Education, Race, and Health

In 1990, I took my first sociological methods course in graduate school. The professor taught us the difference between categorical variables and ordinal variables: he said that race was usually put into categories, but that once he had a student use skin tone as a set of ordered categories (lighter to darker) rather than race as a set of unordered categories (like college majors or nationalities). The professor presented his student’s approach as a creative anomaly, praising it but emphasizing how unusual it was.

Jackie, a darker-skinned Haitian-American woman I lived with during college, does not find measuring skin tone along a continuum particularly creative or insightful. She grew up in New York City, where she had experienced discrimination somewhat routinely from whites as well as lighter-skinned Black people. Decades later while living in Boston, she told me that one silver lining of the COVID pandemic was that she got a break from microaggressions when working at home. Let this image sink in: a talented Ivy League graduate, who also holds a two master’s degrees and a doctorate in law and policy, felt more peaceful during quarantine than during her ordinary work life. It’s also noteworthy that she has spent most of her life in Northeastern cosmopolitan cities.

With her permission, I am using details from Jackie’s experience to help others understand why Reed DeAngelis, Taylor Hargrove, and Robert Hummer were able to document, in a recent study published in Demography, that Black Americans with darker skin tones do not experience health improvements as they attain higher socioeconomic status. DeAngelis and his colleagues used data from a nationally representative cohort of Black and White adolescents who they followed up with as they transitioned to adulthood and into their 40s (the Add Health survey). The researchers can be sure that the health disadvantages among educated, darker skinned Blacks that they observed at midlife accumulated during the transition to adulthood because there were no health differences among them by race or by color when they were adolescents. Jackie and I had similar health when we met as college freshmen, and we’ve both become more educated since, yet we have had very different healthcare experiences over the years. 

Why is education associated with better health for white people like me (as well as for lighter-skin Blacks like my husband) but with worse health for darker-skin Blacks like my college roomate, Jackie? The researchers’ findings tell a compelling story out of the richness of the Add Health data. 

First, they show that reports of unfair treatment differ by skin tone and education: whites and Blacks with lighter skin tone report less unfair treatment when they have more education, but Blacks with darker skin tone who hold college degrees report more unfair treatment than their less-educated counterparts. 

Second, they show that reports of unfair treatment do, in fact, predict lower subjective status (where people picture themselves on a 10-rung ladder representing American society and those with the most money, education, and respected jobs are at the top). 

Third, they show that lower subjective status really does “get under the skin”: levels of C-reactive protein, a biomarker of chronic inflammation that also predicts cardiovascular risk and mortality, were higher in those with lower subjective status.

Finally, C-reactive protein measured at ages 24-32, predicted health about a decade later among their participants. This sequence explains why higher education is not associated with better health among darker-skin Blacks: unfair treatment leads to lower subjective status that contributes to chronic inflammation which produces poorer health.

Jackie shared what it is like to be treated unfairly. One of the many things she learned while we were undergraduates is that medical interventions and medications are typically tested among predominantly white volunteers. This motivated her to participate in clinical trials so that medicine would have data to inform treatment of people like her. She volunteered for studies that didn’t involve ingesting anything, particularly ones that tried to recruit Black people.

In a study that involved skin biopsies being taken from her arms, the investigator, who was particularly interested in dark pigment, took samples from her that were three times larger than those taken from the other participants. Years later, a doctor thought Jackie had track marks from injecting drugs (despite being told of their origin in the clinic trial) and ordered a test for Hepatitis C. The investigator didn’t need to brand Jackie in the first place—in another clinic trial requiring skin biopsies, Japanese researchers used skin near the armpit and closed with a butterfly stitch instead. Also, the doctor could have believed Jackie’s explanation of the marks rather than doubting her moral virtue. To add financial insult to these injuries, Jackie ended up paying $400 for the Hepatitis C test because her medical insurance said it was not medically necessary (they were right). 

Furthermore, during screening for a study of Black women in families with multiple fraternal twin births, the investigator recommended that Jackie consult her primary to diagnose the source of high prolactin levels and heavy bleeding. Her primary doctor would not follow up because, she said, Jackie’s heavy bleeding could be explained by a miscarriage. Jackie answered that she only believed in one immaculate conception, but this testimony to her virginity was ignored. A case worker at the hospital ended up ordering Jackie’s primary to schedule her for an MRI, but the primary ordered an MRA instead—a test that would not diagnose any of the potential causes of hyperprolactinemia and heavy bleeding. The radiologist, however, did listen to Jackie and changed the orders. Thus, after 14 days of heavy bleeding, she was finally diagnosed with uterine fibroids. The most typical corrective surgery for this condition leaves just a four-inch horizontal incision at the bikini line; sometimes it is necessary to make three additional one-centimeter incisions at the belly button and each hip. But in Jackie's case, the surgeon simply made a large jagged vertical incision. 

Jackie also explained how the health literature has changed since we were undergraduates. For a long time, research on Black-White health disparities focused on what Black people were doing differently, i.e., seeking the behavioral explanations for Black health problems. A big theme was non-compliance with treatment protocols. More recently, structural and institutional racism have become central in the health disparities literature. DeAngelis and his colleagues were the first to show that lower returns to education among Blacks depend on skin tone, but the fact that upward mobility has health consequences among Black Americans had already been shown. We are not paying attention if we still expect upward mobility to improve health regardless of skin color.

Returning to the pathways DeAngelis and his colleagues found in the Add Health cohort, highly-educated women are more likely to recognize when they are being treated as unreliable sources for information about their own bodies, to understand how they ended up with a $400 bill for an unnecessary test, or to know the difference between a butterfly stitch and an ordinary suture—small wonder they report more unfair treatment. It is also unsurprising that such treatment would confer low subjective status contributing to inflammation and its later health consequences. The oldest Add Health respondents in the DeAngelis study were only age 43 at the most recent wave of data collection, leading the authors to conclude: “The fact that we are already begin­ning to uncover racialized disparities in inflammation and self-rated health could be a harbinger of more serious aging disparities down the road.” 

Unfortunately, they could be right. Jackie feels more in control of her own health today in her 50s because she has a PPO that makes it easier to circumvent unhelpful physicians. One of the key ways education is supposed to promote health is by qualifying people for jobs that have good health benefits. She emphasized, however, that this wouldn't be sufficient if she hadn’t learned how many doctors persistently disregard legitimate symptoms that darker-skinned Blacks report. She also noted that the reasonable health care she is receiving today may not remove the health effects from decades of poor care.

Laurie DeRose is a senior fellow at the Institute for Family Studies, Assistant Professor of Sociology at the Catholic University of America, and Director of Research for the World Family Map Project.