- Hello, welcome everyone.
Can you hear me fine?
Good.
Okay, my name is Jeanne Shea and I'm the director of the
health and society program, and it's so great to see
so many colleagues and students and fellow staff members,
and it is my great honor today
to present Dr. Clarence, Lance Gravlee.
I first became aware of Dr. Gravlee's work several years ago
when I read his brilliant article,
"How Race Becomes Biology"
that traced mechanisms and pathways by which racism
leads to disparities in health along racialized lines.
I brought this to my colleagues
and
due to the generous
support of all of you, we're able to bring
Dr. Gravlee here today.
And I'd like to thank the departments of anthropology,
biology, critical race and ethnic studies program,
the health and society program, health sciences,
the college of arts and sciences Dean's office,
and the office of diversity, equity, and inclusion
at the Larner College of Medicine.
It truly takes a village.
Dr. Gravlee is an associate professor in anthropology
at the University of Florida,
where he did his master's and PhD work.
He is a medical and biological anthropologist
who focuses on critical biocultural approaches
to the health consequences of social inequalities,
including racism.
Sorry, this mask is really getting me.
I also have asthma, so there's my excuse.
So Dr. Gravlee has done research in many communities,
including USA mainland
and Puerto Rican African-American communities
and Amazonian Bolivian communities, among others.
He is a member of the health disparities
and equity promotion study section
of the National Institutes of Health.
He is published in many high profile scholarly journals,
such as the American Journal of Human Biology,
BMC Public Health, the American Journal of Public Health,
and Social Science in Medicine,
and he has numerous grants
alone from the National Science Foundation
and the American Heart Association,
and most distinguished on his CV.
He is now an honorary Vermonter,
having deemed our weather refreshing,
so Dr. Lance Gravlee, welcome to the University of Vermont.
(audience claps)
- Well, Professor Shea,
thank you so much for that warm welcome, and it's true.
It is still hurricane season back home,
so it's wonderful to get a little taste of fall
here in Burlington.
I would like to thank the University of Vermont
for this opportunity to speak to you all today,
and for all of you for being here,
whether you're here in the room with us now,
or tuning in online, I'm very grateful for the opportunity,
and I take it as a sign, both of Professor Shea's vision
and the vibrant intellectual climate here
at the University of Vermont,
that she just rattled off such a long list
of units on campus who have come together
to have this important discussion,
so I join Professor Shea in saying thank you to
the various deans and program directors
and department chairs
who have offered their support to this event.
I'd also like to thank the many people who have
worked so hard behind the scenes to make my visit here
such a stimulating one.
Those that I know about in addition to Professor Shea
include Marilyn Eldred, Debra Blum, Margaret Gilman,
and Professor Alison Brody from the department of biology
so thank you all, and if there are others I don't know about
know that you have my gratitude.
Now before I proceed, let me note
that my talk, as the title suggests,
deals with the harms of racism
and what I have to say will land differently
for each of you, depending on where you sit
in relationship to the violent systems of racism
and white supremacy.
If you believe you are white,
as James Baldwin might've said, then it is important,
I think, to confront racism and white supremacy
for what they are,
violent systems of oppression.
I simply don't know how else we can redress the harms
or stand a chance of dismantling white supremacy
unless we face that basic fact.
I also recognize that if you have
experienced the harms of racism firsthand,
then my remarks will mean something different.
I hope that you will find them empowering,
maybe enlightening,
but I also acknowledge that some of the images and themes
that I will discuss may be challenging in a different way,
and I will try my best to approach that tension with care.
So almost 20 years ago,
Scientific American inadvertently set up a puzzle
that has preoccupied me ever since
with this question posed on the cover, does race exist?
Now part of what has kept my attention all of these years
is the ambiguity of the question itself.
The implicit question on the cover
and the focus of enduring debate in the biomedical
and other health-related sciences
is whether race exists as a natural, biological division
of humankind.
In particular, to what extent does race capture
meaningful genetic differences
that confers susceptibility to disease,
response to pharmaceutical therapy,
or other meaningful outcomes?
The importance of this question has never waned,
although
it
is in sharper focus now
as the COVID-19 pandemic wears on.
So it's an important question,
but it's incomplete because we should also be asking
in what ways does race exist
as a political, economic, and social structure
that has force in people's lives?
Indeed, that has biological consequences.
Now today, more than anytime since I began working
in this area, I shouldn't have to work very hard
to convince you that race has force in people's lives.
The Black Lives Matter movement draws attention
to the extreme, but routine forms of violence
that shorten the lives of black mothers, fathers,
sons, daughters.
We recite the names of Trayvon Martin, Michael Brown,
Eric Gardner, Sandra Bland, Tamir Rice,
the Charleston Nine, Elton Sterling, Philando Castile,
Ahmaud Aubrey, Breonna Taylor, George Floyd, Tony McDade,
and a shameful number of others
to reclaim their humanity
and acknowledge the value of their lives.
These cases compel us because of the overt violence
and devaluation of black life that they betray,
but we should be careful not to allow police brutality
and overt violence to define or limit
our understanding of racism
because the system that gives rise to such violence
has more subtle and pervasive effects
on black lives every day,
shaping the risk of good or poor health,
of long lives or premature death.
And again, current events make the cost of racism plain.
The slow violence of systemic racism and white supremacy
means that the COVID-19 pandemic
has exposed the fault lines of deep seated,
historically rooted racial inequities in our society.
And so, as we mourn all of the more than 675,000 people
who have died from COVID-19 in the United States,
we should also be outraged
that the age adjusted death rates
for indigenous, black, and Latinx people in the U.S.
were all more than 2.7 times greater
than for white people in 2020.
And we should also be clear that the racialized dynamics
of COVID-19 and police brutality
did not just happen to coincide.
They are in fact deeply intertwined.
Both crises reflect forms of violence,
one fast, one slow, rooted in centuries of state sanctioned,
racialized oppression.
Both have been met with struggle and resistance.
Each exacerbates the other,
and both in haunting echoes of history,
lead disproportionately to the premature, unjust,
excess death of black and indigenous people,
that is the descendants of those from whom
settlers took land and of those they forced to work it.
