The Contested Whiteness of Arab Identity in the United States: Implications for Health Disparities Research

Abstract

In response to the Institute on Minority Health and Health Disparities’ (NIMHD) new health disparities research framework, we call on the National Institutes of Health (NIH) to acknowledge Arabs in the United States as a health disparity population. Arab classification as White leads to their cultural invisibility and perpetuates a cycle of undocumented health disparities.

We provide examples of how this contested identity reinforces challenges associated with identifying this population and contributes to enactments of structural violence and undocumented health disparities. Decades of research with Arabs in the United States provides consistent evidence that their health does not fit the health profile of White Americans and that Arabs do not benefit from Whiteness and White privilege associated with their White racial categorization. On the contrary, Arabs in the United States experience discrimination and health disparities that require urgent attention; this can be achieved only by identifying the population with a racial category other than White.

We conclude with recommendations to NIH and NIMHD to revise their definition of health disparity populations to include Arabs in the United States.

Arabs have been immigrating to the United States since the 1800s¹; however, Arab invisibility is a central theme in the historical narrative of Arab immigrants.² Although the term “Arab” in the US context is simply defined as immigrants from Arabic-speaking countries and their descendants, Arab identity is widely contested in the United States. Arabs are not recognized as a minority group and are classified as White.³ This classification, a form of structural violence, has left them invisible⁴ and their needs unaddressed.⁵ Structural violence⁶ encompasses social forces that perpetuate harm to certain groups of people, producing and reproducing inequities in health. This violence includes social, economic, and political processes that are manifested in social exclusion, stigma, and discrimination and that lead to increased health disparities.^7,8 Since the early waves of Arab immigration, Arabs in the United States have experienced historical and persistent systemic stigma and discrimination⁹ that significantly increased following the 9/11 terrorist attack, and with recent political events (e.g., Muslim travel ban, hate crimes, Islamophobia, xenophobia, microaggressions, antiimmigration policies). The stigma and discrimination against Arabs have negatively affected their health and worsened their vulnerabilities to violence and trauma.^10–12

This commentary is a call to the National Institutes of Health (NIH), and in particular the Institute on Minority Health and Health Disparities (NIMHD), to acknowledge that Arabs in the United States are experiencing undocumented health disparities. The release of NIMHD’s new multilevel, multidomain health disparities research framework¹³ offers a unique and timely opportunity to reevaluate the inclusiveness of health disparity populations. We welcome NIMHD’s openness about the fact that the new framework is a work in progress, and we thus call on NIH and NIMHD to revise their definition of health disparity populations to include Arabs and other groups from the Middle East and North Africa (MENA) region. Throughout this commentary, we use the term “Arabs” to include those who identify as Arab or Arab American and reside in the United States.

THE CONTESTED ARAB IDENTITY

As with other people of color, Arabs in the United States are racialized into a paradox of visibility and invisibility, which Naber further conceptualizes as four paradoxes that complicate the Arab identity in the United States⁴:

1. Arabs are defined as a monolithic category. Similar to Latinx and Black people, Arabs are diverse in terms of nationalities, religions, and ethnicities. The conflation of “Arab” with “Middle Eastern” and with “Muslim” undermines the unique characteristics of these three categories, in particular regarding their health and health disparities.

2. Arabs in the United States are simultaneously racialized as White and non-White. Although many, but not all, Arabs phenotypically can pass as White, their lives are racially marked, as they are perceived and treated as non-White.^2,14,15 Although they are considered White by the US Office of Management and Budget (OMB)³—and thus on the US Census—the daily lives of Arabs in the United States are marked by discrimination because of their ethnicity, religion, and immigration status.¹⁶

3. Arabs in the United States are racialized and discriminated against based on one religion, Islam: Most Arabs in the United States come from diverse religious traditions, including Christianity, Judaism, Bahá’í, Druze, and Yazidism, and others adopt no religious tradition. However, Arabs are portrayed as uniformly Muslim, and Islam is portrayed as a violent and uncivilized religion. In this context, Islam is used to racialize Arabs as inferior to White Americans.

4. Arab identity in the United States is influenced by the intersection of religion (integral to the structure of Arab societies) and race (integral to the structure of US society). In most Arab countries, social structures are constructed by religion, whereas in the United States, social structures are organized, or perceived as organized, based on race. These social structures conflict and overlap for Arabs in the United States and can create confusion over their identity.

A recent manifestation for these paradoxes is the 2018 election and postelection environment of representatives Ilhan Omar (D, MN) and Rashida Tlaib (D, MI). Both representatives have been high-profile targets of a combination of anti-Arab sentiments and Islamophobia. Based on their ancestry (from Somalia and Palestine, respectively), they both would be considered White according to the OMB definitions³; however, neither of the representatives has been treated as White by US politics and media or has benefited from their supposed Whiteness or the White supremacy that structures US racial systems. Of note, Representative Omar is a member of the Congressional Black Caucus. Arab identity does not depend on US and other colonial distinctions of race, particularly the White supremacist difference between White and Other. Despite OMB’s inclusion of Arab in White, Representative Omar has Arab and Black identities. Overall, each paradox of the Arab identity not only contributes to the inability to accurately identify this population but also enables structural violence and undocumented health disparities through their invisibility.

