“Weathering”, health inequities, and structural violence: An interview with Dr Arline Geronimus

Interview by Mita

“The way the institution runs is based on understandings that are really quite racist, and you could have everybody else running that institution, and in that institution genuinely not be personally racist, but because they didn't understand the impact that cultural norms and expectations of the institution had on people with different levels of resources or lived experiences, or cultural norms, how much that takes a toll on people.”

Professor Arline Geronimus

In this interview, Prof Arline Geronimus discusses her work on weathering, a conceptual framework that locates structural discrimination at the root of health inequities among minoritised groups. Arline is a professor at the University of Michigan School of Public Health, and the Institute for Social Research. She is also a Member of the National Academy of Medicine of the National Academy of Science, and the author of Weathering: The Extraordinary Stress of Ordinary Life in an Unjust Society. This interview will explore the concept of “weathering”, what it means, what motivated its development, and its implication on health equity today.

Arline is also featured on an upcoming episode of the Race & Health podcast, where she discusses weathering with host and Race & Health founder, Delan Devakumar. You can look out for this episode by following the Race & Health podcast.

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Mita: Thank you for joining us, we're excited to have you. To get started. Do you want to talk a little bit about yourself and what you currently do?

Arline: I'm a professor at the University of Michigan School ofPublic Health, and the Institute for Social Research. I've been here for 36 years. I've done research over that time on health inequities, particularly racialised health inequities in the United States, but also on other populations in terms of ethnicity, or in terms of LGBTQ status or other denigrated groups.

I developed a theory I named “weathering”, and I've published many studies that support the idea that health inequities by social identity groups --and by social identity group I mean race or ethnicity, or gender or gender orientation, etc., any identity a person has within the context of their society that to some degree was imposed on them--are the result of constructs that have real impact on life chances and lived experiences.

One way that structural racism works to harm your health is through the wear and tear on your body’s systems. This erosion is activated not only by chronic exposures to structured racism, discrimination and environmental injustice or poverty and the various kinds of exposures we think of that are bad for your health, and which, unfortunately, are more disproportionately the fate of people and denigrated groups. It is also fomented by the persistent high effort of coping that members of those groups have to engage in to withstand life stressors, and survive and overcome its limits, or make meaning in life despite the barriers. In effect, this leads to a kind of accelerated ageing, a breakdown and weakening and dysregulation across all your body systems, and therefore a great vulnerability to all sorts of disease, chronic diseases, infectious diseases, autoimmune diseases, and early functional limitations and death.

Mita: That's really clear. Thank you for sharing a bit about weathering. How did you develop this conceptual framework, what led up to your interest in this area?

Arline: It's been a very long process that I think started when I was in college. I was at a very elite school in New Jersey. I had several experiences there that led me to start on the trajectory that would lead me to weathering.

One was that I was in one of the first classes of women at this school, when they were trying to become more diverse and have more public school students, as well. And in fact, bringing women on was contested, bringing people of colour and other ethnicities was contested. So it was a strange place to be if you are a woman from a public school and a first generation person in terms of going to an elite school when a large proportion of my classmates were legacies. And so I started having new experiences… I had been aware, from my upbringing of working class or middle class contexts–even some affluence, but not intergenerational .01% wealth, which is what most of my fellow students came from. When I went to college…that made it kind of awkward for me in some ways.

That started my thinking about different ideas of entitlement and privilege and– I was not poor, I was at Princeton University, one of the best universities in the world. I was privileged in many ways, but still there was a clear lower-classness about me as viewed by many of my Princeton classmates. And that was new to me. I began to understand that there is this way that when, depending on the context, you're in a lesser group, you sort of wear an armour all the time. is You're on your guard. You're managing your social identity.

My parents were were raised in working class immigrant familiess . This armour metaphor came from my father, who used to talk about how, when he came home from work, we weren't supposed to talk to him for a while until he had time to take off his armour. I remember not understanding armour. He wasn't in combat. And then at Princeton I certainly found I was wearing armour all day, and took it off at the end when I was on my own. So I started thinking about it in these different contexts.

