‘Weathering’ Theory Scholar Says Researchers Don’t Focus Enough on Black Americans’ Lived Experience
By TED HARTZELL BERRIEN SPRINGS, Mich. – The pictures on the auditorium screen showed five vibrant, accomplished young women, all African-American, all in their 20s and 30s. There was super-muscular superstar Serena Williams of tennis renown. And Shalon Irving, Ph.D., an epidemiologist with the federal Centers for Disease Control and Prevention. And Erica Garner, who became a tireless advocate for racial justice and for holding police accountable after her father, Eric Garner, died at the hands of police. There was veteran and dedicated East Orange, N.J., police Sgt. Tahmesha Dickey. And, finally, Kira Dixon Johnson, a marathon runner, licensed pilot, avid skydiver, international businesswoman and speaker of five languages.
In little more than a year, four of the five had died. Their deaths were so close to the expected due dates of their babies that they were labeled maternal deaths. Only Williams, who suffered a near-death experience, survived the delivery of her baby.
These Women Defied Stereotypes
Arline Geronimus, Sc.D., a professor at the University of Michigan School of Public Health and Institute for Social Research, put those pictures up on the screen at Andrews University’s Howard Auditorium. She said the four deaths and Williams’ near-death have caught the U.S. public’s attention because “the tragedies defied many of our most cherished beliefs, whether it’s public health professionals or simply Americans.” She continued, “None of the black mothers featured in the news fits the conventional wisdom on health disparities. They were not stereotypes. None of them were poor, welfare-dependent or teenage mothers. Many were indisputably fit. All of them made active contributions to their communities.” Geronimus has a suspect in mind for what, in addition to their celebrity, race, relative youth and tragic or near-tragic outcomes, could link these five women. The suspect is “weathering.” It is a term and theory Geronimus, who has a doctorate in behavioral sciences, developed over the 40 years she has been studying what at one time were called health disparities and now are called health inequities.
Geronimus has a suspect in mind for what, in addition to their celebrity, race, relative youth and tragic or near-tragic outcomes, could link these five women. The suspect is “weathering.” It is a term and theory Geronimus, who has a doctorate in behavioral sciences, developed over the 40 years she has been studying what at one time were called health disparities and now are called health inequities.
Read How Geronimus says society can fight “weathering”. Her theory of weathering maintains that members of marginalized groups in a population, such as black people in America, endure chronic stress from living in an unequal society. The stressors – and, importantly, the high-effort coping it takes to confront them – combine to produce damaging or deadly consequences. They cause wear-and-tear on important body systems: the neuroendocrine, cardiovascular, metabolic and immune systems. As the integrity of cells is violated, those body systems become dysregulated or exhausted. The body ages faster. A person’s overall health becomes more vulnerable and susceptible to diseases.
What Can Happen to the Body
This vulnerability can lead to various damaging results, Geronimus said in her presentation Oct. 22. Among them are poor maternal health, chronic inflammation, obesity, depression/mood disorders, early-onset chronic disease – hypertension and diabetes are examples – and increased susceptibility to some cancers and infections. Black and other marginalized people may experience diseases and deaths at a significantly younger age than white people. Weathering happens dynamically over time. It is a response to a host of factors that fluctuate, including the person’s social and economic conditions, physical environment, behaviors and biological processes. The health professor’s theory of weathering fits well with the theme of a project called Community Grand Rounds: Healing the Trauma of Racism, whose leaders invited her to speak. Community Grand Rounds, now in its second year, is sharing current research to illuminate how chronic, systemic racism is now considered a cause itself for gaps in health outcomes between black and white Americans – a cause distinct from such things as bad lifestyle choices or access to health care. In Berrien County, the biggest gap in life expectancy is 19 years between the predominantly black neighborhoods in and around Benton Harbor and the across the river of Lincoln Township. The project is a collaboration between The Todman Family Foundation and Spectrum Health Lakeland.
These Women Weren’t Oddities
Speaking of the five black women who made the news because of their maternal deaths or near-death, Geronimus said, “We don’t know how representative these particular mothers are, but they’re not anomalies.”
“We don’t know how representative these particular mothers are, but they’re not anomalies.” – Arline Geronimus, Sc.D.
