Dr. Paula Braveman, director of the Center on Social Disparities in Health at the University of California, San Francisco, says her latest research revealed an “astounding” level of evidence that racism is a decisive “upstream” cause of higher rates of preterm birth among Black women.
The tipping point for Dr. Paula Braveman came when a longtime patient of hers at a community clinic in San Francisco’s Mission District slipped past the front desk and knocked on her office door to say goodbye. He wouldn’t be coming to the clinic anymore, he told her, because he could no longer afford it.
It was a decisive moment for Dr. Braveman, who decided she wanted not only to heal ailing patients but also to advocate for policies that would help them be healthier when they arrived at her clinic. In the nearly four decades since, Dr. Braveman has dedicated herself to studying the “social determinants of health” – how the spaces where we live, work, play and learn, and the relationships we have in those places influence how healthy we are.
As director of the Center on Social Disparities in Health at the University of California, San Francisco, Dr. Braveman has studied the link between neighborhood wealth and children’s health, and how access to insurance influences prenatal care. A longtime advocate of translating research into policy, she has collaborated on major health initiatives with the health department in San Francisco, the federal Centers for Disease Control and Prevention, and the World Health Organization.
Dr. Braveman has a particular interest in maternal and infant health. Her latest research reviews what’s known about the persistent gap in preterm birth rates between Black and White women in the United States. Black women are about 1.6 times as likely as White women to give birth more than three weeks before the due date. That statistic bears alarming and costly health consequences, as infants born prematurely are at higher risk for breathing, heart, and brain abnormalities, among other complications.
Dr. Braveman coauthored the review with a group of experts convened by the March of Dimes that included geneticists, clinicians, epidemiologists, biomedical experts, and neurologists. They examined more than two dozen suspected causes of preterm births – including quality of prenatal care, environmental toxics, chronic stress, poverty and obesity – and determined that racism, directly or indirectly, best explained the racial disparities in preterm birth rates.
(Note: In the review, the authors make extensive use of the terms “upstream” and “downstream” to describe what determines people’s health. A downstream risk is the condition or factor most directly responsible for a health outcome, while an upstream factor is what causes or fuels the downstream risk – and often what needs to change to prevent someone from becoming sick. For example, a person living near drinking water polluted with toxic chemicals might get sick from drinking the water. The downstream fix would be telling individuals to use filters. The upstream solution would be to stop the dumping of toxic chemicals.)
KHN spoke with Dr. Braveman about the study and its findings. The excerpts have been edited for length and style.