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AFRICAN-AMERICAN WOMEN AT MIDLIFE:
THE SOCIAL CONSTRUCTION OF HEALTH AND AGINTG
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
This work is dedicated to the memory of my foremothers. First, I thank my
grandmother, Jessie, who taught the value of spirituality and fun. To my mother, Alberta,
who always knew I could, I give thanks for the lessons of perseverance, belief in the
indomitable spirit, and ballet lessons. To my othermothers, Frances Robinson-Combs,
Elaine Frazier, Leslie Houts, Shannon Houvouras, and Sheila Roytman, I acknowledge
their gifts of patience and kindness. To Sylvia Ansay and Renee Ruffin-Price for
compassionate listening, I give thanks. I am grateful to the women of this study, who
through the gift of their time shared my vision. Finally, I acknowledge and give thanks to
my honorary othermothers, Joe Feagin, my academic advisor, and the other members of
my dissertation committee, who helped put the pieces together and taught me to press on.
I am grateful to my brothers, Gregory and Kenneth Combs, and to my spouse, Bobby
Jones, for sharing and supporting my vision. I wish them peace and love.
TABLE OF CONTENTS
ACKNOWLEDGMENT S ........._._ ...... .__ .............. iii...
AB STRAC T ................ .............. vii
1 INTRODUCTION AND LITERATURE REVIEW .............. .....................
Purposes of the Study .............. ...............2.....
Back ground ................. ...............5.......... ......
Research Questions............... ..... ... ... ... .. .. ..........
How Do African-American Women Define Their Aging Experience? ................7
What Roles do Intergenerational Learning and Collective Memory Play in
Developing the Beliefs of African-American Women about Aging and
H health? ............. .......... .... .. .. .........
Intergenerational relationships and collective memory ............... ...............10
Afrocentricism and the collective memory ............... ........... .. ..............1
Is there a Relationship between Perceptions of Access to Health Care and
Beliefs about Black Women' s Ability to "Age Successfully?" ........._...........13
What is the Role of Spirituality in Aging and Health?..........._. ............____...15
Theoretical Framework............... ...............1
The Life Course Perspective .............. ...............17....
Dec on strcti on................. ...............21.......... ....
Organization .............. ...............21....
Sum m ary ................. ...............22.......... ......
2 METHODOLOGY .............. ...............24....
Perspectives .............. ...............24....
Afrocentri sm ................. ...............25......_._. .....
Feminism ........_................. ..........._..........2
Data Sources ................. ...............27......... .....
Content .............. .. ..... .... .............2
Data Coding and Analysis............... ...............29
The Interviews ........._..._.._ .......... ...............30.....
Volunteer recruitment .............. ...............32....
The interview environment ............. ..............32.....
The interviewer as participant ................. ...............33................
The W omen .............. ...............36....
Demographics............... .. .............3
Distinguishing Characteristics............... ............3
Socioeconomic status .............. ...............38....
M id life ................. ...............40...___ ......
Summary ........._._... ......... ...............42....
3 "AGE AIN'T NOTHIN' BUT AN~UMBER!" ............... .............................44
Traditional Views of Aging ................. ...............46.......... .....
Women and Aging............... ...............49.
Age as a Social Construct................ ..............5
Defining M idlife .............. ..... ....._ ...............51....
When the Number and the Mirror Disagree .............. ...............57....
The Importance of Primary Data Sources ........._ ....... ___ ... ....__.........5
Sum m ary ............. ...... ._ ...............64....
4 "PEANUT BUTTER AND JELLY AIN'T A BLACK THING! "............_ .............65
Typif cations of the Life Course ............__......__ ....___ ...........6
Body Image and Dietary Practices .............. ...............66....
Sum m ary ............. ...... ._ ............... 1.....
5 "BUT I DON'T KNOW WHERE YOUR EVERYDAY BLACK FEMALES
ARE SEEKING CARE" ................ ...............83................
Historical Perspective on Health Care ................. ...............83........... ...
Barriers to Health Care Access ................. ...............85........... ...
The Black Middle Class............... ...............93.
Summary ................. ...............100................
6 "YOU HAVE TO COUNT YOUR BLESSINGS" ................. .................103
Defining Spirituality ................. ...............104................
Historical Roles of the Church .............. ...............105....
Voices: Constructing Spirituality .............. ...............105....
Sum m ary ............. ...... ._ ...............117....
7 CONCLUSIONS ............. ......___ ...............119...
Defining Midlife and Aging .............. ...............120....
Images of the Self ............... ...............121.
Barriers to Health Care Access ........._.. ...._._..... ...............124..
Spirituality .............. ...............126....
Answering the Research Questions .............. ...............127....
Lim stations of the Study .............. ........... ........ ... .. .................13
Building Theory: Towards a New Model of Health and Aging from the
"Borderlands" ............ ...............131.....
Continued Health Activism .............. ...............133....
A WRITTEN QUESTIONNAIRE ................. ...............135................
B INTERVIEW GUIDE............... ...............137.
LIST OF REFERENCE S ................. ...............139................
BIOGRAPHICAL SKETCH ................. ...............148......... ......
Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
AFRICAN-AMERICAN WOMEN AT MIDLIFE:
THE SOCIAL CONSTRUCTION OF HEALTH AND AGING
Chair: Joe R. Feagin
Major Department: Sociology
The intersections of race and gender clearly present a challenge in the study of
health, aging and the life course among black women. Black women who experience the
"double jeopardy" embedded in their status as black and female are dually penalized in a
society that consistently discriminates on the basis of race and age. Moreover, the aging
patterns of African-American women are issues made more complex by diversity due to
social class. Inferences about the health and aging patterns of this group are frequently
made using biomedical models and comparing black and white women. Such
comparisons and models fail to account for the sociohistorical experiences through which
the belief systems of black women are filtered. This study has two obj ectives. First, it
seeks to disclose the social mechanisms that contribute to the health and aging beliefs of
black women at midlife. In this respect the study is designed to examine the health beliefs
and behaviors of black women as socially constructed within the context of family
through intergenerational learning and a culturally bound collective memory. Second, this
study seeks to establish within-group patterns of normalcy, especially those that redefine
midlife and aging within the context of the life course experiences of these black women.
This research proj ect is structured around four guiding questions. First, how do African-
American women define their aging experience? Second, what roles do intergenerational
learning and collective memories play in developing the beliefs of African-American
women about aging and resultant changes in health? Third, is there a relationship
between African-American women's perceptions of health care access and beliefs about
their ability to "age successfully"? Fourth, what is the role of spirituality in the lives of
these African-American women? In answering these questions I interview 26 midlife
African-American women age 36 to 74 years of age. This study relies on the reported
experiences of these participants to deepen the understanding of the interaction between
individual and social constructs that affect health and aging across the life span of
INTRODUCTION AND LITERATURE REVIEW
At what age were you when you entered midhife?
I don't know if it was in my 40s, or my kids were grown and I didn't have to
bother. I don't know. Kind of look to enj oy life for myself and not so much having
someone dependent upon me. Not that I minded 'cause I enjoyed having them. But
I was fortunate enough to look at them one day and started making sure that I
enjoyed them. But after they were born it was a different stage of life. Maybe that
was it, maybe it was the children that brought it on not necessarily an age.
The opening quote comes from a woman who declines to reveal her age until much
later in the interview. "You really want to know my age?" she asks and wrinkles her
nose. Rose is active with a part-time job related to her former career in education. Like
many women in this study, she is well educated both formally and informally. Also like
many of the women in this study, she is ambivalent as she searches for ways to define
midlife and the experiences of health and aging. Rose's confusion, at age 71, is perhaps
reflective of the research to date about African-American women and their health and
Black women as a group have rarely been studied in a systematic way. Yet there is
evidence to suggest that early in the life course, and certainly by the time they reach
midlife, African-American women have already experienced declines in health that are
generally associated with older populations (Combs, 2001; LaVeist, 2000; Geronimus,
1996). In these studies, evidence suggests that being black is a maj or health disadvantage.
In this sense, being black conditions the ways that African-Americans experience health,
illness and aging. This observation establishes the importance of conducting research that
includes the social environment of the participants.
Purposes of the Study
This study has two purposes. The first is to disclose the social mechanisms that
contribute to the health and aging beliefs of African-American women that manifest at
midlife. To achieve this goal, twenty-six midlife black women are asked about life course
events such as their earliest experiences with racism, the treatment they have received in
the medical care system and the development of their spiritual beliefs.
Conceptually, the women's definitions and associated beliefs about midlife; their
beliefs about health; and the roles of spirituality crystallize to form a cohesive
Afrocentric and black feminist standpoint based heavily on their everyday experiences. A
fourth concept relates solely to social structure and develops around the structural
environments in which they operate. Their encounters with the social structures of the
medical world serve to amplify beliefs about access to health care. These four concepts
are more fully developed in separate chapters of this study.
The second, more complex purpose of this study is to establish within-group
patterns of normalcy that define midlife and aging within the context of the life course
experiences of black women. To the best of my knowledge, previous research has not
attempted to define midlife and health related aging from the perspective of middle class
black women. Typically studies of black women are conducted using models that
compare black and white women and focus on the biomedical details of health. In this
report, the data are generated by the participants. In this manner they themselves
determine the cogent issues of midlife and health.
There are a number of reasons for choosing a within-group approach to the study of
African-American women at midlife as opposed to one that compares black women to
white women. I looked specifically at four of them in my study design.
The first basis for a within-group perspective for this study concerns the history of
studies of black women. In general, black women are rarely studied from within the
group or from outside of the biomedical models of health and aging. This causes most
inferences about the aging and age-related patterns of health in African-American women
to be made using biomedical models that compare black and white women. Moreover,
the comparisons between black and white women tend toward labeling outcomes for
black women as pathological (Whitfield & Baker-Thomas, 1999). In this respect, the
research outcomes serve to bolster and increase the cultural capital of white women.
Cultural capital, according to Bourdieu and Wacquant (1992), is a commodity and
a source of power for those who possess it; it is distributed when decisions are made
about the source and the content of legitimate knowledge. This study regards the
acknowledgment of the experiences of black women from their historical, political and
structural positions in American society as cultural capital. The absence of these
experiences from research robs black women of the cultural capital that legitimizes the
knowledge produced by their experiences. In short, it produces a cultural assault that
devalues their experiences and perspectives. The argument presented here is that it is far
more significant to connect proven health disparity to individual and structural
circumstances than it is to continue to compare rates of disease. The documented facts
that African-American women have higher rates of diabetes, heart disease, stroke, and
cancer do little to bring research closer to explaining the cause for early onset of illness
and higher mortality rates among black women.
A second reason to conduct within-group studies of black women stresses the
importance of the sociohistorical experience. A sociohistorical experience considers the
historical, political and social structures of C. Wright Mills' (1959) "sociological
imagination," that impact individuals as they move through the life course. In the case of
African-American women, this history includes slavery and the structures of institutional
racism. Comparisons between black and white women fail to account for the
sociohistorical experiences through which the belief systems of black women are filtered.
In theory, as well as application, the experiences of racism and the ensuing
discriminatory treatment filter the sociohistorical experiences of African-American
Third, comparisons between black and white women negate the intent of this
research and violate one of the basic principles of feminist research methodology. The
feminist standpoint seeks the creation of knowledge by those who reside in the
borderlands of the dominant culture and not by those who are privileged by gender and
race. In the traditions of feminist thinkers (Harding, 1998; Collins, 1998; Smith, 1987),
this project addresses the issues of aging, health and wellness from the viewpoint of the
women it studies. In this respect, this proj ect argues that gaining an understanding of the
daily lived realities of African-American women does not warrant a formalized
comparison across racial lines. Informally, the women of this study make both implicit
and explicit comparisons between themselves and white women that are consistent with
the qualitative framework of the study.
The fourth and final argument regarding the strength of within-group study relates
to the balance of power in the production of knowledge. This proj ect, in using a within-
group study approach, represents a resistance to power. It is this resistance to a power
imbalance in the production of knowledge that so clearly distinguishes this study from
those that are comparative in their approach. Thus the positioning of the black women
represented in this study is not influenced by the ways in which they have previously
This study of the health and aging beliefs among middle class African-American
midlife women emerges from my earlier interest in the rates of age-related illness and
early mortality among black women. That interest generated the question: Why are
African-American women predisposed to higher rates of functional dependency than men
and white women? The result of combining this information is that black women are
assessed by health care practitioners as having more physical limitations or functional
dependency as a result of aging than do white men and women or black men. However,
there appears to be no literature that discusses physical limitation or functional
dependency among black women. In short, this group of women is missing from the data.
In studies of aging, this functional dependency is gauged by the ability of the
individual to perform specified tasks related to mobility and cognition. Traditionally this
mobility and cognition have been measured by a count of activities of daily living (ADL,
basic functions such as eating and bathing) and instrumental activities of daily living
(IADL, cognitive functions such as taking medicine and keeping track of money). That
model has since been adjusted, redefined, and renamed to include the consideration of
conditions that demonstrate a conflict with the individual's environment. This has
brought into use the term physical limitation (Verbrugge & Jette, 1994). This expanded
model takes into account environmental adaptations that make the categories of ADL and
IADL too restrictive and allows a more accurate assessment of disablement. For example,
certain environmental conditions, such as the close proximity of family member and
fictive kin, may not consistently restrict aging black women. The historical strength of
the social support networks among black families may operate to ameliorate those
limitations. The simple reporting of numbers of ADL and IADL does not necessarily
consider such factors as the support networks in black families and the cultural biases of
self reporting. Studying the viewpoint of the participants ultimately encourages the
discovery of the social structures within the community of black women that may
contradict biomedical models of health and aging.
One of the primary purposes of this review is to situate the social construction of
health and aging within the context of the African-American family unit. To do so, two
key points need to be emphasized. First, the family as a social system is regarded to be
the primary source for the development of values, beliefs and attitudes. It has been
reported that, by and large, "families influence attitudes or beliefs [even] past childhood"
(Glass, Bengston & Dunham, 1986, p. 696). Second, the real and mythical constructs of
the American blacks' family unit, like most social systems, develop and continue to
evolve within a particular but fluid social environment. (Glenn, 2002; Gubrium, Holstein
& Buckholdt, 1994; Elder, 1974). For example, Mullins (1997) reports that the mythical
pathologies of the black family surfaced at a time "when African American women, men
and children, along with some Euro-Americans were mobilizing against institutional
racism and making significant gains in civil rights" (p. 79). In the era of the civil rights
movement, the strategy of devaluing the black family was used to diffuse movements
against racism. Up to that point, African-American family structures were not considered
a relevant social issue.
For African-Americans, there is a social environment that heavily influences their
ability to participate equally in all aspects of American life. That environment includes a
history of slavery and the legal segregation imposed through the Jim Crow laws of the
last century. Furthermore, the social environment of blacks in the United States
influences the roles of black women in the family, as well as conditions of unequal access
to medical care. It is important to the arguments presented in this study to acknowledge
and thereby begin to understand the historical biases that permit race and gender to act as
barriers to blacks' access to health care.
The literature review associated with this proj ect was a by-product of three guiding
questions. In the progress of the fieldwork, however, a fourth question emerged and was
incorporated into the study. These four research questions and the related literature are
How Do African-American Women Define Their Aging Experience?
This first research question derives from the literature that examines the social
construction of health and aging. Although I could find no evidence that qualitative
research has been conducted among midlife or aging middle class black women,
literature does exist that develops the theory that health, illness and aging are social
constructs external to the individual. As social constructs, beliefs about health, illness,
and aging develop within the context of a specific social environment (Lorber & Moore,
2002; Lupton, 2000; Gubrium, Holstein & Buckholdt, 1994; Bordo, 1993; Andersen,
1988; Berger & Luckmann, 1967; Durkheim, 1979; Parsons, 1950). I apply the social
construction viewpoint to develop the position that the women of this study have
constructed a view of health and aging specific to their sociohistorical experiences as
black women in America. At the same time, these individual viewpoints are collective
standpoints that reflect the everyday realities of their lives. The following comments by
one of the study participants illustrate this phenomenon:
I don't know if this is factual, but I think black women age faster because of the
stress and the pressures. Some may not agree. Although, white women show their
age faster. We can be 75 and not look our age. White women may be able to hide it
through cosmetic surgery, but black women don't because they can't afford it.
Look at Tina Turner. She looks great.
In this woman' s evaluation, the aging experience of black women is filled with the
stress and pressures of being black. From the standpoint of a social context, this stress
causes black women to age faster. Moreover, despite being middle class herself, she
reasons that the financial resources of most black women restrict their ability to afford
cosmetic surgery. However, she further reasons that because black women look younger
that they are, cosmetic surgery is unnecessary. Thus in the social context of being a black
woman, stress and unequal financial resources define aging black women.