I had four part time jobs with two that matter to this conversation. I was a research assistant to a professor in their office of population research writing an article on teenage pregnancy. I also worked at a school for pregnant teenagers. And there was a complete disconnect between what I was seeing, getting to know actual pregnant teen mothers to be, and what everybody just took as common sense about teen moms in the world of academia and policy, you know, the White upper class world.

This construct of being a teenage mother as a mistake or a sign of deviance was gaining enormous dominant cultural currency just at this time, largely based on stereotyping, not strong evidence. Yet, most people in the world are technically “teenage mothers”. Most people of my parents' generation started having kids as teens. My grandmother was technically a teen mother. But it was new to consider becoming a mother as a teenager a social problem or a poor choice in and around the 1970’s. The concept was publicized in ways that incited moral panic in the country. If you were a teen mother, the broader society inferred you lacked future orientation, were giving up opportunities, and were somehow morally questionable. So were your parents, who were coded as having not provided proper supervision, or instilled the morals in her she should have had, or her boyfriend, who was probably just a predator, taking advantage of her. The concept was branded as “babies, having babies” or “children, having children” or as a strategy to qualify for welfare and “bleed the rest of society dry.” These mothers would raise a new generation of anti-social, incompetent people. There was a whole mythology about it, and it crossed political boundaries among White leaders.

Nobody was questioning this construct of “teenage mother” as a bad thing, even if different constituencies had very different ideas about how it came about or what should be the solution. And yet the young woman I was working with, who I got to know really well because we were basically the same age, were happy about their pregnancies. They hadn't necessarily consciously planned them, but some had, and all had the support or their parents and their partner’s, even though they were mostly not married. It didn't look like a tragedy that it was being melodramatically made out to be in the broader public. I saw these young women had some real problems no one was talking about: the problems of poverty, the problems of pollution, the decaying built environment, their health… I also escorted them to all their various medical and social work visits as a kind of peer companion and I observed several disturbing aspects of their appointments. I saw through their exams that they were much less healthy than my peers at Princeton. These young women were far less healthy than women of approximately the same age, 20 minutes away from my college. Listening to them and the social workers, I got an understanding of poverty which I thought I already understood, but that I learned I really didn't. I hadn't seen this kind of deep, intergenerational, racialised poverty that they were contending with.

The other thing I saw on all their medical or social work appointments was that, whether it was the physician or the social worker, the professional didn't listen to them. These young women said they [social workers, doctors] didn't take them seriously. They professionals didn't ask questions, they didn't act sympathetic. And these were the professionals who had presumably chosen to work in underserved places, these are probably the good people. The people who wanted to help the poor in some way. And so I left college totally obsessed with trying to understand this disconnect, trying to understand how people who are thought of as experts or professors at Princeton, or the physicians, or the social workers could be so unaware and insensitive…And were content to caricature these young women by virtue of their race and socioeconomic position, and the very fact that they had decided to have a baby a young age.

I started to think that maybe all the problems associated with teenage childbirth, and, statistically, there were many: if you're a teenage mother in the United States, you're more likely to have a lower income, to have less education, to have a baby born too small or too early, or die, than if you're an older mother. But people had jumped to the conclusion that these problems were caused by their young age as mothers, whereas what I was seeing is that these young women faced far more poignant and difficult tradeoffs, constraints, and life experiences than those who were judging them.

So I went to public health school with the thought that we were mis-specifying why teen child bearing was associated with all these bad outcomes. It wasn't because teen mothers were irresponsible and they had no moral compass, etc. But it was because they came from populations that were already disadvantaged, whether by race or poverty or geography. Most teen moms at that point lived either in the high poverty and disinvested urban areas or very isolated high poverty rural areas. I thought if you could take some of these background characteristics into account when comparing outcomes to teen versus older mothers, you'd find that the teen mom's outcomes were no worse than older mothers from their same background and lived experience.

