Putting British social medicine in conversation with Black feminist health science studies: considerations for racial health disparities


Introduction

At present, we are living through several major, arguably foreseen, historical events and political shifts. For example, the COVID-19 pandemic has destabilised and further fragmented Britain’s social, economic, and healthcare systems. Additionally, the cost-of-living crisis has resulted in the disturbing increase of the reliance on foodbanks for the employed and unemployed alike (BBC News. 2022a; 2022b) and has also contributed to a devastating increase in the number of people who live in poverty and suffer from poverty-related diseases (Marmot et al., 2020). In many ways, Britain is in an era of exceptional social, political, and economic uncertainty and instability. Furthermore, there has been a weakening of accessible public health services (Hopson, 2021; British Medical Association, 2022). One does not have to look far to see that, although the British healthcare system was founded on the principles of social medicine with the creation of the National Health Service (NHS) in 1948 (Worsnop, 1961; Pemberton, 2002), the theory, practices, and radicality of social medicine are not as effective as they once were. There are tangible efforts, as seen in the continued existence of the Society for Social Medicine & Population Health, the publication of the 2010 and 2020 Marmot Reviews (Marmot et al., 2010; Marmot et al., 2020), and the establishment of the medical humanities in academic institutions (such as the undergraduate module I took in Durham University’s Anthropology department, and the departments/centres/research groups established at the universities of Birkbeck (Birkbeck University 2022), Oxford (TORCH, 2022), and Kings College London (Kings College London, 2022)). Nevertheless, in reconciling these efforts with the growing divides between society and Britain’s healthcare system, it is challenging to contend that British social medicine– which I define as social medicine as is theorised and practiced in Britain– is as effective and responsive to the needs of the times as it could be. Despite the laudable efforts of those aligned with its values, British social medicine still faces many obstacles and, at present, its future as a force for social justice and medical equity seems bleak.

Racism: Society & Scholarship

One such obstacle is that of anti-Black racism– both systemic and interpersonal. Black peoplein Britain are living in a chronic crisis of racism and are suffering from its effects. For example, Black women are four times more likely to die during pregnancy or childbirth, or within a year after birth (Knight et al., 2023), due to structural racial discrimination and obstetric racism1 (BirthRights, 2022; FiveXMore, 2022). Moreover, Black-African and Black-Caribbeanfamilies respectively earn, on average, 10p and 20p for every £1 white families earn (Runnymede Trust, 2020). Systemic racism is also found in academia, where Black academics continue to receive fewer funding awards, principal investigator roles, professorships, and tenure advancements than white academics (Adelaine et al., 2020; UKRI, 2021). In Britain, anti-Black racism is a far-reaching, omnipresent type of structural violence inflicted upon those racialized as ‘Black’. It is unsurprising, therefore, that racism has been identified as a significant risk factor for several kinds of racial health disparities prevalent in Black communities. This identification forms part of the shift away from the socio-economic model of health, which has been critiqued for being too linear and reductionist (Mullings & Wali, 2001; Mendenhall, 2019), to a more nuanced one that bridges the biopsychosocial2 (Engel, 1977; 1980) and stress3 (Selye, 1956) models of health with critical race studies. Over several decades, the pursuit of more nuanced understandings of race in, and out of, health has led to the creation of concepts likeintersectionality’(bylawyer-activist Kimberlé Crenshaw (1991)), ‘misogynoir’ (by feminist scholar-activist Moya Bailey (2010; 2018)), ‘necropolitics’(by the often-cited political theorist Achille Mbembe (2003)), and ‘culture talk’ (by sociologist Ruha Benjamin (2017)). Altogether, these concepts, models, and frameworks can be understood to be enfolded in what Moya Bailey and Whitney Peoples call Black feminist health science studies (BFHSS) (Bailey & Peoples, 2017). BFHSS is a category that houses and integrates interdisciplinary ‘social justice science’ scholarship with activism in the aim of identifying and challenging the assumptions behind racial health disparities (namely genetic determinants). In doing so, BFHSS aids the deconstruction, exploration, and articulation of the health and wellbeing of marginalised groups through critical analyses of race science, racism, and the socio-structural determinants of health (Bailey, 2016; Bailey & Peoples, 2017). One example of BFHSS is epidemiologist Sherman James’s ‘John Henry Hypothesis’; a quantitative and inductive investigation into the relationships between anti-Black racism, resilience, stress, and hypertension risk (James, 1994). A further instance is the arguably Black feminist iteration of the John Henry Hypothesis: anthropologist Leith Mullings’ ‘Sojourner Syndrome’, which is a qualitative and partially inductive/ partially deductive exploration into the relationships between racism, the ‘Strong Black Woman’ trope,4 psychological resilience, and poor maternal health outcomes (Mullings & Wali, 2001; Mullings, 2002). These are but two examples of the long proposed, relevant, and applicable hypotheses and concepts that are ready to be applied (with caution and relativity) to racial health disparities in Britain.