(IN)VISIBLE HEALTH DISPARITIES OF ARABS

NIMHD recently released their new health disparities research framework endorsing a multilevel, multidomain exploration of health disparities.¹³ This framework reflects a commitment to “move upstream” and away from individual-level determinants of health, moving closer to a conceptualization of health disparities as health differences manifested in the unjust distribution of social and structural determinants that adversely affect disadvantaged groups.¹⁷

Socially disadvantaged groups are designated as “health disparity populations” by the NIMHD, which means they are “characterized by a pattern of poorer health outcomes, indicated by the overall rate of disease incidence, prevalence, morbidity, mortality, or survival in the population as compared with the general population.”^13(pS16) Arabs in the United States have long been excluded from this taxonomy, despite multiple calls by researchers and community advocates to reverse this practice.^9,18 Data from the American Community Survey show that 61% of Arabs in the United States speak a language other than English at home, and 22% speak English less than “very well.”¹⁹ Almost a quarter of Arabs in the United States live in poverty, compared with 13% of non-Arab White Americans. Around 10% of Arabs in the United States do not have any insurance coverage compared with 9% in non-Arab White Americans.¹⁹ These figures describe a population that is radically different from the mainstream understanding of White race, and a population that does not benefit from the White racial privileges and Whiteness of White Americans. Furthermore, around 60% of Arabs in the United States reported workplace discrimination after 9/11, and 40% of Americans admitted to being prejudiced toward Arabs, Muslims, or both.²⁰

The misclassification of Arabs as White has also perpetuated a vicious cycle of invisibility in health disparities research, whereby population-level data demonstrating these disparities are sorely needed but difficult to obtain because of the inability to identify the population in large data sets. Instead, most research on Arab health is conducted in ethnic enclaves and thus is unlikely to capture the diversity of the Arab population in the United States and generate nationally representative findings. Indeed, a systematic review published in 2018 could only provide a fragmented understanding of the health of Arabs relative to other groups in the United States.²¹ This review does, however, hint at potential disparities in health outcomes perpetuated by social determinants of heath, a pattern that is parallel to other health disparity populations. For example, in the systematic review,²¹ diabetes prevalence was found to be higher in Arabs (4.8%–23%) compared with non-Arab non-Hispanic Whites and could be mediated by both biological pathways (e.g., vitamin D insufficiency) and social determinants, including lack of knowledge and access to care.

Barriers to cancer screening were also largely shared with other health disparity populations and included lack of knowledge, language barriers, lack of access to health care and culturally sensitive providers, and immigration-related fear.²¹ A national study reported that, compared with US-born White (potentially including Arab) women, foreign-born Arab women in the United States had higher estimates of not receiving recommended vaccinations and cancer screenings.²² Arab women were less likely to report receiving a flu vaccine (odds ratio [OR] = 0.34; 95% confidence interval [CI] = 0.21, 0.58), pneumonia vaccine (OR = 0.14; 95% CI = 0.06, 0.32), Papanicolaou test (OR = 0.13; 95% CI = 0.05, 0.31), or clinical breast examination (OR = 0.16; 95% CI = 0.07, 0.37) compared with US-born White women.²²

Discrimination against Arabs has significantly increased since 9/11,¹⁰ which arguably makes adverse mental health outcomes urgent indicators to monitor, yet their prevalence is unknown. Local studies showed that anti-Arab sentiment was indeed associated with depression, distress, and unhappiness in Arab populations in the United States.^10,20 This pattern may be a warning sign of potential disparities in mental health outcomes. In addition, Arab women experiencing domestic violence face language barriers, discrimination-induced fear, lack of culturally sensitive support, and lack of trust in US providers, possibly leading to disparities in accessing domestic violence care and support.²³ Although Arab mothers were generally healthier than non-Arab mothers, studies report that discrimination-induced stress among Arab mothers in the United States was associated with increased adverse birth outcomes.¹¹ Arabic-named women were 34% more likely to have a low birth weight infant in the six-month period after 9/11 compared with the period before 9/11; this difference was significantly higher than for White women (P = .029).¹¹ It is alarming that researchers are unable to confirm, measure, or track these health issues at the population level, which can only exacerbate existing health disparities in the Arab population in the United States.

WHY AREN’T ARABS BENEFITING FROM WHITENESS?