What I found through my dissertation where I aanalysed the relationship between maternal age and poor birth outcomes that I was wrong. But I was wrong because I didn't realise how right I was. What I mean by that is, it wasn't that maternal age was being confounded by socioeconomic position. It was that if you're already in a denigrated group, you and your baby will do better if you become a mother younger. Everybody had accepted it was a law of nature that the teens were the highest risk ages for poor pregnancy outcomes, and then in your twenties through early thirties, you were at the lowest risk stage for childbearing, and then maybe thatrisk increased a little by your mid-30s as you headed towards perimenopause and menopause. Well, that did describe what was happening in White America. In Black America, the mid-late teenages were the healthiest time to have a child and risk of a poor outcome increased with every year of age after that. At any age, there was more chance of low birthweight, preterm birth, infant mortality, if you were Black compared to if you were white; but there was a lower chance of a poor birth outcome if you were Black and 18 than if you were 25, and chance if even a smaller chance compard to if you were 30. higher you know, there was much more chance of it. For Black American women the trajectory of poor outcomes with age was just straight up. The lowest risk ages were the late teens, which is when most teen births occur. Most teen moms are 18 or 19, about three quarters of teen moms are 18 or 19, and those were the lowest risk ages for Black women.

That led me directly to weathering. I spent the subsequent decades trying to think of scientific tests of this idea, quantitative and also more ethnographic work, to understand lived experiences more, and to try and figure out the social mechanisms, institutional mechanisms and biological mechanisms that explained variation in maternal-age patterns of risk in Black compared to white American women . I finally, after all these years, have pieced together the answer to my question from college.

Mita: That is really interesting. I think it really illustrates the way that people use things like moral superiority culture, even religious subhues to essentialise things like a label.

When we talk about racism and health, we tend to encounter this issue where people point to patients’ racial or ethnic background and state it as a natural process, and this is widely accepted in the scientific community, and to the average person. How does your work confront this claim? And why is it important to consider institutions and systems in our work?

Arline: Yeah, I think weathering is the antidote in a way or the opposite. The oppositional gaze on those more common understandings which get put under a label like genetics or a culture of pathology. Or essentialising them either through culture, or through genetics, whether it's the genetics in your biology that gives you health problems or the genetics that somehow makes you culturally inferior or less intelligent.

Those have been the go-to places for most policymakers who see that Black Americans have higher rates of almost all chronic health conditions and diseases, and think, therefore, there has to be something central about race. There are other, much more plausible explanations, and now, scientifically, a well-supported explanation, which is weathering.

And this is why I called it weathering. It has two meanings. One is the weathering most people think about: being exposed. Exposed to more toxins in your environment, to less healthy food, to dangerous environments of other kinds, to police surveillance, to all the things that you can imagine that can erode your health through large and small acts of structural violence. But I also called it weathering because what I saw was young women and their multigenerational families working diligently and actively to cope with these circumstances and overcome them, or at least survive them, and to find joy and meaning in life despite all the horribleness around them, or targeted at them. And so I thought of “weather” in that sense, as high effort coping, as weathering the storm. The storm unleashed negative exposures, but you could still weather it through your own autonomous networks of people and cultural expectations. So the name was meant intentionally to point out that all these ideas of cultural deficiency or lack of personal responsibility, are off base. In fact, the opposite is ore apt. People autonomously working together in tough situations to help each other and overcome [these difficult experiences]. I wanted weathering to capture both sides. The storm and the autonomous attempts to withstand the storm and come through to the other side, or to keep trying to come through to the other side.

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I realised that if I was feeling like a fish out of water at Princeton, that people who are part of deplored groups have to be feeling that on steroids compared to my little experience with it…that they had to be wearing armour, they had to be managing their social identities. They were seeing things every day that were unjust, or even life threatening. That's where I began to add to the construct of weathering: this idea that one of the a very important ways that structural racism works is that it puts the denigrated group in a situation where they have to be endlessly calculating how safe they are in different circumstances and contexts. And if they're not feeling safe, what is the best way to protect themselves. In otherwords one of the defining circumstances of their lives was the need and to be perpetually vigilant to threats..

There are many, many colloquial terms members of denigrated groups use to capture this perpetual vigilance to threat such as talking about having their “head on a swivel.” Both consciously and unconsciously they are perpetually alert to danger, and they're always sizing up cues in their environment to understand whether this setting is dangerous or not. That has a physiological impact on your body. A clear example would be if you're a young Black man who is stopped by a police officer, you will automatically become hyper-vigilant. You don't know if you're going to walk away from that police officer alive. Now, 99% of the time you are, and you even know that cognitively. But there's enough times that people who look just like you ended up dead from the very same interaction that it is reasonable to worry that death might be your fate and to act vigilantly: to remember what your parents told you about how to act in the presence of a police officer and do your best to act accordingly.

