Roberts, D. Fatal Invention chapter 6 PDF

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Copyright © 2011. The New Press. All rights reserved.

Embodying Race

White women in Chicago are slightly more likely than black women to get breast cancer, but black women are twice as likely to die from it. That is a startling statistic by itself. But what is equally as shocking is that in 1980 Chicago’s black and white breast cancer mortality rates were identical: black and white women died at the same rate. Over the course of the next twentyfive years, the astounding gap emerged.1 Consider this additional aspect: the disparity in breast cancer mortality in New York City is only 15 percent. In Chicago, the racial gap is ten times greater than in New York. It is unlikely that genes explain these numbers. Did something change in white women’s DNA between 1980 and 2005 that decreased their likelihood of dying from breast cancer? Is there something genetically distinct about black women in Chicago versus New York that makes breast cancer deadlier? A more logical explanation is that there is something about having breast cancer that changed and that affected black and white women in Chicago differently.

Life and Death in Chicago In 2006, a group of Chicago breast cancer researchers released their study showing the alarming racial divergence in breast cancer deaths. An article in Chicago magazine featured a photo of co-author Steven Whitman, an accomplished epidemiologist with a PhD in biostatistics from Yale who directs the Sinai Urban Health Institute.2 Whitman and the Institute have been at

Roberts, Dorothy. Fatal Invention : How Science, Politics, and Big Business Re-create Race in the Twenty-First Century, The New Press, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/brandeis-ebooks/detail.action?docID=729441. Created from brandeis-ebooks on 2021-01-26 18:32:20.

Copyright © 2011. The New Press. All rights reserved.

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the forefront of documenting health disparities in Chicago. Whitman is pictured holding a giant graph with two lines representing the white and black mortality rates across the 1980s and 1990s. The lines converge at the beginning and remain fairly similar for the first decade, then begin to move apart in the mid-1990s. The space between them gradually widens over the next decade, until they reach the huge gulf between black and white women in 2005. I met with Dr. Whitman on a hot summer afternoon in 2009 to find out why. Whitman’s office in an aging brick building at Mount Sinai Hospital was small and shabby. There was no air- conditioning; a couple of fans blew hot air at us from opposite ends of the room. Whitman began by describing the hospital’s location. Mount Sinai sits in an all-black community called North Lawndale on Chicago’s West Side, a block from the border of South Lawndale, which is predominantly Mexican. “The patient population here at Mount Sinai is about half black and half Mexican. Sometimes, if a white person gets hit by a car down the street, they’ll bring them here, but almost never do white people walk in here and get treated willingly,” Whitman says.3 Whitman tells me that before 1950 all of the residents of North Lawndale were white, mostly Jews from Eastern Eu rope. Then black families began to move into the neighborhood, triggering a white exodus. What followed was a racial metamorphosis in the space of a decade. There were 110,000 white people living in North Lawndale in 1950. By 1960, they were replaced by 110,000 black people. “It’s really extraordinary,” Whitman says. “That’s a migration of 220,000 people, which is larger than most cities in the United States.” When Martin Luther King Jr. brought his civil rights campaign to Chicago, he stayed in North Lawndale. Half the neighborhood was burned down in the riots precipitated by the King assassination, and decades of disinvestment followed. North Lawndale claims only 40,000 residents today. The median income is strikingly below that for the city overall, $28,203 in North Lawndale compared to the $46,767 Chicago average; half the adults are unemployed and uninsured.4 The fate of Mount Sinai Hospital was tied to the neighborhood’s racial transformation. In 1950, the hospitals in Chicago, like the city’s neighborhoods, were segregated by race. When whites fled North Lawndale, Mount Sinai stayed behind, losing its support from white philanthropists and politicians. Its fi nances mirror those of its patients: it is one of the poorest hospitals in the city. Whitman likes to compare the paltry resources at Mount

Roberts, Dorothy. Fatal Invention : How Science, Politics, and Big Business Re-create Race in the Twenty-First Century, The New Press, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/brandeis-ebooks/detail.action?docID=729441. Created from brandeis-ebooks on 2021-01-26 18:32:20.

