“We embody everything around us,” Ryan Petteway, Ph.D., told his students Tuesday during a lecture on racism and community health at Portland State University. “You’ll hear about epigenetics. You might think about genes. Forget about genes. Think about the social conditions that become embedded in those genes.”
Petteway’s students leaned against walls, sat on the cold concrete floor and slid into the few seats available Tuesday during the crowded presentation, hosted at PSU’s Native American Student and Community Center. Members of the public had come to hear from Jones, a family doctor and public health scientist who had formerly served as president of the American Public Health Association and as research director on social determinants of health for the Centers for Disease Control and Prevention.
First Petteway set the scene.
Exposure to racism chips away at the body’s ability to recover from stress, he explained. And over time that leaves the body vulnerable to sickness. A person doesn’t even have to experience an act of racism directly for it to impact her health. Simply anticipating a racist act might be enough. So when a Black man is killed by police, any African American person might reasonably fear for himself or a loved one. Recent changes to federal immigration policies have correlated with adverse effects on birth outcomes for Latinx people.
“The possibility that it might happen can activate the stress response, whether or not it actually happens,” he said. “Health outcomes are expressions of what happens to our bodies because of oppression.”
Jones picked up the narrative and, through stories about the edge of a cliff and a San Francisco diner, explained how privilege allows some to ignore injustice, while oppression causes others to get sick and die young. Jones laid out a case for going beyond investments in acute care and safety nets and deeper than discussions on the social determinants of health.
Those are vital, indeed, she said, but it does not equip us to talk about how health disparities arise.
“Health is not created within the health sector. It’s created by the difference in the conditions of our lives, which make some individuals and communities sicker than others,” she said. “When we talk about systems of power we are now talking about social determinants of equity. Now we talk about racism, sexism, economic systems of power.”
Following her talk, Jones joined a panel of experts including Multnomah County researcher Duldulao.
As an epidemiologist whose work shapes policy and programs that advance health equity, Duldulao spends a lot of time thinking about power and place, including her own. But lately she’s begun to think about her body too.
“There’s a great book called The Body is Not an Apology. It’s getting me to think about the study and surveillance of bodies, in the context of oppression,” she said. “I’m asking myself how these processes manifest in myself and what that does to me.”
For the first time she began to wonder whether her family’s story might be one reason she got sick.
Duldulao’s parents immigrated from the Philippines with only two suitcases worth of possessions. The family lived for a time in an aunt’s basement. They struggled financially. Her father weathered racism at work. There was mental illness and abuse. She felt an obligation to succeed. She worked hard, earned degree, after degree, after degree. And she lived well. She didn’t smoke. Yet she was diagnosed, in 2017, with breast cancer.
“How did this happen?” she asked the doctors. “There’s no history in my family.”
“It's spontaneous,” the doctors said.
“‘O.K., I guess it just happened,’” she told herself.
But she has recently begun to wonder, did it just happen? Or is this part of her story too?
“Putting all these things together, the examination on how systems and structures sit inside you,” Duldulao said. “It’s a painful but necessary process.”
Before visiting PSU, Jones stopped by the Multnomah County Health Department, where she spoke to dozens of employees. Among them was Public Health Director Rachael Banks.
“Her analysis squarely validated why starting with race and centering on the margins is the only way to achieve health equity,” Banks said later. “Racism is alive and well, but how do you face that? Do you shy away? Absolutely not. We need to stay the course on equity.”
Banks can easily call out ways Multnomah County has stayed that course — by centering community preservation and healing in the county’s Community Health Improvement Plan, through the Future Generations Collaborative, by maintaining culturally specific strategies, by continuing to support community partnerships and capacity building, and training community health workers.
After nearly two decades working in public health at Multnomah County, Banks knows health equity wouldn’t come about by an individual’s actions; it takes systems to mobilize. But she still feels moved by Jones’ reminder that it takes us all to do this work.
“It's inspiring for me, to be part of cultural change,” Banks said. “It’s not about one person, but about the systems we create.”