Use ‘racial privilege’ — not race — to measure and understand health

When I go to a health care provider and check “Black” for my race or ethnicity, it means that my provider — before even seeing me — knows I have dark skin and “different” hair. But the biases or stereotypes emanating from my answer could include assumptions that I have no husband, limited education, or earn a low income or none.

What would be far more helpful than a “race” checkbox is a racial privilege index.

Such an index would be a score derived from a validated set of questions. This score would align with two drivers of health disparities: race and socioeconomic status. The scoring would be a proxy for how individuals experience their race in America and how their (or their caregiver’s) socioeconomic status contributed to or limited their lives.

A racial privilege score would be the sum of an individual’s lived social experiences, treatment based on race, socioeconomic status, and other factors, similar to how various factors or behaviors produce a credit score.

In Western civilization, race is mainly dictated by skin color. Along with society’s approach to making everything about race, it contributes to racism. This leads to erroneous data collection, particularly in the U.S. health care and public health systems.

Roberta Oiler’s family in Ohio may “look white” to some, but they identify as Black. I identify as Black but have attributes that are often incorrectly synonymous with being white. I believe that these attributes — wrong or right — could affect my health care.

As a Black woman, I sometimes wonder what the “race” checkbox signals, not only in my provider’s office but on a larger scale of data collection describing racial disparities or poor health outcomes. The checkbox to identify my race could be just another way to stigmatize my beautiful brown skin.

“Racial disparities are not a consequence of Black skin but a consequence of treatment because of Black skin,” I continuously tell myself and the students I teach.

In the United States, there are 55.3 deaths per 100,000 live births among non-Hispanic Black people compared to 19.1 per 100,000 live births among non-Hispanic white people. Which gets me thinking: Are maternal mortality rates higher for Black people because their skin is black, or do they have worse maternal mortality rates because of their lived social experiences due to having black skin?

Some Black mothers live with lower socioeconomic status, which can contribute to a host of conditions that can influence pregnancy and childbirth, like buying and consuming lower-quality foods, not participating in regular exercise due to costs and time, working inflexible jobs with long or unusual hours, or arduous labor such as working as a waitress or a maid. They may experience stress from raising Black children in a society filled with historical and current racial violence toward them. These stressful circumstances, in addition to carrying life and giving birth, may contribute to poor health outcomes like preeclampsia in Black mothers.

Racism makes people sick, something both the American Medical Association and American Public Health Association agree on. Both cite racism as a public health threat. It’s time to dismantle race — the foundation and cornerstone for racism — and develop a tool to measure racial privilege, the societal and health privileges a person experiences due to their lived experiences based on their racial identity.

Over the years, I’ve been exploring the concept of racial privilege in several avenues. I developed a course on social determinants of health. My colleague Brandi White and I described how students examine privilege as a social determinant of health. I’ve developed a peer education program that pairs students with lower racial privilege scores with those with higher scores to discuss racial privilege as it affects their lives. I’ve talked about the similarities between Covid-19 and racism in the United States: how insidious racism is to all Americans, regardless of race and skin color. I’ve also submitted a grant proposal to the National Institutes of Health to develop a validated tool to measure racial privilege, though it was not funded.

Despite some successes in trying to establish the concept of racial privilege, it has been an uphill battle pointing out the erroneous way data on race are collected and reported to discuss health disparities in the U.S.

What I envision is a credible set of questions related to one’s lived experiences — instead of their skin color — focused on their physical and social communities that could determine the effect of racial privilege on health outcomes, rather than just using someone’s skin color. Educator and activist Paul Kivel developed a questionnaire to examine class and race. Developing a validated racial privilege questionnaire that examines the relationship between people’s racial privilege scores and their health outcomes is the best way forward. The results could show how Black people, particularly Black women, are treated due to their skin color. I imagine that the results would apply to everyone, regardless of skin color.

Without developing and using a validated racial privilege measure, health care providers and researchers will continue to measure race as one restrictive checkbox that incorrectly characterizes people and disregards the intersection and interconnectedness of race, treatment due to skin color (a poor stand-in for race), socioeconomic status, and lived experiences and their effects on primary care and public health. All public health stakeholders, including patients and people who access various health services, deserve a validated approach to measuring racial privilege. It’s time to dismantle race as we know it.

Elizabeth A. Brown is an assistant professor and director of the bachelor of science public health program at Old Dominion University and a Public Voices Fellow of The OpEd Project.