Public Health & Prevention

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The Calm Before the Storm: Addressing Race as a Vulnerability Before and After Hurricane Katrina  CME/CE

Introduction

The 133rd meeting of the American Public Health Association (APHA) was scheduled to take place in New Orleans, Louisiana, in November 2005. However, due to the devastating effects of Hurricane Katrina, the meeting was postponed until December and held in Philadelphia, Pennsylvania. It is impossible to discuss the issues facing public health professionals today without attempting to address both the preexisting and exacerbated conditions of population vulnerability surrounding Hurricane Katrina.

Katrina exposed hidden pockets of the poor and disenfranchised in the United States, in addition to revealing discriminatory practices and policies in our society that many Americans may have thought were ancient history.^[1] After all, slavery was abolished nearly 150 years ago and integration established 2 generations ago. Yet we know that even in the most affluent and developed country in the world, there are vulnerable Americans among us.^[2]

Defining Vulnerability and Vulnerable Populations

The United Nations Committee on Economic, Social, and Cultural Rights (CESCR) defines vulnerable populations as "segments of the population which are or should be the recipients of special care and attention."^[3] Defining vulnerable groups further can prove difficult, but broadly speaking, vulnerability may encompass the following factors:

• Age;
  
  
• Sex;
  
  
• Race or ethnicity (including minorities, rural populations and/or people living in disaster-prone areas);
  
  
• Health status;
  
  
• Liberty status (such as detainees or prisoners); and
  
  
• Others (eg, homelessness, refugee or asylum-seeking status).^[4]

Parsing out multiple vulnerabilities such as race, gender, socioeconomic status, and health status are not possible within the confines of this conference coverage. However, it is important to note that the cumulative effect of co-vulnerability or membership in multiple vulnerable groups cannot and must not be underestimated. Often these individual vulnerabilities may in fact be a determining factor, if not the cause, of additional vulnerabilities.^[5]

A recent New York Times study (based on a convenience sample of 260 individuals who died due to Hurricane Katrina) found that almost three quarters of the black victims lived in neighborhoods where the average annual income was below the city average of $43,000. Not surprisingly, the Times also found that in New Orleans, the median income for whites is almost twice what it is for blacks. Most of the individuals in the study were Louisiana natives, and almost all were members of the working class -- highlighting the ways in which multiple vulnerabilities may build upon one another.^[6]

Race: Biological or Sociological Construct?

The scientific community is currently debating whether race should be understood as a biological or social construct.^[1] The basis of the biological argument is now primarily focused on mapped variations in the human genome that exist across the 5 racial subcategories. However, counterarguments to this view include the fact that Homo sapiens are 1 single species that share 99.9% of their human DNA.^[7] In fact, in early racial typology, Blumenbach^[7] arrived at the conclusion that all humans belong to 1 species with equal capacities.Error! Bookmark not defined. In regard to health research, race has not been proven to effectively predict the cause, prevalence, individual vulnerability to, or outcome of disease.^[7]

Race as a social construct can be understood as "an amalgamation of ancestry, education, language, literacy, and economic and social status."^[7] However, the category of race is still used in health data reporting. Disaggregation is a valuable component in identifying the specific vulnerabilities faced by racial and ethnic groups; however, caution should be paid to ensure that discrimination and stigma are not perpetuated by such reporting. Between 1982 and 1985, the United States Centers for Disease Control and Prevention (CDC) classified Haitians as a risk group for HIV along with homosexuals and heroin users.^[8] Such classifications may have contributed to stigma and discrimination against individuals within these groups regardless of their HIV status. Since that time, the public health community has moved toward identifying "risk behaviors" as opposed to risk groups.

Even given the existing arguments that there is no biological basis for perpetuating the category of race as such, there is no denying that the historical categorization of race has resulted in discriminatory treatment. Race as a biological category may not exist, but race as a socioeconomic factor and racism in its many, sometimes insidious forms, do. Katrina has reminded us that just because the Jim Crow doctrine of "separate but equal" no longer exists in the law, it may in fact exist in practice.^[9] This was made obvious by news media reports that depicted images of black Americans who "looted" after Katrina while white Americans "searched" for food.