Copyright © 2011. The New Press. All rights reserved.

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Sinai to the bounty at fancy university hospitals that serve mainly white patients. “To get an A rating for a bond, a hospital is supposed to have 115 days of cash on hand,” Whitman tells me. “Northwestern University Hospital has about 400 days of cash on hand. They probably spend about 5 or 10 million dollars a day. So they have literally a couple billion dollars on hand. Mount Sinai normally is lucky to have one day of cash on hand. The way we measure cash on hand is more often in hours than days. There’s virtually no money.” Whitman believes this backdrop is essential to explaining why black women in Chicago are dying of breast cancer at twice the rate of white women. “The way that happened was the black rate hasn’t changed at all in twentyfive years while the white rate has halved. The improvements in the white rate began to take place just as we began to figure out how to do early detection with mammography. We also began to learn more about treatment— developing medicines and radiation therapy. White women were able to take advantage of these improvements and black women not at all. So what you have is a stunningly painful observation that in twenty-five years black women have gained nothing, not one iota, in terms of breast cancer mortality from any of our advances.” As Whitman sees it, this is a man-made catastrophe for black women: “One hundred and ten black women die each year from breast cancer simply because the black rate is not the same as the white rate. That’s almost half of the black breast cancer deaths. So every week in Chicago, a little more than two black women on average die from breast cancer just because of the disparity. It’s literally a matter of life and death.” What blocks black women from getting the cancer care available to white women? One barrier is that black women do not have the same access to mammography. Black neighborhoods have fewer facilities that provide breast cancer screening. The sole mammogram machine in Englewood, a predominantly black area on Chicago’s South Side, was broken for months. Women were sent ten miles away to get screened. Even the state-of-the-art John H. Stroger Hospital, which replaced Chicago’s aging Cook County Hospital in 2002 and serves many of the city’s poor African Americans, ran up a backlog of more than ten thousand women seeking mammograms.5 Mammograms cost about $150, which can be prohibitive for a woman struggling to feed her children. Medicaid paid only about half of the cost, so many hospitals in Chicago didn’t offer mammograms to women on Medicaid. “What does it mean if you have to take three buses to get to a place that gives mammograms,

Roberts, Dorothy. Fatal Invention : How Science, Politics, and Big Business Re-create Race in the Twenty-First Century, The New Press, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/brandeis-ebooks/detail.action?docID=729441. Created from brandeis-ebooks on 2021-01-26 18:32:20.

Copyright © 2011. The New Press. All rights reserved.

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and then when you get there, you say, ‘Here is my Medicaid card,’ and they say, ‘Sorry, we don’t take that’?” Whitman asks. Many private insurers required co-payments for mammograms. A survey of 366,000 women by researchers at Harvard and Brown medical schools published in the New England Journal of Medicine in 2008 found that copays deter women from getting mammograms.6 “A small co-payment for a mammogram can lead to a sharp decrease in breast cancer screening rates,” says Amal Travedi, the study’s lead author.7 The 2010 Patient Protection and Affordability Act increased women’s access to mammograms by requiring health insurance plans to cover the full cost of biennial screening for women aged fi fty to seventy-four years, the current recommendation from the U.S. Preventive Ser vices Task Force. Lack of trust in a health care system that has treated black women badly for generations is another possible deterrent. “If you’ve been screwed over by the health care system all your life, why would you go?” says Whitman. “It’s one thing if you’re bleeding; you don’t have a choice. But why would you get a preventive test on a stigmatized part of your body if you didn’t trust the health care system?” A second reason is mammogram quality. Even when black women in Chicago get screened, the quality of the mammography tends to be inferior. Compared to white women, black women are far more likely to have their mammograms performed at public facilities and far less likely to be screened at academic institutions. These public facilities usually rely on older equipment and frequently lack digital mammography and trained mammography specialists—both of which are key to diagnosing cancers earlier and more accurately. The opposite is true for most white women.8 One local facility serving poor women was catching only two cancers per thousand instead of the expected six.9 “It wouldn’t matter if every black woman in Chicago could get mammograms if we miss half the cancers,” Whitman said. A third reason has to do with access to breast cancer care. When cancer is detected in black women, they encounter multiple obstacles to high-quality treatment. Neighborhood segregation is the main one. The best treatment facilities are located far from black neighborhoods. Of the twenty-five Chicago community areas with the highest breast cancer mortality rates, twenty-four are predominantly black. Only one of these has a hospital with a cancer program approved by the American College of Surgeons Commission on Cancer.10 “They are located the farthest from the women are who are sickest

