Critical Race Theory, Race Equity, and Public Health: Toward Antiracism Praxis

Abstract

Racial scholars argue that racism produces rates of morbidity, mortality, and overall well-being that vary depending on socially assigned race. Eliminating racism is therefore central to achieving health equity, but this requires new paradigms that are responsive to structural racism's contemporary influence on health, health inequities, and research.

Critical Race Theory is an emerging transdisciplinary, race-equity methodology that originated in legal studies and is grounded in social justice. Critical Race Theory's tools for conducting research and practice are intended to elucidate contemporary racial phenomena, expand the vocabulary with which to discuss complex racial concepts, and challenge racial hierarchies.

We introduce Critical Race Theory to the public health community, highlight key Critical Race Theory characteristics (race consciousness, emphases on contemporary societal dynamics and socially marginalized groups, and praxis between research and practice) and describe Critical Race Theory's contribution to a study on racism and HIV testing among African Americans.

ALTHOUGH RACE REMAINS salient to public health in a variety of ways, the field's theoretical and methodological conventions inadequately address the complexity with which structural racism influences both health and the production of knowledge about populations, health, and health disparities. Many projects lack clarity about the nature of racial stratification. They conceptualize, measure, and analyze race- and racism-related factors using tools better suited for studying other risk factors. Although structural forces drive inequities, research and interventions disproportionately emphasize individual and interpersonal mechanisms. Additionally, overconfidence in the objectivity of research can blind investigators to the inadvertent influence of a priori assumptions on research.

Race as a category denoting skin color was first used to classify human bodies by Francois Bernier, a French physician.¹ The notion of racial groupings was introduced in Carolus Linnaeus's Natural History in 1735 and subsequently advanced by many others.¹ Both Linnaeus's concept of race and the subsequent racial groupings devalued and degraded those classified as non-European.² Linnaeus's classification became the foundation on which many countries, including the United States, based their racial policies. Later, racialized policies gained “scientific” affirmation in the work of scholars such as Josiah Nott, whose publications reinforcing White supremacy appeared in 1843 in such respected journals as the American Journal of the Medical Sciences.

Prevailing notions about race shaped early scientific research, but because investigators were not critical about their relationships to their racialized social contexts, they were unable to perceive the insidious influence of racism in their work. The contributions of minorities who might have challenged underlying assumptions were largely excluded. Their exclusion buttressed artificially high levels of confidence among researchers about the import and validity of racial findings. Against this backdrop, progressive scholars, many of them racial or ethnic minorities, began to scrutinize knowledge production processes and the implications for minority communities. By the late 20th century, they had begun developing new frameworks such as Critical Race Theory to explicitly account for the influences of racism on both outcomes and research processes.

Gilmore defines racism as “the state-sanctioned and/or extralegal production and exploitation of group-differentiated vulnerability to premature death.”^3(p247) This definition suggests that health for all cannot be achieved if structural racism persists. Eliminating racism, therefore, is part and parcel to achieving the objectives of public health. Table 1 provides definitions of public health and of the Critical Race Theory concepts discussed in this commentary.

TABLE 1.

Definitions of Public Health and Selected Concepts of Critical Race Theory

Concept	Definition
Public health	The art (i.e., practice) and science (i.e., research) of protecting and improving the health of communities
Centering in the margins	Making the perspectives of socially marginalized groups, rather than those of people belonging to dominant race or culture, the central axis around which discourse on a topic revolves
Critical consciousness	Digging beneath the surface of information to develop deeper understandings of concepts, relationships, and personal biases
Experiential knowledge	Ways of knowing that result from critical analysis of one's personal experiences
Ordinariness	The nature of racism in post–civil rights society: that is, integral and normal rather than aberrational
Praxis	Iterative process by which the knowledge gained from theory, research, personal experiences, and practice inform one another
Primacy	Prioritizing the study of racial influences on outcomes
Race consciousness	Explicit acknowledgment of the workings of race and racism in social contexts or in one's personal life
Social construction of race	The endowment of a group or concept with a delineation, name, or reality based on historical, contextual, political, or other social considerations

Source. Critical Race Theory concepts adapted from Delgado and Stefancic.⁵

Critical Race Theory offers the field of public health a new paradigm for investigating the root causes of health disparities. Based on race equity and social justice principles, Critical Race Theory encourages the development of solutions that bridge gaps in health, housing, employment, and other factors that condition living.