And so claims that the current moment
is unprecedented ring hollow.
The crises we are living through now are an extension,
not an aberration of U.S. history.
To the extent that any of it is unprecedented,
it is the fact that it is harder and harder
for people who are racialized as white to look away.
Indeed, if we look at the history of life expectancy
in the United States,
here I'm showing you just a snippet from 1980 to 2006,
we can see that the good news is that death rates
have been coming down for our population as a whole,
and
yet
the chances of living a long life
is also distributed along racial lines.
It's difficult to overstate
the magnitude of these inequities.
About 20 years ago, one group of public health researchers
estimated that between 1940 and 1999,
some 4.3 million African Americans died prematurely
compared to their white counterparts.
That works out to about 88,000 people every year
who died earlier than they would if death rates
for black and white Americans was the same,
and these inequalities are not due to any single cause.
We can find evidence of racial inequities
in all sorts of biological parameters, from
birth weight and body mass,
certain cancers, cardiovascular disease.
Just about everywhere we look,
we find evidence of clear and consistent inequalities
in the end points of life.
And for many observers,
these disparities appear to legitimate the assumption
that race corresponds to some fundamental,
biological differences between types of humans.
Media portrayals like the one that you see here
appear to confirm what everybody knows,
that race is biology,
and then it sanctions this folk belief
with the authority of science.
But this report also highlights
the conceptual problem with the science,
because the study on which it's based
inferred genetic causation even without genetic data.
This inference is clearly unwarranted,
and yet the article was featured
in the American Journal of Obstetrics and Gynecology
as the editors choice of that issue,
along with an independent commentary asserting that quote,
"The genetic link is very strong,"
all in the absence of genetic data.
And during the COVID-19 pandemic,
we've seen similar ideas reach a broad audience.
In an April 7th, 2020 interview with NPR News,
Louisiana senator Bill Cassidy, who is also a physician,
speculated that his African-American constituents
were at higher risk of death from COVID-19
because of unspecified genetic reasons.
Again, this claim is entirely unwarranted
as there remains no credible evidence
of racial genetic differences in susceptibility
to COVID-19 mortality, while it is abundantly clear
that social factors shape both the risk of exposure
to SARS CoV-2
and the distribution of comorbid conditions
that increase the likelihood of severe outcomes.
And so
we need to understand
that there are three elements, three reasons,
why race is not a useful way
for understanding these inequalities.
The first is that contrary to folk wisdom,
race is a poor proxy for what we know about
patterns of human genetic variation.
Second systemic racism has biological consequences,
which we can see manifested in COVID-19,
but were also evident beforehand.
And third, the embodied inequalities that we witness
in COVID-19 as in cancer and diabetes and hypertension
reinforce the folk view of race as biology
and deflect attention from the modifiable aspects
of our political and economic structure,
which would result in a healthier population
if we had a more just society.
So I'd like to pick up these ideas
in the context of work on what some had called
"The Puzzle of Hypertension in African-Americans."
The first piece of this puzzle is that
in populations of African ancestry throughout the Americas,
rates of hypertension and average blood pressures
tend to be higher in people of African descent
than in others in the same societies,
and this pattern is best documented in the United States
where we know that hypertension is roughly 50% more common
among black people than it is among white people.
Similar trends have been observed in parts of the Caribbean
and in Latin America, although the magnitude of inequalities
is nowhere as great as it is in the United States.
And the first reason that this puzzle is important
is because of the devastating impact
in terms of public health.
One group of researchers estimated
that racial inequalities in hypertension,
chronic high blood pressure,
account for 15% of black-white disparities
in potential life years lost.
So if we could do one thing to close the gap
in racial inequalities in life expectancy
dealing with racial inequalities in hypertension
would have a massive impact.
Another reason that the puzzle of hypertension
is significant is that generations of attempts to solve it
have assumed that some intrinsic racial difference
is at the root of the problem.
And we can see this assumption reflected
even in the language
of biomedical reports.
Consider for example,
this
1981 article in the Postgraduate Medical Journal
"Is Blood Pressure Different in Black People?"
Or some 15 years later in the Journal of Human Hypertension
"Is the pathogenesis of hypertension
different in black patients?"
As if the bodies of black patients worked differently
than did the bodies of others,
or perhaps most revealingly this 2000 article
from the Journal of Hypertension,
which implies that the only open question
is which genetic factor is responsible
for excess hypertension among people of African descent,
not whether it is primarily a genetic factor.
The same default assumptions about race, genes, and disease
persist into the present.
Consider for example a recent review article in the journal
Current Opinions in Nephrology and Hypertension.
In this review, the authors concede
that the genetic basis of essential hypertension
remains largely unknown,
and yet they are willing to assert that racial inequalities
in hypertension pathophysiology
are largely genetic in origin.
They write for example, "Relative to European Americans,
African-Americans more often manifest salt sensitivity
with expanded plasma volume
and suppressed plasma renin activity,
non dipping phenotypes, albuminuria,
and end-stage renal disease.
These factors support an inherited basis for disease,"
they say.
Even if you don't know what non dipping phenotypes are,
hopefully you recognize the logical flaw,
which is that the researchers have inferred a genetic cause
based only on differences in phenotype.
And we have known at least since Mendel,
that such inferences are unwarranted,
even for traits as simple as the hydro color of garden peas,
not to mention complex phenotypes like blood pressure.
So it remains an open question,
to what extent the phenotypic differences
these authors observe are attributable to genes,
to environments, or more likely to complex interactions
between them.
The available evidence, by the way,
undermines the assumption that in this case
genes have much to do with it at all.
Researchers have spent incredible sums of taxpayer money
searching for genetic contributors
to racial inequalities in health.
In a systematic review of research on cardiovascular disease
in particular show that this effort has been for naught.
Kaufman and colleagues write that,
"Despite the rapid increase in the number
of genomic studies over the past decade
that covered many outcomes,
the accumulated evidence for a genetic contribution
to cardiovascular disease disparities
in blacks versus whites has been essentially nil."
