In 2019, a joint committee on community pediatrics and adolescent health published, “The Impact of Racism on Child and Adolescent Health,” a policy statement calling on medical professionals to take decisive steps to both end racism and take better care of people impacted by it. Published in the American Academy of Pediatrics (AAP) journal Pediatrics, the statement labeled racism as a “socially transmitted disease.”
The diagnosis fits. Racism infects institutions and interpersonal relationships. It is suffocating and relentless and omnipresent in hospital delivery rooms and doctor’s offices, school classrooms and admissions offices, police stations, courtrooms, places of business, and bank lending offices. The damage wrought by racism is visible, quantifiable, and traceable through generations.
But what is often lost in discussion is the physiological toll it carries. Racism, asserts the AAP policy paper, is a “determinant of health that has a profound impact on the health status of children, adolescents, emerging adults, and their families.” And it turns out that perhaps the most pernicious symptom of racism is the stress and stress-related illnesses it causes.
The stress itself isn’t hard to pinpoint, especially not in recent months. The COVID-19 pandemic ravaged communities of color in disproportionate numbers, throwing into sharp relief the inequities defining life in this country for people of color, from unemployment to education to the healthcare for those incarcerated. The spring and summer of 2020 found another level of tumult as black Americans were confronted with, in quick succession, the shooting death of unarmed jogger, Ahmaud Arbury, in Georgia; the shooting death of Breonna Taylor during a raid by Louisville police; the death of George Floyd by Minneapolis police; and the nearly fatal shooting of Jacob Blake by Kenosha police. Months of despair, anger, and protest ensued. This followed with a bruising election season that saw efforts aimed at suppressing the vote in minority communities, not to mention the literal attack on the nation’s Capitol that included a vocal subset of White Supremacists.
The stressors are there, clearly, but what direct impacts do they have on adults and children of color? How wide-ranging are the health effects and how could they leave a mark on future generations?
Dr. Natalie Slopen is an epidemiologist at Harvard’s T.H. Chan School of Public Health. Her work focuses on the social influences on stress, health disparities, and “psychological and biological mechanisms through which childhood experiences like adversity are embedded to increase risk for later chronic diseases.” Fatherly recently spoke to her about the impact of racism and race-related stress on the health of children and adolescents.
How do stress and race relate?
Racism is pervasive across our institutions and structures, and the lived experience of people of color, particularly African American, Hispanic, and Native American adults in the United States, are extremely different based on the opportunities and the resources related to nearly every sector of our society, be it, the education system, the healthcare system, the lending system, the types of community investments our governments make. These are systemic issues that pervade nearly every aspect of life, and in ways that make life in the United States incredibly different across subgroups of our society.
How long have researchers been connecting the links between stress and race?
In the ’90s there was a big emphasis on the study of health and health disparities by race, ethnicity, and socioeconomic status in the United States. Researchers began to devote serious attention to understanding the ways that stress contributed to racial and ethnic health disparities, by measuring stressors that affect everyone as well as those types of social conditions that disproportionately impact disadvantaged racial and ethnic minorities in the United States.
“Elevated levels of [stress-induced] inflammation track over time in the same way that we know that kids who are obese are more likely to have higher body mass indexes when they’re adults.”
What are the direct impacts of these stressors?
So we can think about both acute and chronic stressors. When individuals experience a stressor, we have what’s called a fight or flight response, which triggers a biological cascade of cortisol and other types of stress hormones that can lead to an elevation in inflammatory proteins. And so if we have stress repeatedly, or have this heightened stress response that doesn’t give our body time to recover — think of it as the revving of a car engine over and over — eventually our body doesn’t respond in the same way to those chemicals. And once they are at chronically high levels it can be harmful to various bodily systems, everything from cognitive processes to the cardiovascular system. Over time it can influence the pace of aging, for example. Research on the connection between stress and health became a major topic perhaps 75 years ago. Since that time there’s been tremendous progress, figuring out the cellular and behavioral pathways connecting stress to health research.
Stress is also associated with elevated levels of inflammation. What’s the significance of this for kids?
These associations between stress and inflammation can be observed in pediatric populations, as well as in adults. Elevated levels of inflammation track over time in the same way that we know that kids who are obese are more likely to have higher body mass indexes when they’re adults. It’s associated with a huge range of different chronic diseases from cardiovascular diseases, stroke, cancer, and mental health. And importantly, it’s one of these markers where there is evidence that it can become dysregulated in relation to stress within the first two decades of life.
Being an adolescent kid is hard and stressful enough. What are the impacts of race-related stress on teens?
