Levels of Racism

The author introduces a theoretical framework to understand racism across three levels: institutionalized, personally mediated, and internalized.
This framework aids in formulating hypotheses about race-associated health outcome differences and designing interventions.
An allegory of a gardener with two flower boxes illustrates the relationship between these three levels of racism.

Race-associated differences in health outcomes are consistently documented but often poorly explained.
Many scientists adjust for race or limit studies to one racial group instead of exploring the basis of these differences.
Ignoring these differences impedes scientific advancement and perpetuates ideas of biologically determined racial differences.
Race is a proxy for socioeconomic status, culture, and genes, capturing social classification in a race-conscious society.
The race noted on a health form reflects its impact on daily life experiences, making "race" a social construct reflecting the impacts of racism.
Some researchers hypothesize that race-associated health outcome differences result from racism.
The Department of Health and Human Services' Initiative aims to eliminate racial and ethnic disparities in health by 2010.

The framework encompasses institutionalized, personally mediated, and internalized racism.
It helps in raising hypotheses about race-associated differences in health outcomes and designing effective interventions.

Defined as differential access to societal goods, services, and opportunities by race.
It's normative, sometimes legalized, manifesting as inherited disadvantage.
It is structural, codified in institutions of custom, practice, and law, often evident as inaction in the face of need.
Manifests in material conditions:
- Differential access to quality education, sound housing, gainful employment, appropriate medical facilities, and a clean environment.
Manifests in access to power:
- Differential access to information, resources, and voice.
The association between socioeconomic status and race in the U.S. originates in historical events but persists due to contemporary structural factors.

Defined as prejudice and discrimination.
- Prejudice: Differential assumptions about abilities, motives, and intentions based on race.
- Discrimination: Differential actions towards others based on race.
This is what most people think of as "racism."
Can be intentional or unintentional, including acts of commission and omission.
Manifests as:
- Lack of respect
- Suspicion
- Devaluation
- Scapegoating
- Dehumanization

Defined as acceptance by stigmatized races of negative messages about their abilities and worth.
Characterized by not believing in others who look like them and not believing in themselves.
Involves accepting limitations to one's full humanity.
Manifests as:
- Embracing "Whiteness"
- Self-devaluation
- Resignation, helplessness, and hopelessness

An allegory illustrating the relationship between the three levels of racism.
Uses the story in teaching and public lectures.
Two flower boxes are on the front porch of a house in Baltimore.
In spring, the decision is made to grow flowers in the flower boxes.
One box is empty, filled with potting soil.
The soil in the other box is assumed to be fine.
Seeds from a single seed packet are planted in both boxes.
Seeds in the new potting soil flourish.
Seeds planted in the old soil do not fare well because the old soil was poor and rocky.
The difference illustrates the importance of environment.
A gardener has two flower boxes: one with rich, fertile soil and another with poor, rocky soil.
Two packets of seeds for the same type of flower: pink and red blossoms.
The gardener prefers red over pink, planting red seeds in rich soil and pink seeds in poor soil.
Red flowers flourish, while pink flowers struggle.
The flowers go to seed, and the same thing happens the next year.
Ten years later, the gardener observes the vibrant red flowers and scrawny pink flowers, reinforcing her preference.

Illustrated by:
- Initial historical insult of separating seeds into different soils.
- Contemporary structural factors of the flower boxes.
- Acts of omission in not addressing soil differences.
Normative aspects:
- The gardener's initial preference for red over pink.
- Assumption that red is intrinsically better than pink contributes to blindness about soil differences.

Occurs when the gardener disdains the pink flowers and plucks them before they go to seed.
Or when a pink flower seed is blown into rich soil, and she plucks it out.

Occurs when a bee comes to pollinate the pink flowers, and the pink flowers reject the pink pollen, preferring red.
The pink flowers internalize the belief that red is better because they see the red flowers flourishing.

Addressing internalized racism by telling pink flowers, "Pink is beautiful!" may not change their living conditions.
Addressing personally mediated racism by convincing the gardener to stop plucking pink flowers may or may not work.
Addressing institutionalized racism is key:
- Break down the boxes and mix the soil.
- Leave boxes separate but fertilize the poor soil.
When institutionalized racism is addressed, pink flowers will grow as strong as red.
The pink flowers will no longer think red pollen is better.
The gardener's children will be unlikely to develop the same preferences.

Illustrates the relationship between the three levels of racism.
Institutionalized racism is fundamental and must be addressed for change to occur.
Once institutionalized racism is addressed, other levels may cure themselves over time.

The gardener has the power to decide, act, and control resources.
In the U.S., the gardener is the government.
There is danger when the gardener is not concerned with equity.
The Initiative to Eliminate Racial and Ethnic Disparities in Health by the Year 2010 is lauded.

What is the role of public health researchers in exploring disparities?
How can we get the gardener to invest in the whole garden?
How can the pink flowers recruit or grow their own gardener?
The reader is invited to share this story to start a national conversation on racism.