Nevertheless,
the assumption that there are racial genetic differences
in predisposition to hypertension persists,
and it has pernicious effects on the practice
of biomedical research.
As one example, consider a study by Tang and colleagues,
out of Neil Risch's Lab at Stanford,
in which the goal was to test for associations between
individual level measures of genetic ancestry.
Described here tellingly as racial admixture.
And two health outcomes, body mass index and blood pressure
in African-Americans and Mexican Americans
in the family blood pressure program study.
The researchers conclude that their results are quote,
"suggestive of genetic differences between Africans
and non Africans that influence blood pressure,
but such effects are likely to be modest
compared to environmental ones."
The second part of this sentence is correct.
The first is not for two reasons.
First, the study actually produced
no statistically significant evidence of an association
between African genetic ancestry and blood pressure,
so their assertion of genetic differences clearly
stretches beyond the data in a way that
some of the peer reviewers and editors
ought to have caught.
Second, the study illustrates a more pervasive
and pernicious problem in the role of race
in health-related research.
These researchers examined the association
between two clearly biological parameters,
genetic ancestry, estimated from DNA, and blood pressure.
If they observed an association,
they attribute it to some unspecified
susceptibility alleles.
That is some form of genetic variation that is presumably
more common among people with higher levels
of African genetic ancestry,
and is also linked to blood pressure,
but they have not identified any such alleles,
and so they have no evidence to support the inference that
if an association exists, it is because of a genetic cause.
And another interpretation is possible.
It could also be that the relationship
between these two biological parameters
is entirely mediated through experience.
If being a person of African descent
shapes the life experiences and exposures one has
in a racially stratified society, and it surely does,
then genetic ancestry could be associated
with blood pressure through socio-cultural processes
involving exposure to discrimination, poverty,
and social stressors linked to systemic racism.
Now I was ranting about this particular study
several years ago in one of my graduate seminars,
and then graduate student Amy Naan who's now a professor
at University of California San Diego
came to my office hours a couple of days later
to point out that the data set
that was analyzed in this study was publicly funded
and therefore publicly available so she downloaded it
and she found that there were not exactly
robust measures of experience,
but there was one simple measure that we could make use of
which is the years of education that people had attained.
So
Amy
and her
mentor Connie Mulligan, and I
reanalyzed the data set and
included this one simple measure,
years of education that people had attained.
Now surely no one would consider this to be a robust measure
of all the various ways in which systemic racism
constrains and shapes people's lives,
and yet in the first analysis where we exclude
education from the model, we appear to replicate
what this other group of researchers did,
which is that there seems to be some modest
though not statistically significant
by conventional standards evidence
that higher levels of African genetic ancestry
are associated with higher blood pressure.
But even that borderline evidence holds only if we ignore
the availability of another measure.
Once we include years of education in the model,
then what Amy found was that each additional year
of education that people had attained
was associated with about half a millimeter of mercury
lower blood pressure,
which when you now scale it up to a population level,
and you think about the differences
between a high school education or not,
a college education or not,
graduate training or not,
we're talking about a pretty substantial fraction
of the inequalities in blood pressure.
And notice that at the same time,
any evidence that had existed before
for an African genetic ancestry effect evaporated.
What this set of findings points us toward is a need
for clarity about the different kinds of things
people have in mind when they invoke the concept of race.
Some researchers talk about race
as a proxy for genetic ancestry,
something that increasingly we can measure directly
so we don't need race as a proxy for that.
And social scientists on the other hand think about race
as an aspect of social classification,
as part of a system that arose to classify humans
in the context of political and economic structures
of white supremacy.
So one of the challenges for us as health researchers
is to move beyond the use of race as a proxy
for these very different sorts of things
and try to measure them directly
so that we can test competing hypotheses more efficiently.
This is the basic motivation for some of my earlier work
on the Southeastern coast of Puerto Rico,
where I set out to isolate
genetic ancestry from local forms of social classification,
and the choice of Puerto Rico was driven by the fact
that generations of social scientists before me
had documented that the way people think about color
on the island is different from the way
people think about color on the mainland.
In particular, it sets up the possibility that
people could have the same kind of ancestry or
even the same physical appearance and yet be assigned
to different social categories.
That makes it possible then to consider,
is it really genetic ancestry
or is it the way that people are classified by others,
and therefore treated,
that helps to drive the pattern of health?
And the punchline from this work is that
the social ascription of color,
the way that people are identified by others,
was associated with blood pressure,
but that genetic ancestry was not.
So to get to this punchline,
my colleagues and I drew on a range of
social scientific methods beginning from
the classic method of participant observation,
which means anthropologists going and hanging out
with people to try to understand
the way that they see the world,
and one day I was sitting in the shop of a friend of mine
asking questions about race,
like generations of North American social scientists
had done before me, and she interrupted me to say
that I was asking all the wrong questions.
She said here, as you see,
"Here there are no divisions of race, of raza,
but there are divisions of color."
And she went on to explain that
when I was talking about raza,
that it meant something entirely different on the island
than it meant in the United States,
that it was a form of expressing
Puerto Rican national identity,
that it involved
the singular intermixture of European
and Taino and African roots, often in that order.
But that people did perceive differences in color
that shape their everyday experiences,
and so my job as a social scientist then
was to try to understand how do those
classification systems work.
One brief example of the answer to that question
comes from this image, which is
a representation of the way that
a diverse sample of Puerto Ricans sorted
a set of standardized facial portraits
that varied in skin tone and hair texture
and facial features,
as a way of saying exactly
how are these differences perceived?
In other words, how is color constructed in this context?
And what matters is
that you see there are five major groupings,
these, the locally meaningful categories
that shape people's perception of color
and the lines that you see
represent the significance of both skin color and hair form,
which is to say that color, color, isn't just about color.
It also differs based on other aspects
of your physical appearance, like your hair texture,
not to mention non-biological markers of social status,
like what neighborhood you live in or what job you have
or where your family comes from,
and we know from the social science literature,
that all of these things affect
the way that people are categorized in this context.
What that allows us to do then is to examine the way
that people are categorized
and how that relates to the risk of poor health.