The newly developed Public Health Critical Race Framework adapts Critical Race Theory for public health research and practice (Ford CL and Airhihenbuwa CO, unpublished paper, 2009). Our aim here, however, is to introduce Critical Race Theory to the multidisciplinary field of public health and, more specifically, to researchers of health disparities and health equity. We also illustrate its application to empirical research.

Critical Race Theory

In the following section, we discuss the origins of Critical Race Theory, highlighting 4 of its basic features: race consciousness, contemporary orientation, centering in the margins rather than in the mainstream, and praxis (i.e., theory-informed action).

Origins

Although the term “theory” appears in its name, Critical Race Theory is not like behavior change or epidemiological theories. Rather, it is an iterative methodology for helping investigators remain attentive to equity while carrying out research, scholarship, and practice. It also urges scholars to work to transform the hierarchies they identify through research.

Critical Race Theory integrates transdisciplinary methodologies that draw on theory, experiential knowledge, and critical consciousness (Table 1) to illuminate and combat root causes of structural racism. It emerged after years of struggle by law students and faculty contesting what they perceived as institutionalized racism in the hiring and curricular decisions of elite law schools.⁴ Convinced that their understandings of racial power dynamics diverged in important ways from those of other legal models, they convened a meeting in 1989 at which they enumerated key racial equity principles. They coined the term “Critical Race Theory” to name the emergent set of methodologies that draws on these principles in pursuing racial equity via the law. Persons whose scholarship relies on Critical Race Theory (called critical race theorists) are often described as “a collection of activists and scholars interested in studying and transforming the relationship among race, racism, and power.”^5(p2)

Over the last 2 decades, Critical Race Theory scholarship has generated a broad transdisciplinary movement toward race equity. Knowledge production is the primary medium through which Critical Race Theory operates. The scholarship distinguishes contemporary racial mechanisms from older ones (e.g., Jim Crowism), expands the vocabulary for discussing racial phenomena and investigating racism effects, and explicitly incorporates the knowledge of racial and ethnic minority communities regarding marginality.

Race Consciousness

Critical Race Theory challenges widely held but erroneous beliefs that “race consciousness” is synonymous with “racism” and that “colorblindness” is synonymous with the absence of racism.⁶ Colorblindness, which is both an attitude and a school of thought, posits that nonracial factors (e.g., income) fundamentally explain ostensibly racial phenomena. Although abuses of race-conscious research (such as early eugenics research) have been noted, in truth, both race consciousness and colorblindness can be deployed in ways that contribute to inequities. Only colorblindness, however, precludes explicit examination of racism's potential contributions to inequities. Race consciousness is essential for understanding racialized constructs and mechanisms.

Contemporary Mechanisms

By definition, structural racism evolves across time and contexts. Research on racism should reflect the aspects of racialization that are contemporarily salient.⁷ Currently, structural mechanisms continue to have the greatest impacts even though contemporary racism is characterized by its subtlety and ordinariness (Table 1). The Critical Race Theory concept of ordinariness posits that racism is normal and integral to society. Minorities are chronically exposed to diverse forms of everyday racism (e.g., being followed while shopping). In response, they may learn to ignore everyday racism because it occurs so frequently, become adept at detecting it, or become hypervigilant about it, perceiving any unfair treatment as racism. Understanding ordinariness can inform research hypotheses about minorities’ health behaviors and attitudes.

Centering in the Margins

To center in the margins (Table 1) is to shift a discourse's starting point from a majority group's perspective, which is the usual approach, to that of the marginalized group or groups. The position of critical race theorists as “outsiders within” their respective disciplines is valuable in facilitating this process. By grounding themselves in the experiences and perspectives of the minority communities from which they largely come, critical race theorists integrate critical analyses of their lived experiences and disciplinary conventions to advance knowledge on inequities. This synthesis can enhance the relevancy of findings for communities and provide disciplines with fresh perspectives on old problems.

Praxis

Critical Race Theory is an iterative methodology for helping investigators remain attentive to equity while carrying out research, scholarship, and practice. Community engagement and critical self-reflection enrich research processes, while research based on the lived experiences of marginalized communities provides the communities with more meaningful data for their ongoing efforts toward collective self-improvement.