Roberts, Dorothy. Fatal Invention : How Science, Politics, and Big Business Re-create Race in the Twenty-First Century, The New Press, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/brandeis-ebooks/detail.action?docID=729441. Created from brandeis-ebooks on 2021-01-26 18:32:20.

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from breast cancer,” Whitman explains. “It’s almost like someone on purpose put the institutions in a different part of the city. Go find the fancy institutions—they are all in white neighborhoods.” Other studies bear out this racial inequity in breast cancer treatment. In 1987, when researchers had begun to notice the decreased survival rate of black breast cancer patients, a team at the National Cancer Institute linked survival rates to the kind of treatment patients received.11 White women were more likely to be treated initially with surgery, which gave them a better chance of survival. Black women were more likely to be treated without surgery or to receive no treatment at all. Twenty years later, this fi nding was confirmed by an Emory University study that analyzed all primary invasive breast cancers diagnosed during 2000–2001 among black and white women living in Atlanta.12 It found that black women experienced longer treatment delays and were less likely to receive the surgical, radiation, and hormonal treatments recommended by established guidelines. In short, black women are diagnosed with breast cancer when it has reached a more advanced stage and is harder to treat, and the treatment they receive is inferior. “I think it’s totally fair to say the system of breast health care in the city of Chicago is killing 110 black women a year,” Whitman concludes.

Copyright © 2011. The New Press. All rights reserved.

Inequality Is Bad for Your Health Unequal access to health care is a major culprit behind racial disparities in health. Building high-quality cancer centers in black neighborhoods— or even just facilities with digital mammograms and specialists to read them— would reduce breast cancer deaths in Chicago. Providing high-quality medical care to everyone is an essential first step to eliminating the appalling chasm in death and disease rates based on race in this country. Yet providing equal access to health care would not be enough to close the racial divide. Nancy Baxter, a surgeon and health advocate at University of Toronto, notes that even the generous Canadian health care system many U.S. citizens envy is insufficient to equalize health in her country. “It would be naive to believe that equal treatment at the point of care could obviate economic, educational and social inequities that, in some cases, have affected our patients not just throughout their lives, but even in utero,” she writes.13 Studies in Canada have found that babies in low-income neighborhoods are more likely to be born premature and underweight, poor children have an increased risk of being

Roberts, Dorothy. Fatal Invention : How Science, Politics, and Big Business Re-create Race in the Twenty-First Century, The New Press, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/brandeis-ebooks/detail.action?docID=729441. Created from brandeis-ebooks on 2021-01-26 18:32:20.

Copyright © 2011. The New Press. All rights reserved.