We can then combine that with the methods
from human genetics,
using DNA, for example,
to
assay so-called ancestry informative markers
that produce individual level measures of genetic ancestry.
This is what the researchers
I was critical of a moment ago just did.
This is a way of trying to take it into account
differences
in population history.
And then in addition,
my colleague and collaborator at the University of Florida,
Dr. Connie Mulligan, suggested that we take that next step
of looking at susceptibility alleles,
that is genetic variants that might increase the risk
of high blood pressure.
And so in collaboration with the center for pharmacogenomics
at the University of Florida,
Mulligan and her lab assayed six polymorphisms
in three genes of the adrenergic receptor family,
and if you don't know what those are, that's fine,
just know that this is basically part of the body's system
that responds to stress,
that's involved in our fight or flight system.
That's what these genes are involved with.
So we now have three things.
We have the way people are classified.
We have DNA based estimates of genetic ancestry,
and we have DNA evidence about candidate genes
for blood pressure.
This sets up the question about how should we understand
the nature of risk for high blood pressure
in people of African descent?
So the first answer comes from this result,
which shows you the association between
locally meaningful categories of color.
In this case, it's Blanco or white,
Trigueno or literally wheat colored,
and Negro or black,
along the horizontal axis.
Along the vertical axis, you see a DNA based estimate
of west African ancestry.
As you might expect, as you move from Blanco
to Trigueno, to Negro,
you see that the average level
of estimated west African ancestry increases,
but more importantly
for our purposes here is the amount of overlap that exists
across these categories.
You can see clearly that there are certain levels of
estimated
west African genetic ancestry in which people
could be classified into any one of these three categories.
This is the core of the anthropological critique of race,
which says that these socially constructed categories
are not good proxies for patterns
of human genetic variation,
even when the genetic markers that we've looked at
have been selected purposely to pull people apart
into groups.
It also sets up the possibility of testing,
is it the social categories that you see
along the horizontal axis
or the estimates of genetic ancestry
along the vertical axis
that best predicts blood pressure variation?
And the answer is
that
the combination of class and color,
so socioeconomic status in this case measured as a
combination of household income, education,
that that intersection between class and color is associated
with blood pressure, but genetic ancestry is not.
First, if you look at this analysis,
we replicate the same model that's common in human genetics
in which we look at genetic estimates of African ancestry
while ignoring the social and cultural data
that we have about class and color.
And in this first result,
it actually looks like we provide stronger evidence
than the other group of researchers,
that higher levels of African ancestry are associated with
higher blood pressure, but that's true only if you ignore
the ways that class and color shapes people's experiences.
Once we include class and social class and color,
as well as the interaction between them,
we see that what evidence might have existed before
for a genetic ancestry effect again goes away,
and what matters instead is especially that interaction
between class and color.
And if you're not familiar with reading a table like this,
here's what it looks like.
If we model that interaction between class and color,
it shows us for people in our sample
who were defined by others, perceived by others
as either Blanco or Trigueno,
white or this intermediate category,
then as they do better socioeconomically
as their income and their education improves,
so does their health.
This is the pattern that we're used to seeing
in the industrialized world,
but for people who were perceived by others
as Negro or black,
then higher levels of socioeconomic status
were actually associated with higher average blood pressure.
Now, we can't know exactly what's going on here
with the data that we have available,
but one interpretation is that the people
who were represented at the upper right-hand part
of this graph,
that is people who are defined by others as Negro,
but who have achieved socioeconomic success
live and work in social contexts that have historically
been dominated by light-skinned Puerto Ricans.
They are in essence Negros living in a world of Blancos,
and the likelihood is great,
that as a consequence they encounter the frustration,
on a day-to-day basis of interpersonal
and institutional discrimination
that leaves a mark on their body,
possibly including elevated blood pressure,
and this is consistent with the way people in everyday life
talk about racism in Puerto Rico.
For example, I once asked Dona Mercedes
how she understood racism to operate,
and she said, "You don't see it much among the poor,"
speaking in reference to Puerto Rico in particular,
"But among those who are better off economically,
you see a lot of racism because they often
reject people beneath them."
So all of all of this evidence lines up to suggest
that what matters about genetic ancestry
isn't a genetic mechanism, but rather it's the meaning
that we attribute to people with African ancestry
in racially stratified societies.
Now, I don't want to leave you with the idea
that this is a simple story of nurture trumping nature.
My argument is not the genes are irrelevant
because in fact what we found was that
when we take account of social class and color,
that it actually alters the evidence
for an association between blood pressure
and those candidate gene polymorphisms that we examined.
So in this first analysis that I am showing you,
when we ignore class and color,
we again see that African genetic ancestry
appears to be associated with higher blood pressure.
There is no evidence that any of the candidate genes
for high blood pressure are associated with blood pressure.
However, once we add class and color to the analysis,
we see that again, the genetic ancestry effect goes away,
and we now find evidence for a significant association
between one particular polymorphism,
one particular genetic variant,
that had previously been associated with blood pressure.
We now see evidence that in our sample too
it is associated with blood pressure,
and the reason this happens
is that yes, at an individual level, genes matter,
but genes are not distributed across our species
in color-coded boxes.
Race is not a way of understanding
the distribution of genetic risk,
and it also matters because
if we take seriously the idea that phenotype,
the observable parts of our biology are a product
of genotype and environment then we need to approach both
with equal rigor and the better we can take account
of environmental exposures,
like with taking into account social class and color,
the more likely we are to understand the way
that genes actually do matter for individuals
in a non-racial way.
So for nearly the last decade
colleagues including Dr. Mulligan and I have taken
the challenges from this work to a new context,
working with community partners
in the African-American community in Tallahassee, Florida,
and time doesn't allow me to go into great depth
about this work, but I want to highlight
one particular set of findings that has emerged from it,
which is that we began this work
by asking people to tell us their stories
of how they experience race and racism,
and in the process,
we learned that many of the existing ways
that researchers approach the study
of discrimination in health omits some of what
is most meaningful to people,
and that is that people are affected
not only by what happens to them,
but also by what happens to those around them.
