darkmatter Journal

Introduction
Racial terminology and its associated assumptions pervade the discourses of health policy, practice and research. The language utilised within and across these discourses emerge from both historical and current ideologies and approaches to the understanding and management of difference. As a result the language used reflects the inconsistencies ‘held’ within and between these ideologies. ‘Traditional’ racial or ethnic categories are juxtaposed with ‘mixed’ and hyphenated categories (such as ‘race/ethnicity’), which in turn have been at least partially deconstruction and problematised by post-colonial and critical race theorists.^[1] The concept of ‘race’ is mixed, moulded and blended as clinicians and researchers search for ways to describe human diversity.

In this article, we examine and unpack the conflation of contested and competing concepts of race with arguments from a critical perspective. We begin by briefly considering the origins of the concept of ‘race’. We then consider how ‘race’ is utilised in three areas of practice: research into and commentary on differential patterns of morbidity and mortality across population groups;^[2] the examination on the impact of social inequalities on specific groups and populations;^[3] and more recently, and most highly debated, explorations of the genomic links to prevalence of diseases.^[4]

Health, as well as other social systems (including education, economics and the law) utilise racial language to produce their own particular versions of injustices,^[5] at least in part by representing such language as ‘natural’ products of the ‘neutral’ findings of science. Through various examples, we show how these knowledge production processes not only create and legitimise such language, but adapt to utilise emerging science to support the perpetuation of these ideological positions over time. Just as in feminist critiques of gender^[6] the link between the presumed bio-genetic specificity and formal rigidity of ‘race’ and racialised inequality can be exposed as a discourse adaptively constructed through a centuries long politics of social categories, and the privileging of unproblematised medical narratives.

Knowing race
Following Hacking it is possible to argue that the discursive nature of racialised language produces ontological effects at the individual, institutional and societal level.^[7] As a socially generated and transmitted construct, ‘race’ has been claimed to affect individuals’ perceptions,^[8] affective response,^[9] cognitive processing^[10] and resultant behaviours and belief, including presumably those engaged in the wider process of knowledge construction^[11] as well as the general population.

Hacking’s (2006) ‘engines of knowledge’^[12] construct maintains that the processes of counting, quantifying, biologising, and geneticising in knowledge production can act confirm the ‘naturalness’ of concepts such as race. Historians have been able to pinpoint when and where these processes emerged, and to demonstrate how claims on science have been utilised to retrospectively affirm and support these socially constituted categories.^[13]

In health systems the privileging of particular kinds and specific types of knowledge has resulted in of the acceptance of forms of racialised, abstract ‘knowledge’. These forms, it has been claimed, operate in such a way as to perpetuate the injustices in health outcomes.^[14] Krieger^[15] has suggested that the racialised construction of biomedical knowledge helps to affirm racism by ‘biologising’ racial inequalities. These inequalities, couched as individual and group failures, affirm the concept of biological difference upon which contemporary racism rests. Krieger further suggests that this is a form of inverse causality. Racism serves to create vulnerable groups and to locate them in poorer schools, riskier locations and more dangerous occupations, creating, in turn, a greater health burden for these vulnerable groups.^[16] Within this context, the racialised language of health operates as a system for producing and maintaining socially and scientifically acceptable knowledge which contributes to disparities by naturalising and essentialising socially constructed ‘embodied differences’.^[17] This critique goes some way to explaining how racism continues to be positioned and represented in the health sciences and why new scientific research is continually called upon to reaffirm the biological ‘reality’ of race.

Examining racialised knowledge in this way provides a starting point for the deconstruction of the discursive mechanisms by which health inequalities are, at least in part, reproduced. The deconstruction of racialised thinking matters because is not simply an abstract academic discussion about the questioning of terms like ‘caucasian’. Racialised thinking is rather, a powerful form of knowledge production that has to be critically analysed and broken down into its various parts.^[18] The epistemology of racism, including a belief in the immutable existence of ‘race’ as a biological fact, has direct ontological effects in people’s daily lives. In health care these affects range from persistently higher rates of miss- to late- diagnosis for conditions including cancer amongst vulnerable groups^[19] to the differential distribution of health care services and providers.^[20]

