Foreword: envisioning health disparities.

I. INTRODUCTION No one approves of it. Our laws prohibit it. Yet racism will not go away. We continue to demonstrate that a colorblind society is just a society where color lurks in the blind spot. Disparities in healthcare offer a telling illustration of how durably racism is woven in our social fabric, and how easy it is for subtle, unconscious differences in treatment to add up to significant disparities in outcome. Disparities also give us an opportunity to see health differently. Instead of focusing on the outcomes of individual cases, disparities invite us to examine the social structures and processes through which the level and distribution of health are determined. Like racism, health is to a considerable degree a social product, reflecting how we order the world rather than our biological or genetic limits. The articles in this Symposium reflect a growing willingness in health and healthcare research to place individual outcomes in a larger, ecological framework.1 They are part of a process of social learning, a process of changing the focus from the final pathological outcomes that now more or less dramatically define our problems to the durable and flexible eco-social machinery that generates the problems and determines how they will be distributed. Solving problems, we are learning, is on its own insufficient: the problem-generating machinery simply makes new ones. The trick is to study the problem production system, and find structural interventions that begin to disrupt it.2 No single law review article can be expected to provide the solution to the problem of health disparities, but each article in this issue is a contribution to our ability to understand the problem and make that understanding salient to policy-makers and the public. In this Foreword, I suggest that the most important job of the health law or health services scholar tackling health disparities is to consider how law operates in relation to other social determinants as a cause of disparities,3 and how it may be used as a structural intervention to influence the social processes that produce them.4 II. RACISM AS A STIGMA Race as described in the articles in this Symposium is essentially a form of stigma, "an enduring condition, status, or attribute that is negatively valued by a society and whose possession consequently discredits and disadvantages an individual."5 Both prejudice-negative attitudes-and discrimination-overt negative behavior-may flow from and help enforce a stigma, but the real power of stigma as a form of social control is that the negative valuation of the stigmatized trait is built into people's basic understanding of the world: it is not an opinion, but a fact; it is not asserted, but taken for granted. Racism can thus be seen as a social process that continues to operate throughout social life even when specific manifestations are universally disfavored. Jim Crow has been repudiated, and racial equality is a valued norm, yet a country full of people who believe in equality and oppose segregation remains physically divided along racial lines. The question of whether race has sufficient biological reality to require or justify its active consideration in clinical research is still being debated,6 but we cannot advance public health or healthcare without accepting the reality of racism in our society.7 As Ross and Walsh point out in their contribution to this Symposium, racism as a cultural force could be producing disparities even if race as a biologic factor makes no contribution.8 The American concept of race is really quite a formidable achievement. Given how undramatically we Americans ultimately differ in shape, genes, culture, values and so on, a visitor from another planet might well be impressed with how intricately we can sort each other by subtle differences in shading and social position. A great deal of effort has gone and continues to go into making sure that we can recognize, respect and enforce racial differences. …