This is the notion of vicarious racism, where
the extent to which your own experience is shaped
by other people's experiences of racism,
and in another set of analyses,
we found that NPR actually says it a little more
in a straightforward manner that knowing someone
who faced discrimination may affect blood pressure
and significantly, we found that this association appeared
to operate through a different biological pathway
than was the case for direct exposure in one's own life.
In more recent work, we have also shown
in the same community in Tallahassee
that higher levels of exposure to discrimination,
when people perceive that discrimination
to be based on race,
shows up with shortened telomere links
and telomeres are the end caps of your chromosomes.
They are sometimes regarded as a marker of cellular aging
because as we age,
the ends of our telomeres get shorter and shorter
if they're not repaired,
so this is often used as a marker
of cellular aging.
This finding also inverts our usual way of thinking
about the relationship between race and genes,
because what it shows is that
it's not that race is mapped on to genetic variants
that increase the risk of poor health.
Instead, it's that exposure to racism
can take such a toll on the body
that it can literally grind down the ends
of your chromosomes.
In other work with colleagues
at the College of Medicine at UF led by Michelle Cardel,
we've also extended this work to understand
how experiences of discrimination can be related
to other sorts of physiological end points,
including the severity of metabolic syndrome
among African-Americans in the Jackson Heart study,
and these various studies contribute to a burgeoning body
of research that has linked the experience of discrimination
to poor health outcomes,
both markers of physiology and of health behavior
ranging from blood pressure and breast cancer
to body mass index, abdominal adiposity, preterm birth
on to HIV testing, smoking, and alcohol use.
And of course, it's not just a matter
of how individuals experience discrimination
in their day-to-day lives,
but also the structures of racism as manifested,
for example, in race-based residential segregation
and the concentration of poverty.
And we increasingly understand the way
that these large scale structural inequalities
are linked to health and development
as reflected here in the likelihood of low birthweight.
And as we consider the unfolding pandemic
in the United States,
I've recently argued that we need to understand
the synergistic interactions
that occur between systemic racism,
as it manifests again, in segregation, in our workplaces,
in our schools, in our homes,
to the concentration of poverty and wealth,
to the racialized nature of mass incarceration
and hyper policing
to the disinvestment in social safety nets
and ways that these various factors
can shape the likelihood of cardio-metabolic disorders
like diabetes and hypertension,
as they also shape the likelihood of exposure
to the SARS coronavirus two
and to interactions among all of these things.
So let me try to end on a forward looking note,
to ask the question of what can we do
in the face of emerging evidence about the ways
that systemic racism harms people's health,
and I'd like to identify three arenas
in which we can intervene.
The first is pedagogy,
which seems appropriate as I'm here at a university,
the second is in practice, and the third is in policy.
So as teachers and in the classroom,
we have an obligation to counter false ideas about race,
notably the idea that race is a meaningful way
of understanding human genetic variation.
And likewise, we have an obligation to explain what we mean
by systemic racism and to trace the pathways
through which systemic racism constrains people's lives
and causes material harm.
In our practice, particularly in the realm of medicine,
we have to move from race based medicine,
which assumes intrinsic differences,
to race conscious medicine and medical practice,
which is aware of the ways in which race as a political
and economic system can harm people's lives
and prevent them from following doctor's orders for example.
And at the level of policy,
we have to think bigger about redressing
the historical and persistent harms of white supremacy.
One compelling way to think about this is a recent analysis
by Jean Richardson and colleagues early in the pandemic.
They asked themselves the question of
how might the pandemic have been different
if the United States had paid reparations to the descendants
of enslaved people in the United States,
as we fleetingly promised after the Civil War?
And what they found was that if the United States
had paid reparations to produce a just society,
that the transmission rate of SARS coronavirus two
would have decreased, as it says,
between 31 and 68%.
Now this means that certainly
many fewer black and brown people would have died
as a consequence of COVID-19,
but it also means that every one of us
would have been better off
because the transmission of the virus across our society
would have been less.
In a word then, I leave you with the idea that
there is no race without racism,
that any question we ask about race,
whether it's about health or any other factor
is in fact a question about racism
and that our obligation is to understand what racism is,
how it operates and what effect it has on people
and on the conduct of research.
I'm looking forward to
what I hope is a fruitful, stimulating discussion.
I thank you all for your attention.
Thank you.
(audience claps)
So it looks like we have a couple of microphones,
so if you have a question or comment,
please just signal to us so that we can
hopefully have a rich discussion,
- [Woman] Call on someone.
- [Short] Hi, Short Smith, he/him pronouns.
What inspired you to take on this line of research
since you pointed out it's contrary
to what would be seen as the normal path?
- Well, the answer starts a long time ago.
So all of my degrees are in anthropology,
and I learned as an undergraduate
that race was a social construct, not a biological fact.
I thought that we had more or less dispensed with that idea
in the mid 20th century,
and then I was beginning graduate school,
and I encountered the way that at that time in the mid 1990s
medical students were at the University of Florida
being taught to think about race.
It was common practice then, and I don't think just at UF,
but everywhere
for
physicians in training to be taught
to think in terms of race,
and the way this showed up was that
I was asked to play the role of an attending physician,
and a second year medical student said,
Mr. Johnson's a 52 year old black man
who presents with a chronic cough,
and as a snotty graduate student, I said,
wait, just a minute.
What exactly does his blackness have to do with his cough?
And she said, honestly,
that's just what they teach us to do,
and it seems strange to me
that 19th century ideas about race and genes
might be circulating in that context,
and so it was at that point, I started reading
about how race was being used in
medical education and clinical practice,
in epidemiological research and realize that
there were a lot of untested assumptions
that were continuing to circulate.
Now, a lot of scholars have been pushing back
on that practice and most medical schools have abandoned
that idea of teaching people to identify race
in the first line of the history of present illness.
I see the dean of your medical school nodding his head
so I'm assuming that's true here as well,
and yet there's still a lot of these assumptions still,
but for me, it was really just
an awareness of the injustice that resulted
from carrying forward ideas that
are fundamentally indistinguishable
from 19th century reasoning about race and disease.
