After the killing of 18-year-old Michael Brown by police in Ferguson, Missouri in August 2014, there has been a renewed movement in the United States and across the world in support of black lives. The movement, under the guiding framework of Black Lives Matter, has resulted in a national conversation on police brutality and racism, and the violent effects these have on the black body. Using the framework of black theological thought on the body, this paper identifies the many ways that racism, as Ta-Nehisi Coates writes, "lands, with great violence, upon the body" across multiple domains and levels throughout history and across the life course. The paper closes with some initial recommendations for historically predominantly white churches to offer an anti-racist response to this violence, as informed by black theology.

Este artigo resenha um crescente corpus de investigação empírica, o qual indica que o racismo, em suas variantes institucional e interpessoal, persiste nas sociedades contemporâneas racializadas de todo o mundo, e pode ter impactos adversos importantes sobre a saúde. Após um breve apanhado das desigualdades étnico-raciais na saúde da população, em vários contextos nacionais, o artigo concentra-se na pesquisa empírica sobre a natureza e persistência do racismo e as múltiplas maneiras em que esse pode impactar negativamente a saúde de grupos étnico-raciais não dominantes e estigmatizados. Primeiramente, através de políticas e práticas que limitam o acesso a recursos e oportunidades na sociedade, o racismo institucional produz consequências patogênicas, por restringir a mobilidade social, e criar diferenciações raciais no status socioeconômico e nas condições de vida e trabalho, prejudiciais ao bem-estar. Em segundo lugar, o racismo cultural, no âmbito da sociedade, provoca e sustenta o racismo institucional e interpessoal, criando um ambiente político hostil a políticas igualitárias. No nível individual, estereótipos negativos, sustentados pelo racismo cultural, fomentam respostas psicológicas prejudiciais à saúde, tais como a "ameaça de estereótipo" e o racismo internalizado. Terceiro, a experiência subjetiva de discriminação racial é um tipo de experiência de vida estressante, mas historicamente negligenciado na literatura, que pode levar a mudanças adversas nas condições de saúde e a padrões alterados de comportamento que aumentam os riscos à saúde.

This article will provide an overview of the rapidly growing body of empirical research which indicates that racism, in its institutional and interpersonal forms, persists in contemporary racialized societies throughout the world and can have marked adverse effects on health. After a brief overview of racial and ethnic inequalities in population health in multiple national contexts, the article focuses on the empirical research on the nature and persistence of racism and the multiple ways in which it can have negative effects on the health of non-dominant, stigmatized racial and ethnic populations. First, through policies and procedures that lead to reduced access to desirable resources and opportunities in society, institutional racism has pathogenic health consequences by constraining social mobility, creating racial differences in socioeconomic status and in living and working conditions that are hostile to wellbeing. Second, cultural racism at the societal level, triggers and sustains institutional and interpersonal racism and creates a policy environment hostile to egalitarian policies. At the individual level, negative stereotypes, supported by cultural racism, fosters health damaging psychological responses such as stereotype threat and internalized racism. Third, the subjective experience of racial discrimination is a historically neglected, but important type of stressful life experience that can lead to adverse changes in health status and altered behavioural patterns that increase health risks.

OBJECTIVES: An association between intimate partner violence and adverse physical health outcomes and health-risk behaviours among women has been established, most scientific research having been conducted in the USA and other developed countries. There have been few studies in developing countries, including South Africa, which has one of the highest rates of intimate partner violence in the world. We therefore sought to study the association between physical intimate partner violence and physical health outcomes and behaviours among South African women. METHODS: Using data from the cross-sectional, nationally representative South African Stress and Health Study, we assessed exposure to intimate partner violence, health-risk behaviours, health-seeking behaviours and chronic physical illness among a sample of 1 229 married and cohabiting women. RESULTS: The prevalence of reported violence was 31%. This correlated with several health-risk behaviours (smoking, alcohol consumption, and use of non-medical sedatives, analgesics and cannabis) and health-seeking behaviours (recent visits to a medical doctor or healer). Intimate partner violence was not significantly associated with chronic physical illness, although rates of headache, heart attack and high blood pressure reached near-significance. CONCLUSIONS: Partner violence against women is a significant public health problem in South Africa, associated with health risk behaviours and increased use of medical services. Public health programmes should incorporate interventions to mitigate the impact of violence on victims and reduce the risk of negative behavioural outcomes. Further investigation of the pathways between violence exposure and health behaviours is needed to inform the design of such programming.

