Map of life expectancy at birth from Global Education Project.

Sunday, June 11, 2006

Almost right can be really, really bad

One of the lesser noted -- but in my view extremely important -- elements of the new health care reform legislation in Massachusetts is a requirement that hospitals collect patient data by race and ethnicity, and that their reimbursement rates be tied to progress in eliminating disparities in health care. The data systems this applies to already exist -- they're the hospital discharge data system, and standard quality assurance systems. What's new is only the requirement for racial/ethnic identification.

If you've been reading for a while, you already know that there is a federal standard, consistent with the census. Because all of the important state public healty data systems feed into federal systems, the states pretty much have to observe the federal standard. And, of course, it's really, really horrible. It's based on long discredited 19th Century theories of biological race, with an awkwardly grafted on attempt to account for the largest "minority" group in the United States, so-called "Hispanics," who don't happen to fit into the race theory. So, as you probably know, people first choose an "ethnicity" - consisting of are you or are you not "Hispanic" -- then they pick one or more "races" -- White, "Black or African American," Asian, Pacific Islander, "Native American/American Indian/Alaksa Native".

The profound, ignorant bogosity of this system has been well described before, here and elsewhere. I won't belabor it, but basically, while the government acknowledges that it has no correspondence to biological reality, they claim that it reflects socially constructed categories. Alas, while it reflects to some extent social constructions of the past, it has little use in the present. The very basic, essential falsehood in the entire edifice is apparent in the assumption that "Black" and "African American" are synonyms. Black is a racial label; African American is an ethnic term, referring to descendants of people brought to the U.S. from Africa as slaves, and people who have assimilated to that ethnic community. There are now innumerable U.S. citizens who are perceived as racially Black, but whose ethnicity is Haitian, Jamaican, Nigerian-American, etc.

Hispanic is also a heterogeneous category. There are huge differences in health status and other social-economic circumstances among, say, Puerto Ricans, Chicanos (U.S. born people of Mexican ethnicity), Mexican immigrants, Salvadorans, Dominicans, etc. Many very important ethnic groups aren't represented in our data in any way, such as Brazilians (who aren't "Hispanic" since Portuguese is the dominant language in Brazil), and Arabs. Pakistanis, Japanese, and Filipinos are all officially "Asian," though what they have to do with each other is a mystery indeed. A Pashtun who steps over the border from Pakistan to Afghanistan to have lunch with his sister's family instantly ceases to be "Asian" and becomes "White." And so on.

So, the Massachusetts Department of Public Health, in collaboration with the Boston Public Health Commission, has developed a draft standard for data collection intended to fix this problem. We still have to ask the official federal questions: Are you Hispanic, and what is your race? But then respondents are to be given access to a large menu of ethnicities: African American, Native American (name your tribal nation), Puerto Rican, Brazilian, Cambodian, Dominican, Chinese, Arab, Pakistani, etc. etc. Also you can pick other and fill in the blank. So far so good.

Now the bad news. One of the available categories is "American." Apparently they intend this to refer to people of the dominant Anglophone European Settler Culture (AESC). At least I so conclude because there isn't any other category that might mean that, and here in the city of James Michael Curley and Tommie Menino they don't Irish- or Italian-American. In other words, American is supposed to mean Gringo, Honky, paleface. European American.

I cannot begin to express how profoundly offensive this is. Obviously it implies that all those other people aren't American. It also happens to be the case that America consists of two continents plus the islands of the Caribbean, of which the United States is a small part, and from which all those exotic Dominicans, Mexicans, Jamaicans, Haitians, and Brazilians actually come. Not to mention those Native Americans. (Duhh.) Furthermore, if we are labeling ethnic groups by their geographic origins, the geographic origin of what they mean by American is England.

Yet the Division of Health Care Finance and Policy, which will enforce the new regulations, intends to adopt this standard. They are having a public hearing on Tuesday, June 13, after which every single person who receives care in a hospital in Massachusetts will be asked whether they are Haitian, Brazilian, Pakistani, Arab, Jamaican, Puerto Rican, etc., or, instead, alternatively, in contrast, are American.

This, my friends, shall not happen. The correct choice is "Euro-American" or "European American." Pick something more specific if you like.

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