Race and Health Under International Law

The right to health is included in several international and regional treaties.^[10] Unfortunately, due to the historical split between civil, political, economic, social, and cultural rights, the United States is not a party to many of the binding treaties that include the right to health.

Article 25 of the Universal Declaration of Human Rights (UDHR) provides a broad definition of the right to health in stating, "Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control."^[11] The United States is a signatory to this 1948 Declaration.

Additionally, the United States has ratified the International Convention on the Elimination of all forms of Racial Discrimination (CERD). This internationally binding treaty requires all states that are party to the treaty to prohibit and eliminate racial discrimination and includes an article on the right to health. Article 5 of CERD states, "...States Parties undertake to prohibit and to eliminate racial discrimination in all its forms and to guarantee the right of everyone, without distinction as to race, colour, or national or ethnic origin, to equality before the law, notably in the enjoyment of the following rights...(iv) The right to public health, medical care, social security and social services..."^[12]

Further, all international and regional human rights treaties, including many to which the United States is a party, contain what is known as the "nondiscrimination clause." This term refers to standard language often phrased as, "regardless of race, sex, religion, language or other status." The United Nations Commission on Human Rights has indicated in several reports that the term "other status" may include health status.^[13] The nondiscrimination clause makes clear the concept of universality of human rights; that is, that human rights apply to all individuals regardless of demographic or other defining characteristics.

The Problem of Health Disparities

Black Americans constitute 12% of the US population, yet suffer disproportionately with regard to several infectious and chronic diseases.^[14] The fact that health disparities exist is not up for debate...

"the infant death rate among African Americans is still more than double that of whites. Heart disease death rates are more than 40 percent higher for African Americans than for whites. The death rate for all cancers is 30 percent higher for African Americans than for whites; for prostate cancer, it is more than double that for whites. African American women have a higher death rate from breast cancer despite having a mammography screening rate that is nearly the same as the rate for white women. The death rate from HIV/AIDS for African Americans is more than seven times that for whites; the rate of homicide is six times that for whites.^[15]

Factors contributing to poorer health outcomes among black Americans include discrimination, cultural barriers, and lack of access to health care systems.^[16] At the 2001 World Conference Against Racism, racial discrimination was identified as a social determinant of health and a call for the elimination of health disparities as a result of such racial discrimination, especially as it applies to health systems, was issued.^[17] In a recent study conducted by the Robert Wood Johnson Foundation and the Harvard School of Public Health, 23% of blacks reported receiving poor quality medical care because of their race or ethnicity, compared with 1% of whites.^[18]

Discrimination as a result of race is a social determinant of health, and such social determinants affect both the distribution and outcomes of disease.^[19] These negative outcomes may reinforce existing inequalities. A few recent examples illustrate some additional issues surrounding race and health disparities, including increased vulnerability and decreased accessibility.

An analysis performed by the Associated Press illustrates the role race may play in vulnerability and disparities. Neighborhoods with the highest pollution tend to be poorer, less educated, and to have higher rates of unemployment than those without such environmental risks. Carol Browner, former head of the Environmental Protection Agency, stated, "Poor communities, frequently communities of color but not exclusively, suffer disproportionately" when it comes to environmental risks.^[20]

Although black Americans may be more likely to be exposed to negative environmental pollution, they suffer the "double whammy" of having less opportunity to participate in research that may improve health status. A recent study conducted by the National Institutes of Health showed that minorities would participate in health research at the same rates as other racial and ethnic groups if given the opportunity. "The main barrier is access, knowledge that these studies exist, eligibility criteria that ensure that minorities can participate, and overcoming logistical barriers that exist."^[21]