The structural racialization of Arabs as White thus disrupts efforts to understand emerging disparities among Arabs in the United States. To investigators exploring these disparities, NIMHD at the outset appears to be an appropriate funding entity; however, again, Arabs are excluded from NIMHD’s definition of populations experiencing health disparities, and consequently researchers exploring health disparities with Arabs as their main population in the United States are excluded from funding. Alvidrez et al. state that the racial/ethnic minority populations included in the new research framework are defined by the OMB in their 1997 revision of Directive 15,^3,13 which was originally published in 1977. However, OMB does not define race or ethnicity in this document; OMB does provide definitions for five specific races/ethnicities for minimum reporting. We would like to note that the 1997 OMB document used by NIMHD to generate its research framework includes discussion of the addition of an “Arab/Middle Easterner” category. Although this category was not added in 1997, “OMB believes that further research should be done to determine the best way to improve data on this population group.”³

Although OMB’s internal discussion continues, further research remains difficult without broad data collection that includes an Arab category. OMB’s “minimum reporting” means that no federal agency, including NIMHD, is restricted from including additional racial/ethnic categories. Therefore, there is no policy to prevent NIMHD from including Arab identity in their health disparity research framework. These minimum categories are also reflected in the Public Health Service inclusion and enrollment reports that are required for federal human participant research applications and annual progress reports and are reproduced in Census Bureau categories.

Because the United States as a political entity was formed from colonialism, White supremacy is and has been the norm. In 1790, White racial identity was required for US citizenship. In the early twentieth century, to reinforce societal racial purity, a “one-drop rule” (referring to any Black or indigenous ancestry) was established in Virginia (1924; overturned 1967) and adopted by the Census Bureau (1930). Arabs in the early 20th-century sought White racial identity to gain citizenship, famously including George Dow’s denied application for naturalization, later overturned by a US court of appeals (1915).^14,15 OMB’s original Directive 15 in 1977 defined White as those with origins in “Europe, the Middle East and North Africa,” a definition that essentially remains today and that reinforces structural violence regarding Arab (in)visibility. Census testing in 2015 included a MENA option, concluding that the addition of a MENA category is “optimal” and that OMB was considering adding MENA as a minimum required category.²⁴ In January 2018, the Census Bureau announced that the MENA question would not be added to the 2020 Census. We note here how easy it is to separate “the Middle East and North Africa” from OMB’s definition of White. Additionally, if Arabs are in fact White, why aren’t they benefiting from White supremacy, Whiteness, and White privilege?

This problem, therefore, is multifaceted:

1. NIMHD’s research framework intends to focus on populations with health disparities that have been established in the literature;

2. Traditional health disparities literature generally comes from secondary data analyses of large data sets in which race and ethnicity are recorded by the Census Bureau or projects that follow the Public Health Service Inclusion and Enrollment Report;

3. The OMB requires five minimum race reporting categories but does not disallow the collection of additional categories. Any institution following OMB mandates can include additional categories. The addition of Arab identity increases population identification accuracy²⁴;

4. Arabs in the United States are invisible in large data sets, unless some entity were to include Arab identity in data collection;

5. Identification of disparities privileges traditional reports from large data sets over other scholarly work that, for example, describes Arab and other identities and isolates links between identity and historical and current treatment and outcomes.

The privileging of traditional large data set analyses (a positivist approach) over community-driven identity analyses (constructivist and participatory approaches) reflects some of the top-down versus bottom-up approaches that the NIH, and science in general, has historically privileged. Alvidrez et al. acknowledge that interpersonal, community, and societal level “health outcomes in areas beyond health services research” are needed.^13(pS20) There are differences recorded in the literature between non-Arab White and Arab groups in the United States; these differences are contextualized by humanities and social science scholarship on Arab identity in the United States.^2,4,14,25

CONCLUSIONS AND RECOMMENDATIONS

In the United States, racial/ethnic categories have evolved to accommodate the rapidly changing demographics of the country. For the past three decades, research with Arabs in the United States has consistently provided evidence that their health does not fit the health profile of White Americans and that Arabs do not benefit from Whiteness and White privilege associated with their White racial categorization. On the contrary, Arabs in the United States face multiple health disparities and discrimination that require urgent consideration, which can only be achieved by identifying the population in a separate category and by acknowledging their (invisible) health disparities.

An optimal solution would be for the OMB and the Census Bureau to adopt a separate Arab/MENA category; however, our recommendations for an easily achievable solution is for institutions, starting with the NIMHD and ideally the NIH as a whole, to revise and expand their definition of health disparity populations to include Arabs. We hope this would include a revision to the Public Health Service Inclusion Enrollment Report for an Arab/MENA category or at least an indication that there are other racialized groups that do not appropriately fit this reporting method. This inclusion will have a long-term significant impact on the health of Arabs, first, by identifying, reporting, and monitoring health disparities data and, second, by expanding the funding opportunities for health researchers to address and reduce these disparities among Arabs in the United States.