For a long time, researchers used to focus on early childhood, because it was a period of rapid development, and there’s been increasing appreciation for adolescence, as a period of rapid neuro developments, as well. And yes, teenagers today are coping with a huge range of both opportunities and challenges. And if we want to take the case of racism in particular, it can be inescapable. Not only are individuals navigating experiences in their own lives, but we can also think about the vicarious trauma that can come from witnessing events, social media, and the news, in ways that are inescapable.
It doesn’t have to be something that you’ve experienced yourself, but it can be something that you hear about that happened to a family member, or perhaps somebody that you don’t even know. There’s research from a big national study that pretty clearly shows that police killing unarmed black Americans have spillover effects for the mental health of black Americans, but we don’t see that same negative impact on mental health among the white respondents in the study.
“Traumas can be passed down from generations and we are learning about the ways that trauma can be transmitted biologically across generations, perhaps in the form of epigenetic transmission.”
Do researchers have any concept about how this bears out over generations?
We have many studies that have taken an intergenerational approach, where we have been able to observe how the experiences of grandparents plays itself out downstream to the health of their offspring, and then those adults’ children. So we know that there’s intergenerational transmission of all kinds of social constructs, like wealth, where you live. And we know that traumas can be passed down from generations and we are learning about the ways that trauma can be transmitted biologically across generations, perhaps in the form of epigenetic transmission. That’s a rapid area of research, but we don’t have great clarity on the specific mechanisms that could be connecting trauma from one generation, to biological changes in the next. And that’s something that researchers are actively working on, but it’s fair to say that we know that these connections exist and researchers are now focused on trying to understand both the behavioral, as well as the biological, mechanisms that occur.
Are there links between race-related stress on outcomes like academic success, or long-term financial success?
There’s very strong literature that racism at the individual, interpersonal, or systemic levels has impacts across all kinds of outcomes from one’s own self-confidence, to academic performance, to workplace opportunities, to physical and mental health, and when people live or die. So it is possible to find evidence to show these connections across the broad spectrum of achievement and health. And there’s a lot of work trying to connect how it is that racism is driving the spread of outcomes across these diverse types of metrics, but the evidence is there.
Is there an antidote to this? Is there a solution?
We will never do away with stress, and our approaches to reducing the effects of race-based stressors can’t be targeting the individual psychological level exclusively. So we really need to be developing societal and systemic approaches, to create a more equitable and anti-racist society. We need to take a prevention-oriented approach, where we restructure these systems that are unfair and lead to inequitable outcomes across groups. So our approaches need to target those broad social factors that are driving these mechanisms in the first place.
Has there been any research into how to address the impact of race-based stress? Who is working on the problem?
Yes. There’s a lot of people working on this topic of anti-racism, not necessarily within schools of public health, like I am. For example, at Boston University they have a brand new initiative called the Center for Anti-Racist Research, and they take a very macro-level approach to think about how to solve these issues. Particularly the structural institutionalized forms of racism that we really need to move things forward, and that perhaps, we haven’t had the political will or the right leaders in place to make it happen.
I think that it’s really important to be thinking about financial stress and the wealth gap across racial and ethnic groups. I mean, there are just such pronounced differences in the level of financial strain, workplace instability. The COVID epidemic has exasperated all of these disparities and put a magnifying glass on these inequities that have existed. And they’re now becoming even more accentuated in light of the pandemic. So we can be thinking about financial strain, children of color are so much more likely to have a parent, I should say black, have a parent who has spent time incarcerated.
“There’s so much uncertainty in our world, and we know that uncertainty and instability is a major risk factor for mental health problems.”
The injustice within the child foster care system is a big issue, so children are much more likely to be separated from their parents in families of color. Those are some topics that come to mind. When we study childhood adversity, I think another major topic has to do with exposure to violence and safety within communities, access to green space, just not having those same resources and enrichments that promote healthy child development. So it’s not just the presence of stressors, it’s also the absence of those things that we know lead to healthy development as well.
From the particular impact of COVID on communities of color to the deaths of Ahmaud Arbery, Breonna Taylor, and George Floyd; the public resurgence of white supremacists… Are we facing a down the road health epidemic tied to the stresses of the last year?
We have to prepare for it. But I also think we’re already there. There’s a lot of national polling that’s happening right now to suggest that Americans are suffering tremendously, mental health-wise. There are so many communities that have had such devastating losses of life. Children are socially isolated, a lot of adults are socially isolated. There’s been a tremendous financial strain, we’re on the brink of an eviction crisis once this moratorium ends. There’s so much uncertainty in our world, and we know that uncertainty and instability is a major risk factor for mental health problems. And then when you think about all of the healthcare workers who are experiencing tremendous strain, if not burn out, and are yet asked to keep going. So we are in a really dangerous time for the health of our country, separate from the COVID epidemic, but yet related to the COVID epidemic.