Broadly speaking, however, BFHSS remains inadequately articulated and under-utilised in British social medicine. This under-utilisation, I ague, is indicative of the systemic racism within academia which under-values and under-cites Black scholarship. It is also indicative of the socio-political structural violence which under-values and under-protects Black lives. This is disappointing given that the goals of the discipline of social medicine are overtly linked to socio-political and structural reform. At its core, social medicine embodies the ethic that social and medical care should be practiced in ways where everyone is treated equitably and in service of community (Ryle, 1943). Its ethic champions the inclusion of all people in both social medicine’s theory and practice. Therefore, because social medicine’s principles directly relate to those of health and social justice across the world, social medicine can be argued and interpreted to be directly allied to racial justice (and, consequently, academic efforts to ‘decolonise’). In the context of Britain, the inadequate utilisation of BFHSS in its fullness is, arguably and unfortunately, unsurprising because it is reflective of the wider socio-political obstacle Britain continues to face: its reluctance to explicitly identify and address anti-Black racism as a present and tangible issue (Gilroy, 1987; Eddo-Lodge, 2018; Hall, Gilroy & Gilmore, 2021).

Whilst it is important to acknowledge the efforts of social medicine, at large, to include analyses of race and deconstructions of racism in its theories and practices – often drawing from the likes of Stuart Hall (Hall & Morley, 2019),Paul Gilroy (1993; 2000), Frantz Fanon (Fanon et al., 2008), and even Achille Mbembe (2019) himself – I maintain that social medicine in Britain has not adequately decolonised itself. By this, I mean that social medicine is still affected by Britain’s racism, particularly misogynoir, despite its efforts.

I have arrived at this position for a few reasons. Firstly, the focus on a handful of (cis)men as the mainstream representation of critical, post-colonial Black thought is problematic. Not only does it erase the contributions of other Black people with different (and less privileged) backgrounds and identities, but it masks the sheer number of critical Black non-(cis)men who are, and have been, doing “the work”. This results in a flattened range of what is recognised as critical Black thought, and who is recognised as a contributor. Clearly, there is a cis-heteropatriarchal hierarchy in the ‘Black canon’ social medicine scholars tend to draw from. Secondly, it is naïve to think that social medicine as it exists in Britain has been untouched by Britain’s particular configurations of racism, which include the denial, downplaying, and burial of the problem of anti-Blackness. See, for example, the Commission on Race and Ethnic Disparities (2021) in which the British government solidified its position on anti-Black racism: that institutional racism simply does not exist. The government’s stance that they “no longer see a Britain where the system is deliberately rigged against ethnic minorities” and that where “impediments and disparities do exist, they are varied, and ironically very few of them are directly to do with racism” (Commission on Race and Ethnic Disparities, 2021: p.8) has resulted in condemnation, including from UN experts (Office of the United Nations High Commissioner for Human Rights, 2021) and the British Medical Association (2021). Thirdly, it would be equally naïve to contend that social medicine is not included in the British academe’s reckoning in the aftermath of the Black Lives Matter movement. Therefore, whilst social medicine is more inclined to identify and address racism in society and its effects on Black people’s health than other disciplines, it still has a long way to go in the ways it does so in Britain. Drawing from BFHSS is one strategy to challenge and change this.

