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June 2020 • Volume Forty One • Number Six
40thAnniversary
It was 40 years ago this month in 1980 when The Epidemiology Monitor was first published and distributed during the SER June meeting in Minneapolis. Since then the Monitor has earned a prized reputation for successfully serving the information and job-seeking needs of epidemiologists and helping enhance a sense of community within the profession. We are sincerely grateful to our readers, contributors, and advertisers whose support has made this marathon-run possible. As we look to the future, we believe new editors and contributors can take these successes to higher levels with new visions of what it means to be “the voice of epidemiology” in the 21st century. Epidemiologists or other readers interested in reporting and writing on key developments in epidemiology are invited to explore with us how they can make such contributions by contacting the editor at the address below.
Racism and Epidemiology Given the moral awakening taking place in America and around the world on racism, our anniversary issue is focused on systemic racism in America. Our lead article reports on an assessment of racism given by Sherman James at the SER virtual meeting this month. Also, highly regarded epidemiologists have been studying the impact of race on health for many years and some of their insights have appeared in past issues of The Epidemiology Monitor. We share these with our readers by reprinting two reports on talks given in 2008 at the University of North Carolina by Nancy Krieger and at SER in Chicago by David Williams. The latter was called an impressive and flawless presentation and received a first of its kind standing ovation. At the invitation of the Monitor for this issue, Dr Krieger provides a new reflection about her earlier talk and shares her unique and highly valuable perspective on recent events in the US based on her years as an educator, epidemiologist, and activist. Roger H Bernier, PhD, MPH Editor and Publisher [email protected]
In This Issue
-2-
Timely Discussion of
Racism from SER Meeting
-5- Reprint of 2008
Cassel Lecture on Racism by David
Williams
-6- Revisiting a
Keynote Lecture on Racism with Nancy Krieger
-7-
Nancy Krieger Looking
Backwards, Looking Forward
-11- Marketplace
The Epidemiology Monitor
ISSN (0744-0898) is published monthly by Roger Bernier, Ph.D., MPH at 33 Indigo Plantation Rd, Okatie, SC, 29909, USA. Editorial Contributors Roger Bernier, PhD, MPH Editor and Publisher Operations Linda Bernier, PhD, MS Operations Manager Advertising Sales Linda Bernier, PhD, MS Director of Advertising 770.533.3436 [email protected] 2018 Advertising Rates All ads listed below also include a banner ad on our website and in our EpiGram emails. Full Page $1,195
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We are in a teachable moment about racism in America, and the question is---what will we do with it? That was one of the opening thoughts shared by Sherman James at the recent virtual SER meeting held in mid-June 2020. As Professor Emeritus at Duke, a former SER president, and a highly regarded researcher on racism in America, James was highly qualified to provide useful insights to the SER community as it seeks to respond to recent events. SER made a commitment in a recent statement to work “toward racial justice and equity in the field of epidemiology, in our communities, and in society as a whole.” Chaired by SER President Martha Werler, the session also included Onyebuchi Arah, Professor at the Department of Epidemiology, UCLA Fielding School of Public Health and Yvette Cozier, Associate Professor in the Department of Epidemiology at Boston University School of Public Health.
Three Crises As the lead presenter, James discussed the three crises facing the US at the present moment, namely the COVID 19 pandemic, economic collapse, and systemic anti-black racism by police. He included as pandemic-related stressors on African Americans their disproportionate death rates which as of late May were 2.5 times greater than whites and 2.2 times greater than Asian Americans and LatinX. Also, black Americans are experiencing increased unemployment, and are at
increased risk as low wage essential workers.
Endemic Stressors James called police and vigilante killings “endemic stressors” for African Americans and included on this list daily activities such as voting, driving, jogging, shopping, house-hunting, receiving health care, and building careers.