BACKGROUND: Europe and North America have low rates of mental health service use despite high rates of mental disorder. Little is known about mental health service use among South Africans. DESIGN: A nationally representative survey of 4 351 adults. Twelve-month DSM-IV (Diagnostic and Statistical Manual, 4th edition) diagnoses, severity, and service utilisation were determined using the World Health Organization Composite International Diagnostic Interview (CIDI). Twelve-month treatment was categorised by sector and province. South Africans in households and hostel quarters were interviewed between 2002 and 2004 in all nine provinces. OUTCOME MEASURES: 4 317 respondents 18 years and older were analysed. Bivariate logistic regression models predicted (i) 12-month treatment use of service sectors by gender, and (ii) 12-month treatment use by race by gender. RESULTS: Of respondents with a mental disorder, 25.2% had sought treatment within the previous 12 months; 5.7% had used any formal mental health service. Mental health service use was highest for adults with mood and anxiety disorders, and among those with a mental disorder it varied by province, from 11.4% (Western Cape) to 2.2% (Mpumalanga). More women received treatment, and this was largely attributable to higher rates of treatment in women with mood disorders. Age, income, education and marital status were not significantly associated with mental health service use. Race was associated with the treatment sector accessed in those with a mental disorder. CONCLUSIONS: There is a substantial burden of untreated mental disorders in the South African population, across all provinces and even in those with substantial impairment. Greater allocation of resources to mental health services and more community awareness initiatives are needed to address the unmet need.

BACKGROUND: The South African Stress and Health (SASH) study is the first large-scale population-based study of common mental disorders in the country. This paper provides data on the 12-month and lifetime prevalence of these conditions. METHODS: Data from a nationally representative sample of 4 351 adults were analysed. Mental disorders were assessed with the Composite International Diagnostic Interview (CIDI). An extensive survey questionnaire detailed contextual and socio-demographic factors, onset and course of mental disorders, and risk factors. Simple weighted cross-tabulation methods were used to estimate prevalence, and logistic regression analysis was used to study correlates of 12-month and lifetime prevalence. RESULTS: The lifetime prevalence for any disorder was 30.3%, and the most prevalent 12-month and lifetime disorders were the anxiety disorders. The Western Cape had the highest 12-month and lifetime prevalence rates, and the lowest rates were in the Northern Cape. CONCLUSIONS: The SASH study shows relatively high 12-month and lifetime prevalence rates. These findings have significant implications for planning mental health services.

BACKGROUND: There are few reports from South Africa on how common mental disorders may be associated with HIV-related perceptions and behaviours. METHODS: Between 2002 and 2004, 4 351 South African adults were interviewed. Psychiatric diagnoses of depression, anxiety and substance abuse disorders were based on the Diagnostic and Statistical Manual, 4th edition (DSM-IV). HIV-related fears, perceived risk and behaviour change were measured using multi-item scales. We analysed forms of behaviour change that were appropriate for risk reduction (such as changes in sexual behaviour) separately from behaviour changes that were inappropriate to prevent HIV (such as care over things touched or avoiding certain social situations). RESULTS: The presence of any DSM-IV-defined disorder during the previous 12 months was associated with previous HIV testing, increased HIV-related fears, and high levels of perceived risk of HIV. There were no associations between depression, anxiety and substance abuse disorders and appropriate forms of behaviour change for HIV risk reduction. However, individuals with an anxiety or a depressive disorder were more likely to report inappropriate forms of behaviour change. For example, individuals with any depressive and/or anxiety disorders were 1.57 and 1.47 times more likely, respectively, to report avoiding certain social situations to prevent HIV/AIDS compared with those who did not have such disorders (p<0.01 for both associations). DISCUSSION: The lack of appropriate forms of behaviour change to prevent HIV transmission, despite increased levels of HIV-related fear and perceived risk, underscores the need for HIV risk reduction interventions for individuals living with common mental disorders in South Africa.