Racial knowledge as an engine of knowledge production
The language of race is a problematic inheritance because it has come to distort the way we think about the world and the people in it, both as individuals and as groups.^[21] Race was incorporated into scientific discourse in the 18^th century with the development of taxonomic hierarchies by Linnaeus, Meiner and Blumenbach.^[22] Its inclusion was a product of the first phase of modern scientific development, during which nature and the natural world began to be catalogued. In the 19^th century with the decline of older institutions and the emergence of the new ‘human’ sciences, racial thinking went from a set of generalised ideas about colour and virtue as a category marker, to a being imbued with ideology(ies) that promoted the superiority of one group over all others. This was the age of scientific racism. A feature of the 20^th century use of this discourse was justification for acts of ‘ethnic’ and religious enslavement and cleansing from Herero and Namaqua in German South West Africa^[23] through the Holocaust^[24] on to Rwanda and Srebrenica in the 1990’s,^[25] amongst numerous other examples.

While the disciplines of science cannot be held solely accountable for the use of their products, it is clear that the sciences, natural and human, continue to play an ongoing role in the reinvention and reconstitution of racialised thinking, research and analysis. This is most evident in the concerns raised by researchers, advocates and the communities themselves, about the presumed neutrality of the ‘new’ racial thinking, particularly in areas such as genetic mapping.^[26]

The History of an Ideological System
The notion that ideas have histories has been understood for some time. The development of the interdisciplinary sub-field of the history of ideas by Lovejoy and Boas^[27] was an early twentieth century example of this understanding. Foucault’s work extended the analysis of the ‘history of things’ to include institutions, concepts, and a variety of material and non-material entities.^[28] Any intellectual schema can be seen as an object in the Foucauldian sense, and can therefore be subjected to an historical analysis. The absence of more widespread history/histories of epistemic technologies knowledge in health systems simply adds strength to the need for such analyses. The health sciences do not, however, draw only on scientific knowledge to support their perspectives. They have a long history of including in their analyses assumptions, concepts and tools from numerous disciplines. The universal use of statistics and demography, for example, points to the application of disciplines that were at best secondary sciences in the recent past. Both of these disciplines share origins deeply imbedded in the arts of statecraft including early English political arithmetic,^[29] British ^[30] and French political economy^[31] and German nationalism and Swedish ‘geopolitics’ which produced concepts such as lebensraum (habitat) and lage (location)^[32]

Any analysis utilising conceptual schemata from these disciplines needs to acknowledge the history of these ideas and units of analysis. The emergence of racial schemata (like the emergence of all concepts and categories) is situated within a specific social and scientific context. Their history can be mapped both by their development and their political as well as scientific application.^[33] As a consequence of their almost universal acceptance as intellectual tools, rather than epistemic mechanisms, they influence not only the ‘knowledge’ produced, but also the way in which such knowledge is integrated and utlised.^[34] When such knowledge is acted upon in health care systems, the intellectual and ideological concepts generated within specific times and places, and as represented through specific disciplines, are also carried forward.

Race is a polysemic concept with a long and contested history.^[35] The term ‘race’ is dynamic and adaptable because it is not the core concept of racialised knowledge and thinking, that is to say ‘race’ has no causal properties. The concept and associated taxonomic devices, including categorisations of race, have no dynamic or processual power. The focus on ‘race’ misses both the production of knowledge about racialised things (entities, dynamics) and the locus of power in racial debates and theories. It is the active process of racism and racialisation that produce racist circumstances, situations, knowledge and beliefs. Racial categories are rather, abstract nouns that act as part of the linguistic architecture of racist knowledge by creating a set of artificial boundaries for knowledge and beliefs that are both fluid and contentious.^[36] The ‘new’ discourses of population ‘mixing’ are a reflection of these false population categories and their presumed borders, since both consensual and non-consensual assimilation/integration are a permanent feature of human history.