For Johnson and Dickey, who had no diagnosable conditions beforehand, Geronimus said, “Their tragic stories get described as some combination of bad luck, acts of God and medical error, perhaps influenced by implicit racial biases of their health care providers. But the weathering hypothesis suggests that long before they entered the hospital, their lives, racialized in an unequal society, may have set them up for that kind of medical error to make such a life-threatening difference to the outcome of their birth.” Geronimus said the known medical conditions beforehand of Garner (an enlarged heart), and Williams and Irving (blood clots), might well have been due to “vivid and biologically plausible pathways” triggered by chronic stressors. “It’s possible, even likely, that in part or whole their pre-existing conditions were measures of their lived experience as black women in the United States and its lifelong wear and tear on their health. “For all of these mothers, even those who had diagnosable conditions, the physiological stress of pregnancy and childbirth may have been that last fateful force, sort of the unwitting stress test and tipping point, that when superimposed on weathering or prematurely aging bodies ripped them apart.”
An Alarming Gap
The unfortunate truth is black women in America are suffering maternal deaths at a rate mirroring that of women of all races in lower-income nations, while maternal deaths among white women mirror those of more affluent nations. Within the U.S., the rates for black women average three-and-a-half times the rates of white women; in New York City black women suffer maternal deaths eight times more often, Geronimus said. The maternal death rate in the U.S. has been rising, while the rate has been declining in other Western nations. She said the U.S. is ranked 50th in the world in maternal mortality, meaning women fare better giving birth in 49 other countries. Geronimus noted the World Health Organization has even called the U.S. rate a human rights violation. As more women, including African Americans, postpone childbearing, there is a greater risk of complications due to age, even though age tends to bring greater education, socioeconomic status and other resources to becoming a mother. This greater risk is particularly true for black women. Geronimus said the causes of maternal deaths in the U.S. for all women have shifted since the late 1980s, when hemorrhaging was the leading cause of maternal deaths, toward chronic “weathering types of conditions.” These weathering conditions have resulted in what she called a huge upsurge in maternal deaths. They include cardiovascular conditions and other stress-related chronic diseases. Maternal mortality itself is a “low-risk event,” but for every woman who has suffered a maternal death, approximately 70,000 have a near-death experience during delivery because of a chronic, extreme disease, she said.
‘Entrenched’ Health Inequities
Geronimus focused on maternal deaths to illustrate a vexing and persistent problem: the failure to narrow the gaps in health outcomes between people of different races or social backgrounds. She criticized what she called well-intentioned, but “serial, shallow efforts” over 35 years to narrow or eliminate health inequities. She said reducing and/or eliminating racial (or other social) inequality in health outcomes has been an explicit, high-priority national public health objective at least since 1987. Every decade the nation sets Healthy People goals for the following 10 years. For example, Healthy People 2020 goals were set in 2010. The goals have risen over the decades. For 2000, it was to reduce health disparities among Americans, she said. The goal got ratcheted up for 2010 to eliminating health disparities. For Healthy People 2020, the bar was set even higher – “to achieve health equity, eliminate disparities, and improve the health of all groups.” “These are all very laudable goals,” she said. “But here we are a hair’s width away from 2020, and health inequities have remained entrenched.”
Hypertension Gave the Proof
When Geronimus was originating her theory of weathering, she reasoned that black people or other marginalized groups living with the chronic stressors inherent in a race-conscious and unequal society might be especially susceptible to weathering. If weathering were real, then African Americans or other marginalized groups would be expected to experience the morbidity and mortality of white people (or people in other dominant groups) who are significantly older. Geronimus was first involved in testing her hypothesis through a study on hypertension. She said the weathering hypothesis would predict that age trajectories of hypertension prevalence through middle age would be steeper for black than for white Americans. And she expected to find a wider racial gap in hypertension prevalence in middle age than at younger ages. “And, in fact, that’s exactly what we’ve found,” she said. The hypothesis on hypertension has been redone and confirmed among several cohorts. She showed a graph comparing hypertension among black and white women. Until about age 20, the differences are small, but from that point on they steadily widen through age 60-plus.
