Black people in the United States are at greater risk than their white counterparts of high blood pressure, late-stage cancer diagnoses, and preterm birth. These disparities can’t be accounted for by parsing income, access to health care and genetic risk factors.
In the last decade or so, epidemiological studies have begun to address the elephant in the room: racism. Racism lurks within all of the socioeconomic characteristics researchers analyze, but it’s not easy to measure.
Brittany Chambers, PhD, MPH, an assistant professor in the Department of Epidemiology and Biostatistics, is trying to find ways to reflect the realities of structural and interpersonal racism in public health data. Her research focuses on how exposure to racism leads to chronic stress among Black women, and how that stress contributes to rates of preterm birth that are 50 percent higher than white women’s.
We asked Chambers whether she feels like her head spins sometimes as she tries to untangle racism from the cluster of related factors.
“I feel like it spins all the time,” she said. “That’s one of the limitations of quantitative research. Our institution and the U.S. value it because they’re looking at numbers: What’s the majority, what’s happening with them? But the how is missing.”
Put another way: When a study finds that a neighborhood with higher proportions of Black residents and poverty have worse health outcomes than neighborhoods without, it doesn’t tell us anything about what drives the correlation. Is the neighborhood a food desert? Is it heavily polluted?
Chambers proposes a simple answer to this problem: what insiders call “mixed methods” and others might call talking to people.
From what to why
In one study, Chambers divided a group of low-income Black women in Oakland, California, by neighborhood: least deprived and most deprived, according to a measure called the Index of Concentrations at the Extremes, or ICE, which identifies what portion of neighborhood residents are Black and of very low income in comparison to those who are white and of very high income.
Chambers surveyed the women about the contexts in which they faced interpersonal racism: employment, medical care, in public spaces and other settings. The women who lived in more deprived neighborhoods faced interpersonal racism in more aspects of their lives. It’s not just the factory down the street or the lack of fresh produce that weighs on their health outcomes.
But the women who lived in more racially and economically integrated neighborhoods also encountered racism, making their risks different than those of white women in the same area.
There’s a common critique of efforts to measure racism by asking people about their experiences. Isn’t it too subjective?
“I feel like people’s responses about their experiences are the most important whether they’re biased at the time or not,” Chambers said. “I also feel like all data is that way – even when you think about census data, you go door to door to collect that data. I guess the question is, when it comes to more sensitive topics such as racism, do you trust the people you are collecting data from? Historically Black women have not been trusted. I’m hoping to change that with my work.”
Listening to learn
As California tries to reduce health disparities related to preterm birth, Chambers’ research is employing what is almost a truism in global health: To solve a problem, you have to partner with the people most affected by it.
“That’s an area where I’m trying to change academia a little bit: It’s not really for me to make a decision off of the analysis,” Chambers said. “I’d rather do the analysis, then bring it back to the communities and say, hey, this is what we’re seeing, how should we address it?”
In a project called Supporting Our Ladies and Reducing Stress to prevent preterm birth (or SOLARS), Chambers and co-PI, Anu Manchikanti Gómez, PhD, are using that model. They’re asking potentially childbearing Black and Latinx people to contribute survey and specimen data to help uncover how racism and other stressors get under the skin to contribute to preterm birth. Study participants are involved in data collection, analysis and dissemination of the findings.
Chambers is also partnering with Black women to develop a conceptual framework of structural racism. In a paper under review, women enumerated nine forms of structural racism. These include the usual suspects: discrimination in housing and health care and disproportionate policing. The study also generated the novel idea of “hidden resources” – existing services and resources in which Black women are not encouraged to participate. Chambers is also leveraging the areas of structural racism to work with women to develop policy recommendations on how to dismantle structural racism in their communities.
Looking at the numbers reflecting that white women are far more likely to have at-home births, one would likely hypothesize that education and insurance – both measurable – were the drivers. But Chambers recalls that one participant told her she wanted to have her child at home but was afraid that if something went wrong, she would be blamed and lose custody of her child. Disproportionate policing, a feature of structural racism, is part of the equation. This heartbreaking anecdote hints at the extent to which racism factors into Black women’s determinants of health.
Chambers is already at work, in her K-grant project, on one arena of racism that hits close to home: health care. Black women are identifying characteristics of supportive and inadequate prenatal care; Chambers is asking clinicians who provide prenatal care to recall instances of racism they have witnessed and propose solutions. Chambers will develop training modules for clinicians that support effective interventions to improve racial equity.
“We work at UCSF – we have the opportunity to change medical systems. We get to help inform what policies are implemented within those spaces, particularly if we have scientific evidence to show that it improves outcomes,” she said.