Racism Definition James borrowed from other investigators to construct his definition of racism as “an organized social system in which the dominant racial group…ranks people into social groups called ‘races’ and then uses its power to devalue, disempower, and limit the allocation of valued resources and opportunities to groups they deem inferior…” This racism can express itself as structural when it is manifested in laws, policies, or social networks (e.g., residential segregation) or cultural when it promotes negative stereotypes (e.g., blacks are lazy). James called racism a fundamental cause of racial health inequities because it is a cause of causes. For example it influences multiple disease outcomes and is responsible for multiple risk factors.
Peculiar Indifference A particularly disturbing point made by James is the quote he shared from WE Dubois in his publication about the
- Racism con't on page 3
Sherman James Leads Timely Discussion Of Racism At SER Virtual Meeting
3
SER Statement on Racism SER has been among the first if not the only epidemiology organization to issue a statement on racism in America as of mi- June. In a statement posted on its website, SER stated “George Floyd’s murder may have been a catalyst for the current wide-spread protests of police violence, but the pernicious violence that preceded George Floyd’s passing highlights the centuries of racial inequality that persist in the everyday lives of our membership and our scholarship, and have enduring impacts on population health. While words remain fraught and hollow, we reinforce our commitment to racial justice and equity, in epidemiology and in our service to membership…We are committed to working toward racial justice and equity in the field of epidemiology, in our communities, and in society as a whole. To listen to the James presentation and listen to the conversation, readers can click on this link: https://bit.ly/314o23Y ■
Philadelphia Negro in 1899. “The most difficult social problem in the matter of Negro health is the peculiar attitude of the nation toward the well-being of the race. There have…been few other cases in the history of civilized peoples where human suffering has been viewed with such peculiar indifference.”
Moral Awakening James noted that recent events have caused a kind of moral awakening and the appearance of a number of what he called “promising green shoots”. However, he warned that a reckoning of some type will be needed before society is truly able to move forward.
Suggestions for SER As concerns SER itself, James believes the society has work to do to be more welcoming to black epidemiologists and to be more proactive in encouraging or showcasing research that has a focus on systemic racism. This latter action could be accomplished by providing more space and time for racism related work at SER meetings. He urged SER to rethink its mission, not to minimize all of the current activities, but to expand the mission for SER to see itself as taking care of the profession of epidemiology, both its current and future members. He urged SER to be more proactive and a catalyst for change by reaching out to epidemiology department chairs to find out what each is doing to create a more welcoming environment for aspiring epidemiologists, especially those of color.
“...human suffering has been viewed
with such peculiar indifference.”
“He urged SER to be more proactive and a catalyst for
change..."
-Racism cont'd from page 2
Join us on our Facebook page at:
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“...an impressive, flawless
presentation style..."
“...African-Americans can be
more compromised than can be
accounted for by their chronological
age..."
mortality rates are among the highest in the US. In that area, rates for whites still do not overlap with rates for African-Americans which are lower still. And for diseases where the incidence is lower for African-Americans, such as breast cancer, persons from that ethnic minority experience a worse prognosis, according to Williams.
“Weathering”
Also, in a phenomenon called "weathering", Williams described how African-Americans can be more compromised than can be accounted for by their chronological age because they have been exposed longer to adverse conditions. And he noted that this effect is due to more than SES variables because adjusting for these still leaves disparities. He used the example from a health professions study which showed higher rates of cardiovascular disease, hypertension, diabetes, and coronary heart disease with higher case fatality rates for African-American doctors compared to doctors with equivalent SES categories. For well educated women, Williams described data showing that infant mortality rates among the best educated African-American women we're still higher than those among white women with significantly lower education.
Many could not recall any previous speaker at SER receiving a standing ovation for his or her lecture. But a standing ovation is indeed what David Williams, the Norman Professor of Public Health at Harvard received for his John Cassel Memorial lecture at the annual SER meeting in Chicago. In an impressive, flawless presentation style in which he never missed a beat, Williams presented finding after finding and statistic after statistic detailing the dramatic impact that the social environment operating through race can have on health.
