Introduction to the Special Issue
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- Gehlert, S. & Hudson, D.L. Race Soc Probl (2013) 5: 79. doi:10.1007/s12552-013-9096-8
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In the late 1970s, Stephen Jay Gould (1978) reviewed the notes used by Samuel George Morton to support his 1839 classification of races (1839) and found what he considered to be serious methodological flaws. Morton had concluded that Caucasians had larger brains, and therefore higher intellectual capacity, based on the measurement of the cranial capacities of skulls that Gould considered to be biased. Heated debates about the meaning of race, specifically whether it is a biological reality or socially constructed, continue to this day (Bamshad et al. 2004; Braun and Hammonds 2008; Gravelee 2009).
Needless to say, whether race is biological has major implications for how it is used to understand the nature and extent of the group differences in health seen in the United States. Further, although we have made some progress in our understanding of how race, social factors, and biology might interact to affect health in the United States, our understanding remains imperfect.
There is general agreement that the causes of group differences in health, variously referred to as health disparities, health inequities, and health inequalities, are multifactorial, with contributions from the societal to the cellular levels that interact in ways not yet fully understood (Gehlert and Colditz 2011). A conceptual framework developed by Warnecke et al. (2008) includes three primary levels of determinants, namely distal, intermediate, and proximal. Distal determinants include determinants whose roots are embedded in shared social norms about health or social practices and social disadvantage. Intermediate determinants include the social and physical contexts in which the distal determinants are experienced. They are the links through which the environment affects individual demographic factors and the biological responses that make up proximal determinants. The latter includes individual behaviors and biological and genetic factors such as ancestry. Most would agree that improving population health relies on critically evaluating determinants at each of these levels and the complex ways in which they interact with one another (Gehlert 2013). Decades of research focused primarily on the level of individual health behavior (i.e., proximal factors) without considering how behavior influences and is influenced by neighborhood, community, and societal factors.
The articles in this special issue of the Journal of Race and Social Problems contribute to our understanding of race and health in three basic ways by: (1) critically examining constructs such as race and socioeconomic status in health research, (2) considering newly conceptualized social determinants of health, and (3) advancing our understanding of how determinants at different levels interact with one another to affect health. We have brought together a group of junior and senior scientists who advance science to examine these issues. To ground our inquiry, Batai and Kittles bring us up to date on scholarship on race, genetic ancestry, and health. The two authors critically examine a key issue raised by previous researchers such as Braun, Hammonds, and Gravelee, namely how to recognize the influence of shared ancestry in a way that does not reify race. Using a similar level of inquiry, Sacks examines the intersection of socioeconomic status, race, and health. After a critical discussion of how the components used to measure socioeconomic status (i.e., income, education, and professional status) might differentially affect the health of African American women, this emerging scholar investigates the health experiences of a sample of middle socioeconomic status women to provide detail on what occurs within a socioeconomic stratum. Recent studies by Ohlshanksy et al. (2012) suggest the need for such work by demonstrating that gains in education (a commonly used measure of socioeconomic status) might produce different benefits in life expectancy for different racial groups.
Articles by Hausman and a multi-site group of scholars led by Margaret Hicken provide new detail on the social determinants of health among African Americans. Hausman looks at the effect of discrimination on health, while Hicken and colleagues indagate how the built or physical environments in which African Americans live affect their health by producing perseverative cognitions that negatively affect sleep patterns. Work such as this helps us to better understand the mechanisms by which living in certain neighborhood and community environments affect biology and health to increase health disparities.
Jones and colleagues look at interactions between the health care system and the health behavior of individuals. Specifically, they examine how engagement in preventive health behaviors by African Americans is affected by their perceptions of health inferiority and physician racial bias. This work is important because it suggests the reframing distorted cognitions in the form of perceived African American health inferiority as a potential target of intervention.
In a previous special issue of the Journal of Race and Social Problems (Special Issue on Race and Mental Health, Volume 3, Issue 3, October 2012), Jackson (2011) noted that underrepresented racial minorities often arrive at adulthood and later life with extensive histories of disease and a variety of individual reactions to their poor health. Spencer and his colleagues move us closer to translating research knowledge to decrease health disparities in the community in a way that recognizes how closely physical and behavioral health are connected to one another. Their community health worker lifestyle intervention for Latinos and African Americans with type 2 diabetes, which incorporates principals of community-based participatory research, integrates treatment for diabetes with treatment for the behavioral health problems that often accompany it in a way that improves outcomes for both.
A recent publication by the National Research Council and Institute of Medicine provides evidence of health in the United States versus that of other industrialized countries (Woolf and Aron 2013). The data are sobering. A comparison of the life expectancy at birth of the United States and 16 peer counties, for example, finds the United States to rank 17th for males and 16th for females (Woolf and Aron 2013). Implementing a more inclusive understanding of how the distal, intermediate, and proximal determinants of health interact with one another can be expected to improve the health of the population as a whole, above and beyond decreasing group differences in health. The six papers in this special issue of the Journal of Race and Social Problems have the potential to move us toward the holistic and nuanced understanding of the determinants of health in the United States that is needed to decrease health inequalities and to increase the health of all residents.