For years, some public health researchers have employed (implicitly or explicitly) Critical Race Theory approaches to investigate racism,^8,9 emphasize the historical and sociopolitical roots of contemporary disparities,^10–12 study how the field's conventions may inadvertently constrain movement toward equity,^13–15 focus on structural forces,^16–19 emphasize the intersectionality of racial and other axes of inequity,^20,21 investigate links between White racial identity and inequities,^22,23 and use allegory²⁴ as an antiracism educational tool. Critical Race Theory can contribute the following: a comprehensive framework for connecting these research endeavors, a vocabulary for advancing understandings of racial constructs and phenomena, critical analyses of knowledge production processes, and praxis that builds on community-based participatory approaches linking research, practice, and communities.^25,26 To illustrate how Critical Race Theory can inform public health research, we describe in the next section several ways that it informed a study²⁷ of HIV testing among African Americans. That study, by C. L. Ford et al., purposefully employed Critical Race Theory in its design and in carrying out the research.

APPLICATION OF CRITICAL RACE THEORY

The study was conducted from 2003 to 2005 in an urban area with a high prevalence of HIV. It sought to understand whether racism-related factors are potential barriers to African Americans obtaining readily available, routine HIV testing as recommended by the Centers for Disease Control and Prevention (CDC). Routine HIV testing has become the backbone of US HIV prevention because, after more than 2 decades of HIV prevention efforts, prevalence remains elevated.²⁸ Although African Americans are diagnosed later and have worse prognoses than members of other groups, the factors influencing their HIV testing behaviors are poorly understood. The focus on racism as a potential barrier grew in part out of formative research during which some African Americans reported that discriminatory treatment by clinic staff might be a barrier to HIV testing.

The study's methods and key findings have been described elsewhere.²⁷ Briefly, we enrolled approximately 400 African Americans presenting to a public health clinic for diagnosis or screening of a sexually transmitted disease. Everyone newly presenting for these purposes was automatically offered HIV testing. Controlling for standard HIV prevention covariates such as perceived HIV risk and patient satisfaction, we examined the contribution of perceived everyday racism to laboratory-confirmed HIV test uptake or decline. As perceived racism may be inversely correlated with segregation,²⁹ we also accounted for levels of segregation in participants’ residential areas. In the next section, we discuss the relevance of race consciousness, contemporary mechanisms, centering in the margins, and praxis to the study. This discussion is illustrative and does not capture the entirety of Critical Race Theory or all the ways it informed this research.

Conceptual Model

The conceptual model integrated the Andersen access to care model,^30,31 which is widely used to examine behavior within clinical settings, a socioecological framework,³² and Critical Race Theory concepts. Figure 1 shows the backbone of Andersen's model, which we adapted to specify variables for inclusion (Figure 2). In Andersen's model, race typically is considered a population characteristic that predisposes one toward particular behavior(s). According to Critical Race Theory, however, race is socially constructed. It is less a risk factor itself than a marker of risk for racism-related exposures. Race is useful in that it enables the identification of persons at risk for exposures that vary by racial category (e.g., discrimination). We removed race from the model as a manipulable variable, limited the sample to African Americans, and incorporated 2 racism variables: perceived everyday racism (individual level) and residential segregation (neighborhood level). Removing race from the model shifted the focus from how Black race might influence behaviors to how the racialized experiences of African Americans might do so.

FIGURE 1.

Andersen's access to care model.

Note. Andersen's model^30,31 goes beyond behavioral outcomes to examine health outcomes.

FIGURE 2.

Adaptation of Andersen's access to care model^30,31 used as the study's conceptual model.

Robert Brackman allied the independent spirit of his young subject with the future of the whole country, titling his portrait of her “Somewhere in America.” From the recent Smithsonian American Art Museum exhibition, “1934: A New Deal for Artists.” Printed with permission. Image courtesy of the Smithsonian Art Museum.

Race Consciousness

Race consciousness (Table 1) informed all aspects of the project, including development of the conceptual model. Race consciousness suggested that considering the racialized social context of African Americans would be germane to research on their HIV preventive behaviors given their historical experiences with the health care system and stigma linking HIV and Black race. Social construction suggests that different racial groups experience the social environment differently. We conceptualized social contexts as racialized at the individual, clinical, and residential levels and sought to explain African Americans’ experiences of their social contexts. Limiting the study to African Americans contrasts with typical approaches that compare groups, making the underlying question, “How do African Americans differ from Whites?”¹⁵ Our within-group design encouraged exploration of the diversity of perceptions, experiences, and attitudes among African Americans.^15,33,34

The study controlled for standard explanatory factors (e.g., perceived HIV risk) to focus on racism-related contributions. Drawing on race consciousness, the investigators first enumerated salient aspects of contemporary racism (e.g., its ubiquity, multilevel nature, etc.) and applied these broad characteristics to Andersen's model. This led to the individual-level focus on perceived everyday racism rather than on the extreme forms of racism (e.g., HIV conspiracy beliefs) previously examined.

