There are a number of stressors that impact people on an everyday basis, but according to Amani Allen, none of them compare to the racially-fueled stressors minorities face — which, quite literally, get under one’s skin.
Allen, a social epidemiologist and professor of community health sciences and epidemiology at the University of California, Berkeley, School of Public Health, spoke at the 10:45 a.m. morning lecture Tuesday, July 16 in the Amphitheater, continuing Week Four, “The New Map of Life: How Longer Lives are Changing the World — In Collaboration with Stanford Center on Longevity.”
As a social epidemiologist, Allen studies the social determinants of health.
“By that I am referring to the conditions in which we are all born, in which we all grow, in which we all live, work and play and in which we age,” Allen said.
That definition also includes the broad social systems that determine the day-to-day conditions of one’s life, as well as their life chances and opportunities.
“There are social norms and institutional policies and practices that confer advantages to some and disadvantages to others,” she said.
Allen examines how those life opportunities and chances vary for different groups of people and how, in turn, those differences affect mental and physical health and overall longevity. Specifically, her work focuses on one question: Why do some groups live sicker and die sooner than others?
For example, research has shown that lower socioeconomic groups do “live sicker and die sooner.”
“It’s not just that those at the bottom of the socioeconomic gradient do worse than those at the top, but those almost at the top do worse than those at the very top,” she said.
In epidemiologist Michael Marmot’s Whitehall Study, he put forth a social gradient measuring mortality rates. The study showed that those in the lowest occupational grade have the highest mortality rates and that those in the highest occupational grade have the lowest mortality rates.
Allen said this pattern, a “global phenomenon,” is seen in terms of income, education, occupation and wealth.
“This gradient tells us that health and longevity is about more than having just enough subsistence to take care of our basic needs,” Allen said. “Otherwise, we would only expect to see higher mortality rates in only the lowest socioeconomic category, but that’s not what we see.”
Allen said some argue that the social gradient is “psychosocial in nature,” meaning it is related to one’s subjective experience of their social status.
“In other words, there is something about our social position relative to others that matters for health, or that causes us psychosocial stress,” she said.
Others argue that social position not only determines whether one has access to health resources such as housing, food and access to quality health care, but also determines their level of access to those resources, which then determines their ability to avoid health risks and maximize well-being.
In terms of race, Allen said there is substantial evidence to prove that African Americans live sicker and die sooner than any other demographic. That pattern is seen among a majority of the leading causes of death: cardiovascular disease, stroke, diabetes and various cancers. But the pattern is not just apparent at the end of life — it is also seen in early life with premature birth and low birth weight, which sets the stage for health problems over a life span.
When explaining these persistent racial disparities, Allen turns to the “usual suspects.” At the top of that list is socioeconomic status.
Given the socioeconomic differences between black people and white people, many scientists have examined whether racial health disparities are really a question of socioeconomic differences between groups.
“However, despite the very powerful and persistent role of socioeconomic status in predicting health, as we just saw with the social gradient, it falls far short in explaining racial disparities in health,” Allen said. “Racial disparities exist despite socioeconomic status.”
Allen said there is something unique about the “experience of race” in the United States that impacts health. Although socioeconomic status, genes, access to health care and behavior matter in improving health, they don’t adequately explain health disparities.
But it doesn’t end with race, either. Allen can predict a person’s life expectancy using their zip code. Allen was born and raised in Washington D.C., where there is an eight-year difference in life expectancy depending on where in the city someone lives. Those disparities extend globally, as well. For example, black men in Harlem have a shorter life expectancy than black men in Bangladesh.
“A startling statistic, but a true one,” she said. “The United States is the richest of all industrialized nations and spends the most per capita on health care globally. So why are there places in the United States, such as some of our southeastern states, where maternal death rates exceed those of sub-Saharan Africa? We should not see such dire health outcomes in the wealthiest nation in the world, not for any group.”
When considering the differences between white people and black people, there is also a long-standing disparity in infant mortality. Allen said some would argue it is due to socioeconomic status, but college-educated black women have higher rates of infant mortality than white high school dropouts.
“For a long time, the focus on race, socioeconomic and gender differences in health focused on documenting differences in life expectancy or mortality rates, which somewhat prove the very sensitive and powerful predictors of population health,” she said.
The majority of this research Allen is referring to focused on binary disparities: men versus women or black people versus white people. One common observation was what scholars call “the gender and health paradox.”
“That (paradox) is that women live longer than men, and they have a longer life expectancy and lower mortality rates,” she said. “However, they also lived sicker lives. So when life expectancy was the primary indicator used to assess population health, the narrative was that women are doing better than men, that we don’t have to worry about women.”
That assessment was called into question when scientists started to look at measures of morbidity such as quality of life, functional limitations, disabilities and chronic diseases. Another common observation was that across almost all indicators of health, black people fared worse than white people. These findings portray what scholars call “weathering,” or the “premature aging and earlier health decline experienced among blacks.”
Allen showed a graph supporting her claim that the decline in health accumulates over the entire life span as a consequence of “persistent psychosocial and environmental stress associated with a marginalized social status in society.”
