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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 |
