Who Are You? (doot doot, doot doooooooo)

One of the biggest challenges we have when it comes to eliminating health disparities is understanding just who the heck it is who suffers from them. We know that socioeconomic status -- income, education, job status -- has a lot to do with health, and we also know that disparities by race and ethnicity remain even when we control for SES. There is a major problem, however, with this "race" and ethnicity concept.

I'm sure that readers have picked up from the zeitgeist, even if they haven't come across the specific history, that in the U.S. there is an official system of racial classification. It was actually promulgated by the Office of Management and Budget in 1997 as the Revised Minimum Standards for Classification of Race and Ethnicity, and became binding on all federal agencies as of January 1, 2003. It replaced an earlier standard called Statistical Policy Directive 15.

First, people are classified by the so-called "ethnicity" question, which is simply, "Are you of Hispanic origin?" Then they are classified by "race," and we all have exactly five choices: White; Black or African-American; American Indian or Alaska Native; Native Hawaiian or other Pacific Islander; and Asian. More specific designations are allowed, but must "roll up" into these categories.

CDC has proposed a standard scheme for racial/ethnic identification consistent with these standards. The system attempts to map various nationalities onto "races." For example, certain African nationalities are listed as sub-races of "Black," European countries as "white" sub-races, and various Middle Eastern countries including Iran, Egypt and Israel as sub-races of a separate white sub-category. Filipinos are a sub-category of "Asian" race. Many nationalities, such as Brazilians and South Africans, are omitted, perhaps because it is obvious that they can't be plausibly mapped onto a "race." Two sub-national groups -- Scots and Assyrians -- are also included as "white" sub-races. Under "Hispanic" ethnicity is a list of predominantly Spanish-speaking countries of the Americas, regions of Spain, and Basques.

This, to put it in technical terms, is completely nuts. Race is a discredited concept with no biological basis. It is a social construct which continues to be important as a source of discrimination and historical inequity, but it does not map onto nationality. Nor does it make any sense, for any purpose, to organize people according to a multilevel racial system in which Arabs, Israelis and Iranians are sub-sets of a "white" race while Pakistanis are sub-sets of an "Asian" race that includes Filipinos (who live on islands in the Pacific and whose native language, Tagalog, is related to Polynesian languages) and Japanese. People who happen to come from predominantly Spanish speaking countries are not the only people on earth who possess ethnicity, nor is there any particular ethnic commonality between Catalonians and Mayans, both of which are "Hispanic" according to the CIPHER scheme.

Among the bizarre features of this procrustean system:

• Pashtuns who happen to be in Afghanistan are white. If they step across the border into Pakistan, they are instantly transformed into Asians.
• People who write "Dominican" in the "race" field are automatically classified as Black. I once had a Chinese-Dominican Research Assistant whose last African ancestor probably lived about 300,000 years ago.
• "Black" and "African-American" are used interchangeably. This habit once caused the New York Times to proclaim that every heavyweight boxing champion since Sonny Liston has been African American. Former World Champion Lennox Lewis is a subject of Her Royal Highness Elizabeth II.

I could go on. Come to think of it I will. The "Hispanic" category is a label imposed by the dominant, anglophone culture on people from many countries who didn't become "Hispanic" until they set foot in the USA. If you look separately at the health status of Mexicans and Puerto Ricans, you will immediately discover that they are as different as "Black" and "White" populations. "Asian" is a completely meaningless category in terms of language, culture, history of immigration, social status, and health status. In some data systems, people are allowed to pick from a limited menu of subsets of Hispanic and Asian, but numbers are usually reported with these subsets conflated. Arrrgh.

There is a very simple solution. Everybody, not just "Hispanics," regardless of "race," should have access to the full menu of ethnicities. Ethnicities should not be conceived of as subsets of races. You can pick Xhosa, or Ibo if you like, or South African or Nigerian, if that's how you prefer to identify yourself. Pick a race if you want to. The ethnicities can be aggregated for analytic purposes in whatever way makes sense for the question you are studying.

Done.