Using culturally sensitive language for race.

Abstract

With the current paradigm shift in health care towards providing value-based care and the echoes to meaningfully reduce racial inequities, nurses, and midwives globally are essential to addressing the needs of populations that have been marginalized based on race. Race describes grouping individuals based on observable characteristics such as skin color, hair texture, eye shape, and other facial and body features. Race and racial categories differ internationally and have changed across centuries as social, political, cultural contexts, and migration patterns change. Importantly, there is no genetic basis for racial differences as all human DNA is the same, therefore, human beings are all equally human. It is critical that nurses and midwives learn and embrace the more contemporary and culturally humble language of race to prevent, mitigate, and meaningfully redress the harm that may have been caused to individuals, especially those from racially minoritized groups. We are cognizant that racial minority groups in the United States are sometimes similar but also different from other countries and regions globally. For example, individuals who are Black or Asian in the United States belong to minoritized racial groups in the country; however, these groups represent a majority of the population in the English-speaking Caribbean, Africa, and Asia, respectively. Why is it so important to use the culturally humble language of race? The race has been used to harm people and create systems of oppression, such as when some groups were forced to give up their right to property to dominant racial groups. Furthermore, race has been used to allocate social resources, political power, education, and employment opportunities, as well as housing. All these factors are now known as the social determinants of health which are increasingly linked to health outcomes and life trajectories of individuals. To improve our fluency when speaking about race in ways that use culturally humble language helps to understand the history of the concept of race in the United States and its subsequent evolution to the present. As we stated in our opening editorial (Squires & Thompson, 2021), language evolves over time along with the associated concepts linked to the words. This brief historical primer will help provide a foundation for understanding how we arrived at the current standards for language use and provide guidance for nurses and midwives to have culturally humble conversations about race. The concept of race emerged at the end of the 17th century. "Race" was a term used to differentiate populations of people who were interacting in North America—for example, Europeans, Africans, and Native Americans (Harris, 1993). By the early 18th century, race increasingly appeared in the written record and became more standardized and uniform. During the U.S. Revolutionary Era (1775–1783), the use of race became more common. Its meaning evolved to reference social groups for individuals who were considered Indian, Black, and White. The concept of race then increasingly emerged as a tool to structure and stratify society. This form of stratification, however, was new to human history. This stratification of humans at the turn of the 18th century was justified by colonialists who had already selected Africans to be in permanent Chattel Slavery. In fact, despite colonialists espousing political philosophies of equality, democracy, and justice, individuals who were Africans were given subhuman status. During the period of chattel slavery, though unnamed as such at the time, codifying race into law was critical in maintaining divisions in many countries. Furthermore, this subjugation of Africans was falsely justified by racist colonial settlers using religious maxims and pseudoscience. Unfortunately, some tribal groups in Africa also supported and profited from the slave trade. Nonetheless, across the globe, many enslaved Africans resisted their systemic oppression.The Haitian Revolution in 1789–1804 was critical to advancing freedom for Africans in the region as enslaved Africans in Haiti—who were considered subhuman—fought against the racist hegemonic society in the country for Liberty, Equality, and Fraternity (Liberté, Egalité, Fraternité) (Ott, 1973). The Haitian revolution was a watershed moment in human history because the 1800s saw the end of legal chattel slavery in most global colonial empires. For example, chattel slavery legally ended for the following empires: British (1834–1838), French (1848), Dutch (1863), Spanish (1868–1886), and American (1865). Despite the end of legal slavery in the 1800s, laws were implemented to ensure White individuals maintained economic and political power in the United States at the expense of individuals belonging to racially minoritized groups. Race was used to ensure White individuals owned land and enslaved humans who were Black were considered property (Harris, 1993). In addition, race was also used to disenfranchise Native Americans from their land which became the property of White colonial settlers from Europe. As plantation and slave societies began to dismantle in the 1800s, individuals who were not categorized as White were further disenfranchised from political power and maintained on the margins of society. During the period of Jim Crow laws in the United States, race was also used to maintain segregation between Whites and people of color. Violent tactics to enforce racial differences and ensure socioeconomic oppression were common, such as the use of lynching to scare and intimidate Black people. The elimination of slavery in the United States in the late 19th and early 20th centuries was followed by discrimination based on “classifications” of races based on country of origin. For example, some White immigrants (e.g., Irish, Italian, etc.) experienced discrimination based on country of origin upon initial arrival in the United States. Yet, often within a generation, their “White” racial appearance allowed them to achieve much more rapid upward social and economic mobility compared to people from racially minoritized groups. The systems that were legacies of slavery and Jim Crow were designed to make it more difficult for people from racially minoritized groups to succeed and have thus, created the current unequal systems in the United States. World events could also drive changes in public perception of “acceptable” races. As an exemplar, following the bombing of Pearl Harbor in 1941 by Japan, individuals with Japanese ancestry were placed in internment camps between 1942 and 1946 in the United States. Many lost their homes and properties that had been in their families for more than a century