Race functions as a labeling system attached to the dynamic and adaptive socio-political system of racism. The history, development and adaptations of racial thinking can be mapped. Its origins, as stated previously, are in the 17^th and 18^th century taxonomies of races developed by Bernier, Linnaeus and Blumenbach. The process continued through early anthropological quantification of human races in the 19^th and early 20^th Centuries, to the present where it is associated with research into deoxyribonucleic acid (DNA), single-nucleotide polymorphisms (SNPs) and alleles.^[37]

All thinking about ‘race’ has a complex history of ideational development. It is possible to observe not only what might be accepted as ‘common sense’ ideas about the categorisation of human populations through racial terms but also the ongoing recourse to biology, medicine and the social sciences as sources of support for this kind of thinking. Bowker and Star (2000) discuss the process of ‘fixing’ racial categories against a social background where mixing is endemic, and the logical inconsistencies this produces regardless of ideological statements and bureaucratic practices.^[38] For racism to be believed in, we suggest, it has to be built on a structure of concepts that hold some general coherence. The normalisation of taxonomies is one the major achievements of late 18^th and early 19^th century science. Such taxonomic features became ‘naturalised’ engines of knowledge because they helped to cognitively order vast amounts of new information in the expanding sciences of the time. The rapidly changing social order also drew from these taxonomic engines to naturalise prevailing social divisions and normalise significant social problems. Examples of these processes include the development of notions of criminality,^[39] mental illness^[40] and eugenics^[41] and their relationships with race, class and gender. The relationship between the biological and the emergent social sciences favoured this approach to the ‘production’ of knowledge about social entities.^[42]

Race and Racism in the Health Sciences
Three areas of scientific medical endeavour illustrate the issues we see as problematic in racialised thinking, analysis and resultant knowledge production across the health sciences. The first is general medical research. In this field racial tropes have a long history of unquestioned, unproblematised deployment, based on the assumption or assertion that they are ‘proven’ to exist by other sciences. The second is the almost universal use of racialised language in the psychological sciences. This field has globalised the language of race and its assumptions via the literature, research protocols, teaching and the general scientific information available in the public domain, especially the media. The last is the emergence of genetics in the early twentieth century and its rapid development as the science for validating the biological basis for, physical, behavioural and or mental traits. This includes the use of pointless and ultimately offensive tropes, such as the ‘warrior gene’ where particular gene sequences are said to be linked to social labels such as ‘delinquent’, ‘antisocial’ or ‘criminal’. Genetics, in this context, has been described facetiously as making expert criminologists of lab scientists.^[43]

Medicine has been a major user of racial terminology, classification, taxonomies and in attributing causality to race in various diseases, real or imagined. The use of race in the control of slaves in the south of the United States is a case in point. The act of escaping slavery was categorised as a medical condition (known as “drapetomania”) in 1851 by Dr Samuel Cartwright.^[44] Drapetomania was considered a mental illness because so many individuals attempted to escape slavery, even though their chances of success were low and the punishments well known and extreme.

The bodies of African-Americans, their ancestors and descendants, both living and dead, were appropriated as part of medical education, research and experimentation for over a century.^[45] The vulnerability to exploitation by medicine of African-Americans was increased because of their status as ‘voiceless’ property.^[46] During the infamous Tuskegee syphilis study (running from 1932 to 1972), funded by the US Department of Public Health, some 600 poor, rural African-Americans were enrolled into a program in Alabama to study the ‘natural’ progression of syphilis.^[47] The control group were not informed of their condition, nor were they offered treatment, even as safer treatments became available during the four decades of the program.^[48] Tuskegee, along with a parallel study, the Guatemalan syphilis ‘experiment’ (1946-1948) illustrate the racialised character of the type of knowledge sought and the methods by which it was acquired.^[49]

In psychology, race has and continues to be utilised by some psychologists in discussions and discourses around social behaviours and intelligence, both key fields for the psychologising of racist thought.^[50] In comparison, critical psychologists have been engaged in unpacking their colleagues work, including Rushton’s writing on ‘race’, intelligence and crime (e.g. 2000) and the continued use concepts such as the “bell curve”. ^[51] Fish (2001) edited a collection of essays refuting most of these purportedly causal linkages between the broad category of ‘race’ and the equally broad category of ‘intelligence’.^[52] Both Lieberman (2001) and Barash (1995) have criticised Rushton’s scientific claims.^[53]

The final example, that of the linking of ‘race’ to genes speaks to the persistence of racism as a form of knowledge production in contemporary society and the widespread confusion of correlation with causality. The issue here is at least partly that highly problematic ideas from one field, historical psychology on race and intelligence, have operated as received ideas in another discipline. The belief that certain individuals were qualitatively better than others was well-established before any mechanism for the examination of heredity became available. The result was a social construct in search of science to support it.