Certainly the vocabulary has changed,
the science is more technically specific, but many of
the assumptions
about what race is
are alive and well
in many disciplines.
- [Roxanna] Hi, Roxanna del Rio, she/her.
Did you compare disparities in health
between the differing races,
is there any improvement
50 years ago compared to today?
- There definitely have been signs of improvement.
Thank you for that question.
The improvement has been slow.
If we look for example at life expectancy,
racial inequalities in life expectancy in 1996
were exactly what they had been in 1946,
so despite the progress of the Civil Rights Movement
and the legislation of the 1960s,
during that 50 year timeframe,
there was no discernible impact in terms of longevity.
In the last 10 or 15 years that had
fortunately begun to change, and the
racial inequities in life expectancy
had begun to close so that in 2019,
they were at the lowest level that we've ever recorded
in the United States.
Unfortunately COVID-19 has set the clock back
at least 10 years because of
the disproportionate impact of the pandemic
and so has erased a decade of gains in racial inequities.
What I hope is that
the
renewed attention to and growing awareness
of the various ways that racism produces these inequalities
will lead to stronger resolve to do something about it,
which means
going beyond individual level sorts of interventions
and thinking about ways that we need to restructure
our political and economic system
to make it possible for everyone
to live a full, healthy life.
Yes?
Do you need?
Okay, sorry.
And Professor Shea, when you have an opportunity,
there's another hand in the front row, thank you.
- [Sophie] Hi, Sophie McCunic, she/her pronouns.
Like you've mentioned,
the COVID 19 pandemic exposed so much
in regards to this issue,
and I think something else it exposed was the fact
that so many Americans don't believe in science
and scientific data so how do you propose we
present this type of data or just
have a lot of the populations see it from this perspective
and understand the importance of research like this
when a lot of the population in America
doesn't believe in science?
Thank you.
- So a softball question.
(audience laughs)
Yeah. I mean, thank you for raising
such an important issue about
how can you communicate what we know from science
when the stakes are, you know,
literal matters of life and death,
when as you say it is apparent that that
scientific reasoning and lines of evidence
don't resonate for everyone,
and I don't think that I actually have an answer
to that question.
I think you've identified it as an important problem.
The way I might build on your observation
is to encourage all of us to be thinking about ways
that we need to think big,
that the solution will not come in the form of band-aids.
I would suggest that some of the same political forces
that have led people no longer to believe in science
are also at the root of why the inequities exist
in the first place,
and thinking about the way that those dynamics
intersect
is crucial.
I'm reminded of another recent study
in Public Health Reports that you see behind me,
where researchers identified
843
state laws
that are linked to structural racism,
and many of these laws also
result
in a disinvestment in our educational system
and foster mistrust in our government and in science,
and so thinking about the ways that
structural racism and white supremacy harm
their targets first and worse,
it also has detrimental effects for the entire society
because of the ways that it results in
the underfunding and dismantling of the public good
including education,
and so
I think I feel safe saying here in Burlington
of all places, that this is a time
that we really have to be thinking really big
about what the solutions will be,
and the solutions will not be in the realm
of biomedicine, frankly.
These are fundamentally political problems
that will require political solutions.
There's a lot of good that,
of course,
we can do in the meantime and whether it's in medicine
or public health or policy,
but yeah, the solutions are gonna require
a much greater political will.
Yes.
- [Marina] I'm Marina, she/her.
I wanted to ask you about, first of all, I love your.
- Sorry, can you hold that just a little bit closer?
I'm having a little difficulty hearing you, thanks.
- [Marina] Sorry. - Thank you.
- [Marina] I wanted to ask you about,
I loved your speech by the way,
but I wanted to ask about sort of
I guess if you ever thought of using sort of like,
what about people that are more than one race, you know,
within the medical field where race has been brought up
as like an argument of like, oh,
that's just what they teach us,
but there are people that are biracial, multiracial,
multiethnic that are more than one race, and so it's,
have you ever thought of using that as an argument
within your research towards people that believe race
as biological when in fact it's not?
- Yeah, that's such a great idea to point out
the people who don't necessarily fit into a single checkbox
on the census forms, right?
Which is a growing and growing number of Americans.
There's an interesting thing that I recently read about,
which is that the rise of direct to consumer
genetic ancestry services like 23 and me, and so forth.
Some researchers suggest has also led
to a fundamental shift in the number of people
who perceive themselves as multiracial,
that in the 2020 census, the number jumped
and many people are attributing this to the fact that
some people now have reports from 23 and me
or ancestry.com that says they're not just one thing,
but they're actually,
their ancestry can be traced to different places.
So I haven't done.
I think certainly the awareness of how these categories
are fluid can be a way of de-stabilizing people's assumption
that race is some natural thing that just exists out there
in the world.
There is some interesting research on
how this produces health inequities.
I'm reminded, your question reminds me in particular
of work by Dr. Camara Jones,
former president of the American Public Health Association,
she was at the CDC for awhile.
While she was at the CDC, she developed
a set of questions called the reaction to race module,
and these questions were taken up by
state departments of health in the routine
epidemiological surveillance that states do.
There's a so-called behavioral risk factor
surveillance survey,
and the link to your question here is that
these questions ask not only how do you identify your race,
but also how do you think other people identify your race?
And what Dr. Jones found was that
in cases where there was discordance,
that is people identify themselves one way,
but they think other people see them another way,
that when other people categorize them as
in ways that were closer to white,
that their health was better as well
which suggests that there's some way in which
these identities are fluid,
there's how I see myself, there's how other people see me,
and that what really might matter in terms of health
is the way that other people see me,
because that conditions the way that
society at large will treat me.
But I think there's a lot of interesting work
that could be done to extend this idea about
people who have multi-racial identities
and I can't wait to read your PhD dissertation about that.
(audience laughing)
- [Kate] Kate Simms, she/her.
So I'm wondering,
this presentation talked a lot about blood pressure,
and you've mentioned other like health areas as well,
and I'm wondering if you're seeing a pattern
across all health disparities, things like
cardiovascular disease, cancers, stuff like that
if this is like a pattern across all health disparities,
or if there's different influences for
different kinds of health issues.
