and class: racism disproportionately concentrates blacks into the lower strata of the working class and further causes blacks in all class strata to be racially oppressed.

I believe we’ve come a long way since the 1980s, but I’m not sure that our analysis of racism and health, or social justice and health, has grown more sophisticated, drawn more practitioners, or explicitly influenced much policy. I can say that because I continue to find myself explaining the very same concepts I wrote about in the 80s in 2015 and 2016, most recently in an interview with Big Think and in a piece for the New England Journal of Medicine about the importance of #BlackLivesMatter.

All of this is true even when there has never been more attention given to concepts like the social determinants of health and health equity. Representative Chisholm’s insight becomes prescient in this respect, for today our analysis of equity and social determinants is ironically myopic, a limitation that keeps us from fully realizing their potential as frameworks.

Today, we can speak of health equity without invoking race at all. Those who do speak of race seldom explicitly name racism, and even in those few forays into racism, there is hardly mention of the history and the contemporary of racial oppression, or the staying power of white supremacy. This troubles me, because it doesn’t take much for invisibility – what we don’t see – to become blindness – what we can no longer see.

My goal is to convince you all that we must explicitly and unapologetically name racism in our work to protect and promote health – this requires seeing the ideology of neutral public health science for what it is and what it does. We must deepen our analysis of racial oppression, which means remembering some uncomfortable truths about our shared history. And we must act with solidarity to heal a national pathology from which none of us – not you and not me – is immune.

There are many well-meaning and well-trained public health practitioners who disagree from the outset that we must name racism. That argument will sometimes claim that the very essence of public health is about helping people, pointing to increased lifespans and decreased infectious disease outbreaks over time. Their argument will at other times claim that we don’t want to muddy the clear waters of public health with the messy politics of race, that this sort of a topic is best left to protesters, opinion editorials and campaign stump speeches. I have also heard the claim that identifying racism opens this Pandora’s Box of problems that our modest field cannot hope to address comprehensively – that identifying racism hoists too heavy a burden. Last, there are those who say that racism is not the core issue, but instead poverty. We cannot fix racism, but we can fix poverty.

Of these, I believe the most dangerous claim is the first, that our technical expertise is enough to meet the challenges of poor health, wherever they are. This mindset presumes a neutrality of public health that has never been true – it ignores the fact that public health both operates in a political context and is itself, like any science, permeated by ideology.

Much is conflated when medicine and public health attempt to fly below the radar of politics by donning the armor of scientific objectivity – guarding the faith by positing the cold logic of the scientific method. Let me start by saying that science is not all methodology – one simply cannot judge the prudence of a whole ecology of funders, research proposals, theory-building, conferences, journals, institutes, and applications by reducing all of that to the scientific method. Each of these facets is fully penetrated by the biases of human behavior, by the ideologies of our time.

Consider two examples: funding priorities of the National Institutes of Health (NIH) and the public health, medical, and criminal justice response to the current opioid crisis.

In the case of the NIH, see its most recent 2012-2013 biennial report to Congress: as my colleague Nancy Krieger has pointed out, not only did it allocate only 9 of its 441 pages to “Minority Health and Health Disparities,” but within these 441 pages, the terms “genome,” “genomic,” “genetic,” and “gene” appeared 457 times, whereas “social determinants of health” occurred only once, “discrimination” and “poverty” twice, “socioeconomic” 12 times, and “racism” not at all.

Or, with regard to the current opioid crisis – and its appropriate reframing as a public health and not criminal justice issue – how differently it would have been had the same framing been used when Nixon declared his “War on Drugs!” But of course he did not. Today, the opioid crisis is perceived as primarily affecting white populations, people who need help. No such frame of deserving victims was used, however, by Nixon. Instead, as shown in Ava DuVernay’s extraordinary new film “13th” that was a “war” that aimed to criminalize the black population and reverse the gains of the Civil Rights Movement and the War on Poverty.

We must remember that objectivity is not a synonym for neutrality. Objectivity refers to the idea that independent researchers can independently seek to test the same hypothesis and, if the hypothesized causal processes are indeed going on, they should come up with the same results if they use the same methods. However, what researchers choose to study and how they frame hypotheses determines the context in which objectivity is deployed. I urge you to consider, for example, that a great deal of unacceptable actions have taken place when objective methodology is utilized without regard for the role of science in oppression: eugenics, forced sterilization, the Tuskegee study. Often these are dismissed as bad science, or unethical science, when they too, in fact, are science.

Knowing this, we must name racism in our research proposals, in our theories, in our oral presentations and conference tracks, and even in our hypotheses. The essence of naming racism is this – how we frame a problem is inextricable from how we solve it.

We must remember that objectivity is not a synonym for neutrality. Dr. Mary T. Bassett, NYC commissioner of health and mental hygiene

The first solution to the inadequate colonial workforce was found in Irish bond labor, and so Irishmen worked the plantations until the English desired more labor to maximize the gains of more land. This is where the Atlantic Slave Trade was born. For an early period, some workers of African descent also worked as bond laborers, freed just like the Irish following the period of their indenture.

