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74 Chapter 6 Discussions of racism and race are uncomfortable for most Americans who idealize equality of all peoples, yet individual and institutional racial discrimination abound. It has been called the elephant in the room, in part due to collective social guilt surrounding historical injustices that now can be openly discussed, and in part to a collective desire to feel that we have moved beyond the social and structural embeddedness of racism. Racism is evident in the framing of issues surrounding breastfeeding disparities, manifesting as the continuing overreliance on race as the defining identity categorization. Although racism and racial categorizing have been widely debated and discussed throughout the social sciences and humanities, with a few notable exceptions the health science disciplines have not participated in these dialogues.1 Although many complex and dynamic influences have created these differences, the overreliance on empirical research approaches and epistemologies, along with the long-standing hierarchical power structure of the health sciences, have led to and perpetuate the lack of attention given to understanding the effects of racism in the health science breastfeeding literature. The focus of this chapter is how these socially embedded realities have affected and continue to affect public health endeavors to support and promote breastfeeding. Conceptual assumptions framing this discussion are drawn from feminist treatments of power and gender inequity within social institutions, including the theory of intersectionality and Social-Ecological Model, all of which are related to the primacy of social justice.2 Racism, Race, and Disparities in Breastfeeding Joan E. Dodgson Racism, Race, and Disparities in Breastfeeding 75 Racism: The Elephant in the Room Racism, an inherent value and power structure based on racial social stratification , has deep historical roots that permeate all aspects of American society—one might say it is a defining feature of American society. Despite many well-intentioned efforts, we as a society have yet to move beyond the resultant embedded them/us power dynamics. Within a breastfeeding context racism is gendered, making it a feminist issue and adding dimensions of complexity.3 We know certain populations, defined simplistically using racial categorizations , have lower breastfeeding rates, but what is far less obvious is why. Most breastfeeding researchers do not explicitly reference racism. They refer to cultural differences and/or cross-cultural misunderstandings, defining culture using generic racial categories (so-called African American culture, Latina culture). Some suggest that “race-associated differences in health outcomes are in fact due to the effects of racism.”4 The first step in understanding the effects of racism is to define how it manifests. Camara P. Jones, an epidemiologist and a physician, developed a theoretical framework that articulates three levels of racism (institutional, personally mediated, and internalized) based on multilayered levels of influence similar to levels within the Social-Ecological Model. Using her framework, I explore historical and contemporary perspectives in the following sections. Racism: The Ground upon which Breastfeeding Disparities Grow Each of the three levels of racism has many manifestations within the context of breastfeeding disparities, too many to adequately describe. Jones states that institutionalized racism is the most fundamental level that must be addressed before the other two levels, largely because it reflects the basic assumptions upon which the other forms of racism grow. Language usage provides a clear example of this type of racism. The language we use to describe a circumstance reflects our underlying assumptions about the world.5 The words used in the health science literature (vulnerable, inequity, disparity, less fortunate) have inferred embedded racism with an inherent them/us distinction, which distances and privileges the researcher. The terminology contributes to a situation where those in a privileged position do not recognize their contextual positionality .6 For example, qualitative researchers interviewing nurses and physicians about racially based, unequal treatment found participants first denied that this phenomenon ever occurred. After being presented with a number of studies where racially differential treatment was obvious, most participants explained these occurrences by referring to patients’ personal attributes or by making a global statement about inadequate access to care. Only one out of twenty-six participants acknowledged that racial bias occurs in health care delivery.7 Institutionalized racism occurs without a designated perpetrator and is normative to the point of becoming invisible.8 Access to breastfeeding services provides another substantive example of institutionalized racism. In 1994 Michael D. Kogan and colleagues reported racially based differential breastfeeding advice was given prenatally by health care providers. Ten years later, Anne...

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