Genetics has its own long and explicit history of engagement with racism (sexism, able-ism, heterosexism) and the deployment of race, through eugenics, one too profound to discuss at length here. James Watson, one of the four scientists involved in DNA’s discovery, publicly linked African intelligence and purported inferiority to the ‘genes’ of ‘black’ people.^[54]Watson’s early research career included involvement with the Cold Spring Harbor research facility, itself associated with pioneering eugenics in the United States from 1910 to 1940.^[55] The intergenerational transfer of racist ideas between scientists is a persistent feature of knowledge production in which science serves to validate existing beliefs.

As with psychology, several genetics programs have attempted to clarify the issues at stake. This includes the Human Genome Project, which itself was a cause for concern among many groups defined by their cultural and ‘ethnic’ uniqueness.^[56]The Project went to some efforts to allay fears that their work would simply validate existing ideas on and about ‘race’ including sponsoring a special issue of the journal Nature Genetics.^[57]

The Power-to-Knowledge Connection
The concept of ‘race’ was developed long before the development of evolutionary theory, genetics, DNA and the various tropes and metaphors of genetic science. Consequently, science and scientists have been variously called upon or been willing to utilise post hoc reasoning to justify a categorisation that lacks legitimacy in both the scientific and philosophical senses.^[58]While a variety of writers had identified prior versions of ‘racial man’ it was Linnaeus who provided the first ‘official’ racial taxonomy. Linnaeus’ authority in this matter rested on his work in botany and zoology, and although his categories included groupings such as ‘feral’ man, he is reported to have attached no moral component to his racial taxonomy.^[59]Blumenbach, who progressed this taxonomy, went on to develop a slightly extended taxonomy of the human ‘races’: one which became explicitly linked categories to moral virtues.^[60]

Historians such as Fields (1989; 1990) and Smith (2008) have shown that the shifting social reality experienced by marginalised groups is a direct causal outcome of the language and practices that racialised language and racial categorisation produce.^[61] More particularly, the development of racialised thinking and practices can be traced back to the conditions existing at the time various types and adaptations of organised racism emerged. The particular ways of knowing about and understanding ‘race’ came into socio-political existence in ways which supported the continuity of organised racism.

One of the major constituents of the authority of racist thinking was and is the social and political power brought to bear on ensuring racism continues to function in the social world.^[62] As there was/is no biology to any early conception of race in a meaningful objective versus attributive sense, the authority racism required, acquired and has maintained had to be grounded in the social and political order. That social authority itself helped ensure the continuity and adaptability of racist modes of thought and, therefore, the social consequences of racist thought and behaviour. The calls to science from the mid 19^th century down to the present are essentially a call for the legitimacy of a mode of thinking that should not have persisted into the present. In other words, the consistent failure of ‘race’ to tell us anything useful about the human world illustrates a preference for dogma over knowledge on the part of those who support naturalised versions of race. Perhaps it also shows how ideas do not neatly progress from less sophisticated to more sophisticated, instead past concepts and interpretations persist in and amongst new and emergent ones.^[63]

The Cognitive and Affective Dimensions of Racism
Racialised thinking is characterised by a wide range of inconsistent concepts and positions. Reconciling these ongoing inconsistencies relies not only on cognitive approaches characterised by ‘reasoning’, as is seen in much of the academic and scientific writings on the tpoic, but also on the support of the affective domain. The affective loading of ideas easily bypasses cognitive processing as it is generally understood and this is why so much racialised language is highly loaded affectively.^[64] When perception, understanding and belief are mediated via highly charged emotional states, there is a very limited level of analysis likely to occur in the human brain. The social and political value of affectively charged perception is apparent within behaviours including racism, sexism and classism. The observer is far less likely to engage in analytical thinking and simply reacts on the basis of the affective responses they have been taught are appropriate. There is an ongoing feedback process between the irrational ideas associated with cognitive racism and the affective ideas so often expressed by people indoctrinated in racialised thinking. Distinguishing between these two linked domains of thought and response can help us to better understand the ways in which racism continues to have social and political power in our purportedly ‘modern’ age. It may also go some way to clarifying why and how otherwise sensible people can be conditioned to deeply ‘believe’ in things that have little ontological substance.

