Quantitative studies of racial health disparities often use static measures of self-reported race and conventional regression estimators, which critics argue is inconsistent with social-constructivist theories of race, racialization, and racism. We demonstrate an alternative counterfactual approach to explain how multiple racialized systems dynamically shape health over time, examining racial inequities in cardiometabolic risk in the National Longitudinal Study of Adolescent to Adult Health. This framework accounts for the dynamics of time-varying confounding and mediation that is required in operationalizing a “race” variable as part of a social process (racism) rather than a separable, individual characteristic. We decompose the observed disparity into three types of effects: a controlled direct effect (“unobserved racism”), proportions attributable to interaction (“racial discrimination”), and pure indirect effects (“emergent discrimination”). We discuss the limitations of counterfactual approaches while highlighting how they can be combined with critical theories to quantify how interlocking systems produce racial health inequities.
AlexanderMichelle. 2012. The New Jim Crow: Mass Incarceration in the Age of Colorblindness. New York, NY: The New Press.
2.
BaileyZinzi D.FeldmanJustin M.BassettMary T.2020. “How Structural Racism Works—Racist Policies as a Root Cause of U.S. Racial Health Inequities.”New England Journal of Medicin384(8):768–73.
3.
BaileyZinzi D.KriegerNancyAgénorMadinaGravesJasmineLinosNataliaBassettMary T.2017. “Structural Racism and Health Inequities in the USA: Evidence and Interventions.”The Lancet389(10077):1453–63.
4.
BaronReuben M.KennyDavid A.1986. The Moderator–Mediator Variable Distinction in Social Psychological Research: Conceptual, Strategic, and Statistical Considerations. Journal of Personality and Social Psychology51(6):1173–82.
5.
BauerGreta R.ScheimAyden I.2019. “Methods for Analytic Intercategorical Intersectionality in Quantitative Research: Discrimination as a Mediator of Health Inequalities.”Social Science and Medicine226:236–45.
6.
BoenCourtney. 2016. “The Role of Socioeconomic Factors in Black–White Health Inequities across the Life Course: Point-in-Time Measures, Long-Term Exposures, and Differential Health Returns.”Social Science and Medicine170:63–76.
7.
BoenCourtney. 2020. “Death by a Thousand Cuts: Stress Exposure and Black–White Disparities in Physiological Functioning in Late Life.”The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences75(9):1937–50.
8.
Bonilla-SilvaEduardo. 1997. “Rethinking Racism: Toward a Structural Interpretation.”American Sociological Review62(3):465–80.
9.
Bonilla-SilvaEduardo. 2009. Racism without Racists: Color-Blind Racism and the Persistence of Racial Inequality in America. Lanham, MD: Rowman & Littlefield Publishers.
10.
BrownTyson H.2018. “Racial Stratification, Immigration, and Health Inequality: A Life Course-Intersectional Approach.”Social Forces96(4):1507–40.
11.
BrownTyson H.RichardsonLiana J.HargroveTaylor W.ThomasCourtney S.2016. “Using Multiple-Hierarchy Stratification and Life Course Approaches to Understand Health Inequalities: The Intersecting Consequences of Race, Gender, SES, and Age.”Journal of Health and Social Behavior57(2):200–22.
12.
CharlesCamille Zubrinsky. 2003. “The Dynamics of Racial Residential Segregation.”Annual Review of Sociology29:167–207.
13.
ChowkwanyunMerlin. 2011. “The Strange Disappearance of History from Racial Health Disparities Research.”Du Bois Review Social Science Research on Race8(1):253–70.
14.
ChowkwanyunMerlinReedAdolph L.2020. “Racial Health Disparities and Covid-19—Caution and Context.”New England Journal of Medicine383(3):201–203.
15.
CogburnCourtney D.2019. “Culture, Race, and Health: Implications for Racial Inequities and Population Health.”The Milbank Quarterly97(3):736–61.
16.
