Racism and the Life Course: Social and Health Equity for Black American Older Adults

Life course theory (LCT; Elder & George, 2015) links human development and behavior to sociohistorical contexts that are embedded within social and personal relationships and processes. Although well-known in gerontology and human development, LCT is seldom used to examine the lives of racial/ethnic minority groups and how systemic racism (i.e., discriminatory policies and practices) operates as a structural driver of social and health inequities across the life course (see Gee et al., 2012). Bonilla-Silva (2006) and Reskin (2012) argue that racism and discrimination is an all-encompassing system that produces race-linked disparities in health and social well-being and represents a: “meta-level phenomenon that shapes our culture, cognitions, and institutions, thereby distorting whether and how we perceive and make sense of racial disparities” (Reskin, 2012, p. 17). Gee and colleagues (2019, p. S43) link racism and the life course in stating: “racism shapes the life course, a perspective for understanding how human experiences unfold over time.” Racism, enshrined in historic and ongoing policies and practices and experienced over the life course, has a continuing impact on the social and health statuses of racial and ethnic minority groups in the United States and in producing inequities in health and social well-being that are unfair, unjust, and avoidable (Braveman et al., 2011). Racism, enshrined in historic and ongoing policies and practices and experienced over the life course, has a continuing impact on the social and health status of racial and ethnic minority groups in the United States and in producing inequities in health and social well-being that are unfair, unjust, and avoidable. Building on prior work, this article has four aims. First, we briefly review the basic principles and processes described in life course theory. Second, we discuss racial residential segregation (RRS) and disproportionate rates of Black premature mortality as examples of systemic and structural racism (i.e., racialized policies and practices), which operate as fundamental drivers of the social and health inequities experienced by older Black adults. Third, using life course theory principles and processes, we demonstrate how racialized policies and practices operate across the life course in producing social and health inequities. Fourth, we discuss how the LCT framework can be used to inform equity-focused aging policy. Life course theory’s six principles have interdependent effects on development that mutually shape the overall life course and the trajectory and timing of personal and intergenerational events and environments. Today’s older Black adults were born and raised when racial discrimination in broad areas of life (i.e., housing, schooling, health care, financial sectors, public services, employment) was codified by formal laws, policies, and informal practices. Although racial restrictions and violence (e.g., racial terror campaigns, lynching) were codified in Jim Crow laws in the South, de facto discriminatory practices and violence were experienced across the United States. Economic recessions, wars, and social movements affect individuals and families in multiple ways by altering the timing of specific personal events, transitions to different life roles (e.g., age at marriage), and/or the overall trajectory and sequence of life pathways. The concept of “critical periods” recognizes differential impacts of events based on a person’s age and their own individual time frame; for example, expanded life opportunities for Black Americans raised in the post–Civil Rights era. Variability and difference within the Black population (e.g., socioeconomic position) is crucial for understanding differences in life experiences, behaviors, and attitudes and for countering racial stereotyping and essentialist beliefs. Heterogeneity calls attention to how simple Black–White race-comparative perspectives obscure important differences in life circumstances and reifies “White” as the normative standard against which other racial groups are evaluated (Taylor & Chatters, 2020). Further, intersectionality frameworks underscore how differences in social positions, identities, and power relationships (e.g., identifying as an older, Black lesbian) are experienced across the life course. Advantaged social and health circumstances in early life are amplified over time, while disadvantages accumulate/proliferate, resulting in poorer health and social well-being. Concepts such as “weathering” (Geronimus et al., 2006) clarify how life experiences (e.g., racial discrimination, environmental exposures) generate harmful physiological changes (e.g., increased allostatic load), leading to adverse health outcomes that further limit the ability to acquire key resources (education) to obtain higher status and future opportunities. The principle of linked lives situates individual development within personal and social networks. Through interdependent connections to others, events and experiences that affect individual members (e.g., poor health, job loss) reverberate throughout family generations and relational systems, producing alterations