“This concept of weathering is really about how these conditions determine life chances and opportunities and structures differently for different groups, and how those differences become embodied, how they get under our skin to impact differences in health and longevity,” she said.
When thinking about the totality of one’s life experiences, Allen said it becomes clear that a person is more than just their race, gender or socioeconomic status.
“We are each our race and our gender and our socioeconomic position and our age and so on,” she said.
Allen, for example, is an African American woman with a high level of education, who lives in a racially integrated, middle-class neighborhood and works in a primarily white, male-dominated environment — all factors that impact her day-to-day experiences.
In some spaces, like work, Allen’s race, profession, education and gender are visible. But in her community, only her race and gender are visible.
“That matters in terms of how I am viewed in society, and how I am viewed determines my day-to-day social experiences,” Allen said. “It determines how I am perceived by others and importantly, how I am treated by others by society, by institutions, etc., which all have an impact on my mental and physical health. It does for all of us, whether we realize it or not.”
Scholars and scientists started to use “an intersectional lens” to examine health disparities. So instead of examining one aspect of social identity, they examined how multiple aspects impact socialization and health.
Because humans are social creatures, Allen said binary comparisons can mask the true nature of social disparities. Allen recalled an example of mortality rates declining among black people in recent years. But what researchers didn’t see was that mortality rates were increasing for white women at the same time.
Many scholars are now examining the “biology of disadvantage,” or how aging disparities are attributed to persistent psychosocial and environmental stress. The stress associated with disadvantaged social status has the ability to disrupt physiological systems in ways that damage health over time.
“Numerous studies, including my own, have shown a relationship between social stress and dysregulation of biological systems responsible for maintaining optimal physical functioning, such as our cardiovascular system, our metabolic system and our immune system,” she said.
Allen’s research specifically focuses on how the stress from racism plays a role in weathering among African American women. In a survey, Allen found that African American women report racial discrimination as a “particularly salient form of stress.” They also described racism as a persistent stressor, with many of their first encounters with racism taking place in early childhood.
Allen recalled her first encounter with racial discrimination. In kindergarten, she was approached by a white girl who tried to rub the “dirt” off her skin. Although Allen realized the girl did not intend to hurt her, she doesn’t want people to dismiss the girl’s ignorance.
“Let’s not make a mistake that ignorance about the impact … excuses the impact that it has on people,” she said.
In response, Allen’s mother enrolled her and her sister into an African charter school in D.C. where she developed a sense of pride in herself and in her African American heritage.
“Despite that, throughout my life, the sense of pride that I had about who I am and where I come from has always existed alongside, or perhaps under, a mantle of marginalized status in society, in classrooms, in colleges, at work, in restaurants, in shopping malls and even when trying to hail a cab,” Allen said.
Allen has heard similar stories from women all over the world. Women tend to report more psychological stress due to racial discrimination based on their own experiences and the experiences of those around them.
Although it is certain that African American women are experiencing premature aging, it has not yet been proved that racial discrimination is the key factor. That’s where Allen’s work comes in. Allen runs the Health Effects Associated with Racism Threats research group at the University of California, Berkeley. HEARTS investigates racism as a social threat and how that threat affects the body.
In addition, Allen and her students have been studying the effects of weathering in two ways.
First, Allen’s team studied allostatic load, the measure of cumulative biological dysregulation as a result of chronic stress.
“We are talking about the dysregulation across multiple systems of the body that leaves us more at risk for a variety of health outcomes regardless of whether it’s heart disease, stroke, diabetes or cancer. Allostatic load has been linked to all of it,” she said.
Regardless of gender, black people have a higher percentage of allostatic load than white people. Regardless of race, women also have a higher percentage of allostatic load, but there is a greater disparity among black people than white people than there is between men and women.
Second, Allen’s team studied telomeres, protein complexes that prevent the instability and degradation of cells. Generally, the longer the telomere, the healthier a person is.
“There is research showing that African American women experience an accelerated rate of decline or shortening of their telomeres over their life span,” she said.
Through a partnership with the HER Lab in San Francisco, Allen’s research group found that racial discrimination was associated with allostatic load, telomere length and hypertension among African American women. They also discovered that racial discrimination in adolescence may be more impactful than experiences later in life.
Although Allen recognizes there is much more research to be conducted, she said there is more than enough to know that when it comes to health and longevity, vast disparities exist between social groups.
Ultimately, Allen said the public health industry has put too much emphasis on fixing people.
“That’s what we like to do in public health, we like to tell people how to eat better, how to exercise; we like to tell them what to do as if they don’t already know,” she said. “But when we think about our neighborhoods, our work environments, etc., it is important to think about how the environment in which we live, work and play, constrains our opportunity to engage in healthy behavior.”
As public health focuses on fixing people, Allen believes officials need to remember that for every person they fix, there is a new person entering the population, which is why there is an unchanged rate of disease.
“It is only going to be by addressing groups or fundamental causes of health, which are not people, but the structures in which people live, work and play, that we will be able to identify the most promising strategies for addressing health equity,” Allen said.