A Consideration from BFHSS: Ruha Benjamin’s Critique of ‘Culture Talk’

BFHSS is broad and has much depth, and elucidating it fully requires scope that goes beyond this essay. Instead, this essay presents a significant example of BFHSS theory, which illustrates the power and potential of BFHSS in British social medicine’s understanding of racial health disparities. To go beyond one-dimensional or flattened analyses, Ruha Benjamin’s critique of ‘culture talk’ (2017) can be utilised. In sum, culture talk is a discursive repertoire that is used to fabricate and defend stereotypes of racial groups. It produces an artificial idea of ‘culture’ through concealing the complexities and nuances in the subjectivities and experiences of the group being described, whilst simultaneously hiding and minimising the power of the group creating the descriptions. There has been a lively debate on the phenomenon of ‘culture’; see, for example, the works of scholars like Stuart Hall (1993; Hall, Segal & Osborne, 1997), Paul Gilroy (1987; 1993), and Clifford Geertz (1973), but also Kamala Visweswaran (1998), Khiara Bridges (2011), and Joyce Bell (Bell & Hartmann, 2007).

Benjamin introduces culture talk in the health sciences as an extension of Mahmood Mamdani’s assertation that ‘culture talk’, as particularly conceived in relation to politics, is “the predilection to define cultures according to their presumed ‘essential’ characteristics” (Mamdani, 2002: p.765). Similar to anthropologists’ Johannes Fabian and Matti Bunzl’s (2014) critique of how essentialisation is a mechanism through which ‘the Other’ is situated in one era, a prisoner of time and unmoving spatial relations, Mamdani criticises culture talk for (re)producing “museumized peoples” (Mamdani, 2002: p.767). These museumized peoples’ identities, experiences, and relationships with the world are frozen in time, thought to be “shaped entirely by the supposedly unchanging culture in which they are born” (Mamdani, 2002: p.767). Benjamin integrates W.E.B. DuBois’s critique that “the price of culture is a lie” (DuBois, 1989: p.7) with Mamdani’s critique to posit two things. Firstly, that culture talk not only exists in the health sciences and social sciences, but that it is a “precondition” of how knowledge is constructed, applied, and disseminated (Benjamin, 2017: p.229). Secondly, that many explanations of Black people’s racial health disparities – which are often taken for granted in health epistemology and practice – have “deeply racist roots” (Benjamin, 2017: p.228) and so are fallacies. Benjamin uses the continued referral to racial genetics as an example for both points. Specifically, she argues that these types of cultural explanations are framed by a language that orients culture as the apparatus through which genetic differences function, and that this is scientific racism (Benjamin, 2017: p.228).

One clear example is how Black people’s hypertension risk is blamed on genetic differences (Jackson, 1991; Wilson & Grim, 1991; Curtin, 1992; Grim & Robinson, 2003; Kaufman & Hall, 2003; Young et al., 2005; Lujan & DiCarlo, 2018). In Britain, the National Institute of Health and Care Excellence (which provides policy and practice recommendations to the NHS) recommended that Black patients receive a different kind of medication to non-Black people (NICE, 2022). This is notable not only because there is minimal evidence that Black and non-Black people’s bodies respond differently to the same medication, but because the data used to justify these race-based biological differences do not consider systemic racism or its bio-psycho-social effects. Furthermore, these biological differences are argued to be exacerbated by poor dietary cultures (which is an example of culture talk), where it is argued that ‘Black foods’ and ‘Black cooking practices’ are inherently saltier and unhealthier than those of white people (Action on Salt, 2010; UCL News, 2011), so the solution is dietary acculturation5 (NHS, 2019). This is despite much evidence that dietary acculturation is a much bigger risk factor in Black people’s hypertension risk than ‘traditional’ African or Caribbean diets (Satia-Abouta, 2003; 2010; Okafor, 2014; Osei-Kwasi, 2017). Such health-centred culture talk not only encourages and reifies cultural essentialism and genetic determinism, but shapes how Black people’s risk, bodies, and persons are understood as a whole.