Contemporary Mechanisms

A key characteristic of contemporary racism is its subtlety and ordinariness. Ordinariness suggests that constant, chronic exposure to seemingly minor insults (e.g., being followed while shopping) may have lasting impacts on one's health. Ordinariness reinforced the decision to operationalize the main individual-level explanatory factor as perceived everyday racism. Everyday racism is an integral element of the social environment. We conceptualized everyday racism as a ubiquitous aspect of the social environment and perceived everyday racism as individuals’ detection of it.

Centering in the Margins

The study was motivated in part by extensive outreach conducted among community residents. Critical self-awareness, especially regarding personal privilege and racial relations, informed team members’ interactions with community members, study participants, and other research project staff. For instance, throughout the research process, members of the research team noted ways that their identities (especially with regard to race) and social positions (e.g., educational attainment) could influence power dynamics in their interactions with participants or recruits.

Through critical self-consciousness, 1 member of the research team realized that she considered her racial identity (African American) to be more important than her other identities (e.g., class), which led her to hold a priori assumptions (e.g., that she and study participants held similar views). By identifying these assumptions and their potential implications early on, she prevented their inadvertent influences on the research process (e.g., data collection or data interpretation) and derived more accurate assessments of the nature of her interactions with community members. For some recruits and participants, her affiliation with a predominantly White institution was a major source of distrust and was more salient than her race. Challenging power differentials is central to Critical Race Theory. Her critical self-consciousness helped her to do just that by attending to intraracial power imbalances throughout the research process.

Praxis

Together, critical consciousness and race consciousness (Table 1) helped the project remain oriented toward race equity. Because all research is produced within and in relation to social contexts that may inadvertently influence research,^35,36 this grounding in equity heightened awareness of the power imbalances between academic institutions and the communities in which they conduct research. We attempted to redress these imbalances throughout the research process. For instance, African American community members were recruited and trained as research assistants even though doing so was more expensive and labor intensive than hiring student research assistants.

The project was attentive to the ways that researchers may be personally affected by racism while studying it. In an arm of the study that entailed phoning a probability sample of residents based on a sampling frame derived from telephone directory white pages, interviewers sometimes reached non–African Americans who, ineligible for the study, responded to the interviewers with hostility. Staff debriefed after such incidents. Research staff also read literature on racism and race, discussed their personal experiences with and perceptions about racism, and regularly checked in with each other during the data collection period.

Analyses and Interpretations

The choice of analytic technique—logistic regression with generalized estimating equations (GEE)—followed from the conceptual model in which perceived racism occurs within racialized social environments. Critical Race Theory was relevant to the analyses in that it informed the conceptual model and interpretations of the study's findings. As in other recent studies,^37,38 our findings suggested that despite perceiving everyday racism, African Americans at high risk for HIV transmission actively engage in primary preventive behaviors.²⁷ On the basis of the Critical Race Theory concept “centering in the margins,” our report of the findings included the strengths on which members of marginalized communities may draw.

One objective of Critical Race Theory is to go beyond merely documenting disparities. Therefore, we included policy and practice implications in the published findings and shared the findings with community members, frontline public health professionals (e.g., outreach workers, clinic staff), and study participants.

CONCLUSIONS

We have introduced Critical Race Theory, a race equity methodology that originated in legal studies, to the public health community, and described several ways that Critical Race Theory informed a study of racism and HIV testing among African Americans. Four Critical Race Theory concepts—race consciousness, contemporary orientation, centering in the margins, and praxis—were central to that study. Critical Race Theory has been adapted for use in several fields, including education and gender studies. Public health's tradition of championing social justice issues suggests that Critical Race Theory can provide powerful new tools for targeting racial and ethnic health inequities. To facilitate appropriate and systematic use of Critical Race Theory within public health, Ford and Airhihenbuwa developed the Public Health Critical Race Framework (unpublished paper, 2009). That framework and the Critical Race Theory concepts introduced here build on the growing public health momentum toward achieving health equity.