Racism and the Social Determinants of Equity: Camara Jones at Beyond Flexner 2015

At the recent “Beyond Flexner 2015” conference in Albuquerque, one of the featured speakers was Camara Phyllis Jones, MD, MPH, PhD. Dr. Jones, a family physician and epidemiologist, is Senior Fellow at the Satcher Health Leadership Institute at Morehouse School of Medicine in Atlanta, and formerly with the Centers for Disease Control and Prevention (CDC), and is currently President-Elect of the American Public Health Association, APHA. (Her election site contains a good biography, and this segment from “Unnatural Causes” a superb interview.) I was truly honored to meet her the day before (we were in the last row of a van headed to visit a clinic in Albuquerque’s International District; she told me her name and I responded with “the Camara Jones?!”) because I have long admired her work, and have used her “Cliff Analogy” for the Social Determinants of Health (SDOH) regularly in lectures to medical students, as well as in this blog (e.g., “Delmar Boulevard, Geo-mapping, and the Social Determinants of Health”, August 16, 2014; ACA after the election: Is it is the "fiscal cliff" or the social cliff that matters to people?”, November 17, 2012).

In brief, the Cliff Analogy portrays the healthcare system as a cliff face, which may or may not have a fence to keep people from falling off (primary prevention), a safety net part-way down to catch those who fall before they hit the ground (secondary prevention), and an ambulance to take them to the hospital at the bottom (tertiary “prevention”). The presence or absence of these, and how fast the ambulance comes, impacts access to health care. But along the top of the cliff, the nearness to the edge represents the social determinants of health, how vulnerable people are to falling off, how their life circumstances (poverty, housing, food, education, dangerousness of where they live) make it much easier for a gust of wind, or tripping (or a disease) to not just knock them down but throw them over the cliff.

It is a powerful and effective method of illustrating the SDOH, but Dr. Jones has other allegories that are also effective, in particular in describing the various forms of racism that exist within our society, and the impact of them on the lives and health of people. Several of these are presented in her wonderful TED talk, given at Emory University in 2014. She describes 3 levels of racism: institutionalized racism that, whether through laws or common practice, keeps its victims down in the underclass with less opportunity and hope; personalized racism, the actions and attitudes of people that perpetuate racial victimization; and internalized racism, by which members of the oppressed group come to believe in their own inferiority, that “the white man’s ice is colder”. All of these are important; efforts to demonstrate that “black is beautiful” and “I am somebody” can work to combat the psychological stigma from internalized racism, but without structural change can go only so far.

Dr. Marc Nivet, Chief Diversity Officer of the Association of Medical Colleges (AAMC), gave an earlier speech, in which he also provided a powerful metaphor, of opportunity in America being an escalator or a staircase. In it he describes the children of the privileged as having an escalator to take them to the top; even if they “bump their heads” or otherwise falter and fall back, it will continue to bring them quickly back up. Others, the children of the poor, have to climb the stairs, and when they fall it is a long and difficult way back up; they have to run very fast and are unlikely to ever catch up. This is a great way of illustrating not only the social determinants of health but of opportunity; it provides a dynamic metaphor to accompany the famous quote from former University of Oklahoma football coach Barry Switzer that “some people are born on third base and think they hit a triple”. Dr. Nivet includes his own children in those who are on the escalator; since he is African-American, this might be seen as support for the argument that the difference in opportunity is due to class (or as Americans like to call it to make it sound more random and less generational, “socioeconomic status”) rather than race.

But Dr. Jones asks us why people of some races are disproportionately represented in the lower class; she coins the phrase “the Social Determinants of Equity”. She helps illustrate this with “the Gardener’s Tale”, beginning with a (possibly true) story of when she and her husband bought their first house, with a lovely wrap-around porch with many flower boxes. In Spring, they discovered only some had soil, so they went and bought potting soil to fill the others, and planted marigolds in all of them. But some weeks later some plants were doing great, and others were struggling; it was clear that those in the old rocky soil were not on a par with those in the new soil. To be sure, some seeds in each box were stronger and doing better than others, but the strongest flowers in the poor soil could barely keep up with the weakest in the good soil.

And what if the gardener decides to plant red and pink flowers, but likes red better, and plants them in the good soil? And when they do better, s/he says “See? I knew red were better!”. And, if the flowers were perennials and went to seed and regrew each year, they would perpetuate, if not worsen, the difference, the inequity. And if the gardener said “these pink flowers are going to do poorly anyway”, and deadheaded the weakest, allowing them no chance at all? And in future generations if her children and grandchildren always grew up knowing that red flowers did better than pink? But why, someone asks Dr. Jones (not in this conference!) should the red flowers give up or share their soil?

Because, she answers (obviously, at least to many of us), the soil does not belong to the red flowers, although they have benefited from it, but to the gardener. It could easily be redistributed by her, and the flowers would have an equal chance to grow. Maybe generations of selection would take a few years to compensate for, or maybe because only the stronger pink seeds survived, they would do even better than the red given the chance to have the same opportunity to grow. We cannot be sure until that opportunity is comprehensively and completely available.

Dr. Jones’ allegories are very helpful in increasing our understanding.

• We cannot truly improve health without addressing the Social Determinants of Health.
• We cannot address the impact of racism without recognizing its many faces and forms, and its self-reinforcing nature.
• We cannot adequately remediate the effect of class upon health without changing how some people and groups are disproportionately represented in the underclass, the Social Determinants of Equity.

Dr. Jones’ allegories can help us understand, but real change will take concerted and sustained action.