In effect, what's happening is you're having a fight or flight physiological stress process in your body. You're having to manage it in a way that's exactly opposite of what it would have you do. Biologically, it wants you to start running or fighting. But you know to do so would up your chances of being shot.

What has become clearer over the years is that being chronically situations that appear dangerous –even though it may be a false alarm --wears down your body systems and your tissues and organs, damaging your cells. Your large muscles, including your heart are flooded with oxygenated blood and energy, your respiration and heart rate are elevated, to enhance your physical ability to fight or flee. As with any muscle that's over exercised, you'll develop an enlarged heart. Over time, your arteries will harden and plaque will develop. You immune system gets continuously mobilized by chronic vigilance to prepare for would healing that my result from your encounter. If you were fighting a tiger and you got away, it would be very helpful to have your immune system at the ready to address any injuries and cuts you had sustained in the fight. But when your immune system is mobilized frequently, including for false alarms, it can become dysregulated, and then it either weakens or over reacts in the presence of biological threats. And that's when you develop autoimmune diseases or when you die of infectious disease. Because either your immune system isn't up to the task, or it tries to over compensate, and that can lead to chronic autoimmune disease or in the case of acute infectious disease, such as COVID-19, the cytokine storms that killed people by attacking their own organs. At the same time, other parts of your body that aren't going to help you in a fight or flight situation, do not get their full share of oxygenated blood and nutrients. And so if that's happening chronically, then they, too, will get worn down, and if you're pregnant when this is happening, your fetus will be denied oxygenated blood and nutrients it needs on a regular basis.

What this description of weathering processes tells us is that even those members of racialized or denigrated groups who do have enough healthy foods to eat, an advanced education and secure and sufficient income, still experience weathering of their bodies. Not to the same degree as their poor and working class counterparts, but more than their White peers, because you can’t escape threats that are made on the basis of race completely. If you're learning or working in predominantly White institutions that were never made for you, if you're negotiating those institutions that were not made for you where you are, second class or lower in some sense where you don't quite know how if it’s safe to be authentic or whether you can expect to be treated fairly, and in your earlier socialization you never got the memos about how to proceed safely in your everyday round in a predominantly white institution. Maybe they're not life or death threats, but they're chronic, nonetheless, and they accumulate over time as you remain vigilant, wearing your armor. Over time, being in this state chronically will weather your body. That explains why we see evidence of poor health and the early onset of dconditions and deceases of aging in Black Americans across class. It’s not because all Black Americans share the same disease genes or a pathological culture, it’s because you are engaging in persistent active, effortful coping trying to make your way according to rules you never learned or are rigged against you, that run counter to the trade-offs you face as a minoritised person. The way the institution runs is based on understandings that are really quite racist, and you could have anybody running that institution, and the people working in that institution genuinely not be inter- personally racist, but because they don’t understand the impact that the cultural norms and expectations of the institution have on people with different levels of resources or lived experiences, they miss the degree its everyday practices take a toll on marginalized people.

So maybe you're not weathering as much because you do have enough money to pay your rent. You're not worried about being evicted. But you're still worrying that maybe your son might get killed by a police officer. You still are not being paid fairly. You don't get the promotions less-qualified white people do. You're still dealing every day with things that make you feel you're in danger, and you have to remain vigilant. And as long as you're vigilant you're having some degree of these biological stress reactions that over time will erode your health.

Mita: Thank you. The way that you illustrated it is very apt and very flexible and dynamic, and shows how institutions are not just built in a way that are not compatible with different groups, but how they are actively built to move against populations to experience minoritisation. Even compared to a decade ago versus three decades ago, things are changing. At least, I'd like to think so. Given your long history of work on this, what do you think is next? And what can researchers, nonprofits and health professionals do to address this?

Arline: I think we're at a very critical time right now. I think that more and more people at least know the concept of structural racism. They know institutional racism. They see there are certain things which are very unfair, in incarceration rates, in sentencing for the same crimes, in death by police officer after a traffic stop for a minor violation… And I like to think there's a large mass of people who are wanting things to be better and that gives me some hope. But what I worry about is, there's also some backlash against that. There's incredible misunderstandings. This is one reason I wrote the book [Weathering: The Extraordinary Stress of Ordinary Life in an Unjust Society], and wrote it the way I did to be more accessible rather than a scientific tone.