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treated in an emergency room for asthma attacks, and there is a higher rate of suicide in indigenous First Nations communities. Racial inequality causes health disparities apart from blocking access to high-quality care. It makes people of color sicker in the first place—before they get to a doctor’s offi ce or a hospital emergency room. The only other possible explanation—that there is something inherently different about these groups of people that affects their health—fails, as previous chapters have shown. Neither genetics nor access to health care alone determines an individual’s health because health is affected primarily by the social environment. Throughout your lifetime, your parents’ income and education, the neighborhoods you live in, the schools you attend, the jobs you hold, your experience of discrimination and privilege, and the resources you and your community have ultimately govern how the genetic hand you were dealt is translated into wellbeing. The way society is organized drives group disparities in health. Because they reflect social inequality, a more accurate word for the racial gaps in health is health inequities. As British public health champion Margaret Whitehead defines it, health inequities result from the “systemic and unjust distribution of social, economic, political and environmental resources needed for health.”14 Racism is not just a matter of wounded feelings or an uneven playing field: it determines the life and health of whole populations. It has been firmly established that the best predictor of health is an individual’s position in the social hierarchy. Hundreds of studies tracking the health of people along the social ladder show that health gradually worsens as status declines.15 In any society, people with low socioeconomic status have poorer health than people with higher socioeconomic status. The classic Whitehall Study of British Civil Servants, lasting for more than two decades, compared heart disease and mortality in employees at four civil ser vice levels: administrators, professional and executive employees, clerical staff, and menial workers. As you might expect, the study found that the administrators at the top had far better health than the janitors at the bottom— high status bought them ten more years of life. But it also found that health got worse and mortality increased with each step down the occupational ladder.16 The clerical staff had higher rates of heart disease and early death than their professional supervisors. These social gradients in disease occurred despite everyone’s access to the British universal health care system. The question, then, becomes whether this relationship between economic inequality and health applies equally to America’s glaring racial disparities?

Roberts, Dorothy. Fatal Invention : How Science, Politics, and Big Business Re-create Race in the Twenty-First Century, The New Press, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/brandeis-ebooks/detail.action?docID=729441. Created from brandeis-ebooks on 2021-01-26 18:32:20.

Copyright © 2011. The New Press. All rights reserved.

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Race also produces huge gaps in advantage and disadvantage that parallel the relative health of people in different racial groups. A new field of scientifi c research shows that racial inequality, like income inequality, causes health disparities— and provides the missing factor that many scientists are erroneously substituting with genetic explanations. Understanding this impact requires changing the way we think about the relationship between race and biology. Thomas LaViest, a leading public health expert at Johns Hopkins, surveyed the use of race in epidemiological studies in the 1990s. He found that most of the articles on U.S.-based populations did use race, but the most common use was as a control variable— to fi lter out the impact of race. So while geneticists were homing in on the biological impact of race, epidemiologists were ignoring it. “What is needed is not simply more research onrace,” LaViest concluded, “but better research on race.”17 Thinking on this issue tends to fall into two camps: either race is a social category that has nothing to do with the biological causes of disease, or race is a biological category that causes differences in disease. Both approaches fail to grasp the way in which race as a social grouping can affect health— because of different life experiences based on race, not because of race-based genetic difference. In this sense, race is biological.18 This is where many people get confused. So let me be clear: race is not a biological category that naturally produces health disparities because of genetic differences. Race is a political category that has staggering biological consequences because of the impact of social inequality on people’s health. Understanding race as a political category does not erase its impact on biology; instead, it redirects attention from genetic explanations to social ones. This new conceptual model disrupts the dichotomy between biological and environmental causes of health inequities by suggesting complex biological interactions between racism, socioeconomic disadvantage, and poor health. According to sociologist Troy Duster, “The task is to determine how the social meaning of race can affect biological outcomes.”19 How does racial inequality get under the skin? How is racism embodied? Nancy Krieger, a prominent epidemiologist at Harvard’s School of Public Health, is the leading architect of the science of embodiment. Krieger sparked a revolution in public health research in 1986 when she published a paper, co-authored with public health researcher Mary Bassett, titled “The Health of Black Folk: Disease, Class, and Ideology in Science.”20 Her paper repudiated the leading explanations for high premature death rates among blacks,

Roberts, Dorothy. Fatal Invention : How Science, Politics, and Big Business Re-create Race in the Twenty-First Century, The New Press, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/brandeis-ebo...