The constructions of these women' s points of view may be influenced by family
systems. This family influence may be even more significant among southern blacks. As
a result of continued segregated living, southern black family systems remain outside of
the dominant culture's sphere of influence. Several participants describe their educational
and general social interactions as being racially segregated. One woman expresses her
separateness in this way: "I didn't really experience it [discrimination], or at least I didn't
recognize it, because I lived in an all-black neighborhood." Her tone is both tentative and
apologetic. This and similar comments about the experiences of a separate culture are
more closely examined and further discussed in Chapter 4.
What Roles do Intergenerational Learning and Collective Memory Play in
Developing the Beliefs of African-American Women about Aging and Health?
The examination of the second research question is informed by the literature on
the transfer of knowledge and beliefs within the context of family and extended family.
However, in order to develop a framework for understanding the roles of
intergenerational learning and the collective memory in developing beliefs about aging, it
is important to acknowledge the historical and stereotypical views of the black family.
From a historical perspective, the African-American family was forged under conditions
of slavery, splintered, and then following Reconstruction (1865-1877), reformed to meet
the country's need for labor (Glenn, 2002; Dill, 1988).This relationship to production
meant that black families, unlike Anglo family units of the pre-Reconstruction era, were
not centered on patriarchal divisions of labor (Davis, 1983). Black women worked side
by side with black men as field hands, often birthing children in cotton fields and
returning to plant and plow shortly thereafter.
Despite egalitarian work relationships outside of the home, black men and women,
and thus black families, maintained and even strengthened family ties. Following
Emancipation, and within the framework of the Reconstruction era, black women left the
work in the fields to manage their households and to supervise the activities of their
children (Glenn, 2002). The stereotype of black women as matriarchs, the dominant
figure in the household, continued to be a strong image in observations of the black
family. In part, this stereotype evolved because black women who were working side-by-
side with black men did not conform to Eurocentric ideologies of wife, mother and
homemaker. Present day images of African-American family life continue to include
these mythical images of black womanhood that overburden black women.
Questions about health and aging beliefs and experiences with health care systems
support previous research efforts to disclose patterns in lifestyle, social environment and
social structure that may influence how these participants construct midlife, health and
aging. In 1984, The MacArthur Foundation brought together a group of scientists from
divergent fields to conduct a 10-year study of successful aging. Their findings were
published in over 100 scientific papers. The conclusion was that the process of normal
aging, and the rate at which it occurs, is related to lifestyle, social environment and social
structure and that genetics played a much smaller role than was thought (Rowe & Kahn,
1998; Elder, 1994; Riley, 1986; Featherman & Lerner, 1985). Additionally, in weighing
the determinants of health, authors Porter and Gaston (2001) report that the most recent
assessment by the national Centers for Disease Control and Prevention indicates that
lifestyle governs 50 percent of the determinants of an individual's health. The remaining
50 percent is divided equally between heredity (20 percent) and environment (20
percent); medical care accounts for the remaining 10 percent of the determinants.
Both the MacArthur Foundation studies and the Centers for Disease Control and
Prevention place an emphasis on socially constructed dimensions of health and aging. In
a similar vein, this research proj ect interviews thirty black women in an effort to expose
those lifestyle patterns, social environments and social structures that may contribute to
the early onset of illness and ultimately higher rates of mortality at earlier ages among
Intergenerational relationships and collective memory
The research literature on aging addresses intergenerational relationships in terms
of intergenerational solidarity. Under the rubric of aging studies, intergenerational
solidarity concerns itself with measuring aspects of family dynamics. Among those
aspects is the "degree to which services are exchanged and the level of agreement about
values and beliefs" (Quadagno, 1999, p. 404).
The existing literature addressing the social support or levels of exchange system
among African-American families is primarily associated with the roles played by
children in the care of aging parents. This study extrapolates from this traditional usage
of intergenerational relationships to suggest that these relationships also provide the
opportunity for the transfer of information, values, and beliefs. In particular, there is
research to suggest that the intergenerational support system of the black family has not
eroded and, in fact, may be stronger than that among white families (Laditka, 2000;
Mutran, 1985). The existence of this support system implies that black families exhibit a
cohesive characteristic that may foster a system for the transfer of knowledge and beliefs
about health and aging. In this respect, this study will disclose evidence that among these
black women, intergenerational knowledge is transferred through a collective memory of
oppression. This collective memory is integral in forming their belief systems of health
At first glance, however, one study participant' s memory of family life failed to
conclusively support this hypothesis about the intergenerational transfer of knowledge.
When asked how she learned or came to know a particular aspect of her philosophy of
life, she responds that she does not know, but thinks it comes from experience:
That is part of the black experience. Our families didn't talk to us about life, of
what to expect in life. We were all thrown out there. I never had a heart-to-heart
with my mother or grandmother, even about our heritage or family tree. In
elementary school, when doing show and tell about family, others would get up and
talk about their different heritages. We can't do that. Our parents didn't talk about
it. That is as far back as I can go, my grandparents. I can't get people to talk about
it. The slavery period, there's a lot of shame. People did things just for survival.
But because it' s not talked about, we don't understand.
In these words, it is clear that this woman has no recollection of being told her
history as a black woman in America. Judging by this account and the others examined in
the succeeding chapters, it appears that the intergenerational transfer of beliefs is implicit
rather than explicit and that the learning from the experiences of family members is more
of a tacit experience among the women of this study.
The literature defines collective memory as "an extension of the past" into present
time circumstances (St. Jean & Feagin, 1998, p. 33). An earlier examination of collective
memory also suggests that the collective memory is cultural and always selective
(Halbwachs, 1950). The hypothesis of a collective memory among African-American
women asserts that the overt experience and traditions of discrimination, as well as the
less concrete perceptions of discrimination, culturally bond African-American women.
(St. Jean & Feagin, 1998; Feagin & McKinney, 2003). It is the position of this research
proj ect that this bonding and sisterhood often transcend
class, age, and regional differences. As shared experiences are the hallmark of
cohorts, in this respect, black women are united as a cohort based on the discrimination
imposed by race and sex. In turn, race and sex formulate a black, female consciousness or
collective consciousness. The women of this study use this consciousness to define their
health status, health beliefs, and health behaviors within a particular cultural environment
and historic framework.
Afrocentricism and the collective memory
This study argues that within African-American families, and in particular among
African-American women, there is an historical, cultural consciousness (Ani, 1994;
Collins, 1991). This perspective, by design, is Afrocentric.
Afrocentrism is a method of social inquiry that has a strong and primarily academic
concern for insertion of a cultural and intellectual African perspective into the social
development of the American African Diaspora (Asante, 1987, 1988). At the center of
this philosophy is the idea that the knowledge and preservation of African culture is
essential to the survival of African-American cohesion. In addition, the Afrocentric
literature maintains that exclusion of this perspective represents a racialized and
inaccurate depiction of people of African descent. The Afrocentric philosophy is
predicated on the belief that culture acts as a means to unify groups of persons. "Group
identification" develops through shared values, attitudes, and beliefs (Ani, 1994). When
group identification or cultural consciousness is lost, the way becomes clear for control of
the group by a more dominant culture. For African-American women, this cultural
consciousness, referred to in this study as the collective memory, has its genesis prior to
Emancipation (Burgess, 2000).
Is there a Relationship between Perceptions of Access to Health Care and Beliefs
about Black Women's Ability to "Age Successfully?"
The third research question this study seeks to answer concerns access to health
care. This question emerges from literature that discusses the structural inequalities of
race and gender that form barriers to health care access. It is answered in part from
literature related to the sociohistorical experiences of African-Americans.
A number of works briefly recount the sociohistorical basis for disparity in health
care access among American Blacks (Feagin & McKinney, 2003; Burgess, 2000; Harris
& Johnson, 2000; Byrd & Clayton, 2000). However, Byrd and Clayton (2000) provide
one the most comprehensive works to date on the history of race, health and medicine in
the United States. They outline seven "health system cultural" manifestations among
them is the "marginaliz[ation] of African-Americans at all levels of the health system" (p.
xxiv). The following story, related by one study participant, presents a poignant
illustration of the history of medical care for blacks in America.
Louise hesitates when asked her age. She is 67 and retired from a maj or retail
chain. Louise has previously stated that she usually does not have an opinion about
things, but after some extended prompting, recounts the birth, in 1957, of her twin sons in
rural Mississippi. Louise quietly and evenly gives the following details of her birthing
I went back to Mississippi during the pregnancy to stay with my family, and of
course I went to the doctor there. From the time I was 4 months pregnant up until
the babies were born, the doctor knew I was anemic. He didn't give me anything
for it to build up my blood. So when my babies were born, he sent me to a hospital
where they didn't take black women for childbirth. He sent me there. I don't know
why. They put me in a room where they had only three other black people in the
hospital. One of them was a diabetic, and I don't know what the others were in
there for. So they put me in the room with these two women. We were in a little
building that was outside of the hospital and it had three beds in there. They put me
in the third bed. I think he was putting me in the hospital to keep me in there for a
few days. I was in there and overnight I went into labor and the twins were born.
After the twins were born, I went into convulsions and he had called my family and
told them that I was dying and there was nothing he could do. And all I needed was
blood, and he refused to give me a blood transfusion. And he had told them that
blood in the hospital was for white people. So you can just imagine how many
black people had died in Mississippi. It was 1957. So he says "she needs blood and
we don't give transfusions to black people. The blood in the hospital is for white
people, and we don't take blood from black people and we don't give blood to
black people, to colored people." So my brothers came down and said "we will
donate the blood". He said they don't take blood from black people and they don't
give blood transfusions to black people.
This is one of the most detailed, candid, and moving accounts that the women of
this study gave about disparate treatment in the American health care system. Although
Louise' s story is historical, it provides rich data about the lived experiences of black
What is the Role of Spirituality in Aging and Health?
The history of health care access among African-Americans is closely tied to the
history of blacks as slaves in America, an historical relationship that is further examined
in Chapter 5. This history of slavery also played a role in the development of a spiritual
consciousness and practice among black women. As I began to closely examine the
interview transcripts, one of the strongest and most consistent themes to evolve from the
interviews was that of spirituality.
Early in the interview process, the participants repeatedly professed a belief and
faith in a higher being they termed "God" or "the Lord." These expressions of spirituality
were connected to family values, intergenerational transfers of knowledge, and evidence
of a collective memory of oppression. In this study, a closer examination of these
spiritually based belief systems provides insight into the construction of participants'
professed beliefs about health and aging.
It is important at this point to define spirituality, a concept that is often
misconstrued as church affiliation. While church affiliation and activism through church
work are traditions among black women, they do not come more from one church
denomination than from another. Perhaps this loose association with church
denomination speaks more of the significance of spirituality than it does of religiosity. In
these words, Perkins (1995) suggests that her own spirituality is a means to connect with
I suspect now there are myriad paths to spiritual fulfillment. Of course, the
assertion begs a definition of what it means to be spiritual; the concept evokes
different meanings for different people. My own belief is that to be spiritual is to
recognize and honor my inherent connection to other beings, to the earth, and to
events in the world around me. It is to affirm life and to tap into the power--the life
sustaining energies and forces that direct the motion of the universe. To be spiritual
.. is to commune with, to nurture, and to celebrate that which is divine around and
within us. (p.162)
Unlike "religion," which Emile Durkheim (1979) defines as a social fact,
"spirituality" is an individual and very personal experience not defined by the walls of a
church. The approach of William James (1997), the early twentieth century American
psychologist and philosopher, comes closest to defining the concept of spirituality
referred to in this study. He relates "religious experience," to religion, but only as the
individual encounters it. In this sense, spirituality as a religious experience is not
associated with any particular practice or physical symbol. In essence, James contrasts
personal knowledge or experience with the inherited tradition of church attendance. In
this respect he separates the church from the individualized religious experience. In some
circles of sociological thought, spirituality appears as a subset of religion; therefore, to be
religious implies that one is also spiritual.
The literature contains little regarding the concept of spirituality and its meaning in
the world of religion. Again, the term is not clearly defined. Perhaps this is in part due to
its relative youth. As a cultural marker, spirituality has been linked to the era of the baby
boomers (1946-1964). Wade Clark Roof, in a 1993 work, surmises that "boomers," in
their rej section of organized religion, precipitated spirituality as a gesture of individuality.
Admittedly, the era of the baby boomer produced maj or shifts in the economy, politics,
and educational responses of the nation. These shifts may include the shift from
religiosity to spirituality and the introduction of the term "spirituality" to the language of
This shift away from religiosity and to spirituality is clear in the words used by the
study participants to explain how they connect to an essence that extends beyond their
own ability to control life circumstances. The women of this study define their spirituality
outside the labels of a religious denomination employing its power to deliver them from
worry and harm. Wilma, a study participant, illustrates this connection in talking about a
difficult situation at work, or a time when she needs medical care. Of the work
environment she says: "I pray about it. But it is still there." She resorts to the same
spiritual tool when she speaks about health care. "If I am going to the doctor, I [still] go.
But I still pray for a healing. I pray before surgery. You want Him on your side."
As with most discussions of religion and spirituality, there is much room for
interpretation, and the debate goes far beyond the parameters of this study. However, the
debate about the differences between spirituality and religiosity is less important than the
fact that these women profess beliefs in a power outside of themselves that helps direct
the activities of their daily lives.
As I will further demonstrate in Chapter 6, prayer is the symbol of spirituality
among these women. Through prayer, the women of this study connect with one they call
God. In their words there is the expressed belief that God has the ability to deliver them
from worry and harm.
The Life Course Perspective
The life course perspective is most often discussed in the context of aging. By
definition, the life-course perspective primarily acknowledges and examines the
circumstances of aging that are "socially created, socially recognized and shared"
(Hagestad & Neugarten, 1985, p. 35). Other research (Riley & Bond, 1983; Featherman,
1983) includes the psychological contexts of human experience, as well as the biological
dimensions of life, in studies of the life course. Across the life course of an individual,
the social environment, individual psychological frameworks, and individual biology,
taken as a whole, determines how individuals experience aging. In discussing the social
construction of realities that produce a black feminist perspective, Patricia Hill-Collins
(1986) examines the work of Berger and Luckmann (1966). Collins suggests that, "it is
impossible to separate the structure and thematic context of thought from the historical
and material conditions shaping the lives of its producers" (p. S16). For the women of
this study, the historical and material conditions that shape the life course are conditioned
by experiences of discrimination and disparate treatment.
Additionally, the life course perspective is particularly useful in studies of aging
when attempting to predict outcomes of later life based on earlier life events and
circumstances (Henretta, 1995). In this respect, this study concerns itself with the
correlation of sequential life course traj ectories that have a cumulative impact and are
therefore most likely to predict health outcomes in African-American women at midlife
Much of the literature that governs studies of aging operates from the perspective
of the life course continuum. The argument for this standpoint is that the life course
perspective makes allowance for, and explains the cumulative impact of, experiences in
the construction of patterns of aging. The multiple experiences and perspectives are due
to the fact that history, social environment and social structure change over the course of
individual lives (Bengston & Schaie, 1999; Riley, 1987). These changes are in tumn
reflected and affect the health, patterns of aging and morbidity of the population. In short,
such a perspective suggests that disparities in health manifested in aging and older adults
may be due in part to earlier life course events and their affect on successful aging
(Hayward & Hernon, 1999; Jackson, Chatters & Taylor, 1993; Moen, Dempster-McClain
& Williams, 1992). For these reasons, it is argued that life course perspective is the most
balanced way to study aging. A note must be made that for African-American women,
early patterns of socialization as well as life course trajectories differ greatly from those
of white women. Thus, the cumulative effects of life course events produce a different
aging experience for African-American women. As one of the studies referenced in this
research proj ect notes, the early appearance of physical limitations in the lives of African-
American women indicates that this group has the potential to experience longer periods
of disability over the life course (Combs, 2001).
The examination of life course events has recently shifted to include events that
occur in early childhood. Specifically, there is a growing body of literature that suggests
early childhood and even fetal exposures to health risks have a cumulative impact on
health (Barker, 1995; Dannefer, 1988, 1987). Some literature also considers the
cumulative impact of racism on health outcomes in later life (Porter & Gaston, 2001).
One complex analysis of cumulative disadvantage (Dannefer, 1987) turns to the work of
Robert K. Merton and the "Matthew Effect." Simply stated, the Matthew Effect is based
on a passage from the gospel of Matthew. The passage intimates that those who have
abundance and those who do not are equally required to give of their resources. Thus if
one has less in the beginning and some is taken away, one still has less than others who
began with more. So it is that blacks and women, who from the beginning of their life
courses are disadvantaged by race and sex, continue to be disadvantaged across the life
course. In Dannefer's analysis, the Matthew Effect is specifically related to the social
processes that influence individual aging. The analysis also has implications for life
course outcomes among blacks and women.