in roles, functions, and structure. Agency and personal control recognize our individual capacities to initiate change and direct the course of our lives. Black advancement in the United States has relied on the essential roles of collective agency and collective control in supporting the development and survival of individuals, families, and communities. Being excluded from mainstream institutions, Black communities developed their own organizations, resources, and sources of social capital (e.g., churches, neighborhood groups, educational institutions) that provided opportunities for exercising collective agency and control (Franklin & Higginbotham, 2011). Accordingly, both collectivist and individual orientations to agency and control coexist and demonstrate how individual outcomes are embedded in broader collectivities and sociohistorical events. Historic and current patterns of racially based residential and spatial distribution are the planned and purposeful results of federal housing and zoning policies designed to segregate racial groups (Rothstein, 2017). Beginning in the 1930s, the federal government (Federal Housing Authority, Veterans Authority), in conjunction with the real estate industry and banking/mortgage lenders (Home Owners Loan Corporation), developed a system of mapping major metropolitan areas and classifying neighborhoods by color codes for their desirability and racial/ethnic make-up. Areas deemed to be undesirable were color-coded as red (“redlining”) and described as having risks and being “hazardous.” The Federal Housing Authority refused to insure mortgages in and near Black neighborhoods or redlined areas, while subsidizing the development of suburban subdivisions that restricted ownership to Whites. Other actions, such as restrictive covenants, prohibited the sale or rental of property to non-Whites (Rose, 2016). Racially segregated Black neighborhoods experienced systematic disinvestments in infrastructure and declines in property values and business enterprises that resulted in limited access to public goods (well-resourced schools), quality services and amenities (businesses, parks, playgrounds), healthy food environments (e.g., food deserts and swamps), and the concentration of poverty. The long-term effects of RRS include lost opportunities to own a home and to build/transfer wealth associated with homeownership across family generations (Mallya & Yentel, 2021). RRS is a barrier to resources and amenities that contribute to good health, while exposing residents to elevated health risks (Armstrong-Brown et al., 2015; Hicken et al., 2018; Kershaw & Albrecht, 2015; Williams et al., 2019). Segregated areas have fewer health-relevant resources (e.g., local clinics, pharmacies, healthy food access), inadequate infrastructure (public transportation, brown fields, sidewalk disrepair), and higher environmental exposure to air pollution and other hazards (Chatters et al., 2020; Schulz et al., 2020). Residents who experience the harmful effects of RRS over a lifetime carry these acquired vulnerabilities into older age (LaVeist, 2003; Williams & Collins, 2016). The lasting effects of RRS in creating racial gaps in housing and wealth, coupled with racially biased rental practices, has culminated in a housing eviction crisis that has intensified during the coronavirus disease 2019 (COVID-19) pandemic (Herwees, 2021; Mallya & Yentel, 2021). Black middle-aged and older women are highly vulnerable to housing insecurity and eviction by virtue of their gender, race, and employment in low-wage occupations (West et al., 2021). In sum, historical and continuing exclusionary housing practices have persistent negative impacts on personal and intergenerational opportunities for home ownership, wealth generation, social mobility, and healthy lives (Perry et al., 2018). Throughout their lives, Black Americans experience the deaths of friends and family members at higher rates than any other race/ethnic group. Life course principles (i.e., linked lives, cumulative disadvantage, critical periods) illustrate how kin loss impacts family composition and intergenerational relationships. At no point in U.S. history have overall Black–White life expectancies reached parity, although recently Black women have surpassed White men in life expectancy (Arias & Xu, 2019). Umberson (2017) examines the impact of racial disparities in life expectancy and disproportional premature deaths on Black families. Early deaths can alter the timing and transition of family roles (e.g., parenthood), requiring members to adjust their life plans to address emergent family needs. Plans and trajectories for education, work, and financial goals may be altered, delayed, or terminated by the early death of a family member. Early deaths alter the size and composition of the informal networks (family, friends, church members, fictive kin) that older Black adults rely on for material assistance and emotional connections that support mental health (Taylor et al., 2013). Early deaths and restrictive kin networks can also place older Blacks at greater risk for loneliness and social isolation (Umberson, 2017; Verdery & Margolis, 2017). Early deaths are associated with increased risks for poor physical and mental health