Lynn Todman (left), executive director for population health at Spectrum Health Lakeland in St. Joseph, Mich., poses with University of Michigan public health professor Arline Geronimus. Todman is heading a project to help close the wide gap in health outcomes between black and white people in Berrien County, Michigan. The project – Community Grand Rounds: Healing the Trauma of Racism – fits in with one type of approach Geronimus advocates: a community-wide effort.

Solutions Can Be as Simple as Swapping Wall Posters, or as Complex as Setting Housing Policy, Says Arline Geronimus, Sc.D.

By TED HARTZELL

BERRIEN SPRINGS, Mich. – Most of us live most of our lives in adulthood, not in the womb or in childhood.

So why don’t health researchers concentrate more on the stressors that happen in adult years? That is a question Arline Geronimus, Sc.D., a University of Michigan School of Public Health professor, raised in her presentation Oct. 22 at Andrews University. She clearly believes researchers are not seeing the bigger picture when analyzing what causes gaps in health outcomes between black and white Americans – gaps that tend to grow with age. She criticized single-cause explanations that come and go in popularity, labeling them “fashions.” (See story Of Race and “Weathering”‘) 

Among the other targets of her criticism was research she considers tilted too much toward the early years, including epigenetic changes during fetal development, or the first few years of life, and to some extent adolescence, that can increase vulnerability for people in marginalized populations.

 “While we’re all understandably very concerned with what happens among youth, whether it relates to homicides or drugs or gun violence or needles, in fact, the inequity between blacks and whites and between the poorest blacks and whites is much larger as we age through middle age,” she said. “And the main causes of those [excess] deaths are chronic diseases.” 

Geronimus offered her theory of “weathering” as one factor to help explain the gaps between black and white people that grow with aging. “We live most of our lives outside developmental windows,” she said. Weathering is less studied or understood than the adverse conditions affecting life from the fetus through the early years.

We Need ‘New Ways’ to Close Gaps

Researchers’ failure to see the whole picture “suggests a compelling need to consider new ways to theorize and study health inequality, and new ways to attempt to prevent, reduce and ultimately eliminate it,” she said.

Researchers in the social sciences and the humanities, along with community partners, need to be “the central protagonists” in this work. She advocated that they should help ensure “our hypotheses are grounded in lived experience and grasp the real-world meaning of our data.    

“We who have been constant partners dedicated to promoting health equity to affirm that black lives matter, now have enough hindsight and insight and foresight that oversights really can no longer be tolerated or are really not excusable,” Geronimus said. “We could have claimed ignorance 30 years ago, maybe 20 years ago, but we can’t anymore.”

Approaches Worth Considering

Here are some things to do. Geronimus said some approaches are ones that communities around the U.S. are already embracing:

REMOVE AND REPLACE “DISCREDITING CUES.”  

Discrediting cues are found in policies, classrooms, workplaces. And they’re big and small, and some are clearly recognizable, but many of them are just completely under the radar. These cues give subtle prompts, also called “primes,” because they prime people for certain later behavior.  Examples she gave:

    1. PLACEMENT OF DEMOGRAPHIC QUESTIONS IN TESTING SITUATIONS: Females who answered demographic questions, including their gender, at the end of SATs scored several hundred points higher in a randomized, controlled trial than females who answered the gender question at the beginning. The vast difference in test scores between the two groups showed “how sensitive we are to cues and primes to our social, and stereotyped social identity” – in this case, that females wouldn’t do as well as males on the test. 
    2. DEMOGRAPHIC QUESTIONS IN A CLINICAL SETTING: While there are no controlled trials to test the theory that asking demographic questions during patient intake affects outcomes, but there’s no reason to doubt such bias occurs. For both the SAT and medical intake forms, Geronimus said it is inexpensive and easy to switch the order of the demographic questions. 
    3. NEUTRALIZE SCIENCE POSTERS IN CLASSROOMS: Females in high school science classrooms with nature posters on the walls did better in controlled and clinical trials than the women in classrooms with “Star Trek” posters on the walls. Girls in the former group also were more motivated and more likely to continue taking STEM classes. Both posters carry a science theme. “How hard is it to change posters in a classroom?” Geronimus asked. 
    4. CONSIDER THE CUMULATIVE EFFECT: Discrediting cues are among the countless stressors for marginalized groups like African Americans in the U.S. Cues are chronic and ubiquitous, whether they’re posters on walls, having to live in polluted areas, not having access to good food, being exposed to crime or violence or threats of militarized ICE raids, or not having heat during the winter or air conditioning during heat waves. It is important to replace damaging cues with ones that make all people feel welcome. 

 

MAKE IMMIGRATION OFFENSES CIVIL RATHER THAN CRIMINAL VIOLATIONS.

Geronimus studied the after-effects of a “surprise, very militarized, very violent raid” on a meat-packing plant in 2008 in Iowa and found even Latino women who were far away and in no jeopardy of deportation experienced a spike in low-birth-weight babies for six months after the raid. This was not true of white women. Geronimus found it interesting “that those processes were set in motion by a cue, in many cases, to people who were not at risk, and nowhere near, that Latinos aren’t valued in our current society.” The social discrediting cue was the raid.

MAKE INCLUSION AND EQUITY – NOT JUST DIVERSITY – REAL.

Diversity, equity and inclusion are often uttered together as goals with the abbreviation “DEI.” It is much easier to focus on increasing statistical diversity than improving and promoting equity and inclusion.  “Racially integrated, “numerically diverse” settings, even when they are elite or comfortable settings, can actually be more triggering for stress responses from black people than segregated settings. Even though black people in these integrated settings might have achieved socioeconomic status on par with the whites around them, what whites might not recognize is what black people endured in “the lived experience of acquiring those resources or access in our racialized system. And so, not having equity and inclusion, even in elite, integrated settings, can activate weathering processes.” Such settings need to be made more welcoming to black people.

 

MAKE HEALTH EQUITY A CONSIDERATION  IN ALL POLICIES,

including health, housing and economic policies. Consider how policies would affect different populations differentially and could lead to health inequities.

 

PROMOTE WELLNESS-BASED DEVELOPMENT.

This approach departs from earlier efforts to revitalize urban areas, which involved making them tourist spots, demolishing public housing, spreading the people who live there to the winds. Wellness-based development means planners consider equity and environmental justice components. In so doing, they can call on the power of existing government programs, local anchor institutions (which are often health systems), and local community organizations and residents.

 

PROVIDE HOMEOWNERS HELP FOR WEATHERIZATION

and help to make their houses more energy-efficient – not just help them pay utility bills. African Americans bear a higher burden of living in energy-inefficient houses in the United States. Programs that provide weatherization assistance will probably promote better health and will have much more enduring effects.

Unintended Racism? “Take a Deep Breath” 

An audience member asked Geronimus, “What specific steps can we take as clinicians to reduce unintended racism in our practice?”

 She answered that just being aware you might have unintended racism is one step to open you up. She cautioned against getting defensive or saying, “I’m not a racist.” Geronimus continued, “But the idea is these things are happening everywhere, and it’s not just that it’s implicit in your head, but it’s just implicit in how we all talk about things, or structure things. So, one part is just to take a deep breath, and realize you probably are, like any of us, helping to proliferate racism, even though you absolutely don’t know it or want to do it.” 

Later, in answer to another question, she said that even for people like her who are dedicated to “making a more equitable world, it doesn’t mean we’re not participating in the maintenance of a range of structures and practices that themselves activate weathering processes.” 

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