Emile Durkheim (1979) and Talcott Parsons (1950) provide additional insight.
From the standpoint of the social construction of health, illness, and aging, both
Durkheim and Parsons suggest that psychosocial factors external to individual
responsibility may influence health and illness, and thus the conditions of aging. The
literature further relates these factors to health disparity (Dess, 2001; House & Williams,
2000; Rogers, Huxley, Thomas, Robson, Evans, Stordy & Gately, 2001; Clark,
Anderson, Clark & Williams, 1999; Marmot, 1998).
For African-Americans, discrimination and the perception of racism as
psychosocial and sociohistorical factors have been demonstrated to elicit strong and
consistent stress responses (Feagin & McKinney, 2003; Feagin, Early & McKinney,
2001; Williams & Wilson, 2001). This stress response is predicted to correlate over time
to negative physical and psychological health outcomes (Clark & Anderson, 1999).
However, no single psychosocial factor assumes responsibility for health outcomes; it is
more likely that a combination of these factors, dictated by the specific and individual
environment, contributes to overall illness or well being (Adler, Boyce, Chesney, Cohen,
Folkman, Kahn & Syme, 1994). In light of this current research, lifestyle, socioeconomic
status and racism as sources of stress are discussed in the lives of the women who
participate in this study.
This research proj ect takes the position that both illness and aging develop within
the context of a specific social environment (Lorber & Moore, 2002; Gubrium, Holstein
& Buckholdt, 1994). For women, the ways in which illnesses develop and are treated are
associated with gender inequality (Lorber & Moore, 2002). Thus, structural, as well as
individual "agency," form the ways in which the individual experiences aging and illness
(Featherman & Lerner, 1985). In this respect, aging and health are both biological and
Beyond the task of constructing the life course lays the task of deconstruction
(Gubrium, Holstein & Buckholdt, 1994). Construction and deconstruction are different
sides of the same coin. From a constructionist viewpoint, the task is to deconstruct,
through careful examination of processes, information about the life course events of
African American women. This occurs in two dimensions. The first is the dimension of
myth; in examining the lives of these women, this study seeks to deconstruct myths about
health and aging at midlife. The second dimension involves the deconstruction, or careful
examination, of how the women assemble their life course events in order to place these
events into a context and give them specific meanings. For example, how do these
women assemble their spiritual beliefs to combat racism?
Chapter 1 contains the cogent issues presented by the accounts of the participants,
and outlines the literatures related to the social constructions of health and aging and the
social context of family and its role in transferring knowledge and beliefs of health and
aging through the filter of the collective memory. This chapter also establishes the
historical perspectives that ultimately form the sociohistorical contexts of health care
access by black women. Similar historical information is also included in Chapter 5 in
order to further illustrate the relationship between the cumulative nature of health
disparity and the patterns of aging among black women.
Chapter 2 presents information about how both content and process form the
structure for the methodology of this research proj ect. Content includes the explanations
and rationales for the methodologies used in this study, as well as a profile of the study
participants. Process includes the strengths of the individual interviews as well as an
examination of the roles of the researcher and strategies of the interview process. Finally,
Chapter 2 provides an explanation of the data analysis methods.
In Chapters 3, 4, 5 and 6, the voices of the women are heard through their
interviews and the interpretations of the interviews. Chapters 3 and 4 specifically reveal
how the women of this study define midlife and aging. In Chapter 5, the participants
suggest pathways and barriers to health care. In Chapter 6, the women formulate their
understandings and applications of spirituality.
This study concludes with Chapter 7 which presents the interview findings. This
chapter examines the interview texts to support the themes of the four research questions,
summarizes the themes that emerge from the interviews, and presents those themes that
extend beyond the scope of this proj ect. Chapter 7 concludes by offering
recommendations for the future study of health and aging among black women.
In summary, this first chapter lays the ground work for examining the construction
of health and aging among midlife African-American women and frames the research
questions within the context of the current research literature. These research questions
take into account possible cultural nuances, such as body image, stress and experiences
with racism that may be characteristic of black women. Should these nuances prove to be
consistent, they may prove to describe culturally bound beliefs of health and aging.
Additionally, this chapter points out that this study concerns itself only with within-group
comparisons. As a result, the patterns of thought that emerge from the interviews will
ultimately define health and midlife within the context of the group's collective
This chapter explains the methodology used to capture the health and aging beliefs
of a select group of 26 midlife African-American women. The explanation includes the
application of Afrocentric and feminist methodological perspectives. These perspectives
not only inform the proj ect, but are viewed as elements that are already embedded into
this social inquiry. The duality of being black and female requires that both culture and
gender are considerations of the study. This chapter also includes a brief description and
rationale for using both primary and secondary data sources to explore the everyday
world of these black women and to develop a more comprehensive body of knowledge
about the health and aging of African-American women. This chapter also addresses the
significance of both content and processes in the effective use of the interview method.
This is followed by an outline the characteristics of the participants and the procedures
for collecting primary data. The chapter concludes with an explanation of the method
used to analyze the content of the interviews.
As methods for sociological inquiry, both Afrocentrism and feminism inform this
proj ect. Both perspectives reflect the viewpoint that race and gender biases cause the
perspectives and experiences of African-American women to stand fundamentally
outside of proscribed norms. This study examines how these perspectives influence the
participants as they construct their beliefs about health and aging.
Afrocentrism is a method of social inquiry that represents a strong, primarily
academic concern for the insertion of a cultural and intellectual African perspective into
the social development of the African population of America (Asante, 1987, 1988). At
the center of this philosophy is the idea that the knowledge and preservation of African
culture is essential to the survival of African-American cohesion. In addition, Afrocentric
literature maintains that exclusion of this perspective represents an inaccurate, racialized
depiction of people of African descent. This philosophy is predicated on the belief that
culture acts as a means to unify groups of persons and that "group identification"
develops through shared values, attitudes, and beliefs (Ani, 1994). When such group
identification or cultural consciousness is lost, the way is clear for control by a more
dominant culture. This study argues that within African-American families, and in
particular among African-American women, there is an historical, cultural consciousness
(Ani, 1994; Collins 1991) that is, by design, Afrocentric.
For African-American women, this cultural consciousness--or collective
memory--has its genesis prior to Emancipation (Burgess, 2000). For these women, the
experience of slavery and continued denigration nurtured an intense and pervasive will to
survive both physical and psychological oppression. Simultaneously, the experience of
slavery gave rise to a particular socially constructed standpoint or self-definition. It is this
standpoint, or collective memory, that is the cultural consciousness whose "presence has
been essential to black women's survival" (Collins, 1990, p. 93).
In this respect, Afrocentrism is the belief system of black women whose history
and biographies include not only enslavement but also continuous and calculated
oppression from within the social structure that attempts to define their worth as African
American women. For C. Wright Mills (1959) and the "sociological imagination," the
consideration of history, politics and social structure is essential in determining the scope
of the social issue. Still others such as Evelyn Nakano Glenn (2002) have effectively
addressed the relationship of social structure to women's role in the economic
development of this country. Finally, Dorothy Smith has previously discussed the
positioning of women within social structures as their relationship to the "ruling
apparatus" (Smith, 1987, p.65)
As a way of collecting and examining the data, a feminist methodological
perspective informs this proj ect. In general, the feminist perspective legitimates making
observations about inequality from the perspective of the women who actually experience
disparate treatment based on their gender. In this study, feminism requires that the
viewpoints of the women being studied are central in the debate about the early erosion
of psychological and biological health among African-American women. This position
challenges the discipline of sociology in two important ways. First, it calls into question
just who and what are the legitimate sources for the production of knowledge. As a
source of power, knowledge and the production or construction of knowledge has
historically been the domain of white men. In this light, women, and in particular black
women, have been removed from discourses about their lives. Moreover, as mentioned in
the introduction to the study, traditional ways of understanding the everyday experiences
of midlife African-American women have centered on comparative models that fail to
account for the different social experiences of this group. Second, a feminist
methodology considers women the subj ects of study rather than the obj ects. For black
women, this is again a departure from how they have previously been studied. For them,
self-definition is critical to their psychological survival. Recent reports of race and health
also suggest that discrimination that results in blacks being treated unequally also erodes
their physical and mental health (Feagin & McKinney, 2003; Byrd & Clayton, 2002;
Feagin, Early & McKinney, 2001; Williams & Wilson, 2001; Brown, Williams, Jackson,
Neighbors, Torres, Sellers and Brown, 2000; Clark, Anderson, Clark & Williams, 1999).
The data for this study are derived from primary sources, that is, personal, semi-
structured interviews with a group of 26 midlife, middle class African-American women.
However, in designing this proj ect, the initial points of departure were secondary data
sources that used biomedical models of health and aging. In this light, a brief discussion
of three of these secondary sources provides a contrasting way of studying black women.
Chapter 3 mentions the findings from secondary data analyses in order to suggest two
things. First, that there is a need for multi-dimensional approaches to studying black
women; and second, that science needs to be reminded of its responsibility to correct the
myths that may emerge from empirical studies that compare black and white women--or
worse, where black women are missing from the analysis altogether. On the other hand,
the processes of collecting and managing data were equally important and integral in the
production of information about this diverse group of women. After extended
deliberation, personal observation, and conversations with other black women, it became
apparent that these models, as issues of content, were incomplete in their portrayal of life,
health and aging among black women.
In this study, a distinction is made between method content and method process.
Content refers to the data from the interviews and the interview instrument or scripts of
the interviews. Process is used to indicate how the data are collected, the methods used to
recruit participants, the makeup of the interview environment, data management
procedures, and interview strategies.
Because this study uses individual, semi-structured interviews as the primary
source for data, the interviews were a factor in terms of both content and process; both
proved to be critical considerations in collecting and organizing the data. However, at
some point the process began to emerge at the more critical of the two. As the interviews
proceeded, the process of engaging in conversation began to outdistance the content of
the interview script and I found myself occupied in deriving ways to strengthen the bond
between researcher and participant. Frequently I found that after the first few questions
the participants entered freely into conversation with me and further questions became
unnecessary. As this began to occur more frequently, I introduced the interview
differently and asked the participants to consider this a conversation rather than an
interview. I told them that the questions I planned to ask were merely a way to guide our
efforts, but that we were not bound to follow any sequence. Changing the word
"interview" to "conversation" appeared to relieve some of the participants' anxiety.
Several demonstrated their relief by adjusting their physical posture; their shoulders
dropped in a gesture of relaxation and smiles appeared on previously expressionless
The interviews have both written and oral components. Participants were asked to
complete a personal history questionnaire prior to taking part in a tape-recorded
interview. The questionnaire asks for responses about age, education, occupation, family
structuree, health, and medical insurance coverage. This written component served two
purposes. First, it eliminated the necessity to record and transcribe standard demographic
information, which reserved more time for taped discussion. Second, in most instances
the participants were given the written component several days before the actual
interview and instructed to complete it prior to the interview. Allowing the participants to
complete the history according to their own schedules provided them with an opportunity
to become somewhat familiar with the content of the interview beforehand and thus more
comfortable with the process. The final question of this written component was: "What
else about your personal background might be important to someone studying the lives of
African-American women?" This question was purposefully open-ended and proved to
be useful in preparing the participant for introspection.
The questions for the taped interview were constructed to provide information
about the participants' health and aging beliefs and their health status. The questions were
divided into the following three subcategories that corresponded with the original
research questions: 1) definitions of health and aging, 2) the role of intergenerational
learning and collective memory in developing beliefs and behaviors of health and aging,
and 3) health care access, race, and successful aging. Following a series of piloted
interviews, I added an additional question regarding the role of spirituality, creating a
fourth category for inquiry.
Data Coding and Analysis
The recorded interviews were professionally transcribed, and then reviewed and
color-coded by sub-categories. Despite using the three research questions to organize the
interview script, eighteen sub-categories emerged from the interviews at first glance.
These sub-categories included relationships between black women and black men, the
stress of being black, definitions of the self, the role of the family and expectations of
children, generalities of being black, and generalities of being white. Some of these
sub-categories took the research agenda slightly outside of its original framework. As a
result, I had to make decisions about which sub-categories contributed the most to
discovering the social mechanisms for the development of health and aging beliefs
among this group of black women. These were then re-coded into the original research
themes. However, as I returned to the transcripts and again evaluated which categories to
examine in support of the theses, it seemed that all of the ideas and the ways in which
they were expressed, depicted how these women constructed their daily lives. I then
began to consider that, although each woman had her own viewpoint, that viewpoint
represented a small segment of a larger consciousness. Themes developed to suggest that
although these women had autonomous personalities, they shared a common bond of race
and gender. It was at this point that I gave each participant a pseudonym. For me,
assigning fictitious names signaled the emergence of their individual perspectives.
In terms of content, the initial interview script inhibited the data gathering process.
The script proved to be to be too detailed and extensive to generate the spontaneity that
was later noted to produce the richest data. When the number of questions was reduced
and the remaining questions posed in a more open-ended manner, the participants
appeared more relaxed and less concerned with providing "the right answer."
As a methodological tool, the interview served four purposes. First, it provided a
means for these black women to disclose how they define themselves, thus making them
the subj ects rather than the objects of the research effort. Their responses--their
"liberated voices" (hooks, 2000, p. 554)--create the research agenda. Historically,
research agendas are set by the dominant culture, with the net result that research
concerning black women tends to define black women from outside of the group and in
comparison to white women. Seldom do studies or social interventions consult the
women themselves (Essed, 1990). In the interest of eliminating this bias, this proj ect is
informed by a feminist research perspective that relies on the women to define
themselves. One participant underscored the importance of this approach in her
I enjoyed the interview. It gave us the chance to rap. Why can't we be called just
women? They don't say Asian women or Indian women. Why do they have to
single out the race? Like in the newspaper they will always say a black person did
this. If they don't say it, then you know they are white. .. When I see people
trying to heighten awareness in the medical field, I am glad." .. You are
interviewing common people. We are not dignitaries. [We are] every day women
with real life situations.
A second purpose served by the interview process was the capture of more accurate
data. Qualitative studies among black populations are reported to yield more accurate
information when the participants are interviewed face-to-face rather than telephonically
(Aneshensel, Fredrichs, Clark & Yokopenic, 1982). A preliminary telephone interview
with one of the study participants supported this perspective. This particular participant
provided more detailed information when she was interviewed face-to-face. Moreover,
during the in person interview she also conveyed information with her facial expressions.
As a result of this experience, the telephone interview was eliminated as a reliable means
to collect data among these black women.
Third, one study further suggests that qualitative research might also contribute to
an understanding of the construction of culturally-bound, self-rated health (Jylha,
Guralink, Ferruci, Jokela & Heikkinen, 1998). In this respect, black women, because of
their race and sex, represent a separate cultural orientation. Such cultural orientation is
said to produce variance in self-reports of health status. David Newman, a proponent of
Parsons' (1951) sick role theory, presents a perspective on the influence of culture on
self-reports of health. Newman (2000) suggests that, "cultural attitudes [about health and
illness] also determine what it means to be sick. Each society has a sick role, a broad set
of rules about how people are supposed to behave when sick" (p. 94). However, the
sharing of a cultural orientation does not assume that all black women are alike in
education or economic status. Both of these factors may also be determinants of health
status in self-reported health.
Fourth and finally, qualitative methods that use information from focus group
sessions and individual interviews have the potential to greatly enhance quantitative
measurements. Just as important as how many persons fit particular categories is the
discovery of how subj ects of the study create or construct the environments in which they
age and experience health and illness.
In recruiting participants for this study, I used social networks to solicit volunteer
participants from among my neighbors, sororities, and other social networks. These
volunteers in turn, identified to me other women who might be willing to give an
interview. Using this snowball or network sampling (Bernard, 1995), I recruited 26
women for interviews. It was not uncommon that the person providing the name of an
individual had already made my purpose known to their contact before I made the initial
phone call. This introduction made interviews with women I did not know more
comfortable for me and perhaps them as well.
The interview environment
The participants were allowed to choose the interview environment. I always
offered to come to their location, but was careful and consistent in encouraging them to
think about the best environment for them to be relaxed and comfortable as we talked. As
a result, only two of the interviews, the most difficult to schedule, were conducted at the
workplace. The balance of the conversations took place in either my home or theirs. More
often than not, we shared a beverage or some light snack. On one occasion I was invited
The interviewer as participant
Interviews can take many forms, some of which are clearly governed by the
environment, the purpose of the interview, and indeed by the participants themselves.
The question that began to plague me early in the interviewing process was: "Who am I
as researcher?" Sometimes I felt as though I were part of the data being generated. At
other points, my role as the researcher, the leader of the effort, was more predominant.
Much like the "shifting" described by Jones & Shorter-Gooden (2003) that occurs when
black women want to fit in, usually with whites' ideas of what is acceptable, I found
myself moving from a political identity to a cultural identity and back again.