outcomes among surviving family members (Umberson, 2017). Family survivors lose important personal relationships and material resources that promote health and informal supports. Further, family deaths produce emotional traumas and economic strains that generate additional stressors that accumulate over time (i.e., cumulative disadvantage) and have important consequences, particularly for children’s development and health over time (i.e., critical periods). Pandemic-related kin loss has been particularly devastating for Black families; it is estimated that every COVID-19 death will leave behind 9.18 bereaved family members for Blacks and 8.86 for Whites (Verdery et al., 2020, p. 17697). The traumatic nature of COVID-19 deaths (e.g., abrupt fatalities, curtailment of funeral rites) within family, peer, and faith community networks generates additional grief-related physical and mental health issues for survivors (e.g., depression, anxiety) and complicated grief reactions (Verdery et al., 2020). The route to achieving equity will not be accomplished through treating everyone equally. It will be achieved by treating everyone equitably, or justly according to their circumstances. (Dressel, 2014) Life course theory’s emphasis on human development as the interaction between sociohistorical events, local contexts, and life course processes underscores how events and social circumstances (e.g., constrained choices and blocked opportunities) shape advantageous or adverse social and health outcomes for members of marginalized social groups (Braveman et al., 2011; Schulz et al., 2020). LCT figures prominently in discussions focusing on how racialized structures and processes produce and maintain racial inequities in social and health outcomes across the life course, as well as strategies and actions needed to achieve health and social equity (Gee et al., 2012, 2019; Peterson et al., 2020; Schulz et al., 2020). Similarly, the Centers for Disease Control and Prevention’s (2020) health equity COVID-19 response acknowledges historical and contemporary inequities and uses population- and place-based assessments to identify those most vulnerable and at highest risk of infection. Building on this work, we discuss several ways that LCT can be used to develop equity-focused policy perspectives for older adults from marginalized racial groups. One of LCT’s primary contributions is acknowledging how sociohistorical events and the social milieu shape our experiences and perceptions. The United States has deeply held cultural beliefs and messages concerning individual responsibility (e.g., “pull yourself up by your bootstraps”) for achieving health and social well-being (Burke et al., 2009) that are mirrored in our institutions and health and social policies (Lindland et al., 2021). Given the reliance on this individual responsibility narrative, conversations about social and health disparities, and particularly racial disparities, are commonly framed in ways that blame victims for their circumstances. Racially marginalized individuals and communities are exhorted to change their attitudes and behaviors, while ignoring the structural conditions that produce higher risks for adverse situations and fewer resources to support well-being. An equity-focused policy perspective understands the potency of the individual responsibility narrative and counteracts policy framing and political (i.e., politicized) responses that blame victims (Lindland et al., 2021). Solutions, therefore, focus on the structural drivers of health and social inequities, while simultaneously identifying the needs and circumstances of individuals whose choices are structurally and systemically limited. Using LCT in developing an equity-focused policy perspective requires that we acknowledge and critically examine historical events (e.g., RRS) and the continuing role of structural racism in diverse public policy domains (i.e., housing, education, health care, financial sectors) that have created and sustained racialized social and health inequities that have intergenerational impacts. An equity-focused policy approach identifies how structural racism in policies, programs, and practice constrains choices and opportunities that limit the ability to achieve health and social well-being (Robert Wood Johnson Foundation, 2021). This requires proactively reviewing requirements, rules, and procedures for programs, agencies, and organizations that serve racially marginalized groups to assess racial bias, while also monitoring for unanticipated adverse consequences. Using LCT in developing an equity-focused policy perspective requires that we acknowledge and critically examine historical events (e.g., RRS) and the continuing role of structural racism in diverse public policy domains (i.e., housing, education, health care, financial sectors) that have created and sustained racialized social and health inequities that have intergenerational impacts. The Race Matters Institute (2019) uses the Racial Equity Impact Analysis (REIA) to assess: (a) whether the priority racial/ethnic group is involved in discussions and decision-making regarding the policy/program/practice; (b) whether the perceptions of and impact on the priority group have been considered; (c) the