BACKGROUND: There are limited data on substance use in South Africa. We describe patterns of substance use based on recent, nationally representative data. METHODS: Data were derived from the 2002 - 2004 South African Stress and Health (SASH) study. A nationally representative household probability sample of 4 351 adults was interviewed using the paper and pencil version of the World Health Organization Composite International Diagnostic Interview (CIDI). Data are reported for lifetime use, socio-demographic correlates of use, and age of cohort predicting lifetime use for four classes of drugs. RESULTS: The estimate for cumulative occurrence of alcohol use was 38.7%, of tobacco smoking 30.0%, of cannabis use 8.4%, of other drug use 2.0%, and of extra-medical psychoactive drug use 19.3%. There were statistically significant associations between male gender and alcohol, tobacco, cannabis and other drug use. Coloureds and whites were more likely than blacks to have used alcohol, tobacco and other drugs. Clear cohort variations existed in the age of initiation of drug use; these were most marked for other drugs and for extra-medical drug use. Use of all drug types was much more common in recent cohorts, with a similar cumulative incidence of tobacco, alcohol and cannabis use across age cohorts. CONCLUSIONS: Epidemiological patterns of use for alcohol, tobacco, cannabis, other drugs and extra-medical drugs provide the first nationally representative data. New findings on race and exploratory data on time trends provide a foundation for future epidemiological work on drug use patterns across birth cohorts and population subgroups in South Africa.

There are few data from South Africa and other low- and middle-income countries on how mental disorders in childhood and adolescence may influence different aspects of socio-economic position, including educational attainment. We examined the association between early-onset disorders and subsequent educational achievement in a nationally representative sample of 4 351 South African adults. After adjusting for participant demographic characteristics and traumatic life events, post-traumatic stress disorder, major depressive disorder and substance-related disorders were each associated with increased odds of failing to complete secondary education (odds ratios and 95% confidence intervals 2.3, 1.0 - 5.1; 1.7, 1.2 - 2.5, and 1.7, 1.2 - 2.5, respectively). These data point to the role that early-life mental disorders may play in educational achievement and subsequent socio-economic position over the life course.

BACKGROUND: Although stressful life events (SLEs) are associated with psychopathology, the contribution from distal and proximal events and the specificity of their association with common mental disorders require further exploration. We examined the association of recent life events and past adversities to mood, anxiety, substance use and impulse control disorders in South Africa. METHODS: Data were analysed from the South African Stress and Health study, a population-based study of mental disorders in a nationally representative sample of 4 351 adults. Psychiatric disorders were assessed with the Composite International Diagnostic Interview (CIDI). This included questions covering early and later SLEs (negative life events, relationship stress, partner violence, social strain and adverse events during childhood) and various socio-demographic variables. Logistic regression models were constructed for 3 957 respondents (2 371 female, 1 586 male) with no missing covariate data, to assess life stress and socio-demographic predictors of 12-month and lifetime disorder. RESULTS: Recent negative life events and relationship problems were significant predictors of any 12-month disorder and any lifetime disorder. Physical partner violence predicted any lifetime disorder. There was evidence of specificity for the prediction of mood versus anxiety disorders, with childhood adversity specifically associated with mood disorders but not anxiety disorders. Single marital status was the strongest socio-demographic predictor of any 12-month and any lifetime disorder. CONCLUSIONS: Stressful life events, distal and proximal, contribute significantly and independently to the prediction of major psychiatric disorders among South Africans, underscoring the importance of screening adversities in adults with common mental disorders, and of providing appropriate adjunctive interventions.

