How Structural Racism Works — Racist Policies as a Root Cause of U.S. Racial Health Inequities

Introduction

The Black Lives Matter movement has put the spotlight on the costly impact of racism on Black lives and led to a growing recognition that racism has a structural basis and is embedded in long-standing social policy. Racism is not ahistorical and neither are U.S. health care and public health institutions and practices. Drs. Bailey, Feldman and Bassett argue that structural racism is a legacy of African enslavement and affects both population and individual health. They offer three examples of structural domains that continue to lead to poorer health outcomes for Black Americans: (1) redlining and racialized residential segregation, (2) police violence and the carceral state, and (3) unequal health care

Dr. Zinzi D. Bailey, ScD, MSPH, is a social epidemiologist, an Assistant Professor at the University of Miami, and Managing Director at Health Equity Research Solutions, LLC. Dr. Justin M. Feldman, ScD is a Research Associate and former Health and Human Rights Fellow at the François-Xavier Bagnoud (FXB) Center for Health & Human Rights at Harvard University. Dr. Mary T. Bassett, MD, MPH is the Director of the FXB Center, the FXB Professor of the Practice of Health and Human Rights at the Harvard T.H. Chan School of Public Health, the Health Commissioner for the State of New York, and a former Health Commissioner for New York City.

Methods and Findings

The authors point out how structural racism functions to harm health in ways that can be “described, measured, and dismantled.” They provide examples of how these functions can be described and measured by providing historical context and tying the history of three specific domains with current health outcomes. 

Redlining and racialized residential segregation 

• Historically, health inequities can be traced back to the policy of redlining, the federally-sanctioned practice of drawing red lines around communities with large Black populations, denying home ownership loans and limiting financial investments. This financial disinvestment led to residential segregation and poorer health outcomes in Black neighborhoods. 
• Presently, racial segregation in housing remains a powerful predictor of Black disadvantage in health, documented with poorer outcomes in preterm birth, cancer, tuberculosis, maternal depression, and other mental health issues. 

Police violence and the carceral state 

• The history of modern US policing is rooted in slave patrols first established in the 18^th century. Since then, policing has continued to disproportionately affect Black Americans negatively, particularly through the “War on Crime” and “War on Drugs” era. Policing and incarceration have profound adverse consequences for the health of Black people. 
• From police violence towards Black Americans to the mental health impacts of policing and incarceration on Black individuals and communities, health disparities associated with incarceration and reentry into the community persist. For example formerly incarcerated individuals, who are disproportionately Black, bear a disproportionate burden of sexually transmitted infections, infectious diseases, and the mental health impacts of the threat of violence and surveillance. Incarcerated people also face a high risk of death after release and have been disproportionately impacted by the spread of COVID-19, for example. 

Unequal health care

• Modern health care has evolved from historically racist practices and policies. The healthcare system has long pathologized blackness to justify inhumane practices like whippings and experimentation on Black bodies. White superiority was the basis for falsely perceived differences in skull size between races, sterilization, scientific racism, and the eugenics movement. 
• Unequal treatment in health care remains a contemporary and persistent reality. For example, research has shown that white medical students inappropriately assess or ignore pain  among Black patients compared to white patients. These individual and institutional practices cannot be disentangled from racial segregation policies which lead to disparities in access to high quality medical care and continued experimentation on Black bodies, evidenced by the disproportionate share of medical training programs that provide services in Black communities.

Conclusions

The dismantling of structural racism must involve the whole of society, including health care and public health practitioners, to whom they offer four recommendations. The first (1) is the need to document racism, which includes recommendations to funders, editors, and reviewers to acknowledge that racism and inequities in social determinants of health more generally are valid research topics. Second (2) is the need to improve both the availability of data that include race and ethnicity and the tools to measure structural racism. 

Third (3), they suggest that the medical and public health organizations must turn a lens on themselves, both as individuals and as institutions to reflect and recognize the harms associated with using racial categories uncritically and connecting the history of racism with the healthcare field. Faculty and students need a more complete view of the ways in which medicine and public health have participated and continue to participate in racist practices throughout United States’ history. Finally, (4) the authors conclude that mass social movements are a necessary tool to dismantling racism in health care delivery and public health. Health inequities cannot be separated from the broader, antiracism movement.