All the dynamics that cause weathering can't just be solved by access to health insurance, medical care and income and education. Not that those are bad things. Not that those won't help, but they will not solve the problem. I believe we're at a critical point because more people see the injustice and want to do something about it. But unless they understand all the mechanisms, social, and in the case of health, biological, and how those come from fundamental social causes and institutions, they won't do the right things. Or they'll just apply more band-aids, or act performatively.

So I feel we could go one of two ways right now. I'm more hopeful than I used to be, precisely because, you know, when I used to talk about this stuff, people looked at me like I was crazy. Now everyone says, “Oh, structural racism! Of course it's structural racism.” But if they don't dig deeper into how structural racism does this, then how do we undo and deconstruct that? We'll be back where they were when they thought they could solve most social and public health problems by preventing teen pregnancy, by giving young people contraception or abstinence education. Now it's, “We’ll give them trainings”. The “DEI” (diversity, equity and inclusion) training. I don't mean to be cynical, but I've been at this for so long. I want to be hopeful. The fact I wrote the book is because I believe there's some reason to be hopeful that people's hearts and minds can be changed and motivate effective acation. There are people who will never change, and who are actively, personally racist, or benefit so much from the social order as it is that they have no incentive to change it. I'm hoping that if enough of us who do take an interest and have a deeper understanding, can communicate to that broad group of people who do have an open mind and sincerely want to promote equity the tide can be turned.

You can do something that will make it better. But you have to be looking under the right lamp post, and we haven't been looking under the right lamp post. But if we're able to have all the people who sincerely want to have a more just world looking under the right lamp posts, I'm very hopeful that there's a lot of places for leverage to disrupt and eliminate weaathering.

Mita: So it's not just standing under the ‘diversity, equity and inclusion’ lamp post. It requires a holistic, thorough grappling with the culture that we were raised in, the ideas that we were taught to believe, and applying that to our work. Be it in the health, research, community or medicine. Also properly listening like you said it all the way back.

Arline: Right. It means knowing our history. It means having humility, understanding that our expert opinions and lived experience are very narrow, and they themselves are influenced by certain values and resources that we have, but not everybody shares. It means being humble. I think humility is the biggest part, some people would say empathy, but I think it's humility, because part of it is we want to do something different from what we’ve done before.

And to that we can’t be the primary spokesman for other oppressed groups.They must have a strong and respected voice. None of the policy changes that would actually make a positive difference will be achieved unless they are made in partnership with people from the group who have socially-situated knowledge of the stakes and trade-offs they face. We should begin with humility about our own flawed expertise and lack of knowledge or even erasure of other lived experiences, and with an openness to realising those with different lived experience have perspectives that can only deepen our understanding of what kinds of policies might make a real radical and important difference.

Mita: I think that's a piece of advice that can really resonate with a lot of people who work in health policy and beyond. And just also the day to day person. Thank you for that. That is all of the questions I have for you. I wanted to ask if you have anything else you would like to say before we close off?

Arline: No, just I appreciate it. You know you're helping give me a voice and I really hope people will take this to heart and realise that they can make contributions.

Whether they're good at community based public health or policy, or whether they're more comfortable in an academic office, or a laboratory, doing the science it helps make those lamp posts light even brighter and more discerning. There's something we can all do cooperatively. It's not about teaching others to behave right. But it's about realising that even in schools these stereotypes, these negative stereotypes impinge on kids' performance, who are from denigrated groups, and start activating stress reactions and undermining performance at a young age.

If you're a police officer, if you're a policymaker, whoever you are, whatever walk of life you’re taking, and whatever you're comfortable doing or feel you have the knowledge or talent to do can make a difference, precisely because structural racism is pervasive, contaminating all of our institutions and interactions in ways that facilitate weathering. Structural racism can seem daunting to change and broad social changes are needed; but the fact that it’s in the air also means anybody can take positive steps to interrupt it.

Mita: Thank you for sharing your story. I think tracing your history has been really insightful and really contextualises weathering very well.

Arline: It's been really wonderful talking to you. So thank you for making time.