The cognitive domain of racialised thinking has received the bulk of scholarly attention. Even in the field of psychology, much research focuses on how early in their development people (especially children) ‘notice’ racial differences in their racist societies. The assumption often presented as a proven fact is that small children who can distinguish ‘racial’ differences as identified and presented by psychological researchers, effectively prove the empirical reality of race. Putting it crudely, the main idea is that if children can be shown to recognise our socially imbedded classifications very early on (even pre-verbally) then those categories must, of necessity, be real.^[65] This is a dubious idea and, we argue, not much of a scientific proof. The fact is that most classifications are, as both anthropologists and philosophers of science would readily attest, cultural constructions and not some embedded essentialised Aristotelian categories ‘out there in the world’. What we suggest instead, as does Pettman (1992), is that causal chain goes thus – if you are born into a racist society then you will very early on be able to acquire and identify the relevant racial knowledge for your place in society.^[66]

Even more importantly, perhaps, when we are talking about how societies function in their acculturation of the young, recent arrivals, the vulnerable and so forth, is that there is a clear link between this kind of assumed ‘knowing’ and the affective domain in which people acquire emotional level responses to these socially constituted categories and characteristics. The affective domain is not rational or objective in the way the cognitive domain is represented as being, and it is a far more difficult prospect to dislodge affective knowing than cognitive knowing. One of the fundamental ways in which this type of knowledge can be seen to be developed is through the construction of sensory ways of ‘knowing’ race.

Smith’s (2008) work on the sensory domain in constructions of racial knowledge illustrates this point far more readily than psychological analyses claiming that children are social tabulae rasae whose early (measured) perceptions ‘prove’ the reality of race.^[67] Smith has shown how the sensorium of race was linked to the affective domain of daily experience or more specifically of European peoples’ daily experiences in the Old South and then, in adapted forms, into the Reconstruction period and the establishment of the Jim Crow regime of segregation – a system underpinned and supported by increased physical violence against African-American citizens.^[68] More significantly he shows in a case-by-case manner how the sensory domain served to provide ‘evidence’ that supported ‘white’ presuppositions of ‘black’ inferiority on a daily basis where all significant interactions occurred. This meant that African-American people looked, sounded and smelt inferior to the ‘white’ mindset. The skin, nerves, bodies and emotions of African-Americans were constituted as variously childish, primitive and underdeveloped compared to European-Amercians. This pattern had global echoes in many if not most colonial encounters, American and other, in which local peoples could be categorised, quantified and then qualified into a broader moral schemata of human merit.

Racism as a social and political ideology adapted itself to shifts in ‘real’ knowledge about the wider world and to the shifting politics of pre and post-Civil War society. Segregation came after emancipation but carried over and adapted pre-existing prejudices in ways that served to provide continuity to racism as a lived practice and an embodied form of social authority. The resistance in the Southern states to changes in the old political order evidenced itself in adaptive strategies like segregation and the committing of crimes against African-Americans (specifically lynching) that were rarely punished and in many cases acted as public, even participatory, displays of the continuation of Southern authority long after the Civil War had been ‘won’ and freedom declared.

Similarly, the attitudes and approaches to peoples living within the framework of European colonial settings also shifted over time to reproduce variations on these racialised notions of cognitive and affective superiority. The experiences of Africans (as generic a group as any) under British, German, French, Belgian and Italian imperial expansion (amongst others) also reproduced versions of these ideas and their associated behaviours. The complexity of empire itself shifted as the structure and shape of, for example, the British Empire changed from an entrepreneurial and often opportunistic trading regime to one of formal acquisition by the crown and an expansion in the administrative class and apparatus of imperial rule. Under the British Empire, male employees of the East India Company were encouraged to learn Indian languages, cultures and belief systems, and to marry local women, as a way keeping them within the colony. This process was far less characteristic of the 19^th century formalised empire in which Britain began to catalogue and position its growing acquisitions in land and peoples. Finally, to close this linking process, we can also see how the processes of integration or exclusion were utilised at the margins of empire in responses to indigenous peoples under empire.