CrenshawKimberle. 1991. “Mapping the Margins: Intersectionality, Identity Politics, and Violence Against Women of Color.”Stanford Law Review43(6):1241–99.
17.
CrenshawKimberle. 2017. On Intersectionality: Essential Writings. New York, NY: The New Press.
18.
DarityWilliam A.Jr.MullenA. Kirsten. 2020. From Here to Equality. Chapel Hill: The University of North Carolina Press.
19.
DelgadoRichardStefanicJean. 2017. Critical Race Theory: An Introduction. 3rd ed.New York: NYU Press.
20.
Diez RouxAna V.2011. “Complex Systems Thinking and Current Impasses in Health Disparities Research.”American Journal of Public Health101(9):1627–34.
21.
Diez RouxAna V.2012. “Conceptual Approaches to the Study of Health Disparities.”Annual Review of Public Health33:41–58.
22.
Du BoisW. E. B.1898. “The Study of the Negro Problems.”Annals of the American Academy of Political and Social Science11:1–23.
23.
Du BoisW. E. B.1899. The Philadelphia Negro: A Social Study. Philadelphia: The University of Pennsylvania Press.
24.
Du BoisW. E. B.1940. Dusk of Dawn: An Essay toward an Autobiography of a Race Concept. San Diego, CA: Harcourt, Brace and Company.
25.
EntwisleBarbara. 2007. “Putting People into Place.”Demography44(4):687–703.
26.
EspositoMichael H.2019. “Inequality in Process: Income and Heterogeneous Educational Health Gradients among Blacks and Whites in the USA.”Race and Social Problems11:269–281
27.
FordChandra L.AirhihenbuwaCollins O.2010. “The Public Health Critical Race Methodology: Praxis for Antiracism Research.”Social Science and Medicine71(8):1390–98.
28.
FrerichsLeahLichKristen HassmillerDaveGauravCorbie-SmithGiselle. 2016. “Integrating Systems Science and Community-Based Participatory Research to Achieve Health Equity.”American Journal of Public Health106(2):215–22.
29.
GeronimusArline T.HickenMargaretKeeneDanyaBoundJohn. 2006. “‘Weathering’ and Age Patterns of Allostatic Load Scores among Blacks and Whites in the United States.”American Journal of Public Health96(5):826–33.
30.
GlennEvelyn Nakano. 2015. “Settler Colonialism as Structure.”Sociology of Race and Ethnicity1(1):52–72.
31.
GlymourMaria. 2006. “Using Causal Diagrams to Understand Common Problems in Social Epidemiology.” Pp. 387–422 in Methods in Social Epidemiology, edited by OakesJ. M.KaufmanJ. S.Hoboken, NJ: Jossey-Bass.
32.
GoosbyBridget J.CheadleJacob E.MitchellColter. 2018. “Stress-Related Biosocial Mechanisms of Discrimination and African American Health Inequities.”Annual Review of Sociology44:319–40.
33.
GreenTiffany L.DarityWilliam A.2010. “Under the Skin: Using Theories from Biology and the Social Sciences to Explore the Mechanisms behind the Black–White Health Gap.”American Journal of Public Health 100(Suppl. 1):S36–39.
34.
HollandPaul. 2008. “Causation and Race.” Pp. 93–109 in White Logic, White Methods, edited by ZuberiT.Bonilla-SilvaE.Lanham, MD: Rowman & Littlefield Publishers.
35.
ItzigsohnJoseBrownKarida L.2020. The Sociology of W. E. B. Du Bois: Racialized Modernity and the Global Color Line. New York: NYU Press.
36.
JacksonJohn W.ArahOnyebuchi A.2019. “Invited Commentary: Making Causal Inference More Social and (Social) Epidemiology More Causal.”American Journal of Epidemiology189(3):179–82.
37.
JacksonJohn W.VanderWeeleTyler J.2018. “Decomposition Analysis to Identify Intervention Targets for Reducing Disparities.”Epidemiology29(6):825–35.
38.