potential of the policy/program/practice to ignore or worsen existing disparities and/or have unintended consequences; and (d) whether and how information gathered from the REIA is used to guide policy/program/practice revisions. In keeping with LCT’s focus on local contexts, policy framing and political responses to social and health inequities must also understand how prevailing community conditions in which older adults live contribute to social and health inequities. Particular attention should be paid to improving built environment conditions in communities that have experienced political, municipal, and business disinvestment (e.g., poor quality public services, healthy food and pharmacy deserts) and infrastructure failures (e.g., street disrepair). Equity-focused policy perspectives acknowledge the value of contextual analyses for understanding diversity both within and across communities, and how racial and other status hierarchies resulting from prior historical arrangements are currently enacted in discrete spatial contexts. Building on LCT principles (i.e., heterogeneity and local contexts), contextual analysis recognizes differences in how communities are resourced, organized, and function and identifies unique assets, opportunities, and stressors. This includes critically analyzing how local governments and policies function to either create/maintain or alleviate inequities. For example, in relation to COVID-19 intervention planning, a vaccine distribution strategy using national drug store chains is inappropriate for a community that has no drug stores, no health infrastructure (clinics), and no reliable and efficient means of public transportation. Finally, local community leadership and organizations are trusted entities with a wealth of knowledge about local history and how their community operates. A strength-based framework (as opposed to a racial/cultural deficit framework) and working in partnership with communities taps into unrecognized sources of collective agency and control that can support the development of interventions that are relevant, appropriate, and acceptable. Policy approaches often advocate for equal treatment of members of a population to remedy a problem. However, interventions that provide equal responses are ineffective for those experiencing long-standing social and health inequities, and may even widen inequities for marginalized groups (Hardeman et al., 2016). The metaphor “centering the margins” is used in several contexts as part of assessment efforts to make visible and support those groups that are largely hidden in policy and practice efforts (Hardeman et al., 2016). An equity-focused perspective recognizes that older adults and the communities they reside in have different personal, social, and material circumstances and needs. Instead of distributing equal resources across all groups, equity would be achieved by providing resources that are proportionate to the needs of individuals, groups, and communities, thus ensuring opportunities to maximize health and social well-being for all. Further, equity-focused policy interventions emphasize intervening early and promptly, before problems intensify, additional stressors and disadvantages are generated, and solutions become more complicated and costly in their human toll and financial expenditures. An equity-focused policy perspective focused on linked lives underscores our connections to family and personal relationship systems across the life cycle from birth to death. Bogenschneider and colleagues (Bogenschneider & Corbett, 2010; Bogenschneider et al., 2012) note that many forms of policy (e.g., education, housing, health) have significant implications for families. Their Family Impact Analysis centers the experiences of family members in the development of policy and programs and documents their consequences (intended and unintended) for family functioning and well-being. The Family Impact Analysis assesses whether a policy or program supports family stability and responsibility, acknowledges the importance of family relationships, understands and honors family diversity across multiple dimensions, and employs family-centered and participatory approaches in programs. For marginalized racial groups, extended family (grandparents, aunts/uncles, cousins), church members, and fictive kin are significant sources of social support to older adults (Chatters et al., 2020; Taylor et al., 2013). Accordingly, equity-focused policy approaches understand and incorporate important personal relationships and resources that exist within diverse family systems. The COVID-19 pandemic and calls for racial justice have revitalized notions of our responsibility for our collective well-being and identified systemic racism as detrimental for members of racially marginalized groups. Life course theory is offered as a framework for continuing efforts toward a “new normal” for aging that provides a guide for collective actions that center social and health equity for Black older adults and other marginalized groups. This article was supported by grants from the National Institute on Aging (P30 AG015281 to R.J.T. and 5T32 AG000029-42 to H.O.T.). None declared.

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