Categories and Classification in Health Care
Contemporary health sciences are all influenced to some extent by the history and assumptions of medicine, a discipline that took on major social influence in the latter part of the 19^th century.^[69] The acquisition in medical research and practice of a range of social attributes and categories as standard instruments of diagnosis and analysis also occurred during this period, as the great phase of social quantification began to unfold.^[70] The emergence of the social sciences including sociology and demography, and their application to the ‘social problems’ of the time produced a generalised set of social attributes that have influenced health research and data analysis that continue into the present.^[71] The lack of clarity and precision associated with racial language in the sciences has itself been a topic of ongoing debate and even conflict since at least the beginning of the 20^th century and various sciences have had internal debates throughout the century.^[72]

The category effects of racial terminology permit, indeed encourage, the production of racist knowledge because it is acceptable in medicine and health care systems to attribute the ill health of individuals or groups to their race or ethnicity, rather than look to the social context which influences and legitimises those poor health outcomes. Krieger’s (2006) finding that race doesn’t cause illness but, rather, that racism does captures this process and tension.^[73] The categories of race have become supposedly neutral measures in health sciences research which invariably show some correlation with health status in many, if not all, studies. At the same time, there is a systematic exclusion of many groups in wider scientific research at all, an exclusion that persists in studies that claim ethnic and racial categories are discrete, Aristotelian entities.^[74] A similar argument has recently been made in relation to the exclusion of women, as subjects, in medical research.

Epistemological Critique
We have briefly summarised how a variety of ideas and political ambitions have come to shape the conceptual schema that we call ‘race’ into the present day. What should be clear from this analysis is that the concept of ‘race’ is polysemic, discursive and adaptive. It has been shown to have no scientific basis. As a result, its primary and ultimate function relates to the constitution of power by one group of people over another, others, in a racialised system.

In more specific terms, the persistence of racial notions of ‘white’, and therefore of ‘whiteness’, are not forms of identity but rather forms of structural complicity in societies that make racial claims to truth. Phrases like ‘poor whites’ illustrate the enormously political agenda at stake in racialised societies (of whatever variants), poor people in the majority, or controlling, racialised segment are permitted a racial sense of superiority over those subjugated by racial categories. However, these in no way challenge the political schema of class and privilege that helped institute racial conceptualisations in the first instance. In these contexts, ‘whiteness’ becomes a compensatory status at the margins. That is, ‘whiteness’ for people otherwise marginalised by class and gender are permitted to think of themselves as superior to some group whose situation may be manifestly worse than their own.^[75]

Race and Causality in the Health Sciences
A key question for any science must be ‘Is this relationship causal?” Ultimately, correlations (including those between tangible disease states and constructed social categories) leave open the question as to what is causal in our health-social group equation. Krieger (2006; 2008a; 2008b) has asked this very question in relation to race. Is race, as in an individual or group’s category position, causal?^[76] Her answer is fundamentally ‘no’. No individual or group of people becomes ill because of the racial classification they are situated in, as discussed previously, because ‘race’ is not a process itself but rather the product of a process, racism. Thus studies which attempt to show that, for example, ‘black’ people develop diseases of a particular type because they are ‘black’ (‘white’ diseases don’t seem to have the same analytic appeal) will never identify a meaningful causality for two simple reasons, firstly, there is no causal linkage to identify and secondly, the function of race is not to explain illness in a group but to validate the unequal position of the group(s) ascribed as inferior. Instead, like classifying slaves in the Old South as suffering from ‘Negritude’,^[77] those who ran away as suffering from Drapetomania^[78] or with the 1840 sensationalised American census (false) findings of higher mental illness in free Blacks than enslaved,^[79] the disease is invested in the social group because the aim is to maintain a particular social order,^[80] not to explain the aetiology of a particular disease nor to make a useful clinical contribution to the amelioration of such illnesses.^[81]

Rethinking Race and Racism
If there is no ontological foundation^[82] to the concept of race or races, as we suggest, then what remains is an entirely epistemic construction. In this sense, then, racism is the active process that permits the construction of ‘races’ and racialised knowledge, including analysis, beliefs and the variety of moralising judgements about people negatively categorised. Therefore, it can be argued that a racist is someone who believes in and acts on the notion that the ‘race’ concept is an empirical feature of the world. That is, a racist is someone who believes race is real. This approach, while challenging for many, both simplifies our approach to race and obviates some of the many circular arguments associated with the concept. It also clarifies the aim of studies that purport to find causal linkages between racial categorisations and health sequelae.