Code switching. Throughout the interview process, I found myself more inclined
to enter the interview environment in a collaborative posture. One way that this was
accomplished was through the use of code switching. Code switching is a term that
sociolinguists typically use to refer to certain exchanges made in the context of bilingual
speech. There was a language attached to the self as researcher, the political identity, and
then there was a language associated with being a black woman, the cultural identity.
This duality found its form in the cultural dialect and the terms of familiarity that we used
to address one another. Most often these linguistic switches were spontaneous and often
initiated by the participant rather than me. They were used to signal a change in the level
of intimacy in the conversation or to emphasize a point that was being made. Code
switching, as I later realized, became an effective method of building a bond between the
participant and me. At the core of the linguists' examination of code switching is "how
language choice reflects power and inequality" (Auer, 1998, p. 3). Feagin and Sikes
(1994) suggest that code switching to standard English may also be a way for blacks to
avoid being treated poorly because of race. Clearly for me, and perhaps for some of the
women of this study, code switching was a way to diminish the perceived differences
between the political and the cultural. These linguistic shifts helped pull me deeper into
their everyday world, where I became a peer.
Open-ended questioning. A second interview strategy was the use of the open-
ended que sti on. I relate thi s to P atri ci a Hill1 C olli ns' (1 9 86) vi ew of the "'outsi der-withi n,"'
a concept that addresses yet another aspect of the duality in being a black woman who
stands with a foot in each of two separate and even distant worlds. For Collins, the
outsider within describes the tension between conducting social research as an academic
"outsider" and continuing to view everyday life from a perspective within the group
In selected instances, as the outsider within, I entered the interview as a participant.
This gave me entrance to spaces that might have otherwise been closed. This occurred in
situations when a participant would ask my opinion, thereby inviting me into the
interview as a participant; or when something the participant revealed resonated with my
own experiences or when I wanted to encourage trust.
Many of the interview questions (Appendix A) are open-ended. In addition to
moving me from outside of the group as an academic to inside of the group as a
participant, the use of these open-ended questions provided three additional benefits.
First, making a statement and then asking the participants to provide a response allowed
the participants to interpret and assign their own meanings to the various categories of
responses, and, in some cases, to construct their own categories of concerns, such as
male-female relationships at midlife. In this way, the information that they provided was
less affected by my own biases (Reinharz, 1992).
Second, open-ended questioning permitted me to give the interview a less formal
format, an approach that encouraged the sharing of information. In sharing information, I
did not bear the burden of having to know the answers to their expressed concerns. In
using the open-ended question as an interview tool, I was not placed in the position to be
"the expert." In many instances I found my role to be that of "the student."
Mostly I attempted to follow the lead of the participant. When I judged that the
woman was engaged with the topic it was frequently more fruitful not to break the flow
of the conversation with questions, but to follow her lead. I would then return to the
question or issue at hand and connect her response to the general framework of the
The third advantage gained from using open ended questioning as interview
strategy was that it encouraged amplification and clarification. At the end of each
interview I extended an invitation to the participant. I asked her if there was anything else
that she would like to add to our discussion about African-American women. In a number
of cases this invitation seemed to be particularly important to those women who appeared
to be concerned about structure and tended to edit their responses during the more formal
portions of the interview. In this light, I noted that some very rich comments resulted
when using this closing as an interview technique. Therefore, the request for additional
information proved to be an effective way to end the interview and resulted in a number
of rich, reflective comments.
I invited twenty-six African-American women ages 36 to 71 to participate in this
study. This age range was chosen to provide a broad range within which the women
could define their ideas of midlife and approaches to aging. The participants represent a
cross section of midlife women who are predominantly middle class by virtue of
occupation, education, and income (Vanneman & Cannon, 1987; Blau & Duncan, 1967).
Ninety-three percent (93%) of this group work full-time. Only two women reported that
they had spent extended periods of time as homemakers, however, both had periods when
the financial circumstances of the family required that they work part-time for pay; one
worked as a cosmetologist in her home and the other found jobs outside the home. The
occupations of the 26 women are varied; they include a domestic worker, several retired
military personnel, nurses and a physician, a teacher, educational counselors, a juvenile
probation officer, a part-time cosmetologist, retail sales clerks, and administrative
assistants. Four of the women work as health care professionals; one is a medical doctor.
Although only two were not currently employed, 25 of the 26 women in this study had at
one time worked full time at j obs outside of the home. Only one of the participants, a
second-generation medical doctor, could be described as upper middle class and standing
outside of this mostly working or middle class group of women. She was the most
educated of the group. The educational level of these women was clustered around those
42 percent (42 %) who held masters' or higher level degrees. Combining both those with
masters' degrees only and those who held masters or higher level degrees, 76 percent
(76%) of these women had some formal education beyond the undergraduate level. Only
one woman, the woman who performed domestic work, had not graduated from high
school. Ninety-three percent (93%) of the women were either born in or had spent the
maj ority of their life in the southern region of the United States. The average age of the
group is 5 1.6 years. Ninety-three percent (93%) of the participants are, or have been,
married. Of those who never married, 50 percent (50%) had given birth. The youngest
grandmother is 43 and was unwed at the time of her daughter' s birth. Among the
grandmothers, one woman has sole custody for her two grandsons, both of whom are
under 2 years of age; one other grandmother has been responsible for the rearing of a
granddaughter, age 15, on and on-and-off basis. Despite the heterogeneity of this group,
racial discrimination and spirituality (both are discussed in later chapters) were common
In terms of study design, I acknowledge that the participants are drawn from a
select population of African-American women. This is a direct result of two factors. The
first is that I use my own existing social networks to recruit the participants; most of
whom have working and middle class backgrounds. The second factor that influenced the
selection of participants reflects what is known about poverty rates among blacks. As will
be noted again later in this chapter, in reality only about one-third of black Americans
earn wages below the poverty level (Walcott-McQuigg, 1997). This makes accessibility
outside of the working and middle-class network difficult, even for a researcher who
shares the same racial identity.
However, regardless of socioeconomic status, blacks are still subj ect to
discriminatory treatment from even the poorest of whites. In essence, while class may
influence interactions amongst blacks, when it comes to black-white relations, poor
whites have a tendency to ignore class, believing that all blacks are poor, underprivileged,
and deserving of overt discriminatory treatment. Hooks (2000) reflects that in her
southern home town "black children learned to fear poor whites more than other whites
simply because they were known to express their racism by cruel and brutal acts of
violence" (p. 112). Thus, from the position of the dominant culture, issues of class among
blacks tend to be invisible. This study argues that amongst these black women, class lines
are equally blurred and often obliterated in their own eyes by the common experience of
Class or socioeconomic status (SES) and midlife are two factors that identify this
group as select among African-American women. These factors reflect a specific socially
constructed framework and for this reason are set aside in this study. This "bracketing"
requires some discussion of the construct of class that is embedded in SES.
Class is frequently associated with education and income or SES (Fussell, 1983)
One participant articulates the complexity of class among blacks in the following way, in
response to my question about in what ways did she feel connected to other black
Sometimes I do. Sometimes I don't. In a lot of ways, most of my crew I like. The
connection starts right there. I have other things on my agenda. Their stuff is
important, but so is mine. I don't have a lot of black friends. A lot of them dislike
me. You don't think you are smarter. You are scared to death. They think because
you have a degree, you got it going on. The crew at church likes me because we
walk [together]. That is our common goal.
Is there anyway that you feel connected?
Spiritually. We are in the same Bible groups together and at church. Outside that, I
don't have any girlfriends that are friends. You have to have a commonality.
Rita is the first of her generation to attend and complete college. Throughout her
educational experience she has struggled with dyslexia, a condition that I sense she does
not mention to most people. In explaining how she feels disconnected from other black
women, she easily cites education as the cause of the riff. In addition to pointing out the
perceived difference that her education makes in her relationships with other black
women, Rita also reveals two other details of her perspective. First, she switches her
language from a more formalized dialect to one that is more colloquial or "black." This
shift in language has previously been discussed as "code switching." For Rita, this occurs
in her words, "They think you got it going on." Rita has previously mentioned that the
way she speaks is still another cause for others to question her "blackness." Here she slips
into a street-wise vernacular, returning herself to being black in a stereotypical way. Thus
for Rita, education and a formal way of speaking serve to distinguish her class status
among other blacks. Second, Rita' s primary social interactions seem to center around the
women of her church, her "crew," with whom she exercises on a regular basis. She views
these women and the spirituality she shares with them as a common bond. It is the way
that she describes her connectedness to other black women. The role of spirituality in the
lives of black women is discussed in greater detail in Chapter 6.
Many earlier studies of health disparity view SES as the strongest social
mechanism affecting health. From this viewpoint, SES enters the debate of health
disparity by serving as proxy for access to health care. American blacks, especially at
midlife, exhibit large differences in SES (Markides & Black, 1996), however, it is
careless to assume that SES is a maj or factor for all blacks in gaining access to adequate
health care. In truth it has been assessed that less than one-third of all blacks in America
have earned income below the poverty level. Yet according to one source, it is this one-
third that is most frequently studied (Walcott-McQuigg, 1997). Given this broad
spectrum of SES and class among blacks, it is more likely that among blacks other social
factors outside of class or SES contribute to profound differences in rates of illness,
disease, mortality and access to health care. Therefore, believing that "upward mobility
does not overcome racial disadvantage," this study controls for SES (Patillo-McCoy,
1999, p. 45).
The second factor distinguishing this sampling of African-American women is
most frequently referred to as "midlife." By definition, midlife represents a
chronological, often biological and psychological, period in the life course of individuals.
Recent discussions of midlife present variations in identifying a chronological age for
midlife and it has been suggested that it may be more accurate to define midlife not in
terms of an absolute chronological age, but as the period between young adulthood and
late adulthood (Staudinger & Bluck, 2001). Among black Americans, differing life
traj ectories such as higher rates of teenage pregnancy suggest that, for African-American
women, the period between young adulthood and late adulthood begins earlier than it
does for white women. This may result in early incidents of age-related health and illness.
At the very least, differing life traj ectories suggests variations in midlife and aging
From the standpoint of biology, midlife is traditionally calculated in one of two
ways. The first calculation is based on the estimated life expectancy or survivorship rates.
These rates tend to vary by country. However, from a global standpoint, 100 years is the
life expectancy. The midpoint of this calculation is of course 50 years. Thus, when an
individual reaches age fifty, from a biological perspective, he or she has effectively
reached midlife. For African American women, shorter life expectancies may also
indicate that midlife occurs earlier for black women than it does for white women. The
current life expectancy at birth for black women is 75 years compared to 79.4 years for
white women. Calculating midlife as the midpoint between birth and death would then
mean that black women typically enter midlife when they are age 37.5.
The second way midlife is calculated biologically is related to reproductive
capabilities. Since many men have proven capable of fathering children long past age
fifty, this calculation only applies to women. For women, that capability typically ends
with the onset of menopause. As will later be noted in the accounts of these women,
midlife may also be marked by life events, such as children leaving home. Rarely
however, do these women describe midlife in relation to biological events.
While little is known and documented about the midlife health experiences of
African-American women, women in general face a variety of health and psychological
challenges at midlife (Porter & Gaston, 2001; Jacobson, 1995). It has also been
suggested, from the perspective of life course studies, that midlife presents the
opportunity to change behaviors that effect future longevity and disability (Spiro, 2000).
For black women, the challenges of midlife include the cumulative impact of racial
discrimination and perhaps early onset of aging. Nevertheless, five pilot interviews gave
the first indication that, at the very least, the middle class women of this study do not
necessarily see themselves as disadvantaged by age or race.
The research methods selected for this study were applied based on the belief that
the most complete profile of African-American women could only be drawn by
investigating the ways by which these women have constructed their identities as aging
beings. In this light, the semi-structured interview seemed the best way to begin an
investigation of health, aging, and illness among midlife black women. In the case of
these women, the semi-structured interview provides the optimal opportunities to create
bonds between the participant and the researcher establish trust and gather candid
perspectives of everyday life. Afrocentric thought and experience filters the responses of
the participants, while feminist methodology encourages and honors the dialogue. This
chapter also begins to use the words of the women to illustrate the ways that class and
spirituality are operationalized
In large measure, the women of this study present a view of what it means to be
black, female, and aging and that view conflicts with common perceptions of their health
and aging experiences. In contrast to the selected reports of the effects of cumulative
disadvantage and despite documented reports of early declines in health, these women do
not see themselves as disadvantaged. The findings from these reports are later and briefly
discussed in Chapter 3. By and large, despite issues of weight, lack of exercise, smoking,
high blood pressure, and age, they view themselves as healthy. This perhaps supports the
report of Byrd and Clayton (2000) that for blacks, "poor health status and outcomes...are
'normal' and acceptable." (p. xxiv).
In Chapters 3, 4, 5, and 6, the texts and ensuing discussions revolve around the
viewpoints of the participants. The women of this study are gracious, talkative, candid,
engaged with the topic, sometimes angry, sometimes tearful, and always encouraging.
Their comments give voice to the constructions of identity and aging that form the thesis
of my argument.
"AGE AINT'T NOTHING' BUT A NUMBER!"
.. the ways in which we think about, treat, and live our bodies are always and
inevitably socially and culturally shaped. we can only ever know, think about
and experience these realities through our specific location in society and culture.
(Lupton, 2000, p. 50)
As the opening quote suggests, the purpose of this chapter is to formulate the social
and cultural context for the expressed beliefs about health and aging of the women in this
report. Here the participants' words build the contexts of their beliefs, and thus shape the
meanings, for them, of health and aging. In this respect, this chapter begins the
integration of the interview content into the development of the study's theses. For
example, among these women, a consistent approach to discussing the aging process was
to contrast the differences between the way white women age and black women age.
Rather than asking the women of the study a specific question about the differences
in aging among black and white women, they are asked to state their beliefs about the
way white women age and the way black women age. In the following words, Ruth, a 42-
year-old participant, makes an initial comparison that focuses on physical appearances:
I feel good and I feel great. I sometimes think that I don't look forty-two. When I
look at other people my age, forty-two is kind of unbelievable.
The other people you look at, are they black or are they white ?
I have to admit that a lot of them are white. I mean people say, and I've heard white
people say, that we age a little bit different. Might be the melanin. I guess as far as
wrinkles and all. It makes me feel great. I feel younger.
That 's interesting because a part of what we 're talking about here is the way that
black and white people age. You have any idea why that is?
I have no idea. The only think I can think of is the melanin in our skin. You think
about it. A lot of the reason wrinkles come from the exposure to the sun. Because
we were designed to be exposed to the sun, live in climates that were hotter, and
that kind of thing. Also, we have oily skin as opposed to dry skin in our faces. That
might have something to do with it also. We don't dry out as much.
The comment that black women age better than most white women was a
consistent response from these women. This perspective suggests perhaps that, despite
data to the contrary, this group of aging and older women does not see themselves as
disadvantaged as a result of age. However, later in the interview, Ruth's response relates
to the differences she has observed in dietary practices of blacks and whites. From her
perspective, the dietary practices of blacks also influence the aging process. She says:
I feel like I've aged better. I don't know why exactly. It might have something to
do with diet. I don't know if diet has a lot to do with it. I do know they [whites]
tend to eat a lot more like boxed stuff and refrigerated stuff and canned stuff. We
don't particularly like stuff like that. It's not our thing. But I think we eat maybe a
lot more fresh stuff. I do know blacks are starting to use a lot of stuff now that is
not good for them.
In the second part of her reply, Ruth demonstrates what qualitative researchers call
typification (Gubrium, Holstein & Buckholdt, 1994). In making this comparison about
dietary practices among blacks and whites, Ruth demonstrates how she orients to whites.
It is the way that Ruth and other women of this study address what it means to be white
in America and contrast it to what it means to be black in America. Similar typifications,
as processes in the social construction of life course, are illustrated and discussed in
greater detail in Chapter 4.
However, before further reading the words and hearing the voices of these women,
it is important to provide a context for the contrasts between the traditional ways of
viewing aging and that presented in the women's statements. This backdrop is created in
three ways. First, through the discussion of two of the traditional ways that aging has
been viewed in the field of gerontology; second, by bringing the women to the center of
the debate by outlining the two maj or challenges faced by aging women; and, third, by
presenting evidence in favor of viewing aging as a socially constructed process that is
largely and almost exclusively influenced by the psychosocial environments of the
individual. I will demonstrate that for the black women of this study, their beliefs about
health and aging are grounded in the traditions and experiences specifically related to
participating in society as member of a double minority. Thus, as women and as blacks,
their experiences of health and aging are filtered through lenses of cumulative, disparate
treatment. Yet these women frequently describe the burdens of racism and sexism as
inconsequential or nonexistent. Despite biomedical reports to the contrary, for these
aging and older women, "Age ain't nothing' but a number." The task here is to disclose
and closely examine the psychosocial mechanisms that allow these women to minimize
the experiences of racism and sexism and their potential to heavily influence the aging
Traditional Views of Aging
According to gerontologist Bernice Neugarten, true senescence, sometimes referred
to as normal aging, begins between the ages of 50 and 55 (Rowe & Kahn, 1998).
