The most difficult social problem in the matter of Negro health is the peculiar attitude of the nation toward the well-being of the race. There have, for instance, been few other cases in the history of civilized people where human suffering has been viewed with such peculiar indifference.

W. E. B. DuBois penned those words in 1899 in The Philadelphia Negro,1 his groundbreaking exploration of segregation, poverty, crime, urban blight, and African American health and behaviors, arguably the first American sociological study.2,3

Today, 111 years later, there is no end to studies demonstrating how health and illness are patterned along racial and class lines, and how economic and social forces, including racism, shape population health.4-6 Even better, public health and other organizations are now tackling health inequities, not just describing them.7,8 Several of these pioneering initiatives are described eloquently in this special volume.

But, if these initiatives are to expand and be brought to scale and if cross-sectoral coalitions are to be built and health equity put in all policies, sound programs are not enough. Participants in these efforts will have to overcome the "peculiar indifference" noted by Dubois, which still greets news of population health differences and impedes public support for their work. This is as true today as it was back in 1899.

But talking about inequality is challenging, especially racial inequality, as the cognitive scientists at Cultural Logic have argued in 2 seminal essays9-11 and we at California Newsreel have learned in the course of literally thousands of screenings of our documentary series on health inequities, Unnatural Causes.12

The persistence of wide, racialized inequalities in a society such as ours that professes a foundational commitment to equality (Jefferson's "self-evident truths") gives rise to a discomfiting cognitive dissonance. Individuals resolve this dissonance by adopting a frame, or model, to read and "make sense" of the evidence. In one model, unequal outcomes tend to be attributed to systemic factors considered a betrayal of American ideals: economic and social structures that disproportionately channel power, status, and wealth to some at the expense of others. In the more commonly held model, inequalities are attributed to personal responsibility, or in the words of Grady and Aubrun, "the inevitable...results of the different ways in which people lead their own lives."9

The problem for advocates is that while they tend to invoke unequal outcomes as ipso facto evidence of injustice, for most Americans, the same evidence only confirms the normative view that the world is working as it should, reflecting choices made by self-determining individuals. Inequality is unfortunate, yes, but not necessarily unfair or unjust.13-15

During the time of slavery and Jim Crow, many white Americans rationalized racial inequality as a reflection of innate biological differences between "races." For if the Negro were like themselves, argued the late historian Winthrop Jordan, how could they explain the bid on the block, the whip on the back? "Slavery could survive only if the Negro were a man set apart."16,17

In 1896, the same year, the Supreme Court upheld segregation in Plessy v. Ferguson, the American Economics Association published Frederick Hoffman's influential Race Traits and Tendencies of the American Negro. Hoffman's (mis)reading of the data suggested that African American mortality rates were so high that they faced outright extinction. Did Hoffman challenge Jim Crow and embrace other social reforms? To the contrary "It is not the conditions of life but in the race traits and tendencies that we find the causes of the excessive mortality," he wrote.18-20

Today, the idea of race as biology stands largely discredited. Yet, in its place, an essentialized notion of cultural difference plays a similar rationalizing function when it comes to unequal racial outcomes. Negative racial stereotypes remain common, especially regarding African Americans, but also Latinos and Native Americans and Pacific Islanders who are more likely perceived by white Americans as lazy, undisciplined, and unintelligent.21-23

These racial stereotypes have become entwined with the personal responsibility/right choices frame to explain health inequalities: Some people are disciplined and smart enough to eat right, exercise, and abstain from tobacco and drugs. Others do not. Of course, there is some truth to this. Although the choices people make certainly are constrained by the choices they have, many people do make self-defeating behavioral choices, while others, even under adverse conditions, manage to make healthy ones.

But it is only a partial truth. The right choices frame renders invisible how inequities outside the body-in the jobs people do, the wages they are paid, the neighborhoods they inhabit, the power and resources they can access-shape risk factors for all the chronic diseases. It removes individuals from their societal context, reinforces the divide between "them" (those making bad choices) and "us," and stops political action dead in its tracks.11 Right choices allow the poorer outcomes of people of color to be cast as individual failure and cultural dysfunction, not racial and economic injustice demanding redress.

The initiatives described in this volume address some of the difficulties of talking about inequality. Rather than just drawing notice to unequal outcomes, they illustrate how many health outcomes have nothing to do with individual choice whatsoever, refocusing attention on the economic and social structures and institutions that generate and drive those outcomes, what Michael Marmot calls, "the causes of the causes."24 Government and corporate decisions over which individuals have little control can expose them to health threats or health promoters: toxic emissions, corporate shredding of pensions, the quality of schools, where parks and freeways and public transit get built, the wages and benefits jobs pay, whether factories shift jobs overseas, predatory lending, even tax policy. These all shape opportunities to lead healthy and flourishing lives. Why are not these actions also labeled as healthy or risky behaviors and assessed not only in the currency of profitability but also in the currency of health?25

Innovative health equity initiatives also communicate a sense of possibility that unequal outcomes are not "natural," not culturally determined, but rather arise from political decisions that we as a body politic, not just individual bodies, have made and can make differently. Ultimately, health equity is unavoidably a public matter of politics: people working with their neighbors and coworkers and engaging in struggles over how government allocates resources, regulates corporate power, and implements the principles of democracy. By illuminating the causes of inequality and utilizing participatory approaches to mobilize communities, these initiatives may yet arouse public opinion rather than feed more peculiar indifference.

-Larry Adelman

California Newsreel,

San Francisco, California

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