JacksonJohn W.VanderWeeleTyler J.2019. “Intersectional Decomposition Analysis with Differential Exposure, Effects, and Construct.”Social Science and Medicine226:254–59.
39.
KaneJennifer B.HarrisKathleen MullanMorganS. PhilipGuilkeyDavid K.2018. “Pathways of Health and Human Capital from Adolescence into Young Adulthood.”Social Forces96(3):949–76.
40.
Kohler-HausmannIssa. 2019. “Eddie Murphy and the Dangers of Counterfactual Causal Thinking about Detecting Racial Discrimination.”Northwestern University Law Review113(5):1163–228.
41.
KramerMichael R.SchneiderEric B.KaneJennifer B.Margerison-ZilkoClaireJones-SmithJessicaKingKatherineDavis-KeanPamelaGrzywaczJoseph G.2017. “Getting under the Skin: Children’s Health Disparities as Embodiment of Social Class.”Population Research and Policy Review36(5):671–97.
42.
Kravitz-WirtzNicole. 2016. “Cumulative Effects of Growing up in Separate and Unequal Neighborhoods on Racial Disparities in Self-Rated Health in Early Adulthood.”Journal of Health and Social Behavior57(4):453–70.
43.
KriegerNancy. 2010. “The Science and Epidemiology of Racism and Health: Racial-Ethnic Categories, Biological Expressions of Racism, and the Embodiment of Inequality—An Ecosocial Perspective.” Pp. 225–58 in What’s the Use of Race? Modern Governance and the Biology of Difference, edited by WhitmarshI.JonesD. S.Cambridge, MA: MIT Press.
44.
KriegerNancy. 2012. “Methods for the Scientific Study of Discrimination and Health: An Ecosocial Approach.”American Journal of Public Health102(5):936–45.
45.
Laster PirtleWhitney N.2020. “Racial Capitalism: A Fundamental Cause of Novel Coronavirus (COVID-19) Pandemic Inequities in the United States.”Health Education and Behavior47(4):504–508.
46.
LundbergIanJohnsonRebeccaStewartBrandon. 2021. “What Is Your Estimand? Defining the Target Quantity Connects Statistical Evidence to Theory.”American Sociological Review86(3):532–65.
47.
MasseyDouglas S.DentonNancy A.1993. American Apartheid: Segregation and the Making of the Underclass. Cambridge, MA: Harvard University Press.
48.
MorganStephen L.WinshipChristopher. 2014. Counterfactuals and Causal Inference: Methods and Principles for Social Research. Cambridge, UK: Cambridge University Press.
49.
MuntanerCarles. 2013. “Invited Commentary: On the Future of Social Epidemiology—A Case for Scientific Realism.”American Journal of Epidemiology178(6):852–57.
50.
MuntanerCarlesBorrellCarmeVanroelenChristopheChungHaejooBenachJoanKimIl HoNgEdwin. 2010. “Employment Relations, Social Class and Health: A Review and Analysis of Conceptual and Measurement Alternatives.”Social Science and Medicine71(12):2130–40.
51.
NaimiAshley I.SchnitzerMireille E.MoodieErica E. M.BodnarLisa M.2016. “Mediation Analysis for Health Disparities Research.”American Journal of Epidemiology184(4):315–24.
52.
OakesJ. MichaelAndradeKate E.BiyoowIfrah M.CowanLogan T.2015. “Twenty Years of Neighborhood Effect Research: An Assessment.”Current Epidemiology Reports2(1):80–87.
53.
PearlJudea. 2014. “Interpretation and Identification of Causal Mediation.”Psychological Methods19(4):459–81.
54.
PhelanJo C.LinkBruce G.2015. “Is Racism a Fundamental Cause of Inequalities in Health?”Annual Review of Sociology41:311–30.
55.
RayVictor. 2019. “A Theory of Racialized Organizations.”American Sociological Review84(1):26–53.
56.
ReskinBarbara. 2012. “The Race Discrimination System.”Annual Review of Sociology38:17–35.
57.