when many Japanese and other Asian people emigrated to the United States to build railroads. When released from the camps, most had to start over and in a world where they were not accepted in the same way as before the second world war. The post-World War II mid-20th century also bore the civil rights movement in the United States that coincided with the independence from colonial powers in many countries. Black people and their allies from all backgrounds persisted in the fight for equality which precipitated the civil rights act of 1964 which gave full rights to all U.S. citizens (Brown, 1984). More contemporary struggles to end Apartheid (1948–1994) in South Africa are clear examples of race being used as a tool to empower White individuals and devalue and disenfranchise Black people. This brief history lesson serves as a reminder that as nurses and midwives, we may not be historical experts, but to speak in culturally humble ways about race there must be an appreciation of how racial categories have changed over time and how race produces class differences which contribute to some of the health outcome disparities in the populations we serve. We must be cognizant of race, its connection to history, and the resulting positionalities of individuals based on these racial categories and social hierarchies to meaningfully engage all clients. It is the differences reproduced using race to perpetuate racism and classism that continue to impact the social determinants of health and the health inequities we observe in the present. Health inequities are ubiquitous. These unjust differences, however, are not caused by biological differences among people but are associated with racism and other forms of discrimination within the larger society. For example, the COVID-19 mortality rate is higher for Black populations (92.3/100,000 population) versus White (45.2/100,000) and Asian (34.5/100,000) populations (Center for Disease Control and Prevention, 2020). As it relates to maternal and child health, Black women have a 22% higher prevalence of hypertensive disorders, and an 83% increased prevalence of preterm births relative to White women (Adegoke et al., 2021). The infant mortality rate for Black American and Alaskan Native populations are 2.3 and 2.0 times higher than those of White populations (10.97 and 9.21 vs. 4.67), respectively (Arias et al., 2020). As it relates to HIV and AIDS care, Black and African American individuals have higher risks for poor retention in care, compared to White individuals (Rebeiro et al., 2018). Furthermore, Black adults are more likely than White adults to live in states that did not expand Medicaid (Buchmueller & Levy, 2020). In addition, as it relates to cognitive impairment and Dementia, at age 50, White males and females are expected to spend more years cognitively normal versus individuals of the same age who are Black (Garcia et al., 2019). These inequities will continue to be reproduced because of the historical and contemporary marginalization of people from racial minority groups. Because of race, people from racial minority groups are more likely to live, work, play, and worship in communities that are deprived of social, health, and economic resources, whereas the converse is true for individuals who are White. The U.S. Census Bureau and the Office of Management and Budget standards recommend a minimum of categories to report on race, these are American Indian or Alaskan, Asian, Black or African American, Native Hawaiian or Other Pacific, and White. The definition of each racial category is found on the website for the U.S. Census Bureau (nd). We acknowledge that even the existing racial categories can be reductive and as nurses and midwives we promote the acknowledgment of the greater diversity within each race. It is well established that race in health records is poorly recorded and often assumed based on the provider's assessment of the person's appearance. The first step in culturally-humble practices regarding race is accurate documentation based on the individual's preference. When documenting racial categories of our clients in notes or manuscripts, the categories should be treated as proper nouns so each race should begin with a capital letter. Yet when writing the term “White supremacy,” only lowercase letters are recommended, unless the term begins a sentence (Flanagin et al., 2021). When reporting the results of a research study, racial categories of participants should be reported in alphabetical order. Racial categories should not be reported in order of their relative population size within a country. Race should also be reported as distinct from ethnicity. For example, do not write “race/ethnicity.” Instead, it is recommended to write “race and ethnicity” since these are two distinct social constructs (Flanagin et al., 2021). In subsequent editorials, we will go into further details about ethnicity. Finally, it is no longer recommended to use the term "Caucasians" to denote individuals who are White because the term is somewhat nebulous and connotes geographic origins. Given the histories of individuals from racial minority groups, it is critical that nurses and midwives continue to develop and exhibit cultural humility when interacting with all clients. This sensitivity will increase trust and comfort levels among clients and promote more meaningful and genuine interactions. As nursing has been consistently ranked as the most trusted profession, this status holds promise for nurses to be instrumental in effecting policies and practice changes that mitigate racial inequities in health outcomes. As nurses and midwives represent a large group of health workers, having a deeper knowledge of clients' racialized histories creates opportunities to provide more culturally humble person-centered care. As health professionals, we should also commit to learning about our racial biases, most of which are unconscious and can negatively impact the care delivered. Increased racial diversity within nursing and midwifery will also help everyone to learn to speak the language of the race better. It is time to acknowledge the racialized histories of the clients we serve as well as how categories of race have changed over time and currently contribute to hierarchical systems of oppression. Nurses and midwives should harness our influence and be a part of policy-making institutions that seek to meaningfully reduce racial disparities. And remember, when learning a language, mistakes will be made. Practice makes perfect but perfection can take a lifetime. The authors declare that there are no conflict of interests. All authors contributed equally to the writing of this editorial. Data availability statement not applicable in this study.