- Very good question.
So all leading causes of death in the United States
exhibit some racial inequities.
The reason that I focus on blood pressure is that
it is one of the cases where the assumption
is most prevalent that the answer lies
in some racial genetic factors.
In fact,
this idea was formalized with
the so-called slavery hypothesis for hypertension,
which held that
mortality rates during the Middle Passage of
the Atlantic Slave Trade were so high
that Africans who were enslaved in west Africa
and survived the passage to the Americas
were ones who survived from salt depleting conditions,
diarrhea, vomiting, and so that those people had
a genetic predisposition to
retain sodium
differences in sodium metabolism that caused them
to be able to retain more hydration levels,
and this idea,
it's one of these just so stories that circulate so widely,
it started to appear in clinical textbooks
about hypertension before any
scholarly article was ever published about it,
before any evidence was collected
to test the hypothesis
and subsequent work that has tested those hypothesis
shows that it actually doesn't work.
The genetic differences we would presume exist
between west Africans and descendants of enslaved Africans
in the Americas, those genetic differences don't exist
in any of the studies that have looked
and it doesn't line up with all the historical record,
but the reason that I focused on hypertension,
it's a key test case where
so many people assume that the answer is genetic
that if we can show that in that case it doesn't work,
the hope is that it causes a broader rethinking,
and there's a broader rethinking happening across
many different fields.
There's some really good news from last week,
the New England Journal of Medicine published an editorial
along with two new papers,
providing
race free
equations to estimate kidney function.
There's been an ongoing debate about
the equations that clinicians use
to evaluate the health of people's kidneys,
and the equations that have been in use historically
have a correction factor
that resets the threshold
at which people could be referred for treatment
like dialysis or for where
they could be put on a transplant list, for example,
and it has the effect that
black patients actually have to present sicker
than do others in order to receive the same treatment.
So there's been a lot of scholarship
pushing back on this idea.
There's been a lot of advocacy,
much of it driven by medical students
at institutions around the U.S.
And so just last week,
some new estimating equations that don't include race
were published in the New England Journal.
New England Journal published an editorial saying
we need to leave race correction factors behind
and new clinical standards of care have been advanced
where physicians are encouraged not to use
these race correction factors anymore.
So yeah, it cuts across a lot of
organ systems, lots of different domains of medicine,
and good things are happening
to move beyond race-based medicine
in a lot of those fields as well.
- [Girl] Okay Annie Sachs, she/her,
so I know someone mentioned how
oftentimes people tend not to trust healthcare systems
just because of like past history,
but I know that oftentimes doctors tend to discredit
their black and brown patients
and do not listen to their complaints of symptoms
due to the racial prejudices
so how do you suggest that we change that
culture in hospitals and among medical professionals?
- Yeah, another very important question.
You know, I think that
a lot of medical schools are attuned to the problem
that you're describing and many have instituted programs
that attempt to combat implicit bias that leads physicians,
unconsciously or consciously,
but most often I believe unconsciously to make decisions
that are shaped by
racial biases.
So I think a lot of people are actually really working
on that problem.
What I would suggest is that it is necessary,
but insufficient
because
one potential downside of the focus on implicit bias
is that it suggests that the problem
is in individual people's minds,
that the problem is in sort of hearts and minds,
the way we see and treat one another,
and I believe that that does matter,
the way we see and treat one another does matter,
but if that's how we understand racism,
we're really missing the picture
because we have to understand racism
as a system of oppression.
We have to understand the way that it is embedded
in social structures and political systems
and economic inequalities,
and so where that matters is we have to think about
who's coming to the med school in the first place?
Who are the faculty at the medical school?
So whether we're thinking about an organizational level
or in local government or in state government
or in federal government,
if we want to address racial inequities,
we have to think structurally,
we have to think about how can we transform the structures
so that we don't recapitulate the inequality.
So I would say it's good to continue work
at the individual level,
but if that becomes seen as the solution,
then it actually is going to be very short-sighted
because the real problem is structural.
- [Diana] Hi, Diana, she/her.
My question is about,
you talked a lot in
your research about predisposition.
I'm wondering how much treatment or lack thereof
contributes to
a higher premature death rate in African-Americans and
how much treatment is the issue between
being well and not.
- Yeah, that's a really good question.
So certainly inequities in treatment
are an important piece of the problem.
About 20 years ago,
it was at that point the Institute of Medicine,
now it's the National Academy of Medicine,
produced a report called called Unequal Treatment,
which systematically reviewed the available evidence
about
inequalities in clinical care
and found overwhelming evidence
from every domain of medicine
that there were significant inequalities
in medical decision-making and
in delivering the standard of care.
What I'm not so sure about is how big a fraction
of the racial inequities in say life expectancy
can actually be attributed to those differences
in clinical care, because
this is not exactly my area of research,
but I do know of work that is attempted to estimate
how much of population level death, mortality rates,
and so forth, how much inequalities in death rates
can be attributed to differences in access to healthcare
or in the quality of healthcare,
and the estimates vary there,
but it's something on the order of about 10%,
which is to say that we could fix all of the problems
in inequitable access to healthcare,
and the problems wouldn't necessarily go away
because what's at stake is who gets sick in the first place.
Now if there's a social pattern to who gets sick
in the first place and then that is compounded
by inequalities in the provision of care,
then of course, that makes things worse,
but I would say that we should be careful not to assume
that healthcare will be a sole solution,
that we also have to be thinking
more broadly in terms of prevention
and in who gets sick in the first place.
- [Juan] Hello, hello.
My name is Juan Florencia.
- Sorry, can you wave your hand?
I haven't found where you are.
- [Juan] Yes, thank you. - Okay, hi.
- [Juan] So my name is Juan Florencia.
I use he/him pronouns.
First want to thank you Dr. Gravlee
for a wonderful conversation today.
I really enjoyed it
and I just want to touch on a couple of things.