This period came to an end when the settlers decided they were releasing too many bond servants into freedom to make full use of their land. At the same time, a growing lower class of peasants would occasionally rise up in rebellion against large plantation owners, light-skinned and dark-skinned fighting side by side against the tyrannies of the wealthy.

The elite and lawmakers in Virginia found the most effective answer to this problem, an answer that is still with us today. In the 1680s, Virginia created a new category of people: whites. White people were afforded rights that were subsequently denied to non-whites. By the 1700s, whites could not be held in slavery into perpetuity and black slaves could not gain their freedom through work. Poor whites were instructed that God made non-whites inferior, in much the same way that the propertied were superior to the poor. What’s crucial here is that poor whites were not given the right to vote, and they certainly weren’t given a way out of poverty. What they were given were financial incentives to turn on their former allies – bounties for runaway enslaved Africans and plantation jobs for policing enslaved laborers.

But superiority was enough – the Virginia solution forever created a fissure between poor whites and blacks that the wealthy and powerful have taken full advantage of ever since. The rest of the story, I think, many of you know.

Knowing the origin of whiteness, and seeing whiteness as a social construct with a particular history – these are crucial to racial justice. The creation of white peoples and the data collected since demonstrate roundly that white supremacy without a doubt privileges whites in relation to people of color, but it still limits the potential gains of our collective liberation, whites included.

One the most telling studies in this respect – I turn again to my colleague Nancy Krieger – looks at the relationship between Jim Crow laws and infant death rates. The graph she assembled compares infant mortality for whites and blacks who lived under Jim Crow to those who did not, before and after the Civil Rights Act of 1965. You might guess that the disparity between blacks living under Jim Crow and blacks not living under Jim Crow was erased. But what is striking to me is that whites living under Jim Crow had higher infant death rates before the Civil Rights Act compared to whites not living under Jim Crow. This disparity too was wiped out following the passage of civil rights legislation.

Yet, dog-whistle politics have harmed whites by racializing the safety nets of our social contract. Since the 1970s, as with Nixon’s “Southern Strategy,” conservative elites in power have linked nearly every public institution to unworthy people of color, hoping that poor whites would take the hint that they’re the better, hard-working race. By tying government institutions to an undeserving non-white underclass, we saw growing populist support to defund the War on Poverty, the Great Society, public schools, public hospitals, all while increasing penalties on drug possession and use. Today – particularly the last several years in which whites have been railing against the War on Drugs – all of these shortchanges have served to harm both non-elite whites and all blacks. The President of Demos, Heather McGhee, talks about the harms of racism on white people like this: “we prefer to drain the public swimming pool of economic opportunity rather than let people of color swim, too.”

All that said, my hope is that white supremacy does not make you anxious or uncomfortable. It should make you mad. Understand that anti-racism is not a witch hunt, but a collective healing, without which our nation will remain painfully and inequitably divided, corroding opportunity, spirits, and bodies alike.

Over time, the explicit bias of white supremacy has turned into an implicit bias, something measured deftly by the Harvard Implicit Association Test – I encourage you all to go online and take it. What it has shown is that implicit bias against blacks, as well as other identities, is pervasive, including among people of color. The socialization we all go through in this country, because it is so thoroughly imbued with anti-black messaging and imagery, creates a bias most of us most exact active effort to counterbalance. So you can see the power of explicitly naming racism and taking stock of white supremacy.

The question arises – how do we act in solidarity? What does this all mean for our practice?

Naming racism, keeping it at the forefront of our consciousness and in our dialogues, is really important. Talking about racism, I hope, will encourage you to read and study more about some of the topics I’ve discussed, and the many more that I have not. If your study leads to critical self-reflection, I say that’s a good thing if you truly believe that racism hurts everybody. I do caution you, if you are a white person, to avoid placing too much of a burden on people of color to explain their racial oppression to you.

If acknowledging racism and white supremacy is the minimum, there’s room for much more. I wrote in the New England Journal of Medicine that we must use our tools in public health to carry out more critical research on racism to help us identify and act on longstanding barriers to health equity. This is why, in part, we are emphasizing the revitalized Neighborhood Health Action Centers I described at the beginning of this talk, and are placing them in neighborhoods long deprived of societal resources that should be theirs.

Further still, we can look inward toward the makeup and conduct of our own institutions. When I started as Commissioner almost three years ago, I put resources toward a group of staff to lead what we call “internal reform” at the health department. With the goal of becoming an anti-racist institution, the agency is acting on recommendations made by staff to reform our budgeting and contracting practices, our recruitment and hiring procedures, our community engagement behaviors, our training protocols, and our communications frameworks. It takes a sustained commitment to realize the full promise of these reforms, but we are laying the groundwork with urgency.

Last, I think one of the most important things we can do to stand in solidarity is lend our voice to advocacy for racial justice, unto itself and fully cognizant of the many other struggles for justice in which the work for racial justice is entwined. Those of us who work in public health have been afforded great privileges, tremendous credibility. The best use of that is to be a voice for the voiceless – and to amplify the voices of those who are speaking up, especially those of the youth who have the energy to drive us forward.


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