Eliminating Health Disparities

The elimination of health disparities has been called the civil rights issue of the 21st century.^[22] The anecdotes above elucidate how integral the issues of access and availability are to inclusive health research. It is the role of government to ensure that such special allowances, care, and attention are given as called for in the very definition of vulnerable groups under international law.^[23] In addition to the legal obligation implied by ratification of CERD, a recent study found that 65% percent of Americans believe that the federal government should do more to address racial and ethnic health disparities.^[24]

Several initiatives have been undertaken at the federal level to address health disparities. The Institute of Medicine (IOM) Report, "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care," makes recommendations in the following broad categories:

• Legal and policy interventions;
  
  
• Health systems interventions;
  
  
• Patient education and empowerment;
  
  
• Cross-cultural education in the health professions;
  
  
• Data collection and monitoring; and
  
  
• Needed research.^[25]

Although the IOM recommendations address important issues such as cross-cultural education, the use of community health workers, and the collection of data identifying the sources of and barriers to eliminating health disparities, the report fails to address several other important factors. Namely, the report does not address the following:

• Issues of power inherent to the doctor/patient as well as the privileged/vulnerable status many times inherent in the healthcare delivery setting;
  
  
• Structural violence such as systemic racism within the healthcare system and societal racism and discrimination more broadly;
  
  
• Social and economic barriers including the issue of nonuniversal healthcare (The United States is the only developed country in the world that does not ensure universal access to healthcare/health insurance.)^[26]
  
  
• Human and civil rights obligations of the United States and the implications of persistent health disparities as a violation of the right to health under Article 5 of CERD.^[27]

Sojourner Truth proclaimed that we are all interconnected in the struggle to achieve our full potential. Currently, more than 45 million Americans do not have health insurance.^[28] The populations most affected by health disparities are expected to grow as a proportion of the US population.^[14] Therefore, the future of health as a whole in the United States will be impacted. Public health approaches most often take a utilitarian approach that seeks the greatest good for the greatest number. The health of the public can only be measured by the status of the most vulnerable among us, and that number is growing.^[29]

The winds of Hurricane Katrina brought to light the issues of race and vulnerability in the United States today. She blew the annual APHA meeting north to Philadelphia, "The City of Brotherly Love." But rather than be lulled by the calm after the storm, let us now engage in addressing the preeminent challenge facing us today, one that is both a moral and legal obligation -- the elimination of racial discrimination and health disparities.

