*745 II. ETIOLOGICAL REDUCTIONISM: SEARCHING FOR MICRO CAUSES IN A MACRO WORLD
Scientific research attempts to identify causes rather than just associations. Biomedical scientists search for the precise causal or etiological pathways of disease and health status. This model has worked well in many infectious diseases categories such as influenza, malaria and AIDS, as well as chronic diseases such as cancer and diabetes. But etiological reductionism can be misleading when applied to race and health.
Researchers generally consider socio-economic status (SES) factors, such as income and education, as confounding variables, to be adjusted for and controlled in any experiment to determine if any residual impact of race remains. But in the United States, Blacks suffer disparities in most SES variables such as income, wealth, education, insurance, occupation, and housing. If race (or racism) is prior or antecedent, then all of these SES variables are co-morbidities or simultaneous symptoms rather than confounding variable. Black disparities of all types may point to a deeper social problem. The cause may be macro rather than micro, obscured by reductionist methodology.
For example, assume a study is undertaken to determine the cause of large health differences between Group X and the general population. Group X is a minority racial group, and suffers much higher morbidity and mortality rates. Members of Group X are overwhelmingly poor, lack health insurance, are disproportionately unemployed, live in unsanitary housing, are poorly educated and otherwise occupy the lowest quintile of any socioeconomic indicator, all resulting from persistent racial discrimination. Adjusting for all of these variables may well show that Group X suffers no racial health disparities, but the overall conclusion would be false. Aggressive adjustment for confounding variables may obscure the relationship between health and race, “treat[ing] race-associated differences as nuisance confounders rather than as important clues to be mined.”
*746 The Institute of Medicine study committee recognized this methodological issue, even as they followed their Congressionally-mandated definition of disparity:
To a great extent, attempts to separate the relative contribution of these factors risks presenting an incomplete picture of the complex interrelationship between racial and ethnic minority status, socioeconomic differences, and discrimination in the United States. For example . . . racial and ethnic housing segregation is a by-product of both historic and contemporary racism and discrimination, as well as socioeconomic differences (itself the legacy of poorer opportunities for many minority groups). The committee therefore stresses that attempts to “parcel out” access-related factors from the quality of healthcare for minorities remains an artificial exercise, and that policy solutions must consider the historic and contemporary forces that contribute to access to and quality of healthcare. Almost all of the rigorous studies examined in Unequal Treatment demonstrated reduced disparities after controlling for SES variables, although most still found remaining racial disparities. The annual National Healthcare Disparities Report issued by the Agency for Healthcare Research and Quality generally reports racial disparities in health measures without adjustment for SES, although it does occasionally present multivariate analyses which adjust for age, gender, *747 household income, education, insurance and residence location. The 2004 National Healthcare Disparities Report recognized that race, health and SES indicators are highly correlated in American society, but nevertheless adjusted for SES in a few categories. Adjusting for SES may underreport the true scope of the Tragedy of Black health in America.
The alternative to etiological reductionism is to treat Black disparities in health and SES as co-morbidities rather than confounding variables. Black disparities of all types point to deeper problems in our society. This approach is similar to that taken by Dr. Paul Farmer. He does not shrink from the “biosocial realities” of health disparities, but includes all available data, “linking molecular epidemiology to history, ethnography, and political economy.” To Farmer, “inequality itself [has] become a pathogenic force.”
This Article now leaves questions of etiology behind, with the suspicion that Black disparities in both health and SES may share a common cause, grounded in American history. The next section examines the history of racism in American health care, paying particular attention to the role of governments as state actors in endorsing or permitting disparities in Black health care, and the continuity of Black health disparities from slavery to the present day. These themes become important when we turn to Black reparations. Readers intimately familiar with the history of Black health in America may wish to skim forward to Section IV.