RobertsDorothy E.2011. Fatal Invention: How Science, Politics, and Big Business Re-create Race in the Twenty-First Century. New York, NY: The New Press.
58.
RobinsonWhitney R.BaileyZinzi D.2020. “Invited Commentary: What Social Epidemiology Brings to the Table—Reconciling Social Epidemiology and Causal Inference.”American Journal of Epidemiology189(3):171–74.
59.
SchwartzSharonGattoNicolle M.CampbellUlka B.2011. “What Would Have Been Is Not What Would Be: Counterfactuals of the Past and Potential Outcomes of the Future.” Pp. 25–46 in Causality and Psychopathology: Finding the Determinants of Disorders and Their Cures, edited by ShroutP.KeyesK.OrnsteinK.Oxford, UK: Oxford University Press.
60.
SchwartzSharonGattoNicolle M.CampbellUlka B.2017. “Heeding the Call for Less Casual Causal Inferences: The Utility of Realized (Quantitative) Causal Effects.”Annals of Epidemiology27(6):402–405.
SenMayaWasowOmar. 2016. “Race as a Bundle of Sticks: Designs That Estimate Effects of Seemingly Immutable Characteristics.”Annual Review of Political Science19:499–522.
63.
SewellAbigail A.2016. “The Racism–Race Reification Process.”Sociology of Race and Ethnicity2(4):402–32.
64.
SharkeyPatrick. 2013. Stuck in Place: Urban Neighborhoods and the End of Progress toward Racial Equality. Chicago, IL: The University of Chicago Press.
65.
SharkeyPatrickElwertFelix. 2011. “The Legacy of Disadvantage: Multigenerational Neighborhood Effects on Cognitive Ability.”American Journal of Sociology116(6):1934–81.
66.
StewartQuincy Thomas. 2008. “Swimming Upstream: Theory and Methodology in Race Research.” Pp. 111–26 in White Logic, White Methods, edited by ZuberiT.Bonilla-SilvaE.Lanham, MD: Rowman & Littlefield Publishers.
67.
TaylorKeeanga-Yamahtta. 2016. From #BlackLivesMatter to Black Liberation. Chicago, IL: Haymarket Books.
68.
WangAolinArahOnyebuchi A.2015. “G-Computation Demonstration in Causal Mediation Analysis.”European Journal of Epidemiology30(10):1119–27.
69.
WilliamsDavid R.SternthalMichelle. 2010. “Understanding Racial/Ethnic Disparities in Health: Sociological Contributions.”Journal of Social and Behavioral Science51:15–27.
70.
WilliamsDavid R.2012. “Miles to Go before We Sleep: Racial Inequities in Health.”Journal of Health and Social Behavior53(3):279–95.
71.
WilliamsDavid R.PriestNaomiAndersonNorman B.2016. “Understanding Associations among Race, Socioeconomic Status, and Health: Patterns and Prospects.”Health Psychology35(4):407–11.
72.
WilliamsDeadric T.2019. “A Call to Focus on Racial Domination and Oppression: A Response to ‘Racial and Ethnic Inequality in Poverty and Affluence, 1959–2015.’”Population Research and Policy Review38(5):655–63.
73.
WodtkeGeoffrey T.HardingDavid J.ElwertFelix. 2011. “Neighborhood Effects in Temporal Perspective: The Impact of Long-Term Exposure to Concentrated Disadvantage on High School Graduation.”American Sociological Review76(5):713–36.
74.
ZuberiTukufu. 2001. Thicker Than Blood: How Racial Statistics Lie. Minneapolis: University of Minnesota Press.
75.
ZuberiTukufuBonilla-SilvaEduardo. 2008. White Logic, White Methods: Racism and Methodology. Lanham, MD: Rowman & Littlefield Publishers.
76.
ZuberiTukufuPattersonEvelyn J.StewartQuincy Thomas. 2015. “Race, Methodology, and Social Construction in the Genomic Era.”Annals of the American Academy of Political and Social Science661(1):109–27.
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