‘How Race Becomes Biology’
A similar weathering pattern pertains to reproductive health between black and white women, with the gap apparent around age 20, but growing to greater degrees at ages 30 and then 40. She said studies of marginalized groups prove anybody can weather, but African Americans are more likely to be under the kinds of stress, and to do the kinds of coping, that weather people. Their much-worse health outcomes are proof. Geronimus summed up the forces that constitute weathering. She said the body reacts over time to historically structured differences by race, the lived experience, exposure to stressors and access or lack of access to coping resources. She gave this simple definition of weathering: “It is how race becomes biology.” And she made it clear that the idea there are essential genetic differences contributing to health disparities between black and white people – an idea she encountered early in her work – is now “a very well debunked view.”
Other ‘Fashionable’ Explanations
The now-discredited theory of genetic differences to explain health gaps is one of several theories that the professor of health behavior and health education said have been “sort of fashions” that have come and gone as leading explanations for health discrepancies between black and white people in her 40 years in the field. Researchers have focused too much on individual human beings, or on single causes. While Geronimus did not reject the value of any of the following causes, which she lumped under the heading “Shallow Risk Factor/Social Determinants Approach,” she did say the academic fashion has been to overemphasize each at some point:
- Poverty/low education
- Demographics, such as being unmarried and teenage
- Individual behavior, including diet, exercise, smoking, sleeping
- Prenatal care/access to medical technology
- Neighborhood/ZIP code
- Interpersonal racism/everyday unfair treatment
Clever Wording, but Not Informative
Regarding one of the above theories, she said, “We then began thinking about neighborhoods that were often defined by ZIP codes … but don’t necessarily tell you a whole lot about what people experience in their communities, but it has led to a catchy phrase: ‘You can know more about a person’s health from their ZIP code than from their genetic code.’ This has captured a lot of people’s attention, and rightfully so, but it doesn’t really tell you what’s going on in these different communities that would explain it.” Another explanation that has enjoyed its time on the fashion runway of research has been what Geronimus called “the ‘R’ word,” meaning the role interpersonal racism plays in everyday, unfair treatment. “There’s a vague knowledge that stress matters” as a cause. “And then we’ve also thought about epigenetics, which are the ways in which your environment actually changes your epigenetic code. Your DNA will stay the same, but your cell integrity, its ability to suppress, say, cancer genes, or to express other genes that aren’t healthy, can change due to environmental factors.”
More Than Exercising & Eating Right
Geronimus said researchers have “lost the forest for the trees” and have failed to factor in how much of a role is played by long-term weathering in an unequal society. For instance, in the death of Erica Garner, who suffered from an enlarged heart, and the near-death of Serena Williams, who suffered from blood clots, people might be tempted to look to individual behavior as explanations. The physiological pathways leading to enlarged hearts and blood clots are well known, “but we mostly think about it in terms of what we eat, or whether we exercise,” she said. “And while those of course do matter, I think many people miss that being subjected to chronic stressors and to high-effort coping with chronic stressors also sets that physiology in motion and will not necessarily be affected in a positive or negative way by just eating correctly or making sure to exercise.” Speaking of the four maternal deaths and the one near-death of the five black women, Geronimus said, “Many of us, I think, have become blinded to the lifelong plight of these very accomplished women, because we simply saw them as playing by the rules, and in many ways, winning. We didn’t understand they could be weathering. “Our go-to interventions are often those that place the onus on individuals to change their behaviors,” she said.
‘Race Still Mattered’
Looking at what are called social determinants of health can mislead researchers, too, Geronimus indicated. “We’ve come to think that if you statistically control, say, for income or education or some manner of SES (socioeconomic status), that you’ve taken care of all the social differences in life experience between better-off and worse-off groups, and that’s really not the case,” she said. Studies have shown that “race still mattered – which it always does.” Again, it is important to emphasize that Geronimus is speaking of race in the lived experience of African Americans, not in the discredited theory of genetic racial differences. Throughout her presentation, Geronimus was describing an approach that has examined risks to health through too narrow a lens and taken out of context of what real life is like for black people. Researchers suffer from “blind spots” and “haven’t put this all together,” she said. They aren’t spending enough time comparing communities to find out why some fare worse or better with health than others. “Unfortunately, academia, the tech and pharmaceutical industries, and biomedical research appear to be veering in a different direction, providing huge resources, prestige and potential profits for doing statistical analysis of big data sets and exaggerating the promise of personalized medicine, while being blind to how speculative it is,” she said. Carrying such research to the implementation stage is “more likely to increase health inequity than decrease it, because of a combination of market forces and entrenched social bias.”