Specifically, this means that some individuals, in the process of normal aging, may begin
during this time to experience "risky physiological changes." While such maladies as
high blood pressure, diabetes, and heart and lung disorders are not inevitable in all aging
persons, the risks associated with changes in these physiological functions increase as a
condition of normal aging (Kart, 1997).
In the last decade, the American Association of Retired Persons (AARP), an
organization in the vanguard of advocates for aging persons, has considered persons
eligible for membership at age 50. Yet the official magazine of the AARP recently touted
white, 60-year-old former super-model Lauren Hutton as the ideal aging citizen. In the
general public, however, senior citizen privileges such as reduced auto insurance rates
and shopping discounts are offered to persons age 55 and older. Gerontologists tend to
begin studies of aging with persons 65 and older. This numbering is driven in part by the
federal Social Security Administration's eligibility criteria for social security benefits.
The point here is that it appears that the older the baby boomers become (the eldest
of the baby boomer birth cohort will turn 65 in the year 2005), the further the age that
defines the beginning of midlife and old age is extended. Other contributing factors may
include the increases in overall life expectancies, as well as the attempts by the market
economy to reach the swell of aging consumers. In all these respects, the chronological
parameters of old age are shifting.
As noted in the MacArthur Foundation' s decade and a half long national study of
well-being at midlife, the processes of senescence, or normal aging, and the rate at which
they occur are not solely related to genetics; rather, lifestyle, social environment and
social structure affect the process of normal aging (Rowe & Kahn 1998; Elder, 1974;
Riley, 1987; Featherman & Lerner, 1985). Especially for racial and ethnic minorities, the
aging process in general, and successful aging in particular, are adversely impacted not
only by the biological process, but also by the structural inequalities of SES (O'Rand,
1996; Markides & Black, 1996; House et al., 1994).
Studies of aging frequently cite Rowe and Kahn's (1998) model for successful
aging. This model uses three overlapping, concentric circles labeled "low risk of disease
and disease-related disability," "high mental and physical function," and "active
engagement with life." The words "successful aging" appears at the center of the model
where the circles overlap. This model suggests that, ideally, aging members of society
will maximize their opportunities to experience aging in a positive manner by achieving
balance in these three areas. In essence, the model focuses on modifications of health
behavior and overlooks structural barriers in the social environment (Feinstein, 1993)
Acknowledgment of historical structural barriers such as institutional racism, are critical
when examining health disparity in the life course of African-American women.
A report from the U. S. Department of Health and Human Services Task Force on
Black and Minority Health (1985) suggests that minority health is influenced by specific
social characteristics. In particular, the Task Force lists demographic profile, nutritional
and dietary practices, environmental and occupational exposures, and stress and coping
patterns as challenges to the physical well-being of blacks and other ethnic minorities
(Edmonds, 1993). Despite the age of the study, the information retains its validity when
consideration is given to the current poverty and health statistics of African-American
women. It has been well documented that this group of women experiences higher rates
of poverty and poorer health than do their white counterparts (Doress-Worters & Siegal,
As key concepts in the study of aging, the notions of normal aging and successful
aging support the theory that aging is not only a managed experience, but one that is
individually constructed as well (Gubrium, Holstein & Buckholdt, 1994). In this sense,
individuals have the opportunity to modify their lifestyle over the life course and even
into late life, and thus positively alter the impact of normal and usual aging. This
alteration in lifestyle may develop a blueprint for successful aging, and will have special
significance for recommendations for health behavior interventions at midlife.
Unfortunately, this approach puts the onus for achieving positive health on individuals
who experience differential and disparate health outcomes. Such an approach continues
to ignore the importance of structural and material support in reducing the cumulative
effect of disparities experienced over the life course. In short, studies of aging have not
successfully isolated the behavioral inhibitors of successful aging from the social
inhibitors associated with limited or inadequate access to resources (Feinstein, 1993).
Women and Aging
Colette Browne (1998) suggests that economics and body or social images are the
primary influences on the aging experiences of women. However, despite outnumbering
men, older and aging women have yet to develop the political presence required to alter
their economic status and social image as older citizens. This economic disparity, coupled
with living in a youth-oriented society, creates patterns of successful aging that differ
based on gender. What the literature on the subj ect of poverty and aging teaches is that, in
essence, aging does not cause poverty; rather poverty is related to a series of financial
conditions that occur in early adulthood (Social Security Administration, 1997). For
women, this has traditionally meant that late, sporadic, unequal and sometimes non-
existent participation in the labor market has retarded their ability to acquire the capital
necessary to enj oy late life. Among minority women, the rates of poverty are even higher
than among minority men and white women.
Social images of women are oriented to having and maintaining a youthful
appearance. The media bombards the senses with clothes, cosmetics, and activities that
are suited to women under the ages of 40. By and large, these images portray the subj ects
of attention as white. This presents aging black women with few, if any, public role
models of aging. The question that this poses for black women is: What should I expect
as I enter this stage or period of my life? For the most part, this question is answered by
current health and aging research that uses biomedical models to address the potential
health issues related to aging. These models tend to overlay historical medical conditions
and outcomes based on that one-third of the African-American population that is so
frequently studied. This causes African-Americans who earn wages below the poverty
level to represent the greater African-American population.
Before entering the discussion of age as a social construct, it is important to note
the difference between Browne's perspective regarding the challenges of aging women in
general and those perspectives of aging found in the words of the women of this study.
First and foremost, Browne' s position speaks to the circumstances of women in general.
In this respect, the concerns of economics and body image may be more reflective of a
larger population of primarily white women. In subtle ways, the women of this study
tended not to appear overly concerned with either economics or body image. Thus their
accounts contradict Browne' s thesis. This is not an unexpected outcome considering that
age and health are both products of individualized social, historical and political
environments. The social, historical, and political environments of this study reflect a
middle class, black experience.
Age as a Social Construct
To say that an individual act, an idea, or even an historical event is socially
constructed is to suggest that the environment and the interactions that occur in that
environment determine its meaning. In this respect, individuals may make choices from a
variety of options available within their social environments (Elder, 1994). These choices
in turn determine the experiences they will have over the life course (Gubrium, Holstein
& Buckholdt, 1994).
As presented earlier, midlife is most accurately associated with a period in the life
course between young adulthood and late adulthood (Staudinger & Bluck, 2001), and
there are many variations in identifying a chronological age for midlife. The women of
this study now voice those variations.
Sunday afternoon finds two participants and me on the patio of Lisa' s home. I have
driven an hour and a half to attend church with these two new acquaintances. Both
women were raised in South Carolina, and at age 49, both are grandmothers. We have
talked while sharing a meal at a local restaurant. Now, after a short drive to the house, we
are contemplating dessert choices. Mindy comments:
I haven't even thought about mid life. I know each year that I get older I like to
think age is just a number. What does it mean though? When you are a child no one
asks you what it is like. What exactly is midlife? I would have to think of it as the
point you are realizing that you are almost there. You went through your youth.
You come to the realization that you are embarking upon the latter stages of life.
Uh-oh, it is around the corner. There is no specific age. It depends on the person.
As Mindy continues, she alludes to the reproductive factor as a marker of aging.
Making reference to the Bible, she discounts the importance of chronological age:
Even in the Bible, Moses was 80 before the Lord fully used him. 'Now you are
prepared. Now I have a job for you.' Abraham was 100 when he impregnated
Sarah. So what is midlife? Where is your thought process? If you think you are
going through midlife, then you keep thinking about it. What is a crisis for midlife?
You have younger men who like to date older women. Does that mean you cannot
be a woman? You cannot be sexy? You cannot be fulfilling your role as a woman?
I went to a doctor for a check-up. The doctor asked if I was in menopause. I didn't
know. I don't think about it. I choose not to participate in menopause. I choose not
to participate in any midlife crisis.
I don't hear the term used other than midlife crisis. You get people at different ages
saying they are going through a midlife crisis just because they are a certain age.
Being a woman who is 49, I never even thought about it. You don't know when
your end will be. How do you determine your age?
Mindy forms her responses as rhetorical questions, suggesting that she is now in
the role of interrogator. There is an edge to her voice that further suggests her impatience
in attempting to wrestle with defining midlife. However, once she settles on her position,
she is not ambivalent. She defines the concept of midlife largely in terms of biology.
Using menopause as her marker for aging, she says: "I don't think about it. I choose not
to participate in menopause. I choose not to participate in any midlife crisis." She simply
rej ects the concept of menopause altogether. For Mindy, the socially constructed and
largely chronological ideology of age prevalent in the United States (Gubrium, Hosltein
& Buckholdt, 1994) does not govern her ideologies. What Mindy is saying is that as long
as she does not allow her mind to accept unwanted images of aging, then aging is of no
concern. It has been suggested (Gullette, 1997) that reliance on this mind-body
connection provides an approach to aging that may prove the difference between aging
successfully and early declines in health and early mortality.
Lisa, Mindy's friend of 15 years and the other member of our trio, relates another
way of looking at what it means to be at or in midlife. Lisa's comments throughout the
j oint interview are not as detailed or extensive as those of Mindy. In some instances, the
fact that Mindy was Lisa's mentor in the workplace may contribute to their informal
hierarchy. Whatever the reason, I am pleased to at last hear Lisa's comments.
Although not the youngest grandmother in this group, Lisa, 49, has full
responsibility for rearing two young grandsons, both under the ages of two. Lisa' s
husband, a truck driver, is often away from home and Lisa manages the care of the
children, runs the household, and travels in her own line of work as a notary. When
asked, "What was the greatest challenge you faced in midlife?," Lisa replied in these
Finding a good balance. I come from a small family. Maybe there are ten people
that I call my family. Adjustments with my children [gone from the house] and
the empty nest syndrome. What do you do when the kids are gone? Even though
we have grandchildren, what do you do? You have to readjust to a new stage in
life. And teetering on whether I should let them go. The void in the house. Less
activity. No PTA meetings or parent-teacher conferences. That is the biggest
challenge. When I left home, I lived in the same town as my parents. I would call
just to say hello. Now I am in whole other world. I don't have my parents. My
children are gone. I remember Job. When he lost his children, the Lord replaced
them with more children. I thought about throwing myself into work and
grandchildren. They are a whole different sex from my children. I had girls. The
grandchildren are boys.
What is it like to have grand'kid's in the house ?
I almost forgot what to do. But that was what I needed. They needed a home. So it
was two-fold. It filled a void. Family was back in my life. Whatever Job lost, like
him, what was taken from my life was added back to it. I went from not knowing
what I was going to do, to back in the nurturing role.
The subj ect of family, children and grandchildren form the challenge, and
ultimately the meaning, of midlife for Lisa. She considers her immediate family to be
small and admits that she misses the activities that accompanied having her two
daughters in the home. With those daughters no longer under the same roof, there was "a
void in the house" and in Lisa's life. She was not certain how to fill her time.
Lisa goes to the Bible and the story of Job to explain how having the grandchildren
with her fills the void of her midlife challenge. Like Job of the Bible, the "loss" of her
children is replaced by her grandchildren, for whom she now has full and legal custody.
Later Lisa explains that the state of Florida has special programs to assist grandparents
who are raising grandchildren. She seems comfortable and happy with this new role of
grandparent-caregiver. Lisa has found a "good balance" in the period she considers as
midlife, unlike the next participant.
The text of Mildred' s interview is difficult to transcribe. Her thoughts contain
mixed metaphors and frequently seem disj pointed. In searching for themes of her
discourse, I come to understand that the presentation, including the mixed metaphors, is
the theme. Mildred seems on the cusp of making a lifestyle change. Several times during
the interview she seeks my advice and even approval about her plans for the future. The
future plans and ensuing transition that she discusses with me seem to be the genesis of
her confusion. After nearly three hours, her interview is the longest. The interview takes
place in her second floor onfce.
In response to being asked to define midlife, Mildred says:
Since I am there now, midlife is being born again. It is like starting all over at
ground zero with this knowledge. I Eind it fascinating. I woke up at 2:30 (a.m.)
and, for a fleeting minute, I started thinking about people who were gone. As I
started thinking about them, I thought I am now at that point. I felt a little sad.
There was this show called "Sarah Plain and Tall." I loved that show. They
referred to the aunt as a treasure. For some reason I started thinking about all
those who passed on. At that time I wondered, "Did anyone think of me as a
treasure?" So midlife to me is that point in time. It is very hard because I think of
what old folks say. 'Be careful what you do when you are young because you will
pay for it.' My mother would say, 'Get off your knees, they will hurt you.' Health
wise, some things are true. Now I want to mop my floors on my knees. I don't
want to use a mop. So it is very hard for me. I don't picture myself as 20, but I
realize that the things I have are not [in] the container that I carry around. My
container does not go along with me. Midlife is taking a [different] container and
mentally we have a different spiritual body. Spiritually I can see myself
somewhere else. I don't see myself there. That' s why some people focus in on
your heart. I wish I knew things then that I know now. I don't regret anything.
There are some things that living in my culture has taught me now. Going to a
doctor you had to be almost dead before momma would take you to a doctor.
They had no money. And they knew everything. Put a cold press on your nose.
Put matches behind your ears. Rub keys down your back. I think about it now,
what in the world would that do? How would that stop my nosebleed? But in that
point in time, that is what they did. What were the matches and keys for?
Kerosene and a little sugar-[that] would blow you up! But they said that would
cure worms. All kinds of stuff I remember now. Midlife to me is a number, a
passing. For me as a woman, it's hot flashes. They are killing me. As you are
talking to me I am having hot flashes. If I could Eind Eve, I would slap her.
I Eind it difficult, if not impossible, to interrupt Mildred's comments. The words
pour out and spill over themselves as she moves her thoughts from past to present events
and back again to the home remedies used in her childhood. Mildred' s patterns of thought
and thus speech are not linear, but rather circular. She defines midlife as "being bomn
again," "a different point in time," taking a "different container," a "number" and a
"passing," and "hot flashes." For Mildred, midlife is marked in two different ways. As a
specific point in the life course, it is a time when she is "bomn again" and would like to be
considered a "treasure." Midlife is also marked by a biological change. For Mildred, this
biology is not her personal appearance but the physiology of "hot flashes." Mildred's idea
of what is means to be midlife is not single faceted. Her definition contains a number of
subj ective signals of midlife and Mildred seems comfortable with the mix.
This interview with Mildred presented the first evidence that it might be difficult to
formulate present ideas of health and aging without references to the past. These
historical references provide an indication that intergenerational experiences influence
social constructions of the present day self.
Iris, the only physician in this study, does not make reference to any particular
source, but had this to say about a chronological age for midlife:
I used to think it was between 40 and 60. But the older I get, the older I make it. I
say 50 and above is midlife. Typically that is the definition.
Iris' numerical pinpointing of midlife and aging presents a conflict between her
personal experiences and what she, as a medical doctor, has been taught is the "typical"
way to identify the beginning of the aging process. For her, the process "used" to be
defined by where she was on the aging continuum. This internal conflict between what
these women sense and believe about themselves and what traditional science teaches is
discussed later in this chapter under the rubric of aging as a social construct.
The next comments, by Ester, present yet another example of combining time-
ordered and event-ordered markers of midlife. At 50, Ester is recently retired. Empty-
nesters, she and her husband have recently moved to Florida. I ask her to define midlife;
she responds by saying:
If you die at 80, then it [midlife] starts at 40. Mine started in my early 40s. It was
rough in the beginning. I had a hard time when I turned 30. You are coming out of
the young group. It was a learning process. Our children were out of high school.
We were just learning to relearn ourselves.
In these words, Ester describes midlife from two standpoints. First, she does a
mathematical calculation in which she reasons that midlife depends on the number of
years a person lives. What is interesting about this calculation is the absence of any
assumptions or preconceived idea about longevity. From this viewpoint, it is only
possible to calculate midlife after the person is dead! Second, Ester sees midlife as
marked by an event. In her situation, that event is her children leaving high school. The
absence of children in the home seems to signal midlife to a number of women of this
study. Mildred and Ester reveal this dual nature of midlife. However one of the
participants provides a definition that is neither time nor event ordered.