Whilst I have given the example of hypertension – a chronic disease – culture talk is also found in relation to infections (like COVID-19 (Alloh et al., 2020; Qureshi, et al., 2020; Mullard, 2021)), acute conditions (like fibroids (NHS, 2018; Huffington Post, 2021)), or ‘other’ health issues (like labour and birthing trauma (Brathwaite, 2020; BirthRights, 2022; FiveXMore, 2022)). I, therefore, argue that British social medicine could use the theories, critiques, and analyses in BFHSS to learn how to better articulate how systems of racism (re)produce racial health disparities. Ruha Benjamin’s conceptualisation of health science culture talk is one such critique.

Gender in BFHSS?

In utilising BFHSS, however, the intersectionality of gender and the roles different kinds of sexisms and bigotries play in Black populations’ health disparities must also be considered. Misogynoir, for example,plays an irrefutable role in how culture talk affects Black women’s historical, socio-structural, and political determinants of health (as articulated in Kimberlé Crenshaw’s framework of intersectionality (Crenshaw, 1991)). Coined in 2008, formally used in a publication for the first time in 2010 (Bailey, 2010), but felt by Black women long before then, the concept of misogynoir “describes the anti-Black racist misogyny that Black women experience” (Bailey & Trudy, 2018: p.726). There is much gendered culture talk that has been interwoven into the very fabric of health epistemologies, particularly in regard to Black women’s bodies and the relationship between sexuality, disease, and defect. In the paper ‘Which bodies matter?’, sociologist Zine Magubane analyses how the foundational accounts of the ‘Hottentot Venus’whose name is believed to be Sarah Baartmann– have reproduced deeply dangerous assumptions about Black women’s gendered and racialised subjectivities in scholarship which (cl)aims to contribute a critical eye to gender and race studies (Magubane, 2020). For example, Magubane posits that Baartmann did not represent the ‘core image’ of the Black woman in the nineteenth century, nor were European cultural ideas of Blackness static as is often implied in literature (Magubane, 2020: p.42). Applied to Britain, this critique has implications for the way Black women’s health disparities and histories of misogynoir are understood, such as in the recent conversations that identify systemic racism, obstetric racism, and colonial ideations of ‘The Black Woman’s Body’ as significant factors in Black maternal health disparities (BirthRights, 2022; FiveXMore, 2022). Whilst Magubane does not use the terms ‘culture talk’ or ‘misogynoir’, the ahistoricism and racial essentialism which Black-African women have been written about can be interpreted to be forms of both and, thus, can be learned from.

A Nod to Virchow

In my presentation of ‘culture talk’ and ‘misogynoir’ as critical elements of BFHSS, I also posit that it is important that British social medicine does not perceive BFHSS as incommensurable with the language and ideas that exist in social medicine’s established scholarship. As aforementioned, BFHSS is an extension of critical race studies and, just as is seen with the fearmongering around critical race studies, there is a risk that BFHSS may be assumed to be a scholarship that aims to usurp all others. This is not so. BFHSS is interdisciplinary and can be read and practiced alongside complementary frameworks and schools of thought. For British social medicine, and social medicine at large, one way BFHSS can be integrated is by placing it in conversation with Virchowian principles. In particular, I am thinking of the idea of ‘artificial epidemics’ and how it is possible for anti-Black racism to be conceptualised as an ‘artificial epidemic’.

In Rudolph Virchow’s idea of ‘artificial epidemics’ (Virchow 1848 in Rosen, 1947: p.678), artificial epidemics are understood as “attributes of society” that are “products of a false culture or of a culture that is not available to all classes” (Anderson, Smith & Sidel, 2005: p.28). They are social diseases, such as poverty, hunger, and misery, which affect those in the margins of the society. These epidemics are often a risk factor for chronic diseases, arising in periods of social disruption and indicate social, political, and economic defects produced by political oppression. Unlike ‘natural epidemics’ (which Virchow argued are traced to pathogens, viruses, or other types of micro-organisms (Virchow 1848 in Rosen, 1947)), artificial epidemics are wholly driven by political decisions, and lead to death (Rosen, 1947).