Specific findings Among the specific findings presented were that African-Americans ( AA) have higher death rates for many outcomes, these higher rates operate from cradle to grave with higher age specific mortality in African-Americans at each age group, immigrants to the US from minority populations fare better in the US than native born minorities, rates of mental health illness increase from 1st to 3rd generation immigrants to the US indicating declining health with increasing length of stay in the US, and life expectancy has been lower in African-Americans from 1900 to the present. The power of the social environment to impact health was illustrated with data from Mississippi where heart disease - Williams cont'd on page 5
Reprint The Epidemiology Monitor - June 2008 David Williams Gives John Cassel Memorial Lecture Detailing The Dramatic Impact Of Race/Social Environment On Health
We Know Enough To Take Action, Says Speaker
Impact of environment In trying to make sense of these health disparities by race, Williams made clear that the differences are not due to some West African gene, and cited the example of hypertension which is higher in US born than in African born residents of the same race. Likewise, diabetes is worse among blacks in the UK and in the US than it is in African populations. Williams pointed to the "social genome" or risks in the social environment as the culprits for the disparities he documented.
Mechanisms of action In seeking to explicate what the mechanisms of action might be for allowing race to operate on health even after SES factors are accounted for, Williams had three possibilities. The first one he called the "non-equivalence of SES" wherein he noted that the African Americans are more likely to have experienced six indicators of economic hardship, and he reminded the audience that income does not equate to wealth and that wealth does matter for health. Second, Williams pointed to experiences in early life to account for racial disparities in health. He said there are multiple pathways to disadvantage in childhood, and that low SES in childhood can create a disadvantaged foundation for adult health. Thirdly, Williams pointed to the historic legacy of racism in the US and said that institutional mechanisms of racism are hard to measure. He cited residential segregation as the most successful form of institutional racism and said that it was very pervasive in the US.
5
Residential segregation Williams believes that residential segregation operates so successfully on health, that the US could completely erase health disparities if it could eliminate residential segregation. He stated that such segregation in the US is now only slightly lower than what was legal under apartheid in South Africa. Williams brought his talked to a close by stating that 3/4 of African-American children and 2/3 of Latino children are now doing worse than white children. He said that the social environment has a dramatic effect on health, and that minorities in the US are living under distinctively different environmental conditions. In such a situation, Williams said we should expect differences by race as people adapt biologically to their environments. He mentioned Arab American women who experienced more low birth weight babies and more preterm delivery after 911 compared to before then.
Challenges Dr. Williams noted several challenges facing those who wish to study the influence of discrimination on health and better understand the pathways to bad health, but he said the most pernicious of all myths is the one which believes that the problem of disparities is so overwhelming and so complex that we cannot do anything about it. "We know enough to take action," said Williams. He stated that health could be impacted by all policy sectors. He called medical care the "repair shop", and said that social policy on the other hand can make it easier or harder for people to achieve
“...income does not equate to wealth and that wealth does matter for
health."
“...the US could completely erase health disparities
if it could eliminate
residential segregation."
- Williams cont'd on page 10
-Williams cont'd from page 4
“...the fact that disparities in
health exist says more about society than it does about
biology..."
"... inequities in health are not immutable."
Nancy Krieger, Harvard University social epidemiologist, gave the 10th annual William Small Keynote Address in late February at the University of North Carolina's annual minority health conference. The first part of her talk, entitled "The Science and Epidemiology of Racism and Health in the United States: An Eco-social Perspective ", was devoted to debunking the often heard concept that race is genetic or that race is about gene frequency differences. According to Krieger, what matters is gene expression and not gene frequency, and as she called race/ethnicity "a historically contingent social category with biological consequences." In other words, race/ethnicity is a social and not a biological construct, and the fact that disparities in health exist says more about society than it does about biology, according to Krieger. However, she argued for the usefulness of race/ethnicity as a social category because it can provide evidence of discrimination that can then be used to argue for counter measures. "No data" could be interpreted to mean "no problem", according to Krieger, and that would be misleading.