Jewel is the mother of one of the other participants. At 70, she is reestablishing her
household and has moved to Florida from New York City to be closer to her daughter,
Ruth, and Ruth's two teenaged children. She has decided to move to Florida without her
husband, from whom she is separated. He later moved to Florida, however they do not
share the same household. She talks easily about her separation from him. For now, our
conversation focuses on her definition of midlife. Jewel, who describes herself as a
fatalist, defines midlife in the following way:
It is inevitable. Like being between two fires. You don't have as much incentive as
[a] younger person. Yet you are [not] willing to withdraw completely from things.
Midlife is easing out of younger life and easing into old age.
Jewel's response is both poetic and profound. Although she refers to midlife as
"being between two fires," she does not identify any specific event that marks the
beginning or the end of the phase. For her, midlife is an unnamed but inevitable midpoint
between a "younger life" and "old age."
When the Number and the Mirror Disagree
The women of the study believe that their functional age--how they look and move
about--belies their chronological age. In this respect, these women construct a subj ective
age identity of themselves as looking younger than white women of the same ages. Their
comments on midlife as time ordered and marked by appearance were typically a result
of asking the participants to tell me about the way white women age and the way black
women age. The first of these comments comes from Iris' observations not only as a
medical physician but as a black woman. Iris makes the following observations without
It is pretty clear, even in terms of being a physician. We [black women] age more
graciously. Our physical appearance is that it is difficult to tell how old we are.
They [whites] can't distinguish between a 40-year-old or 50-year-old black woman.
When we get in our 60s, 70s, 80s, it is hard to tell how old we are. You may tell
from other ailments, but not just by skin and appearance.
Iris does not talk about her own appearance at this point. Instead, she focuses on
what she observes as a physician. However, in the use of "our" and "we" she numbers
herself among those black women whose "skin and appearance" fail to reveal their
chronological ages. In her view, to "age graciously" is to appear younger than your years.
Betty, 58, is also a health practitioner. She describes the appearance factor of aging
in this way:
A lot of females that come in here [a Veteran' s Administration health clinic] look
older than I am. They look like they have had a harder life, like things weren't easy
for them. It wasn't [easy] for me either. I don't know if it is heredity for me or
Betty has a bird' s eye view of many women in her work as a nurse. Although she
doesn't specify whether or not the women she primarily observes are black or white, her
perception is that she looks younger than they do. Again, there is an air of self confidence
about looks at midlife.
Juanita, age 52, presents a final example of how these black women view the
physical self at midlife. Again, I ask her to compare the way black women age and the
way white women age.
I think we age beautifully, especially at this age. When I was overseas and came
back, the black women looked so great. We are gorgeous women. I think the whites
are out in the sun. They want their skin dark. [Whites are] being very weight-
conscious. They are always dieting. I hardly ever hear of blacks doing Botox. It
doesn't seem to improve their [whites] looks when they age. You can tell when you
look at their necks. When I first moved here, I would say look at all the old people.
Now I am one of them. But you see these beautiful black women, big and plump,
their skin looking great. Although, I always complain about my arms and the skin
hangs down a little. You have to pick up the rolls. Some people don't think
anything about it. I think all women do this. I am 52, but in my mind I am 30. I can
dress the same way. Even when you are 70, 80 or 90, you probably are the same
way. To wear a short skirt or put on heels, that is something white women will do. I
may be stuck in time, but I don't dress that way.
Juanita admires the way she believes black women age. She highlights "big and
plump" and "skin looking great" as positive signs of black women' s beauty. Moreover,
Juanita continues to think of herself as younger than 52, admitting that "in my mind I am
30." Certainly, in a youth-oriented society, Juanita's interest in keeping young is not
unusual. However, she seems to draw the line between feeling mentally young and
dressing appropriately for her age.
There were many more examples, similar in tone to the ones discussed above.
These examples serve to demonstrate that the women of this study believe their physical
appearances at midlife are acceptable and indeed exceptional.
The Importance of Primary Data Sources
Findings from historical reports of health disparity among black men and women
(Combs, 2001; LaVeist, 2000; Geronimus, 1996; Barker, 1995) suggest that African-
American women generally manifest age-related declines in health early in the life
course. This decline is coupled with a deterioration of access to adequate health care
services. Unfortunately, with the exception of my own aforementioned work, it has been
presupposed that the information from these studies can be extrapolated to include middle
class black women. This raises the troubling point that cumulative disadvantage,
especially among poorer black populations, fails to explain why these same results exist
among black women whose income and education do not expose them to the same risks.
In essence, this would indicate that other social factors contribute to early signs of decline
in health related aging.
I anticipated that there would be a difference between what has previously been
reported and what the women of this study believed about themselves as examples of
successful aging. The first such report is derived from an analysis completed using the
National Survey of Midlife Development in the United States (MIDUS) (Combs, 2001).
This analysis, like many of its kind, compared black and white women in order to
identify variables that contribute to the continuing dilemma of health disparity among
African-Americans. It noted that compared to white women of the same ages, black
women reported experiencing physical limitations, a sign of aging, as early as age 25.
This same condition was reported nearly ten years later in white women. The same age
difference existed in queries about whether or not these same women were receiving
prescriptions for medical conditions. Also, the black women of this data set had less
health insurance at an earlier age than did their white counterparts. However, because
physical limitation was self reported, I was reluctant to make a strong link between self-
reports of physical limitation and socioeconomic status (SES); I believed that self-
reported physical limitations were influenced by factors other than SES. These findings
inspired further study and search beyond the biomedical and socioeconomic models for
the causes of early life course health disparity.
Three other studies (LaVeist, 2000; Geronimus, 1996; Barker, 1995) also provide
evidence that declines in health and markers of aging appear early in the life course
among African-Americans. These studies suggests that reports of early signs of aging
may not be consistent or even reliable predictors of health and aging in later life among
middle class black women.
My interest in the subj ect of black women' s aging processes stemmed from two
separate and seemingly unrelated pieces of information. Namely, that information was
that blacks reported more functional limitations than whites and that women reported
more functional limitation than men. I later began to note that despite The National
Institute of Health' s increased general interest in health disparity among African-
Americans, there was little if any specific or in-depth information about issues of health
and aging among black women.
Given my serendipitous discovery that black women were reporting and
demonstrating signs of aging as early as age 25, I became reluctant to accept information
about this population that did not address the following three concerns.
The first concern relates to culture. Again, I argue that the social construction of
health and aging occurs within a cultural environment. This environment presents internal
normative realities such as dietary practices, community structures, community SES,
family dynamics and geographic location. Arguments for early and cumulative
disadvantage must be balanced by cultural realities. For example, in this study I discuss
that among black women, concepts of "normal" boy weight are influenced by the cultural
and historical notion that more weight is a sign of prosperity and therefore being
"overweight" may be relative and certainly acceptable.
Second, as I have previously noted, only one-third of the black American
population earns wages below the poverty level, yet it is this one third that is routinely
studied and used as the model for intervention. This is not to suggest that this one-third is
unimportant, rather that this group represents only a narrow view of life within the
population of black Americans.
The third concern is related to the exclusive use of comparative, biomedical models
to investigate health disparities. Although these models may introduce the scope of the
issue, they are less effective than interviewing populations to determine possible
structural causes such as institutional racism for health disparities. As LaVeist notes in
his analyses of scientific j ournal articles, "the maj ority of articles published in these
journals failed to offer insights into the causes of health disparities among racial and
ethnic groups" (LaVeist, 1998, p. 18). Moreover, because such studies do not have the
benefit of input from the target audience, they have the potential to produce interventions
that fail to address the subj ect group's perceived needs for health care services. Input
from the target population is instrumental in planning interventions. For example,
research into breast cancer among African-American women has begun to examine
culturally-bound health beliefs that may affect choices in treatment (Edwards, McClave
& Combs, 2000; Lannin, 1998). Finally, in all likelihood, these models use the dominant
culture as the norm. This has the potential to render reports of health outcomes among
minority groups as pathological when in some instances of disease and illness, whites
actually fair worse than blacks.
In examining the early and cumulative nature of illness among blacks, early life
course events have been identified as a maj or contributor to health disparity (Hayward &
Hernon, 1999; Jackson, Chatters & Taylor, 1993; Moen, Dempster-McClain & Williams,
1992). I closely scrutinized two reports to determine how they applied to American black
The first report was an analysis conducted among economically disadvantaged
black women (Geronimus, 1996). The study produces what is most commonly referenced
as the "weathering hypothesis," the view that, much like the gradual erosion of land by
environmental elements, human bodies "weather" or erode in response to environmental
assaults. In this case, the assault is racial discrimination. Thus the report concludes that
among black women of lower socioeconomic statuses, the risk of undesirable low birth
rates increases with age. In essence, this hypothesis captures the notion that despite
efforts to alter individual health behaviors among disadvantaged black populations, the
net effect of structural racism is a cumulative impact on the infant birth weights among
this group. The question that I pose and attempt to examine with the women of this study
is: Does higher SES protect middle class blacks from the same health disadvantages?
The second report that I scrutinized (Barker, 2002) analyzes statistics collected on a
population outside of the United States. In this report, reviewed in Discover(2002), David
Barker, MD presents an argument frequently referred to as the "Barker hypothesis." The
argument is that:
...conditions of the womb and in early infancy 'program' the way our kidneys,
liver, pancreas, heart, and brain develop, and they function later in life. When a
fetus must adapt to a poor environment in the womb, or when infants are exposed
to malnutrition or infection shortly after birth, permanent and even lethal damage is
This hypothesis seems obvious in its conclusions that early exposures to health
risks have life course consequences. However, as straightforward as these conclusions
might be, they do not address the confounding effects of race and class.
Both the weathering hypothesis and the Barker hypothesis have been cited
hundreds of times in studies of health disparity that focus on the one-third of blacks who
earn wages below poverty level or come from disadvantaged childhoods. Neither
hypothesis, however, addresses the issues of race and class. In large measure, the women
in this study present views that conflict with both of these hypotheses. In contrast to these
selected reports of the effects of cumulative disadvantage, and despite documented
reports of early declines in health among black women, these women do not see
themselves as disadvantaged. By-and-large, despite issues of weight, lack of exercise,
smoking, high blood pressure and age, they view themselves as healthy. This perhaps
supports the report of Byrd and Clayton (2000) that, for blacks, "poor health status and
outcomes...are 'normal' and acceptable." (p. xxiv).
This chapter provides a general discussion of the existing framework for the study
of aging, and how the experiences of aging women in general, and black women in
particular, fit this framework. Against the theoretical framework of aging studies, the
participants begin to link their social, political and historical perspectives to their beliefs
about aging. From their words, the reader learns that these black women calculate midlife
in two ways. First, "midlife" may be a numbered or time-ordered event. However, the
chronological age is less meaningful when making within-group comparisons. For these
women, lack of the physical signs of aging, usually the condition of the skin, make aging
a fluid and pleasant experience. Second, the period of midlife may also be signaled by
life course events, such as children leaving home. A few women, primarily those without
children, assigned menopause the task of announcing midlife.
The following chapter again uses the words of the women to explain their
perspectives of health, and race is introduced as a significant factor in the construction of
health and aging beliefs among the women of this study.
"PEANUT BUTTER AND JELLY AIN'T A BLACK THING! "
This chapter has two obj ectives. The first is to introduce one of the ways that the
women of this study organize their everyday thoughts about whites. This is a typification
process, one of several processes in the construction of the life course (Gubrium, Holstein
& Buckholdt, 1994). For the women of this study typification takes the form of making
observations that contrast the traits or beliefs of black women to those of white women.
Generally these address physical signs of aging among white women. Selected portions
of interviews and the biographical data of the participants provide examples of
The second obj ective of this chapter is to examine how the women of this study
view themselves as a part of the greater whole or consciousness of black women. In this
respect, the proj ect seeks to gain insight into construction of an individual, yet collective
black female consciousness. In large measure, this consciousness develops as a result of
shared psychosocial experiences, particularly racism. The words of the women are used
to examine the influence of racism on health.
Typifications of the Life Course
In the previous chapter, Ruth' s comments about the dietary practices of whites and
aging provide one of the first examples of the typification process. To typify what whites
do and to demonstrate how she sees herself in contrast to whites, Ruth says: "I do know
they tend to eat a lot more boxed stuff and refrigerated stuff and canned stuff and we
don't particularly like stuff like that. It's not our thing." As a characteristic of social
constructions during changes in the life course, the process of typification serves the
purpose of "organiz[ing] events and courses of action, to give them meaning" (Gubrium,
Holstein & Buckholdt 1994). Typification adds slices of information to form the entire
pie of black-white relationships. As Gubrium, Holstein and Buckholdt point out,
"Recollected anecdotes may suggest that someone is 'obviously' this or that type of
person. On the other side, once typfications are formed, they in turn are used to warrant
and elaborate the meaning of the available information" (p. 62). In this way and in the
circumstances of these black women, they are now constructing a "whiteness" of aging
and health as well as a "blackness" of aging and health.
By using typification as a way to contrast themselves to white women, the women
of this study determine who they are not rather than explicitly stating who they are.
Expressed another way, these women construct and define their selves not only explicitly
but implicitly through the use of typification. If white women are described as 'thus and
such' then the obvious description for black women is the implied opposite. As a process
embedded in the conversational patterns of these women, typification is the most
complex theme that appears in these interviews. It develops as the women use their
personal observations and experiences with whites to form belief systems about whites in
Body Image and Dietary Practices
Comments about the physical appearance of aging whites and dietary practices of
whites serve as examples of this belief system. I was especially struck by Rose' s
comment regarding dietary practices and the source of her knowledge about eating foods
for good health.
Rose, age 71, is recalling her life in Philadelphia and her mother' s work
environment as a domestic worker. She recalls that some of what she knows about
nutrition came from the whites who employed her mother. She smiles and confesses an
encounter with peanut butter and jelly sandwiches. At this point she remarks that eating
peanut butter and jelly is clearly not what blacks do. As Rita does in the previous chapter,
Rose makes use of code-switching to emphasize her point and her connectedness to being
Rose, like Rita, is a retired educator and has acquired patterns of speech that not
only reflect the region of the country where she was reared, but also her formal
education. Towards the end of the interview, Rose repeats in a code-switch that, "Peanut
butter and jelly ain't a black thing!" Subtlety and implicitly, the comment frames the way
this particular black woman thinks about what she considers are the unusual eating habits
of whites. This and similar comments may serve to reveal how responses to black-white
differences and resultant conflict also serve to form beliefs about equal access to health
care. These beliefs are not myths nor are they immediately obvious. They do however
arise from processing ordinary, consistent and everyday observations about the white
world in order to understand everyday racism (Essed, 1991).
Chapter 3 presented the women's comments about the contrasts between the
physical appearances of aging black and white women. These comments, coupled with
ways of viewing the body and dietary practices, suggest a patterned viewpoint among
these women. One issue of body image for black women is weight and obesity. Among
black women, obesity has been reported to be a health threat of epidemic proportions.
However, the following comments from the participants will indicate that issues of
weight may be of less concern to the women of this study than biomedical models would
Several years ago, Mary, now 57, underwent surgery to reduce the size of her
stomach. At the time of the surgery she considered herself overweight and was
experiencing multiple chronic illnesses. Her physician agreed to perform the procedure in
hopes of reducing Mary's future health risks. Mary's approach to weight, health and body
image is the most divergent among the women in the study. In response to my inquiry
about her satisfaction with her looks Mary had this to say:
I think I am [pleased]. I am [pleased]. The only thing I would change is the surgery
on my eyes. I don't like wearing glasses. I am only 57. I think I look well. I don't
want to get heavy again. I would like to lose another pound. I have allergies. But I
am otherwise okay. Weight is very important in anyone's life. It can hurt you. It
means an early death if you are overweight.
There are a lot of black women who are overweight
Way overweight. I was at a birthday party with over 200 people. There were some
very heavy black women. Maybe it is something in the genes. Or we are not eating
properly. They are young women too.
Some say we eat to compensate.
I heard that, too. Maybe, I don't know. But there are an awful lot of younger
women overweight, very overweight. Weight will take you down. It may be in the
genes. Or it may be because of frustration. I am sure a lot of black women are upset
over things in their life. You have a lot of single parents among the blacks. There is
some among the whites, but more among the blacks.
Mary has expressed three reasons for excess weight among black women: genetics,
inappropriate dietary practices and being frustrated "over things in their life." In her
everyday observations she suggests that the high rate of single-parent households among
blacks is one of things in their lives that cause frustration. Mary says "their" lives,
indicating that she is not part of collective. She has left the ranks of the overweight and
now concerns herself with the loss of a single pound. Although she is less decided about
the causes for overweight among black women, Mary's overall message is that "weight
will take you down. .. It means an early death if you are overweight." Mary's viewpoint
diverges from several of the women in this study who express a higher tolerance for
Like Mary, military retiree Ann connects overweight or obesity to issues of health
and illness. Ann has recently had a hysterectomy. She is still recovering as she prepares
to move her household. Her furniture is gone so we sit on the floor of her near vacant
duplex to discuss issues of health and aging. Near the end of our time together I ask Ann
to tell me what she thinks is the most important thing for African-American women to
know about health care.
