Virginia’s New Race-and-Healthcare Dogma

Colin Greene. Photo credit:

by James A. Bacon

It is now outside the bounds of acceptable discourse in Virginia to question the proposition that “structural” racism accounts for health disparities between racial/ethnic groups.

Virginia’s new health commissioner, Colin Greene, has been called on the carpet for expressing the view that racism is not a public health crisis and, in particular, as The Washington Post summarizes his views, for saying that he was not convinced that structural racism causes higher rates of maternal and infant mortality among African Americans.

Members of the Virginia Legislative Black Caucus have declared themselves “outraged,” and members of the Virginia Board of Health have reprimanded him for publicly questioning “basic scientific facts regarding disparities.”

It did not take long for the Youngkin administration to cave. In a letter to Department of Health employees, Greene issued a groveling apology: “I am fully aware that racism at many levels is a factor in a wide range of public health outcomes and disparities across the Commonwealth and the United States.”

The science, it appears, is settled. Virginia’s political-pundit class — in this case, Black legislators, political appointees to the Board of Health, and a Washington Post essayist masquerading as a reporter — now arbitrates what the “science” says. No one is allowed to question it. With Greene’s capitulation, structural racism as a cause of health disparities  now can be considered Old Dominion dogma.

The disparity in health outcomes is real, but that may be the only thing incontrovertible about this controversy. The Post noted the widely-cited figure that the maternal mortality rate for Black women is 2.5 times that of White women. College-educated Black women are at 60% greater risk of maternal death than a White or Hispanic woman with less education.

The question is what causes the disparity. Is structural racism at play, and if it is, what are the mechanisms by which that racism is expressed? Alternatively, could other factors be responsible?

A fog of obscurity clouds the discussion. What does “structural racism” even mean in the healthcare context? Does racism occur at the institutional level — inadequate insurance coverage for African-American women, for example, or hospitals discriminating in the quality of care — or does it stem from personal biases? Are older doctors, as is sometimes alleged, more likely to overlook or dismiss health warning signs for Black mothers?

Alternatively, could the higher risk for African-American women be attributed to environmental and medical conditions that have nothing to do with bias or discrimination by hospitals and doctors? Risk factors for preterm birth include cigarette smoking, drug use, consumption of alcohol, blood pressure, diabetes, multiple abortions or miscarriages, trauma, stressful events such as domestic violence, and pregnancies at an age below 17 or after 34.

The prevalence of hypertension (high blood pressure) is significantly higher for non-Hispanic Blacks (40.3%) than for non-Hispanic Whites (27.8%). Likewise, the prevalence of diagnosed diabetes is higher for Blacks (12.1%) than for Whites (7.4%). Black women are two to three times more likely to have abortions than Whites. Teen births per 1,000 women are twice as frequent among African-Americans as among Whites, and African-American women are roughly twice as likely as White women to experience domestic violence. On the other hand, White women are significantly more likely to engage in binge drinking during pregnancy.

Greene reportedly said in a contentious meeting with VDH employees that he had not seen compelling evidence that racism was a factor in poor health outcomes for Black mothers and their babies. He didn’t deny that race was a primary factor, he just questioned it. Asked if racism accounted for the disparities, he said, “If you’re going to be intellectually honest, you start with no assumptions and then you go back and look at causes, and that’s what I want to start fresh on this.”

Under the New Rules, it is impermissible to start any such analysis with no assumptions. One must start with the operating premise that racism is the cause of disparities in health outcomes, and all discussion must flow from it.

Those who advocate the “structural racism” approach have developed a theory in the past few years to explain how social factors translate into medical risk factors: Black Americans bear a heavier “allostatic load,” the cumulative wear and tear on the body in response to chronic stress, which impacts diabetes, heart disease, blood pressure, and asthma. According to this body of thought, Blacks on average experience more stress than Whites, and the excess stress can be attributed to racism. In this view, the racism of society as a whole is responsible for the risk factors that in turn effect pregnancy outcomes.

The medical mechanisms suggested by this theory are still in the “hypothesis” stage. Also unproven is the assertion that racial differences in average stress loads can be attributed to racism, as opposed to poverty or social breakdown. But the hypothesis is widely accepted in the political-media class as medical fact, and any denial of that fact itself borders on racism. The Virginia Legislative Black Caucus letter charged that Greene’s views “signal the intentional slowing down of lifesaving policies and actions” for Black mothers.

Just what are those lifesaving policies and actions, exactly?

Should mothers (of any race) be more assiduous about not drinking and smoking, about controlling their weight, and about bringing their hypertension and diabetes under control? Do mothers bear any responsibility for their own health outcomes?

Do we need more government programs? Should we, for example, put more money into the Supplemental Nutrition Program for Women, Infant, and Children, which funds programs for supplemental food, health care referrals and nutrition education for pregnant women?

Or is the best way to attack preterm births to address supposed society-wide racism as reflected in everything from poverty to microaggressions?

Apparently, our public health officials are not allowed even to ask these questions. Greene’s job as health commissioner is to sit and listen as the arbiters of permissible thought inform him of what the “science” says. Insofar as the reported “science” is an incoherent, ideologically driven jumble, however, it does not bode well for anyone, least of all Black mothers and their babies.