Traditionally, the concept of artificial epidemics has been utilised for greater class consciousness, with Virchow drawing attention to disparities in hunger, living conditions, poverty, and education levels. However, the concept of artificial epidemics can be extended and applied as a tool for greater race consciousness (as is an aim of BFHSS) – after all, racism is a social disease that produces and exacerbates class-related social diseases. For example, structural economic racism has left Black African households owning, on average, 10 times less wealth than white British households, as is mentioned above (Runneymede Trust, 2020). Given this fact, it is unsurprising that more than half of the UK’s Black children (53%) are also living in poverty (Guardian, 2022). It is also unsurprising that Black people’s consistently high COVID-19 morbidity and mortality rates (Office for National Statistics. 2022) have been found to be unequivocally rooted in these instances of systemic socio-political and economic racism (Alloh et al., 2020; Qureshi et al., 2020; Mullard, 2021).

Conclusion

In situating ‘culture talk’ and ‘misogynoir’ within BFHSS and exemplifying how the Virchowian idea of ‘artificial epidemics’ is conducive with critical analyses of racism, this paper aims to exemplify the ways that British social medicine can learn from Black feminist health science studies to addresses the role of anti-Black racism in theory and practice. Not only does understanding these three concepts in tandem further support the long-argued point that race consciousness cannot be separated from class consciousness (because racial and economic oppression are inextricably bound), but doing so gives British social medicine a meaningful way of advancing anti-racism efforts and better responding to a significant issue of the times. Currently, the stance of the British government is that there is “no evidence of systemic or institutional racism” in Britain (Commission on Race and Ethnic Disparities, 2021. (p.77)). Therefore, social medicine has a responsibility to (re)turn to its roots of socio-political reform and health justice activism in order to further advance the discipline into a more inclusive practice that equally benefits Britain’s Black people and advocates for their health, safety, and wellbeing.


Notes

1. ‘Obstetric racism’ is a descriptive term and framework, championed by doula-anthropologist Dana-Ain Davis, to describe the specific forms of racialised violence Black women experience during pregnancy, childbirth, and the post-partum period. It expands the concept of ‘obstetric violence’ and applies Crenshaw’s intersectionality theory to better conceptualise the systemic and medical racism that largely constitute the obstetric violence experienced by Black women (Davis, 2019; Scott & Davis, 2021; Van Der Waal et al., 2022). 

2. The biopsychosocial model of health is a critical approach pioneered by psychiatrist George Engel. It expands upon the concepts of psycho-sociality and bio-sociality in that it integrates biological implications into the former, and psychological implications into the latter, producing an alternative to biomedical models of health and disease aetiology. In sum, Engel objected to the linear cause-and-effect model which was prevalent in describing clinical phenomena, arguing that health and wellbeing are far more complex and complicated than what was typically articulated in mainstream medical education.

3. Loosely defined as the twofold experience of physiological and psychological trauma and chronic strain, the most prominent stress model of health is founded on the work of Hans Selye, an endocrinologist who conducted pioneering research in the mid-1900s. In sum, Selye suggested three key facts: 1) stress is a defence mechanism, 2) it has three stages (alarm, resistance, and exhaustion), and 3) prolonged/ severe stress can result in disease and death. His model has been used to support and uphold the premise that, over time, operating in an unconscious state of stress due to external, social factors (made possible through homeostatic changes triggered by the autonomic nervous system) will lead to maladaptive diseases.

4. The ‘Strong Black Woman trope’ is a stereotype that comes from the dehumanization of Black women. It draws from the colonial idea that Black women have a superhuman tolerance for pain and strength, meaning that they can tolerate abnormally high levels of pain without extra support (be it in the form of social or medical aid). See Beauboeuf-Lafontant (2009), Watson & Hunter (2016), and  Corbin, Smith &  Garcia (2018) in addition to Leith Mullings’ work.

5. Dietary acculturation is a type of social assimilation, typically targeted at (im)migrants, where the eating habits and food choices of the general population are adopted.

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