Premature mortality She used part of her time to present information from a recent paper published in PLoS Medicine on "The Fall and Rise of US Inequities in Premature Mortality: 1960-2002". The main purpose of this work was to examine what happens to the gap in income and health disparities between populations when the overall population health improves as it did in the 42 year period indicated 6
in the title of the paper. The work was prompted in part by speculations that health disparities are inevitable because efforts to improve the health of the less well-off would also be taken advantage of by those better-off and therefore disparities would remain. Krieger found that actually the gap narrowed during the period 1966-80 and later widened after 1980. If the entire US population had done as well as those most well-off during this 42 year period, an estimated 14% of the deaths among whites and 30% among persons of color would have been prevented. These figures equate to 4.9 million lives cut short, according to Krieger. The major point from the work is not the uniqueness of the findings but the implication that inequities in health are not immutable. As Krieger told the audience, "death is inevitable. Premature mortality is not. If we make reducing disparities a priority, progress is possible". [Editor’s Note: Following her presentation, Krieger fielded several questions from the listeners, many of whom were interested in knowing how to can see convince others about the validity of these findings and how to translate them into public health action. To read the article including the questions and answers, click here. Dr Krieger’s perspective on this talk more than a decade after it was written and her views today about the current focus on racism in the US and around the world continues on page 7.]
Reprint - The Epidemiology Monitor - March 2008 Nancy Krieger Gives UNC Keynote Lecture On Racism And Health
7
“...to talk about racism and health in 2008 put one on
the fringe."
"... there is a new leap in awareness, with possibilities for real action..."
[Editor’s Note: In light of her previous talk on these topics and the new focus on them following the death of George Floyd, we invited Dr. Krieger to share her perspective at this critical time. She is Professor of Social Epidemiology, American Cancer Society Clinical Research Professor, Department of Social and Behavioral Sciences, at the Harvard T.H. Chan School of Public Health]. Back in 2008, when I gave this presentation on “The science and epidemiology of racism & health in the United States: an ecosocial perspective” at the University of North Carolina (UNC) Minority Health Conference, it was the 29th annual conference in this series, and the 10th annual William T. Small, Jr. keynote lecture (1). I thus was in a long line of those who shared the concerns of the original organizers of this conference, the UNC Minority Student Caucus.
Background Founded by students of color in the early 1970s, its two-fold objectives were to raise awareness about need for more research and action focused on racial/ethnic health inequities and to increase the number of students and scientists of color (2). Inspiring its work were the monumental changes of the 1960s, with the organizing of social movements leading to passage of federal Civil Rights, Voting, and Fair Housing Acts, the War on Poverty, the establishment of the Occupational Safety and Health Administration, and the Environmental Protection Agency. When I spoke in 2008, it was nearly a
decade after I wrote the first review article on epidemiologic research on discrimination and health – and nearly 30 years after the 1980 onset of the economic and social backlash to the progressive changes of the 1960s and 1970s (3). In this interim, a small albeit growing number of epidemiologists and other public health professionals were expanding research demonstrating that racism is a key determinant of population health and health inequities. However, our frameworks and evidence were still outside of the mainstream of the field of epidemiology, and to talk about racism and health in 2008 put one on the fringe.
Leap in Awareness And here we are in 2020, just 12 years later – and there is a new leap in awareness, with possibilities for real action, to take on racism in the US and its myriad impacts, including but not limited to how it harms health. Roger Bernier, the editor of Epidemiology Monitor, invited me to write this reflection on my 2008 talk, which he had previously reported on in the pages of this bulletin, on June 19 of this year – that is, Juneteenth, a day celebrating and marking the emancipation of those who had been enslaved in the US. In the past two weeks over 20 US cities and counties and 3 states have declared or are in the process of declaring that racism in a public health crisis, following in the steps of the first city to have done so: Milwaukee, in
Nancy Krieger On Looking Backwards, Looking Ahead—Structural Racism, Health Inequities, And Epidemiology
- Krieger con't on page 8
8
"... there are kinds of knowledge which, once
learned, cannot be unlearned."