References

1. Krieger N. "Stormy weather: race, gene expression, and the science of health disparities. Am J Public Health. 2005;95:2155-2160.
2. Jenkins, B. Eliminating health disparities: Misinformation and misdirections. Program and abstracts of the American Public Health Association 133rd Annual Meeting; December 10-14, 2005; Philadelphia, Pennsylvania. Session 4206.0, Abstract 120659.
3. United Nations. Committee on Economic Social and Cultural Rights General Comment 12: The Right to Adequate Food. May 12, 1999. Available at: http://www.hrea.org/erc/Library/display.php?doc_id=606&category_id=32&category_type=3. Accessed January 13, 2006.
4. Morawa AHE. Vulnerability as a concept in international law. Journal of International Relations and Development. 2003;2:139-155.
5. Weinstein C. Race, gender and war: inhumane treatment and torture of US prisoners. Program and abstracts of the American Public Health Association 133rd Annual Meeting; December 10-14, 2005: Philadelphia, Pennsylvania. Session 3084.0.
6. Dewan S, Roberts J. Louisiana's deadly storm took strong as well as the helpless. New York Times. December 18, 2005. Available at: http://www.nytimes.com/2005/12/18/national/nationalspecial/18victims.html? pagewanted=1&emc=eta1. Accessed January 13, 2006.
7. Fine MJ, Ibrahim SA, Thomas SB. The role of race and genetics in health disparities research. Am J Public Health. 2005;95:2125-2128.
8. AIDS. Haiti Table of Contents. Available at: http://countrystudies.us/haiti/41.htm. Accessed January 13, 2006.
9. Davis RLF. Creating Jim Crow. Available at: http://www.jimcrowhistory.org/history/creating2.htm. Accessed January 13, 2006.
10. Evans D. "You have the right to...Health?" Available at: http://www.medscape.com/viewarticle/499688. Accessed January 13, 2006.
11. United Nations. Universal Declaration of Human Rights. Geneva, Switzerland: UN; 1948. Available at: www.unhchr.ch/udhr/lang/eng.htm. Accessed January 13, 2006.
12. United Nations. International Convention on the Elimination of all forms of Racial Discrimination. Geneva, Switzerland: UN; 1965. Available at: http://www.ohchr.org/english/law/cerd.htm. Accessed January 13, 2006.
13. See, for example, the United Nations Commission of Human Rights resolutions 1994/49, 1995/44, 1996/43, 1999/49, 2001/51.
14. Census Bureau, Census 2000 Brief: Overview of Race and Hispanic Origin, 2000. Available at: http://www.census.gov/prod/2001pubs/c2kbr01-1.pdf. Accessed January 13, 2006.
15. United States Centers for Disease Control and Prevention, Office of Minority Health. About Minority Health. Available at: http://www.cdc.gov/omh/AMH/AMH.htm. Accessed January 13, 2006.
16. United States Commission on Civil Rights. The Health Care Challenge: Acknowledging Disparity, Confronting Discrimination, and Ensuring Equality. September 1999. Available at: http://www.law.umaryland.edu/marshall/usccr/documents/cr12h34z.pdf. Accessed January 13, 2006.
17. Durban Declaration and Programme of Action. Report of the World Conference against Racism, Racial Discrimination, Xenophobia and Related Intolerance; August 31 - September 7, 2001; Durban, South Africa. Updated January 31, 2002. Available at: http://www.un.org/WCAR/durban.doc. Accessed January 13, 2006.
18. Robert Wood Johnson Foundation. Americans' Views of Disparities in Health Care. Available at: http://www.rwjf.org/files/research/Disparities_Survey_Report.pdf. Accessed January 13, 2006.
19. United Nations, Economic and Social Council. Economic, Social, and Cultural Rights E/CN. 4/2003/58 13. February 2003.
20. Pace D. More blacks live with pollution. Associated Press. December 13, 2005.
21. United States Department of Health and Human Services, National Institutes of Health. New Findings on the Willingness of Minorities to Participate in Health Research. [press release]. NIH News. December 6, 2005. Available at: http://www.nih.gov/news/pr/dec2005/cc-06.htm. Accessed January 13, 2006.
22. National Black Women's Health Project, Congressional Black Caucus Health Brain Trust, and U.S. Senate Black Legislative Staff Caucus. National Colloquium on Black Women's Health; April 2003; Washington, DC.
23. Evans D. Human right to health. Program and abstracts of the American Public Health Association 133rd Annual Meeting; December 10-14, 2005; Philadelphia, Pennsylvania. Session 4105.1, Abstract 120250.
24. Robert Wood Johnson Foundation. Americans' Views of Disparities in Health Care. Available at: http://www.rwjf.org/files/research/Disparities_Survey_Report.pdf. Accessed January 13, 2005.
25. Smedley BD, Stith AY, Nelson AR (eds). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academic Press; 2003.
26. LaVeist TA. Minority Populations and Health: An Introduction to Health Disparities in the United States. San Francisco, Calif: Jossey-Bass; 2005: 283-297.
27. Morgen S. Movement-grounded theory: Intersectional analysis of health inequities in the United States. In: Schulz AJ, Mullings L (eds). Gender, Race, Class and Health: Intersectional Approaches. San Francisco, Calif: Jossey-Bass; 2006: 394-423.
28. Mullings L. Resistance and resilience: The Sojourner syndrome and the social context of reproduction in central Harlem. In: Schulz AJ, Mullings L (eds). Gender, Race, Class and Health: Intersectional Approaches. San Francisco, Calif: Jossey-Bass; 2006: 345-370.
29. Livingston M. Political context. Program and abstracts of the American Public Health Association 133rd Annual Meeting; December 10-14, 2005: Philadelphia, Pennsylvania. Session 3315.0, Abstract 120578.

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