BACKGROUND: A nationally representative study of psychiatric disorders in South Africa provided an opportunity to study the association between perpetration of human rights violations (HRVs) during apartheid and psychiatric disorder. Prior work has suggested an association between perpetration and post-traumatic stress disorder (PTSD), but this remains controversial. METHODS: Subjects reported on their perpetration of human rights violations, purposeful injury, accidental injury and domestic violence. Lifetime and 12-month prevalence of DSM-IV (Diagnostic and Statistical Manual, 4th edition) disorders were assessed with Version 3.0 of the World Health Organization Composite International Diagnostic Interview (CIDI 3.0). Socio-demographic characteristics of these groups were calculated. Odds ratios for the association between the major categories of psychiatric disorders and perpetration were assessed. RESULTS: HRV perpetrators were more likely to be male, black and more educated, while perpetrators of domestic violence ( DV) were more likely to be female, older, married, less educated and with lower income. HRV perpetration was associated with lifetime and 12-month anxiety and substance use disorders, particularly PTSD. Purposeful and DV perpetration were associated with lifetime and 12-month history of all categories of disorders, whereas accidental perpetration was associated most strongly with mood disorders. CONCLUSION: Socio-demographic profiles of perpetrators of HRV and DV in South Africa differ. While the causal relationship between perpetration and psychiatric disorders deserves further study, it is possible that some HRV and DV perpetrators were themselves once victims. The association between accidental perpetration and mood disorder also deserves further attention.

BACKGROUND: Mental disorders are a major contributor to the burden of disease in all regions of the world. There are limited data on the epidemiology of major depressive disorder in South Africa. METHODS: A nationally representative household survey was conducted between 2002 and 2004 using the World Health Organization Composite International Diagnostic Interview (CIDI) to establish a diagnosis of depression. The dataset analysed included 4 351 adult South Africans of all racial groups. RESULTS: The prevalence of major depression was 9.7% for lifetime and 4.9% for the 12 months prior to the interview. The prevalence of depression was significantly higher among females than among males. The prevalence was also higher among those with a low level of education. Over 90% of all respondents with depression reported global role impairment. CONCLUSION: In comparison with data from other countries, South Africa has lower rates of depression than the USA but higher rates than Nigeria. The findings are broadly consistent with previous findings in South Africa. These findings are the first step in documenting a level of need for care in a context of significant under-funding of mental health services and research in South Africa.

Raça tem sido amplamente utilizada em estudos sobre desigualdades em saúde e assistência, principalmente nos Estados Unidos. Diversos problemas relativos à validade e confiabilidade da mensuração de raça são relevantes para o campo da saúde pública. Este artigo faz uma revisão da literatura sobre o conceito e mensuração de raça e compara como os achados se aplicam aos Estados Unidos e ao Brasil. Os autores discutem em detalhes diversas questões da qualidade dos dados relacionadas à mensuração de raça e os problemas levantados pela mensuração de raça em sociedades multirraciais como o Brasil. Além disso, analisam como essas questões se aplicam à saúde pública, e formulam recomendações sobre a mensuração de raça em registros médicos e pesquisa em saúde pública.

Race has been widely used in studies on health and healthcare inequalities, especially in the United States. Validity and reliability problems with race measurement are of concern in public health. This article reviews the literature on the concept and measurement of race and compares how the findings apply to the United States and Brazil. We discuss in detail the data quality issues related to the measurement of race and the problems raised by measuring race in multiracial societies like Brazil. We discuss how these issues and problems apply to public health and make recommendations about the measurement of race in medical records and public health research.

Raça tem sido amplamente utilizada em estudos sobre desigualdades em saúde e assistência, principalmente nos Estados Unidos. Diversos problemas relativos à validade e confiabilidade da mensuração de raça são relevantes para o campo da saúde pública. Este artigo faz uma revisão da literatura sobre o conceito e mensuração de raça e compara como os achados se aplicam aos Estados Unidos e ao Brasil. Os autores discutem em detalhes diversas questões da qualidade dos dados relacionadas à mensuração de raça e os problemas levantados pela mensuração de raça em sociedades multirraciais como o Brasil. Além disso, analisam como essas questões se aplicam à saúde pública, e formulam recomendações sobre a mensuração de raça em registros médicos e pesquisa em saúde pública.

Race has been widely used in studies on health and healthcare inequalities, especially in the United States. Validity and reliability problems with race measurement are of concern in public health. This article reviews the literature on the concept and measurement of race and compares how the findings apply to the United States and Brazil. We discuss in detail the data quality issues related to the measurement of race and the problems raised by measuring race in multiracial societies like Brazil. We discuss how these issues and problems apply to public health and make recommendations about the measurement of race in medical records and public health research.