A lot of us [black women] are gaining a lot of weight and we are not taking care of
our bodies. We think that is okay. You start getting hypertension, diabetes, heart
disease. A lot of us are overweight. We don't know how to control that weight.
Why do you think there is an overweight issue among black women?
Diet. What we eat. It is difficult to change.
Ann sees weight as a pervasive issue among black women and one that is
associated with several illnesses. Her list of chronic health conditions begins with
hypertension, which is undisputedly the number one health concern of African-
Americans. She sees diet--"what we eat"-as the reason for overweight. Like other
women of this study, Ann sees a particular pattern of eating among blacks and questions
the wisdom of these practices. Finally, Ann determines that these eating patterns, perhaps
because of being culturally embedded, "are difficult to change."
Despite the warnings of Mary and Ann, research into the cultural views of weight
among black women point to one strong cultural reason for acceptance of high body mass
indices among blacks. Researcher Estelle Disch (2000) states that "In African-American
communities, a certain level of obesity [are] considered attractive. Historically, African-
Americans have associated degrees of obesity with well-being. To be thin is to be poor"
(p. 449). It is suggested here that a few extra pounds of body fat signifies that the family
has the money to afford large quantities of food. One participant' s testimony supports this
idea. Wilma, one of two girls and three boys in her family, has this to say about eating
practices in the southern household of her youth:
I wouldn't let the boys out eat me. So maybe that is why I am overweight. I have
always been overweight. The doctor never told me about my weight until this last
visit. I was always active. I never let weight stop me.
At 55, Wilma sees herself as having always been overweight. However, the first
time weight became an issue of health was during a recent doctor' s visit. Wilma' s
previous acceptance of weight appears to conflict with some current medical guidance.
For Wilma, who says she was "always active" and that she "never let weight stop [her],"
weight only becomes an issue for concern as she transitions to another phase in the life
course. What is interesting about this situation is that Wilma appears to only recently
begun to consider herself overweight, and then only in light of a medical standard that
may not accurately portray the cultural realities of black womanhood. The question
remains, who and what sets the norm for weight among black women?
In the following two interviews I attempt to unveil the meaning of weight among
these women. The first attempt is with Ruth. I ask her if she considers herself overweight.
Just slightly. Not enough to stress over.
What is "slightly to you?
I probably could lose about 10 lbs.
Is that what you think or because you have read a chart.
No, I look at my tummy and my butt and neck and it's sticking up a little bit. Slim it
down and it'll look great. No saddle bags.
Ruth's tolerance for overweight is ten pounds, while Mary, whom we know has
undergone stomach reduction surgery, is interested in losing one pound.
Juanita provides the second set of comments regarding weight tolerances. Juanita,
who considers weight management the greatest challenge of her midlife experience, and
her mother have agreed to come to my house for the interview. We are sharing some light
refreshments. This is the first of two dyads among the interviews. Juanita comments:
Weight [is the greatest challenge at midlife].
What is your concept ofweight?
Maybe not weight. It is just stuff that happens to you. I have this tire now. I will
lose weight, but this tire stays. I think that comes from mom's side of the family.
You get this pouch that develops. Some women can be nice and flat. But some
black women have this thing going on here. I inherited the big shoulders and
What is the basis for this comparison?
[I compare myself] to other black women.
Juanita reconsiders her initial reply to suggest that body composition may be
genetic. Her bases for comparison are the black women of her family, as opposed to
media images in which white women are the standard.
For these women, weight is both an issue of body image as well as one of health.
Lee wants to get her weight under control so that is does not develop into "a serious
problem later on." Mary says that weight "can take you down." Ann produces a
chronology of illnesses related to being overweight. Juanita believes that weight is her
greatest challenge at midlife. Yet despite concerns about weight, none of these women
appears to have any obsession about the subj ect. In fact, they indicate satisfaction with
the appearances of their bodies despite what may be considered as extra poundage.
Food and Diet
In discussing weight and diet, typifieation is again employed to contrast how these
women see themselves in relation to white women. The first of these comparisons is
made by Lee who has invited me to have dinner at her home as part of the interview
process. The meal, a ritual among African-Americans, serves as a spring board for our
discussion of health and aging. At 48, Lee has recently completed her master' s degree
and received a job promotion. She is extremely proud of these accomplishments.
In defining midlife in the early part of the interview, Lee stated that she wanted to
make changes in her lifestyle. Among those changes, she believed that she "needed to get
serious" about her weight. These are the words she uses to demonstrate how she
constructs her standard of appearance:
I tried to put on something and it doesn't fit. But it is not because I look at other
people. It is a personal thing. And I realize if I don't take care of my weight now,
there will be a serious problem later on.
Like Juanita and Ruth, Lee sets her own standard of appearance. She does not
gauge being overweight by any standardized body shape but by the way her clothes fit
and the way she feels about herself. We also hear Lee connecting weight to health and
taking responsibility for improving her health through weight management.
As our conversation continues, we turn to the subj ect of eating, specifically the
meaning of eating among some black women and how this differs for white women. Lee
expresses and contrasts the cultural meanings and purposes of food in the following:
When I look at black women, including myself, we eat because it makes us feel
good. We like the food. But when I talk to white women, they want to keep a
healthy body. They don't care what it costs. If they have to eat a yogurt every day,
they will. We look at our bodies differently. I don't want to eat beans and rice.
They will eat nothing and it won't bother them. They will talk about going out and
partying. Most don't talk about food.
Why to you think this is so?
Culture. The way you are brought up. To us [blacks], food would make you
happy. When I am around my siblings we will say, 'wasn't Laura' s baking the
best...?' I don't think white women talk about the food at Thanksgiving. We will
sit around and talk about food all the time. [For example], when you said you
were coming I said I would make something. White women don't care about it.
From Lee's typification of white women' s attitudes about food we learn that Lee
believes there is a marked difference between the way black women and white women
view food. In two respects Lee alludes to eating as a ritual among blacks. Phrases such
as, "We sit around and talk about food all the time" and "when you said you were coming
[for the interview], I said I would make something [to eat]," point to sharing food and
eating as ritual.
In the preceding discussion and interview analysis, the reader comes into contact
with examples of the perceived differences in the dietary practices of blacks and white.
These differences are part of the ongoing dialogue of health and aging among black
women at midlife. These expressed differences demonstrate how the women of this study
construct their beliefs of health around issues of weight and dietary practice.
The Stress of Being Black
The discussion now moves to another pervasive health issue among black women:
stress. Most often, stress is associated with being black, and occasionally the participants
make links to the impact of stress on overall health.
The stress of being black in America is a frequent topic of research. This study
adds to that body of knowledge by disclosing how some women link stress of being black
to health outcomes. The indicators of intergenerational learning and collective memory
are most visible in the following section that discusses the intersections of health, racism
and stress. For the women of this study, their explicit recounts of experiences with
racism, as well as their implicit ideas of the impact of racism, crystallize around early
childhood, racial encounters. What occurs in the texts of these interviews demonstrates
the filtering of everyday life through the experiences of race.
Racism expressed as discrimination has been identified as a maj or cause of stress
among African-Americans. Overtime, the stress of being black in America has been
associated with producing higher risks of illness (Feagin & McKinney, 2003; Feagin,
Early & McKinney, 2001; Williams & Wilson, 2001; Clark, Anderson, Clark &
Williams, 1999). However, for the women of this study, most of who were educated and
raised in the southern regions of the United States, their exposure to racial discrimination
was controlled by their environment and did not appear until later in the life course. For
them, their parents and segregated environments in which they lived prevented
interaction with whites. It was not until the woman entered young adulthood and left their
hometowns that they became fully aware of racial discrimination. Juanita described her
childhood experiences with racism in this way:
I didn't know it was racist at the time, but I went uptown with my siblings in
Knoxville. They said we don't serve you here. We had no clue what that meant.
We just thought we couldn't go to that store. Later on I found out what it meant. I
was about 10 or 12.
What kept you unaware of it?
My environment. I just knew I couldn't go in there. But it didn't bother me. When
you are in controlled neighborhood, you don't know. If no one is talking about it,
you don't worry about it.
Wilma' s experiences were similar to Juanita' s. She had this to say about early her
childhood memories of discrimination.
My earliest memory wasn't pertaining to me. But in our hometown, my mother
was especially protective. There was a store that had different bathrooms. I asked
my mother why. If I was going to one, she would redirect me. She wouldn't let us
go to the movies. We went upstairs, and they [whites] would be downstairs. At
the bus station, we would sit on one side of the bus. I would ask why we were
doing that. I was about six or seven. I never paid attention to it. We went to
church. I had a good life. My mother would explain it in a way like we are not
Catholic; we are Baptist. My life was so good that I never really thought about it.
My first encounter was in Greenville, South Carolina. My brothers were involved
in that. Even in school, I never really paid attention to it. It wasn't until I got
older. The clerks in stores would wait on the whites before they waited on you.
Mildred also offered an observation about childhood experience with racism:
I can remember hearing my momma and the older ones talking about white folks.
I grew up in an all-black community. Everyone looked like me. I didn't really
know what racism was until I was somewhere else. I was in the north. Racism
was the pecking order in the community. The only things I can remember was
when I went south with my grandmother and went into town; going and buying
something. We couldn't buy it. Those were subtle things. We were from the
north. That didn't happen. But that community shielded you away from it. It was
There was a whole new world out there. Teachers, doctors, everyone that took
care of me, looked like me. We were a black community. I didn't know anything
until I moved away. When I went to college I went to a whole new universe. My
roommate was from Mobile, Alabama. I [would say to her], 'hey, how are you
doing?' There was no [answer]. When I left my community, everything kicked in.
I went to Indiana University. There are teachers that prepared me with the best
they could, but they couldn't prepare me for the standards that were out there.
That is the mental pain that is caused. Those are the things we drag. That is what
causes us pain. But I am at a point that I am over my mental trauma. Racism has
made us a strong people. It makes you strong.
We learn several things about racial discrimination and childhood from these
statements. The first is that prior to the civil rights movement, segregated living--
especially for children--was the order of the day and that the realities of discrimination
were learned outside of the community. Second, parents did not necessarily discuss their
own experiences of racial discrimination with young children. Third, we begin to
understand just how pervasive racial discrimination is in the life course of these women
and how early that appears.
Stress and Health
Explicit references to stress and health surfaced frequently during these interviews.
These included references to conditions, especially while at work that were stress
producing. As a general rule, those stressful incidents at work were not explicitly
connected to health. They were however, always related implicitly to the stress of
operating as black women in white worlds. Mildred talked about this duality in this way:
We live in the world of being black. When you walk out the door, you take on the
world of whiteness. You have to learn the survival skills of the white world.
Education is important. It is like going in the battlefield--you need to strategize.
Some days you walk in [to work] beat up. We live in two worlds. From the time
you grow up, you learn that. The person you are at home is not the person that is
at the air force base. [For example], my hair. I couldn't wait to get out of the
military. [Now] I can do it as I please. We are the only group that lives in two
Mildred's pattern of speech slowed as she used her hands to describe the "shifting"
that takes place as she moves from the world of blackness to the world of whiteness and
back again. Researchers Charisse Jones and Kumea Shorter-Gooden (2003) describe this
adaptive behavior as one in which black women are "relentlessly pushed to serve and
satisfy others and made to hide their true selves to placate" (p. 7).
Leading double lives implicitly exposes black women to consistent stress. As
mentioned earlier, this stress has been reported to have a negative and cumulative impact
on health. Two participants address the cumulative nature of stress over the life course
due to racial bias. For Ruth, exposure to the stress of being black was an everyday lesson
of "growing up." She says of her childhood in New York City:
Growing up, I was always taught to do everything twice as good to be considered
half as good. That is a lot of stress to deal with every day, especially if you are an
achiever. You see your white counterparts and they do not have this, and that's a
tough thing to deal with everyday.
Jean, who grew up in rural Mississippi, does not specifically mention the day-to-
day dimension of stress, but she does imply that the process of surviving as a black in
America is an on-going one. Jean phrases it like this:
We've overcome a lot, but we still have a long way to go, and those of us that
have the knowledge need to try to continue to tell our brothers and sisters what
we know works [and what] helped to make us better physically and mentally.
Both Ruth and Jean have effectively captured the continuous nature of racial biases.
Two situations or opportunities in the interview elicited responses about racism,
stress and health. The first occurred when I asked the woman to tell me one good thing
about being a black woman in America, and one bad thing about being a black woman in
America. Depending on the point in the interview, this question was also sometimes
phrased as, "What is it like to be a black woman in America?" The second occurrence
came when I asked, "If you had proof that black women became ill and died before white
women, what would you say was the cause for this?"
I posed the question about being a black woman in America to Rita earlier in the
interview than I did for some of the other participants. Rita, age 40, is employed as a
juvenile probation officer. She has invited me to her office for the interview. It has been
difficult to schedule the interview during her work day, and because she has already
cancelled one appointment to meet for coffee outside of the office environment, I am
skeptical about the success of this second attempt. My sense of the current situation is
that she is busy, stressed and easily distracted. I want to get her attention and interest
quickly. Almost immediately after entering her office I ask to "Tell me about being a
black woman in America." Just as immediately she fires back:
Not fun. It is a lot of pressure, but the pressure comes from [us]. We are pushing
ourselves to be the best professionally with appearance. We want to be the perfect
parent, perfect Christian, the perfect everything. although that is unrealistic.
I found this response so strong that I was compelled to ask a second question to
learn if there was a positive side to her observations of being a black woman in America.
"Are there times when you are happy to be a black woman? Again, a quick response
comes forth. Rita says:
All the time. But there is so much pressure to succeed in all that you do. That is
from my generation more than the women today. That's from the 60s. Your
parents want you to achieve all the things that they didn't achieve. My mother
looks to me because my sisters didn't get it, so I am the only one who is
achieving. You have to be a big sister to all those black women coming up. Being
a black sister is a great thing. Being part of organizations is a great thing. Being
out there and knowing what you are talking about is a big thing. Being in the
mix. Having a learning disability, it wasn't always the way, But [after] identifying
that [my learning disability], I am now in the mix.
Although it is not fun, Rita is always happy to be a black woman. However, her
caveat is that as a black woman who is now "in the mix" there is, "so much pressure to
succeed in all that you do." Thus, for Rita, the work world presents a maj or challenge to
her as a black woman. Earlier she has stated that the pressure to succeed is self-imposed,
but as the interview progresses we begin to see that the pressure may have begun within
the family environment. "Your parents want you to achieve all the things that they didn't
achieve," she says. Whether self-imposed or reflective of family values, Rita attributes
stress to being a black woman.
One final illustration of the stress imposed by being a black woman is presented in
the words of Mildred, who has generously and previously commented on the subject of
being a black woman. I ask Mildred to tell me one bad thing about being a black woman
in America. She says:
We don't think of each other as girls. When you say 'girlfriend,' that is an
endearment. We were raised to be women. We were never girls. You were adult
all your life. I don't remember playing. You were always raised to work. It wasn't
about a party. You were constantly prepared to be a woman. You don't know
anything else. Even our young girls today; it is the same way. When you leave
your environment, you realize it. Black women were raised differently and that
can be a hindrance.
Mildred suggests that black women do not enj oy a traditional childhood. For
Mildred, the responsibilities of adulthood or being a black woman do not allow a time to
play. Mildred equates this adulthood and being a woman to working when she says: "You
[black women] were always raised to work." This sense of responsibility and obligation
to work, echo the thoughts of bell hooks, author and scholar, regarding the meaning of
work for black women. In hooks' (1984), estimation work represents another difference
between the socialization of black and white women: "Historically, black woman have
identified work in the context of the family as humanizing labor, work that affirms their
identity as women, as human beings showing love and care" (p. 133). Although hooks is
specifically addressing the early feminist issue of work inside of the home, what might be
concluded from the collective remarks of Mildred, an organic intellectual, and bell hooks,
the author and scholar, is that for black women working is a part of their everyday lives.
However, as noted earlier, because of pressures to excel, workplaces outside of the home
are also sources of stress among black women. Thus, for many black women, complex
tensions exist between contributing to the maintenance of the family through paid or
unpaid labor and developing a sense of self that is unrelated to the world of work. For
Mildred, this tension may well be construed as a source of stress related to being a black
As I conducted more interviews, I noted that the source of the stress changes with
the age of the women, however, being black continued to be the catalyst. Wilma, age 55,
sees race as a stressor in another light.