So I believe it was Clarence Graham who propagated
that idea about the Middle Passage,
which was totally predicated on him reading
Alex Haley's fictional Roots,
and I really appreciate you
talking about how we need to think about racism differently
in terms of structural and thinking about how it's
racist power that generates racist ideas to support
the types of policies and laws they enact,
and then redirect that blame away from the policies
to make them look normal,
then redirect that onto the very people they've racialized
to begin with.
I have to say though that I am
not optimistic,
but hopeful
regarding the future of health equity
because since the Civil War,
we've only experienced three notable or
types of health equity victories, the Freedmen's Bureau,
the Social Security Act, Medicare, Medicaid,
and most recently the Affordable Care Act,
all of which have come under tremendous attack
as evidenced by
the Affordable Care Act, trying to be dismantled
and constantly
in the hands of the Supreme Court.
So I agree with you that our political
and economic conditions need to be restructured, but
how do we go about
doing something as monumental as addressing
like global predatory capitalism mixed with racism
as the exercised version of white supremacy
when everything like our democracy, our country,
and our institutions are all founded on
those twin pillars of power.
Thank you.
- I kind of want to see your talk now.
Yeah.
I just would like to co-sign everything that you just said,
except I'm gonna try to express a little bit more,
maybe a little bit more hope.
I think what's important about what you're saying is
that you're diagnosing the problem right
by recognizing racial capitalism as the core structure
that shapes the likelihood that people are gonna live
long lives or short lives,
and so I think it's that kind of big thinking,
asking those questions is a huge step forward, right?
Because even some of the examples
that you talked about,
did you identify
Social Security as one of those?
Yeah, okay.
Well if you really look at the history of Social Security,
you see how it was also an instrument of white supremacy
because of the ways that agricultural and domestic workers
were excluded, which was a compromise
that had to be made with Southern senators
who did not want those dollars
going to black people in the south,
and so we have to simply open our eyes
to the enduring reality
of white supremacy as the fundamental structure,
the fundamental political structure of our society.
So the more we can have that conversation,
the more we can talk about that historical context
and about what's really at stake here,
the more hopeful I am about the possibility
of doing something about it.
If we think about it instead as well,
we just need different anti-hypertensive medications
for black people, then that simply serves to naturalize
the very inequities that our society has produced
and has the effect then of letting us all off the hook.
So I appreciate very much the sources of your pessimism,
and
it's very daunting for sure,
but simply asking the question
and bringing that framework into the analysis I think
moves us a little bit closer to the possibility of
doing things differently.
- [Gall] Hi, my name's Gall, I use she/her pronouns,
I was wondering, I feel as though a big part
of solving the issues that you brought up in this speech is
listening and including people of color in
like the fight almost,
and I was wondering how you and your research
and how other social scientists are including
their voices and their opinions, other than
just studying the outcomes of racism on people of color,
but rather having them, you know,
do hands-on work and share their knowledge
versus the people who are studying them
like sharing their knowledge.
Thank you.
- Yeah, thank you so much for that question,
and by way of answering it,
I first want to refer all of you
to a really important investigative report
published by Stat,
which is an online magazine subsidiary of Boston Globe
that focuses on health and medicine,
and last week they published
a piece
that adopted language from
Elle Lett,
who described what she sees as a health equity tourists,
and the rush of especially white researchers
who are colonizing this space
to take advantage of the sudden influx of resources
that the National Institutes of Health and others are
pouring at this,
and very often in the process recapitulating
the structural inequities that exist in the first place.
And so there, there is a real responsibility,
especially for white researchers,
to
do our homework,
to study the
generations of especially black and indigenous scholars
who have been making these arguments in various ways
for a long time.
I gave a talk in the biology department earlier today where
I was quoting W. Du Bois from 1899,
who basically laid it out for us,
in many ways.
So I think to do our homework, to understand,
to respect this intellectual tradition,
to recognize the ways in which
we have been miseducated
because of the nature of white supremacy.
In the last 18 months,
I've been doing this work since I was a graduate student
in 1997, and in the last 18 months,
I had to confront all of the things that I should have read
in grad school that nobody ever asked me to read.
No member of my dissertation committee asked me to read,
no peer reviewer of my articles or my grants said, Hey,
how do you relate this to Dubois,
or which any of the countless other people
who've been having these conversations,
and, you know, I was able to,
like nobody ever pressed me on that
so that's a fundamental issue, I think,
and just the ways that we all are sort of miseducated
by who gets erased from the canon.
I also think that we have an obligation to
partner with people in ways that don't
recapitulate power inequities, but rather try to
distribute resources in a more equitable way.
So the work that I briefly touched on in Tallahassee
has happened in the context of
a community academic partnership
that I co-founded with Ms. Myesha Mitchell,
who's a community organizer from Tallahassee,
and our
framework has been based in
principles of community-based participatory research,
where there are university researchers like me,
but there are also members of the community,
representatives, community based organizations,
policy makers,
and we become partners,
equal partners with mutual respect,
recognizing that each of us brings something to the table,
and this has to also come with real material commitments
from the university.
So I'm very proud of the fact that in
the last three grants that we got to support our work
from private foundation and from
the National Science Foundation,
that more than half of the money
that we won in those grants went to the community,
and you probably don't appreciate just how unusual that is
because most universities,
if you as a researcher write a grant,
say it's going to cost me $200,000 to do the research.
Then the university has what's called a
facilities and administrative fee or indirect costs,
they're sometimes called
and different universities negotiate the rate
with the federal government.
At my university, University of Florida,
that indirect cost rate is 52%
so that means that when I submit that grant proposal,
it's gonna be the $200,000 that I say I need,
plus the university is going to impose a tax
of 52% of dollars that goes just to the university,
and often that money just,
it's to keep the lights on at the university,
it's used for good things,
but what happens then is when researchers
come into communities
and the community doesn't have a financial stake
in the grant
that it actually vastly,
it recapitulates and exacerbates these power inequities
between university researchers and the communities
where we do the research in order to benefit
our own careers,
and so there's a fundamental structural problem there
that has to be addressed.
And so,
there's a lot there, but thank you for the question.
(woman giving instruction in the background)
(audience claps)
Thank you.