Are you ready to talk about racism? We are.

We had several comments on my story this week about the disturbing disparity in infant mortality rates between African-Americans and whites in Michigan. A number of the comments took issue with the the claim that racism could be "a major cause" of the disparity. 

As we said in the intro to my piece, racial inequality shows up in just about every possible measure of opportunity. It's a subject we simply can't avoid talking about on this project, and you're going to hear about it a lot. 

With that in mind, I thought it might be worth clarifying some of the issues in my piece, so that you'll know a little bit more about where we're coming from when we talk about race. 

So, first, I think we need to clear up what we mean when we use the word "racism." I think we're all pretty clear about what racism means at the individual level. It's the extreme and violent treatment that we've seen in our nation's history. More often in today's America, it's what Jamisha Alexander talked about in my piece when she said, "I have to deal with people looking at me a certain way, or not, just not being treated ... fairly." This experience of being treated differently because of one's race is what we typically think of when we think about racism. It's what our anti-discrimination laws are designed to prevent. But in its more subtle (and perfectly legal) forms, it can result in someone feeling like they always have to be "twice as good." It's a feeling that is often real, and sometimes imagined. Having to wonder which is which just creates another level of stress. 

But the stress that comes from this kind of racism isn't the only thing we're talking about when we talk about racism's effect on opportunity and health. It's not the only thing I was talking about in my piece on infant mortality. 

In 2004, the National Academies Press published a 318-page guide for social scientists, called "Measuring Racial Discrimination." The book itself has two definitions of racism: 

I had to read those definitions a couple of times to really understand what they meant, but basically the first definition includes treating people differently because of their race. The second definition addresses different treatment that, on its own, has nothing to do with race, but the end result gives a disadvantage to one racial group. The second definition is more likely to be what most people refer to as "structural racism." 

And, I think, this second definition is what led to some of the confusion about my piece. The fact is that, even though we've gotten rid of many of our discriminatory laws in this country, and even though racial violence has gone down dramatically, many of the institutions in our country are still set up in a way that disadvantages racial minorities. We may not have any policies on the books that say black people have to live in one neighborhood, and white people have to live in another. And yet, black children are more likely to be born in high-poverty neighborhoods. That means they're more likely to go to a low-performing school. They're more likely to be exposed to drugs and violence. They're less likely to have access to healthy foods or good medical care. All of that results in less opportunity, which can create a cycle of dysfunction for everyone born into that circumstance - many of whom are black.

Trying to sort out and measure the effects of both discriminatory treatment, and discriminatory results on infant mortality has been a challenge for the public health community. 

"It's a really ... complicated thing to sort out," says Claudia Holzman, who chairs up the Epidemiology and Biostastics department at Michigan State University. When I interviewed her for my piece, she told me that different kinds of racism create different biological "pathways" that can lead to poor health, and poor birth outcomes.

"The same people who aren't eating well, perhaps because there's not a lot of fresh food available at a reasonable price, are the same people who are exposed to unsafe neighborhoods where they can't walk around and exercise as easily," Holzman told me. "It's the same people  who may be having the stress of 'Where's my next rent going to come from,' or 'Will I keep my job.' And when all of this is overlapping, how do you parse it out, you know? That's really difficult."

Difficult as it is, plenty of researchers have taken a crack at it, and there are ample studies that implicate racism in infant mortality disparities. 

I have to admit, when I started researching my piece, I thought that using racism to explain the differing rates of infant death had to be a fringe theory. But as I began pouring through the archives of the journal Obstetrics & Gynecology, and searching for articles on PubMed, I was surprised at how much research is out there. 

One of the researchers who shows up again and again is James Collins, a neonatologist at Children's Memorial Hospital in Chicago. Unfortunately, Collins wasn't available for an interview in time for my piece. But reading his studies is like going down a check-list of factors that could explain the racial disparities in infant mortality.

Collins is one of the authors of a study mentioned in my piece that looked at immigrants of African descent, and compared their infant mortality rates to African Americans. That study, and others like it, provide evidence that the disparity doesn't come from genetics. 

As Claudia Holzman told me, "Genetics really doesn't have a strong rationale at all." 

Collins, has also been involved in studies that examine the effects of high poverty neighborhoods on African American mothers and infants. Since African Americans are more likely to live in these neighborhoods, it's a plausible theory that it could have an effect on infant mortality. 

In a paper published in 2009, Collins and his co-authors concluded that life-long experience in high-poverty neighborhoods does raise the risk for having a low-birth weight baby (low-birth weight is among the leading causes of infant mortality). But, in comparing how this affects Hispanic women compared to African Americans, the study found "African Americans experience a greater health burden from this phenomenon."

Another study compared white and black mothers who'd lived their entire lives in high income neighborhoods. Again, the racial disparity in high-risk birth outcomes persisted. 

One other area to look at is the health of the mother. Here again, there's lots of research, but one study I found compelling comes from the journal Obstetrics & Gynecology. In a paper published in 2008, researchers looked at birth outcomes for moms who were obese. Turns out African American mothers who were obese were more likely to lose a child. Those who were "extremely obese" were even more likely to lose a child. But white mothers who were similarly obese saw no increased risk for losing a child. So, obesity is a risk for black mothers, but not white mothers. Again, this can't explain the disparity.

So, let's talk about stress. There's a whole new field of medicine trying to explain how stress affects the body. The quick and dirty version is that chronic stress causes your brain to release chemicals. If this happens only occasionally, or over a relatively short period of time, these chemical changes may not be harmful. But ongoing, chronic stress can create over-stimulation, leading to something doctors call "allostatic load." High allostatic load can lead to immune problems, and increased likelihood of disease. It's bad news. 

Now, what's one form of chronic stress that black mothers would feel and white mothers wouldn't? What is a form of stress that would follow black mothers, regardless of whether they lived in a high-income neighborhood or a low-income neighborhood? What's a form of stress that would affect obese black mothers, but not obese white mothers?

These kinds of questions are how racism came to be an explanation for the disparity in infant mortality figures.

James Collins worked with a team of researchers to investigate this question last year. They handed out questionnaires to African American mothers who had just delivered a child. Mothers who reported experiencing racism within the past year, and across their lifetimes were more likely to have premature babies. Prematurity is one of the leading causes of death for African American babies. 

Collins and his co-authors found that the effects of reported racism could be mitigated by coping strategies. And there are always questions about self-reported effects like this, though perhaps we could say that even the perception of racism - whether the racism occurred or not - does have an effect on babies. 

This is not an open-and-shut case. The precise biological method by which racism affects pregnancy has yet to be sorted out, as Claudia Holzman warned me. 

And other studies, such as this one from 2004 found no connection between reports of "stressful life events" and premature delivery. 

There's also the paper, out earlier this year, from the American Journal of Public Health, which reviewed other studies on discrimination in health care from 2008 - 2011. The review concluded that the field of public health needs to use "better instrumentation, innovative methodology, and strategies" to quantify the effects of racism in the health care field. This review doesn't challenge the findings on discrimination in health care. It just says that more work needs to be done to quantify the problem. 

What do we take away from all this? 

For me, and for my reporting, I think it's fair to say that we can't ignore the effect of racism on health, just as we can't ignore it in many other aspects of our lives. We also can't brush it off as a "fringe" theory, only put forward by people afflicted by "white guilt." 

Racism may not explain the entire reason why more black babies die in America than white babies. But there's enough research to show that it is playing a role, and that it functions as a sort of base-level factor, leading to all other kinds of negative outcomes. 

I know this has been a long, and probably pretty boring explanation of these issues. But we're not done talking about race on State of Opportunity. I thought it was worth letting you know why we think it's so important.