"... systemic racism truly exists
and is so deeply harming..."
-Krieger cont'd from page 7
May 2019 (4-6). Major public health, epidemiological and medical societies and organizations have newly made similar declarations (7-9).
Recent Events What is occasioning this sudden change is not some dramatic new discovery of something unknown – or, at least, not unknown to those most affected by and those concerned about health inequities and their origins in long histories and present realities of white supremacy and kindred police brutality (10,11). Rather, it is a new broader awareness galvanized by the organizing around the horrific murder of George Floyd by Minneapolis police on May 26, 2020, who died because he could not breathe, because a police officer knelt on his neck – in open view, and as videoed for all to see – for an agonizing 8 minutes and 46 seconds. This upsurge of public protest builds on the leadership and organizing of so many groups, including but not limited to Black Lives Matter, which itself was born in 2013 in response to the acquittal of Trayvon Martin’s vigilante murderer, George Zimmerman, followed by the murder of Mike Brown by Ferguson police officer Darren Wilson in 2014 (12). It is also being fed by the disproportionate impact of COVID-19 on the health and economic well-being of US Black, Latinx, and American Indian populations (13-15), coupled with post-2016 rising hate crimes and overt expressions of racism at the highest levels of US government (16, 17).
What Will The Future Bring? What comes next? Will these declarations that racism is a public
health crisis turn out to be simply empty words? Or will they lead to transformative change, affecting governance, political priorities, budgets, and programs? My hope, as an educator, epidemiologist, and activist, is that there are kinds of knowledge which, once learned, cannot be unlearned. It is encouraging to witness – and to help abet -- the opening up of minds and hearts in the US of so many, including in public health and epidemiology, to understandings that systemic racism truly exists and is so deeply harming the health and well-being of Black, Indigenous and other people of color in the US. At issue are harms tied to the very founding of this country as a settler-colonial nation and slave republic, and to their progeny of massive wealth and income inequities in the US, harms which require acknowledgment for repair to be feasible (18-20).
Work For Epidemiologists Social movements are what makes change possible. In our professional roles, I encourage epidemiologists to step up and offer our skills in monitoring and analyzing determinants of health inequities and in evaluating health equity impacts of health, economic, and social policies, in order to generate rigorous and useful knowledge that can inform the work of the organizations, activists, and policymakers working for racial and health justice. To do so well requires learning the history of our field and the ways it has been shaped both by long histories of scientific racism – and efforts to oppose it, fueled by more expansive
- Krieger con't on page 9
9
"I encourage epidemiologists to step up and offer
our skills..."
“...epidemiologists – as scientists –
need to understand the obstacles
posed..."
understandings about the embodied links between social justice, human rights, and people’s health (21). Moreover, for our work to have impact, epidemiologists – as scientists – need to understand the obstacles posed by interests that jointly and deliberately undermine both good governance and public health and are indifferent to or seek to conceal the health inequities that these interests foster (22). For epidemiology to advance the people’s health, this is the least we can do. REFERENCES (1) Krieger N. The science and epidemiology of racism & health in the United States: an ecosocial perspective. Invited presentation: the 10th Annual William T. Small Keynote Lecture for the 29th Annual Minority Health Conference, University of North Carolina School of Public Health, Chapel Hill, NC, February 29, 2008 https://unc.live/3fMGCBR (2) Students Minority Health Caucus. Our Mission. UNC Gillings School of Global Public Health, Chapel Hill, NC.
https://unc.live/317cvAU ; accessed: June
20, 2020. (3) Krieger N. Embodying inequality: a review of concepts, measures, and methods for studying health consequences of discrimination. Int J Health Serv. 1999; 29(2):295-352. https://bit.ly/2BqDn4d (open access) (4) Milwaukee County Executive. Milwaukee County Executive Chris Abele signs resolution declaring racism a public health crisis. May 20, 2019. https://bit.ly/3eo0gUE ; accessed: June 20, 2020. (5) Singh M. ‘Long overdue’: lawmakers declare racism a public health crisis. The Guardian, June 12, 2020. https://bit.ly/3dvU5N6 ; accessed: June 20, 2020.
