The concept and measurement of race and their relationship to public health: a review focused on Brazil and the United States

The concept and measurement of race and their relationship to public health: a review focused on Brazil and the United States

Cadernos de Saúde Pública/Reports in Public Health
Volume 20, Number 3, Rio de Janeiro, (May/June 2004)
pages 660-678
DOI: 10.1590/S0102-311X2004000300003

Claudia Travassos
Departamento de Informações em Saúde
Centro de Informação Científica e Tecnológica,
Fundação Oswaldo Cruz, Rio de Janeiro, Brazil

David R. Williams, Florence Sprague Norman and Laura Smart Norman Professor of Public Health; Professor of African and African American Studies
Harvard University

Race has been widely used in studies on health and healthcare inequalities, especially in the United States. Validity and reliability problems with race measurement are of concern in public health. This article reviews the literature on the concept and measurement of race and compares how the findings apply to the United States and Brazil. We discuss in detail the data quality issues related to the measurement of race and the problems raised by measuring race in multiracial societies like Brazil. We discuss how these issues and problems apply to public health and make recommendations about the measurement of race in medical records and public health research.

“Race is a social construct, but as for other aspects of social stratification, with biological consequences.”

The notion that health is influenced by the social position of individuals has been known for many centuries. Nancy Krieger notes that since Hippocrates the relationship between health and social position has been acknowledged. It has also been shown that social disparities in mortality exist for almost all causes of death in most societies, and these disparities have been increasing in recent decades in several developed countries.

Race has been used extensively in the medical and public health literature, especially in the United States, to measure social differences in health outcomes and treatment, and its use has increased in recent decades. In the US, there is a vast literature that relates race to disparities in health outcomes, which shows that race is an important predictor of health status. “Blacks” in the US are disadvantaged compared to “Whites” on most indicators of economic status and health. Despite a reduction in these racial inequalities on both of these indicators during and immediately after the Civil Rights movement (the mid-1960s to the mid-1970s), they have remained large or have widened ever since. In the US, adjustment for socio-economic status (SES) always reduces and sometimes even eliminates racial disparities in health. A recent publication of the Institute of Medicine also documented that there are large racial differences in the quality and intensity of medical treatment in the US, even after adjustment for access factors, SES, and severity of illness.

In Brazil, there are fewer studies of racial inequalities in health. Batista, using data from death certificates, has shown that “Black” men and women had the highest crude mortality rates in 1999 in the State of São Paulo. Data based on census and national household surveys show that aggregate infant mortality in Brazil in the years 1977, 1987, and 1993 was higher for “Blacks and “Pardos” (“Browns”) and that it declined at a lower rate when compared with “Whites”. Martins & Tanaka, using data from the Committee on Maternal Mortality, have also shown large differences in the risk of dying due to maternal causes in the State of Paraná in the years 1993 and 1997, which disproportionately affected “Black” and “Yellow” (Asian) women. Maternal mortality did not differ between “Parda” (“Brown”) and “White” women. Dachs, using data from the 1998 National Household Survey (PNAD), found no statistically significant difference by “skin color/ race” in self-assessed health status after adjusting for education and income level. Barros et al., based on longitudinal data, have shown worse health outcomes for “Black” children in Southern Brazil, which is reduced after adjustment for SES and various other variables (marital status, maternal age, parity, planned pregnancy, social support, smoking, work during pregnancy, and antenatal care). The study results also suggest that “Black” mothers receive lower quality of care as compared to “White” ones. There are also indications that in Brazil racial inequalities are more common in treatment than in access to health care services.

The objective of this article is to review the literature related to the concept and measurement of race with a focus on the US and Brazil. We will discuss both the measurement of race in these two multiracial societies and data quality problems. We also make recommendations about the measurement of race in medical records and public health research. Although the use of race in public health research has been discussed in relation to definitional and methodological problems in the United States, the Brazilian public health literature has not discussed in detail how such problems apply to Brazil. This article is intended to review the literature and introduce a discussion regarding broader as well as country-specific questions and problems related to the use of this category in public health…

…Despite the fact that race has been used as a surrogate for genetic information until the onset of molecular genetics, there is no scientific support to continue using race in Public Health as a marker for genetic susceptibility. Parra et al. have recently shown that skin color in Brazilians cannot be used as a genetic marker, because physical traits have been shown to be a poor predictor of African ancestry in this population. In both the United States and Brazil, although the risk of sickle-cell anemia varies by race, race is not a reliable predictor of sickle-cell anemia…

…Despite existing controversies in the biomedical literature, it is widely accepted that racial/ethnic categories are imprecise and changing measures that are historically, administratively, and politically constructed. The salience given to race, as well as the meaning and the measure of race itself in census and health data, varies across countries and across time. The history of race classification in the US and Brazil are good examples of these variations as will be discussed later in this article…

Measuring race in admixed populations

The question of whether populations of mixed origins can be categorized into any simple, finite, discrete categories is becoming central to racial/ethnic taxonomy. Some societies have large proportions of admixed people and many others are increasingly becoming admixed. Immigration in the US, especially from Latin American countries, increased in the last few decades, making its population much more heterogeneous. The projection of the US Census Bureau is that by 2050 one half of the US population will be “Non-White” and 21% of the population will be of multiple ancestry.

Despite the possibility of answering questions with multiple races, the new OMB classification in the US is not a good solution for classifying admixed people. For miscegenation that goes back many generations, individuals simply do not know about their ancestry. Whenever people’s parents, grandparents, and great-grandparents descend from intermarriages of admixed people, “pure” ancestry becomes very difficult to trace. In Latin American countries such as Brazil where miscegenation occurred at very early stages, it is difficult for a large number of people to answer questions about their origins.

It can also be argued that people do not know their ancestry because origin played a distinct role in societies with early miscegenation. As a result, many people may not find a place in any of the selected discrete “races” categories. In the 2000 US census, 43% of people that identified themselves as “Hispanic or Latino” chose, in the race question, to answer “some other race” (, accessed on 10/Oct/ 2002). And they usually inserted their country of origin or an alternative term for their Hispanic ethnicity for their race.

When assessing their own race, recent immigrants from countries where race is not as central in social structure as in the US may apply criteria adopted in their original country. On the other hand, descendents of migrants are more likely to respond to the race question using different criteria from the ones used by their parents. The fact that this classification is based on pure-race categories of ancestry and the absence of a multiracial category increases the chance of misclassification or non-specification for admixed people. On the other hand, multiracial categories tend to be very heterogeneous, and the greater the admixture in a population, the lower the discriminatory power of racial classifications.

Therefore, fluidity and ambiguity of racial measurement increases as the population becomes more multicultural and admixed. The more admixed a society, the greater the misspecification and heterogeneity of racial categories based on ancestry. Bias will also affect classifications that allow people to be classified in more than one pure-race category, as in the new US classification. Multiracial categories also tend to be very heterogeneous. At the same time, US data on children born to Black/White unions indicate that infants with a Black mother and White father consistently have higher health risks than those with a White mother and Black father, suggesting that in at least some situations there may be health risks linked to the specific pattern of multiracial status.

The use of skin color may be a more adequate proxy for racial/ethnic discrimination in admixed societies than racial measurement based on ancestry. Ethnicity or nationality may also be more meaningful in societies with recent migrants…

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