Race, Health Care and the Law 
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Women of Color In Health Disparities Policy

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Vernellia R. Randall
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 Lisa C. Ikemoto

Excerpted from: Lisa C. Ikemoto, In The Shadow Of Race: Women Of Color In Health Disparities Policy , 39 U.C. Davis Law Review 1023 -105, 1025-128 (March, 2006) (123 Footnotes)


At various times, federal health policy has taken aim at reducing the role of racism and patriarchy in health and health care. For the most part, it has done so by treating racism and patriarchy as separate targets. Until recently, most federal initiatives that have addressed the health needs of women of color have done so incidentally, not expressly. Women of color, in other words, have not figured significantly on the federal health agenda.

In broad terms, the health arenas that racism and patriarchy mediate include biomedical research, health care access, and quality of care. Federal initiatives have sought to intervene in each of these arenas. For example, federal efforts have required the inclusion of women in clinical trials, conditioned federal funding on racial desegregation of hospitals, and, more recently, provided guidelines for culturally and linguistically appropriate services in health care. Each of these arenas, in turn, has implications for health status. The state of one's health, or one's group's health, is partly a function of the availability of biomedical knowledge, access to health care, and the quality of care received.

Critical Race Feminism's two most basic insights tell us that antiracist and feminist projects that fail to explicitly examine the synergistic effects of racism and patriarchy tend to default to androcentrism and white privilege, respectively, and that any gains these projects achieve fail to trickle down to women of color. In the context of health care, the core failure -- inattention to the intersections of categories used for social ordering -- leaves the particular ways that racialized patriarchy allocates health risks to women of color out of sight and out of mind. In practice, the inattention means that health needs particular to women who are African American, Latina, Native American, Native Alaskan, Pacific Islander, and Asian American will receive less attention and fewer resources than other members of society.

Tracking the history of the federal government's efforts to intervene in the operation of racism and patriarchy in health care shows that these efforts were limited and very much of their times. Each period's initiatives used the then-dominant antidiscrimination paradigm. For example, antiracist efforts in the 1960s focused on racial desegregation, a key goal of that era's fight for civil rights. More importantly, for purposes of this analysis, the history shows that federal initiatives to reduce the role of racism and patriarchy have been almost wholly separate and that the health needs of women of color have, in fact, remained largely out of sight and out of mind.

In the 1990s, the federal government launched a series of initiatives aimed at "health disparities," or population-based differences in health status and health care. The health disparities initiatives ostensibly aimed to reduce differences by "race, ethnicity, gender, education or income, disability, geographic location, and sexual orientation." Many hoped that the multi-axis approach to disparities would prompt a deep examination of how sociopolitical differences allocate health risks among us, and that the examination would yield an understanding of how those differences operate as markers "for differential exposure to multiple disease-producing social factors" both inside and outside the health system. That kind of critical approach would place women of color, as well as many other groups, on the federal health agenda.

The historical examination and a critical analysis of the disparities approach show that three limitations have thus far stymied the promise of developing a multi-axis approach to health disparities. In the 1990s, the disparities approach focused on data-based differences in health status by race and gender. There was relatively little effort to gather data on other potential sociopolitical bases for health disparities, or to examine the role of discrimination as a contributing factor to health disparities. As a result, other explanations, such as biological race, socioeconomic status, and "lifestyle" became the prevailing explanations for statistical differences in morbidity and mortality among racial groups. Even less effort was made to account for health disparities particular to women of color because they appeared primarily as a statistical subcategory of race. More recently, policy makers have recognized that racism is a significant contributor to health disparities among racial groups. At the same time, however, the scope of the inquiry into health disparities seems to be narrowing. Race is becoming the sole focal point. The narrowing scope of the health disparities inquiry threatens to constrain the understanding of health, as well as to push the health needs of women of color and others back into the shadows.

Finally, to the extent that the disparities efforts acknowledge racism's role in creating health disparities, the understanding of how racism operates and the proposals to reduce health disparities have been primarily structuralist. They focus on organizational structures, practices, and the formal and informal rules of health care institutions. Accounts of how racism affects health care access and quality of care acknowledge the complex, interactive nature of stereotyping and lead to proposals for organizational change, such as affirmative action, to eliminate the problems. While structuralist analysis is good at identifying opportunities for legal intervention, an exclusive focus on health care organizations and practices fails to fully account for how orders of power formed by racialized patriarchy can persist despite the dismantling of specific institutional structures and practices.

Critical analysis of cultural formation sheds light on this phenomenon. As many others have shown, critical cultural inquiry is sensitive to multi-axis difference, differential subordination, and the fact that ideology, including racialized patriarchy, adapts quickly to structural change. Critical theory's attention to ideology allows for a more nuanced and complicated understanding of how inequality becomes embedded in our understanding of "health."

In Part I, I track the federal government's initiatives to reduce the role of racism and patriarchy in health care from the 1940s to the 1970s. I focus on the ways in which race and gender differences have been framed within federal health policy and the resulting inattention to the health needs of women of color. In Part II, I describe the federal government's return to examining the role of difference in health care in the mid-1980s and the subsequent emergence of a "health disparities" approach to that work. The new disparities paradigm focused on quantifiable health status differences among sociopolitical population groups. I argue that the tendency to decontextualize the data de-linked race from racism and thus precluded that work from providing a substantial account of health disparities. In addition, while the disparities approach held the potential to develop a multi-axis approach to the role of difference in health care, the commitment to examining anything other than the role of race wavered. As a result, women's health initiatives and minority health initiatives have remained largely separate endeavors. Part III tracks the most recent shift from an understanding of "disparities," in which racism and patriarchy received little attention as explanations, to an emerging understanding which recognizes racism as a significant contributor to health disparities. I argue that despite the necessity of re-linking race and racism in disparities research, the disparities work is still hampered by the past. The analysis of racism remains primarily structuralist, and race seems to be the only axis of difference at issue in disparities research. I describe the resulting proposals for institutional change and argue that the resulting structuralist discourse, as well as the near-exclusive focus on race, may inhibit efforts to place the health needs of those not privileged in the categories of "race" and "gender" on the national health agenda. In Part IV, I sketch an analytical approach that combines the strengths of structuralism and critical cultural inquiry. This approach holds greater potential than structuralism alone to deepen understanding of the roles that difference plays in health and health care, and to move beyond the traditional race-only civil rights analysis in health


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Professor Vernellia R. Randall
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The University of Dayton School of Law
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