To begin with, we suggest that this construction of race, racism and racists removes from the knowledge equation arguments about morality, intention, personal action and accountability.^[83] The claim by some individuals and groups that they are not racists because they do not (they claim) act with racist intent relies on the individualist construction of social knowledge and action, and recalls the Socratic paradox.^[84] Lack of intent does not preclude participation in or contribution to the negative sequelae of racism. However, if we say that racism is less a moral position but much more an epistemological one, that is one of the process of knowing, the possession of knowledge and a belief or beliefs about what we know, then the simple response to the oft debated question “Who is a racist?” becomes much simpler to answer. One answer to this question is that a racist could be argued to be any individual, group, or even (more pertinently to this discussion) a variety of human systems (education, politics, justice, health care etc) that believes in (and legitimises the resulting knowledge) the premise of the empirical reality of race and acts as though the ideas (some, all, a selection, an inconsistent assortment, arbitrary collections of ideas or on a whim perhaps) are tangible and real, then that constitutes an enacted form of racism.

The value of this analytical approach is that there is no requirement that anyone have a consistent set of ideas on these issues, in the same way that they do not have to prove or disprove intent. The idea that people have consistent bodies of knowledge or that their behaviour follows on from their beliefs or intentions is poor science and a denial of what we know from history. People are frequently inconsistent in their daily lives and exaggerated, abstracted or exclusive models of rationality have simply confused our understanding of the ambiguous nature of human knowledge and behaviour, and the links between the two. The ‘rational man’ model is a self-justification for an irrational man who seeks a better self-image. It is more an abstract psychological projection than an example of any observable individual or collective humanity. This is, effectively a racist for our times and we think it begins to address ideas about personal virtue or vice by instead emphasising the aspect of assumed knowledge predicated on untested beliefs and responses. In this context, we believe that a truly anti-racist platform for this century is the project of un-knowing race by unpacking the ideological schemata of racism.

Conclusion
Similar to the social processes of class(ism) and gender (sexism), the concept of race has to function through active social processes, and not simply through the continuing attribution of unscientific categories of racial ascription.^[85] Race cannot function without racism because racial terminology is simply an instrument of racist societies and their practices. This is another reason why continuing to use racialised language to count instances of racism will never actively reduce racist behaviour. The terminology is itself constitutive of the reality it seeks to ‘capture’.

This critique goes some way to explaining how racism continues to be positioned and represented in the health sciences more generally. It also helps explain why new scientific research, such as genetics (pre-genetics, pre-DNA, post-DNA, molecular biology etc) is continually called upon to support the concept of race. Historically, racism has relied on emerging science to buttress the social consequences of racist (knowledge) practices. The argument is that ‘race’ is natural because it can rely on science, or at least some science, to confirm its naturalness. Two important considerations underpin this analysis: firstly, from philosophy we can see how Hacking’s (2006) engines of knowledge operate in the health sciences to endorse and support racial thinking and analysis – counting, quantifying, biologising, geneticising; and secondly, historians have shown us when and when these processes emerged and their reliance on science (the biologisation of African American social inferiority in the American South, for example, or the eugenics-based approach to ‘half-breeds’ in Australia).^[86]

The epistemology of racism obviously has genuine ontological effects, otherwise the health inequalities associated with racialised differences would not be so persistent. If researchers and practitioners believe in the terminology and categories of racism, they will produce racist knowledge that has tangible implications for the people so categorised. It cannot be otherwise because epistemology shapes our ontological understanding of reality. That is, the reality we collectively produce is affected by our knowledge and understanding of how the world works. And if our understanding of the world is shaped by racism then a substantial proportion of the knowledge and understanding we produce and act on will be racist. This is the discursive and adaptive nature of social and political ideologies like race. If people act as though they are true, then the social reality they work towards will serve to reproduce that kind of social reality.

This could potentially provide an important contribution to the way the health sciences currently approach and work with ideas about race. What is needed is a ‘de-neutralisation’ the language and terminology associated with race, and therefore with racism. It must be examined through its function of shaping knowledge production as a method for perpetuating an ideology that continues to do considerable damage to vulnerable individuals and communities. No one becomes ill because of the racial category the census or patient admissions places them in, they become ill because of the negative attributions and social authority brought to bear on people who cannot escape this dominant form of knowledge production in our societies. As researchers and practitioners in the global field of the health sciences, we believe that this new century deserves a better approach to understanding this issue.

Notes