Wilma is retired. Although she and I have never met, she greets me at her front
door with a hug. The interview takes place in her front room where there is a piano that
she admits she cannot play. Early in the interview, Wilma talks about the transition she is
making from working to not working and her move to Florida. Although born and raised
in North Carolina, she has spent most of her adult working life in Queens, New York
City. At the moment, her chief concern as a new retiree is being able to afford adequate
health care because her retirement package did not include a health care component.
Wilma and her husband are too young and too "wealthy" for Medicaid.
I have asked Wilma to comment about possible reasons that black women became
ill and die earlier than white women. Wilma had this to say about the illness and
I would think not eating properly and stress. Black women have more stress than
white women. The women have to raise children by themselves. There is more
friction in the household. The black families don't have enough finances. Now it
is in white families, too. If you don't have the money [to raise] children by
yourself, that causes stress. That will trickle down. You work double shifts. You
are not home to prepare food. So then you are not eating proper foods. You don't
have the money to buy the proper foods. You don't have time, money or energy
to care for your family. That will stress you out.
Wilma' s response about stress and the relationship to finances and medical care
appear to reflect her present day concerns. However, she does not fail to underscore that
in her opinion, regardless of the reason, black women have more stress than white
The interviews contain additional comments about stress and race that provide
insight into constructions of race as a stressor for blacks. Summarizing these comments, I
noted that sources of stress among this group of women are varied. That is to be
expected, given the heterogeneity of the group, however what is most telling is that
regardless of the nature of the stressor, in the minds of these women the circumstances of
the stress are directly attributable to being a black woman. The women also reveal a
variety of reactions and coping strategies for dealing with this stress, including the
development of the 'strong woman' archetype and overeating and obesity. A rather
significant proportion of these women turn to spirituality to cope with racial
discrimination. Spirituality as a coping mechanism is discussed separately in Chapter 6.
This chapter has identified how the women of this study use typification to
organize their beliefs about whites. Here I have especially emphasized that the differing
beliefs about body image, weight and food are integral to the construction of the patterns
of aging among these women at midlife. Moreover, these typifications are universally
assigned among the women of this study. In this respect, typifications serve as a unifying
strategy of these women to organize thoughts about everyday life as it contrasts to that of
white women. The value in exploring these typifications comes from the belief that the
implicit and explicit comparisons between blacks and whites are ultimately the
cornerstone of beliefs about a number of interactions with whites. With respect to aging
and health care these systems of beliefs have the potential to influence whether blacks
enter the predominantly white operated medical system as well as whether or not they
comply with medical directives.
In the following chapter, the issues of access to medical care and compliance with
medical directives are woven into the background and subsequent historical experiences
of blacks in the health care system. In concert with, and sometimes in contrast to this
collective history of receiving disparate medical treatment, the women expound on their
own experiences, expectations and beliefs about medical care.
"BUT I DON'T KNOW WHERE YOUR
EVERYDAY BLACK FEMALES ARE SEEKING CARE"
This chapter examines possible pathways to health care for the middle class
African-American women of this study. The discussion looks at the categories of age,
gender, race and class in an effort to illustrate how these designators potentially influence
access to health care in America, especially among black women.
As the chapter title suggests, everyday women are the focus of the discussion as I
draw a contrast between them and the participants of the study.
The chapter opens with a brief historical background of medical care among blacks
in America. Following this history, the discussion turns to the words of the women for
insight into how medical care is accessed. The challenge in organizing their words is to
draw the lines of demarcation between instances of disparate treatment that are related
solely to age, gender, race or class. In many cases, these stratification devices are
interconnected and cannot clearly be separated. The overarching task of this chapter is to
begin to provide a framework for the study of aging middle class black women within the
context of their life course experiences.
Historical Perspective on Health Care
The history of medical care for black Americans begins primarily with
Reconstruction (1865-1877). Prior to that time, medical care for blacks was the
responsibility of slave owners, many of whom provided minimal medical attention to
their slaves. Thus, much of the responsibility for the health of enslaved blacks fell to the
individual and his or her kinship network. In this respect, community based folk medicine
was an integral part of black health care.
Many changes occurred in the social structure during the Reconstruction period that
followed the Civil War and. Among them was the transfer of the responsibility for
medical care for blacks to the state and federal governments.
The primary purpose of Reconstruction was to provide infrastructure and thus
support for the South. However, because President Rutherford B. Hayes' administration
never gave its full support to Reconstruction as an intervention into the affairs of the
region, programs failed to produce the expected results. With the withdrawal of Union
troops from the South, the new-found rights of former slaves were unenforceable. For
African-Americans, the era "based on the slaves' material role in the U.S. political
economy, was over" (Byrd & Clayton, 2000, p. 329). Many former slaves could neither
read nor write. No longer a valuable commodity, American blacks were left with few
marketable skills that could be parlayed into a means for subsistence. Moreover, even if
medical care had been affordable, the stigma of having been enslaved continued to exist.
Blacks were discriminated against in both private and public sectors because of this
In response to the need for programs that addressed the medical needs and
increasing health disparities faced by blacks, the black medical community established
the National Medical Association (NMA) in 1895. The establishment of this organization
was necessary because the all-white American Medical Association (founded in 1847),
was unwilling to include black physicians or the concerns of blacks on its agendas. The
role of the NMA was to "upgrade the quality of medical life several notches in the Black
community .. and provide the medical leadership and organization required to address
the black health crisis of the future" (Byrd & Clayton, 2000, p. 357). The extensive work
of Byrd and Clayton reflects current, conflicting views and interests of the National
Medical Association and the American Medical Association. As the authors state:
They (the NMA and the AMA) are diametrically opposed ideologically and
philosophically, regarding health needs and health care services, and the health rights of
minority and disadvantaged populations. Failure to address, and eventually resolve these
race-and class-based health policy, structural, medical-social and cultural problems
plaguing the American health system could potentially undermine any possibility of a
level playing field in health and health care for African Americans and other poor
populations. .. (p. 572)
In short, the establishment and maintenance of these separate health care structures
continues to marginalize the health interests of African-Americans.
For aging African-American women, this marginalization is compounded by the
intersections of age, gender, race and class. A primary concern of this study is to examine
the ways that black women manage their health and health care access through these
barriers. This study now turns to the women for further comment about the barriers they
face in gaining access to health care access.
Barriers to Health Care Access
Voices of Ageism
For women, both ageism and sexism present challenges over the life course.
Although studies of aging rarely consider how these conditions intersect (Calasanti &
Slevin, 2001), the challenges become more profound in a society in which youth and
youthful appearances are highly prized. As was noted in Chapter 2, aging women are
disadvantaged not only by the socially constructed images of aging, but also by
occupying positions outside of the power structures because of gender. This position
limits income, which in turn limits access to goods and services. Lack of access to goods
and services in part explain the high rates of poverty among older women. Furthermore,
research reports that for American blacks, differentials in income become more
pronounced at midlife. It follows that African-American women at midlife would be
greatly disadvantaged by both age and gender.
Nevertheless, the women of this study do not specifically link their aging
experiences to disparate treatment. This may, in part, reflect two thought processes that
occur in their assessments of aging. First, they tend not to view themselves as
disadvantaged by age. As one woman puts it, "I think black women .just accept life
and move on." This position was strongly voiced in Chapter 3, "Age Ain't Nothin' But a
Number." The women's comments told of positive approaches to aging and general
satisfaction with body images. Second, the biases inherent in the intersections of race and
gender and may override considerations of age.
Voices of Sexism, Voices of Racism
Mildred has found a way to address the intersection of racism and sexism. These
are the words she uses to combine these elements of black womanhood:
There are too many [black] women who are walking around with something
[illnesses] because nobody will take the time to see that this is a different body.
Not just a woman's body. You first have to Eight the sexism, and then you have to
Eight the racism. Even some of our black women doctors haven't been educated to
the differences [of incidences in] diabetes, heart [attack], and stroke. If you are
weaned on tofu, things will be different. But fast food will kill you. You have to
understand that. We talk about our bodies, but our [bodies are] different. There
are things that go with these hips, these eyes.
Mildred's words illustrate the subtle way that race and sex combine in the medical
world to disadvantage black women. In her mind, differences in medical pathologies,
medical incidences, and diets require different medical protocols. She also suggests that
differing physiology, which she describes as "these hips, these eyes," is cause for
different medical considerations.
Iris, the physician in this group of women, underscores the belief that black
women's bodies are different:
There are different responses in African-American women to medicine.
Physicians as a group are beginning to recognize that. There are definite genetic
markers that will make you respond differently to certain medicines. Even in
terms of the disease process, there are certain diseases that are white people
diseases and certain ones that are black people's diseases.
Mildred provides a similar, though less clinical, response:
For years and years I remember watching television and the only people that got
put in the hospital were white. How long does it take to know if this drug is okay
for my system? My fear is [going] to the hospital and not being able to talk for
myself. They see me as this poor little black woman. You have no voice there.
[pause] Even the medical resources aren't shared. There is racism in the sharing
Mildred' s observation of who is hospitalized reveals two facets of how she views health
care. First, she bases her conclusions on observations that span a period of time ("For
years and years"). She also draws out her words to further emphasize that her opinion is
formulated not by any early or brief example, but over an extended time period. I have
the impression from the inflection in her voice that she has given the matter a good deal
of thought. Second, Mildred' s answer is a critique of the media and its portrayal of
blacks. Mildred uses the absence of a black presence in the fictitious world of television
to draw conclusions about the medical needs of African-Americans. She also uses her
observation to draw conclusions about her own safety in the predominantly white medical
world. Mildred is an educated woman with a responsible position in a government
agency. As a researcher and trainer in the Hield of equal opportunity, she is intimately
familiar with the questions of race. Yet, she turns to the media to acknowledge her fear,
especially as she ages, of the white world. Mildred believes she not only has "no voice"
in the medical system, but that the system is flawed because of the lack of shared
resources. This lack of shared resources is reminiscent of the "separate but equal"
ideology present in the Jim Crow laws, the systematic practice of discriminating against
and segregating black people, particularly in the American South from the end of
Reconstruction to the mid-20th century. Mildred shares with Louise, whose story is told
in Chapter 1, a fear and mistrust of the medical system. For Mildred, going to the hospital
and being mistreated because she is old, black, and poor reflects the lack of black images
she sees on the television. In this way, she expresses an underlying fear that since she
sees no blacks in hospital scenes on the television, perhaps real life is the same. That is,
the medial systems have no experience in treating illnesses that may require different
procedures when the patients are black women.
Louise also mistrusts and perhaps fears the medical system; however her emotions
are grounded in her personal experience, rather than in media representations. In Chapter
1, Louise told the story of her near-death from childbirth as a result of medical
mistreatment in rural Mississippi in 1957. This experience continues today to influence
her perspectives of the medical system. Louise says, "Since that happened to me in
Mississippi, I haven't trusted doctors that much anymore." For Mildred and Louise, both
fabricated and actual experiences of the medical system form mistrust and fear.
Iris, the physician, adds additional information about what she has observed from
within the medical system about the treatment of blacks and whites:
My experiences observing the treatment of blacks to the treatment of whites [is
that] the people that had an unkempt demeanor were treated more horribly than
the people who had a better appearance. There was less an effort to explain things
to people of color. They Healthcaree providers] assumed they didn't have the
Iris addresses appearance and race in the same breath. In unpacking her statement,
it appears that Iris may be associating an "unkempt demeanor" with people of color. The
lesson here, of course, is that appearance, along with "color," may also weigh heavily in
determining the treatment received in the medical system. Finally, Iris intimates that race
and appearance lead to assumptions about levels of education. Education as a marker of
class is discussed later under the rubric of classism. For now, the discussion continues to
focus on race-related medical care experiences.
Although it is not a first hand account of disparate medical treatment, Beth, a
practicing registered nurse, provides some additional information regarding the
experiences of blacks in the medical system. Below, she relays the observations of a
black doctor with whom she currently works:
I work with a black doctor now. The first thing that he has noticed is the white
person is receiving much better medical care, and the black patients are not. I
must admit he said if a white client came in and needed a test done, that the
physician would order it without question. But if a black person came in, he
didn't get as many tests or the more sophisticated tests as needed as the white
Can you speculate why that was?
It' s simply related to the fact that the person is black. I don't know. I've never
seen it, but...
Before turning to a discussion of how classism buffers racial discrimination, I will
present one final example of a secondary account that surfaced from inside the healthcare
system. It further strengthens the argument that many women of this study, because of
their class privilege, do not have first-hand experience with racism in the medical system.
The observer, Pam, is 36 years old. She commutes several times a week to complete her
certification as a nurse practitioner. She also works at night as a full time registered
nurse. Pam mentions that because of her light complexion and facial features, she is
frequently mistaken as being other than black, a source of sadness and frustration for her.
However, when interacting with doctors and patients, this mistaken identity gives her
lenses to view the racial nuances of patient care. Pam has this to say from her vantage
You don't know how many patients will request they not have a black nurse. Not
me, because they don't know I am black. They [whites] think they [blacks] are
not as smart. That is how narrow minded they [whites] are.
No. [I don't see patients treated poorly because of race].We are nurses and we
care about people. People are people. We have empathy. I don't see that at all. I
have never heard another nurse make any reference to anything racial towards
patients. I have seen black patients come in there that don't trust what the white
nurse or what the white doctor says. Maybe because of the prejudice they [blacks]
experienced in their life.
Pam Einds several occasions during the interview to defend her profession. In this
instance, while she notes that race calls to question professional ability, she is firm in her
conviction that race is not a factor for nurses in providing patient care. She also seeks to
advocate for the patient as she explains the source of mistrust for blacks who enter the
hospital's patient care system. Pam's ability to empathize leads her to conclude that
perhaps black patients mistrust white nurses and doctors because of past experiences with
Pam continues to weave the threads of racial interplay by explaining the patients'
perceptions of black nurses and the issue of trust from the perspective of the physician.
Here and in the following quote, she links the patients' mistrust back to remembered
Then you get a black nurse who tells them the same thing and they believe it. I
had white doctors tell me the same thing. [The doctors] think the patients think
they are not telling them the truth. The patients don't trust them because of what
happened to them [the patients] throughout their lives. In their past, there was so
much prejudice that when they [blacks] come to hospital they think they won't
get the same care. You have to explain they have ethical values that they have to
maintain--to care for every patient the same, regardless of race.
As always, Pam presents a loyalty to her profession with an explanation of the
"ethical values they have to maintain." That ethical value to which she refers is to
demonstrate color blindness in order "to care for every patient the same, regardless of
Finally, Pam returns to the issue of trust. This time she establishes the explanation
from the standpoint of the physician. She says:
The doctors know it is a trust thing. And they understand a lot of times, even if
you are not black, if you are smart, you can understand. You know what racism is
about. You would be surprised by how many doctors would say race is a barrier
because of trust. I have only seen it between black patients and white doctors.
That is the only race I have seen it in. [It is] because of discrimination. [Patients
think that] 'Outside [of the hospital] I am discriminated against, but in here you
are supposed to be looking out for my best interest?' It is a fear.
From inside of the medical system, the perspective is the same. The perspectives
and thus beliefs are that blacks are treated differently and sometimes inequitably when
they enter the medical care system.
Voices of Classism
Bell hooks asserts that "the evils of racism, and later sexism were easier to identify
and challenge than the evils of classism" (hooks, 2000, p. 16). This designation of
classism as "evil' does not concern this study, however, what did stand out as important
about class identification through these women's comments was that it made a subtle
distinction between how these women viewed their own experiences with the healthcare
system versus the experiences of other black women in the same system. In this respect,
class appeared to set these women apart from other black women who had fewer
resources. As the analysis of the interviews took form and were organized around certain
common themes, I began to note frequent mentions of education, occupation and income.
The meanings of these status markers, as well as their importance in obtaining adequate
medical care, were expressed frequently enough for me to consider class to be a
significant factor in the lives of these women.
My original hypothesis was that racism serves as a barrier to blacks' receiving
medical care on par with that received by whites. While this may be true for certain
blacks, the remarks of the study participants reveal a variation on the theme. In short,
while looking for evidence of current racial discrimination in the interview texts, I found
that the texts failed to support the original hypothesis. I began to search for a
commonality among these women, in hopes of identifying the cause for a lack of
evidence about racism in the medical care system. One of the variables that seemed to be
consistent was that of class as defined by education, occupation and income. The
question that surfaced from this observation was, "Does middle class status among blacks
affect views of racism?" Moreover, the search for a plausible answer, in part allows the
study participants to explain racism within the context of a constructed social class. At
this point in the discussion, it is important to examine the parameters and meanings of
class among blacks in America. The following brief examination of middle class status
among blacks sheds new light on why it is that the women of this study generally fail to
identify and experience a more personalized racism in the health care delivery system.
By- and- large, on the basis of race and gender, they do not perceive access to medical
care and treatment to be problems for them. I now argue that this is so because, as middle
class women, they are privileged by education, occupation and income.