(6) Vestal C. Racism is a public health crisis, say cities and counties. Pew Stateline, June 15, 2020. https://bit.ly/2V8q0N6 ; accessed: June 20, 2020. (7) American Public Health Association. Racism is an ongoing public health crisis that needs our attention now. May 29, 2020. https://bit.ly/3djcYTe ; accessed: June 20, 2020. (8) Society for Epidemiologic Research. A statement on Racism from SER. June 3, 2020. https://bit.ly/3dkIMHb ; accessed: June 20, 2020. (9) American Medical Association. AMA Board of Trustees pledges action against racism, police brutality. https://bit.ly/2NiwXa7 ; accessed: June 20, 2020. (10) Krieger N, Chen JT, Waterman PD, Kiang MV, Feldman J. Police Killings and Police Deaths Are Public Health Data and Can Be Counted. PLoS Med 2015; 12(12): e1001915. https://bit.ly/37Qo9Sa (open access) (11) American Public Health Association. Addressing law enforcement as a public health issue. Policy Number 201811, November 13, 2018. https://bit.ly/2AQfW4z ; accessed: June 20, 2020. (12). Black Lives Matter. Herstory. https://bit.ly/316E3qk ; accessed: June 20, 2020. (13) Chen JT, Krieger N. Revealing the unequal burden of COVID-19 by income, race/ethnicity, and household crowding: US county vs ZIP code analyses. Harvard Center for Population and Development Studies Working Paper Series, Volume 19, Number 1. April 21, 2020. https://tinyurl.com/ya44we2r
(14) Chotiner I. The interwoven threads of inequality and health. The coronavirus crisis is revealing the inequities inherent in public health due to societal factors, Nancy Krieger, a professor of social epidemiology, says (Interview with Nancy Krieger). The New Yorker, April 14, 2020. https://bit.ly/2Yqq393 (15) Pilkington E. As 100,000 die, the virus lays bare America’s brutal fault lines – race, gender, poverty, and broken politics. The Guardian, May 28, 2020. https://bit.ly/2YrG8LP
-Krieger cont'd from page 8
- Krieger con't on page 10
"...the only thing necessary for the triumph of evil is
for good men to do nothing."
-Krieger cont'd from page 9
(16) Hassen A. Hate-crime violence hits a 16-year high, F.B.I. reports. New York Times, November 12, 2019. https://nyti.ms/2YmvsOl ; accessed: June 20, 2020. (17) Boghani P. Racism in the Era of Trump: An Oral History. Frontline, January 13, 2020. https://to.pbs.org/37TYBDW ; accessed: June 20, 2020. (18) Dunbar-Ortiz R. An Indigenous Peoples’ History of the United States. Boston: Beacon Press, 2014. (19) Kendi IX. Stamped from the Beginning: The Definitive History of Racist Ideas in America. New York: Nation Books, 2016. (20) Du Bois WEB. Black Reconstruction; An Essay Toward a History of the Part Which Black Folk Played In The Attempt To Reconstruct Democracy In America, 1860-1880. New York: Harcourt, Brace, 1935. (21) Krieger N. Epidemiology and the People’s Health: Theory and Context. New York: Oxford University Press, 2011.
(22) Krieger N. Climate crisis, health equity, and democratic governance: the need to act together. J Public Health Policy. 2020; 41(1):4-10. https://bit.ly/3eotnqI (open access)
■
appropriate health behaviors. He cited the Perry Preschool Program as an example of an effective intervention. This program provides high-quality early childhood education to disadvantaged children in order to improve their later school and life performances. "There is more to learn but a lot we can do", said Williams, "and giving more active support to families is one promising area or intervention." Williams closed by quoting Edmund Burke that "the only thing necessary for the triumph of evil is for good men to do nothing". ■
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-Williams cont'd from page 4
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