In a 2018 interview, Rep. John R. Lewis explained that, despite our nation’s progress, “scars and stains of racism are still deeply embedded in American society.”¹ One of these ‘lasting stains’ is the disproportionate rate of poor health outcomes among racial minority groups. While public health has focused greater attention on addressing these disparities in recent years, the field often stops shy of addressing the discriminatory systems that sustain these inequalities. Because racism is so insidious, those working in public health must recognize the vast and intricate ways in which structural racism, rather than ‘race,’ affects health. This refined focus should be viewed as fundamental in our efforts to achieve health equity in the U.S.

‘Structural racism’ describes reinforcing and overlapping systems of housing, education, employment, health care, and other institutions that create unjust racial hierarchies.² All of these systems, when designed to marginalize certain groups, work in tandem to hinder well-being and flourishing. For years, Black, Indigenous, and Latinx communities have been disproportionately affected by ‘food deserts,’ for example, which limit access to nourishing foods like fresh produce.³ Similarly, toxic waste sites and industrial plants, which are more likely to be placed near these communities, contribute to contaminated air and water and lead to chronic respiratory⁴ and gastrointestinal illness.⁵,⁶ And, within our health systems, a recent study revealed that Black infants are three times less likely to survive birth when cared for by a white physician as a opposed to a Black physician⁷. These examples illustrate a few of the ways in which structures, such as systems of agriculture, housing, and medicine, embody and perpetuate racist ideologies that unfairly impact historically-marginalized racial groups, resulting in significant health disparities along racial lines. These disparities are all the more visible today, as new cases of COVID-19 continue to rise, with 31% of Black and 17% of Latinx respondents reporting that they know someone who has died from COVID-19 compared to only 9% of whites.⁸

Prioritizing Research and Advocacy on Structural Racism

One of the immediate actions we can take in public health to more directly address racial disparities is a commitment to research focused on ‘structural racism’ as a key driver of adverse health outcomes. While this effort is indeed growing, we believe it warrants greater attention. In 2017, a team of researchers reported finding nearly 50,000 articles on ‘race’ in conjunction with ‘health,’ ‘disease,’ or ‘public health’ during a systematic review. When the team replaced the term ‘race’ with ‘racial discrimination’ however, only 2,000 articles were found; a search with ‘structural or systemic racism’ yielded a mere 195 articles.² The dearth of literature on structural racism signals an important shortcoming of current public health knowledge: race has long been used as an important metric when studying population health, but the explicit effects of structural racism that produce differences between races are still under-examined. 

The Center for Antiracist Research at Boston University and the Satcher Health Leadership Institute at Morehouse School of Medicine are two institutions that exemplify this kind of cutting-edge research on structural racism and health equity. In addition to collecting multidisciplinary, multisector data on differential disease burdens, and studying approaches to community engagement, they are also developing socioculturally responsive guidelines, evaluation metrics, and policies to address structural racism, which can be scaled to national and global levels.

Beyond research, structural racism can also be addressed and dismantled through local activism. For example, several U.S. cities, including Los Angeles, Charlotte, and Boston, have recently declared racism a ‘public health crisis.’ These declarations enable increased public funding and support for initiatives that aim to achieve more equitable employment, education, housing, and healthcare opportunities.⁹ Those of us in other cities can also lead the charge, by holding city-wide campaigns, putting pressure on public officials to take a more powerful stance against racism as a barrier to health, and helping to raise public consciousness of the detrimental effects of structural racism.

Methodological and Ethical Questions

Despite contemporary strides made by researchers and activists, efforts to address the  structural causes of health disparities must overcome significant challenges. Racism is entangled not only in some of our most fundamental institutions in the U.S., but it is also deeply-rooted in the attitudes, minds, and behaviors of individuals and communities. Due to the complexity of how implicit biases and power dynamics become ingrained in the way we see, understand, and operate in the world, dismantling structural racism appears particularly intractable when compared to other factors that impact health. Structural racism is also difficult to analyze and ‘quantify’ — more robust research methods and metrics are needed. Finally, ethical concerns also arise in the study of structural racism, including the possibility of re-traumatizing survivors of racial violence and exploiting the experiences of harmed communities for research purposes. These challenges make it all the more urgent for public health researchers and activists to focus our attention on structural racism, rather than dismiss it as an entrenched condition that is ‘too complex’ to combat. We must carefully grapple with these challenges and continue to forge pathways forward.

A Social Determinant of Equity

Understanding the complex and myriad ways in which structural racism affects health will be crucial in overcoming it. Without this understanding, the upstream causes of racial health disparities cannot be adequately addressed. Dr. Camara Phyllis Jones, former president of the American Public Health Association and senior fellow at the Satcher Health Leadership Institute, uses a ‘cliff’ analogy to demonstrate how addressing structural racism helps promote health. Rather than solely focusing our interventions on those who have already ‘fallen off the ‘cliff,’ she argues that we must invest more in preventive measures, such as greater access to fresh produce, local environments free of toxins, and health systems attuned to eliminating racial bias, all of which would move communities of color away from the precipice of poor health. 

Preventive interventions like these address the social determinants of health, the non-biological conditions which shape an individual’s wellbeing.¹⁰ While structural racism has been increasingly described as one of these social determinants, Dr. Jones explains that structural racism may be more aptly described as a social determinant of equity. By this, she means that racism contributes to the political, sociocultural, and historical contexts that result in the stark differences between people’s circumstances.¹⁰ Her powerful reconceptualization of structural racism as a determinant of equity helps to explain the wide-reaching effects of prejudice across a multitude of sectors. Her perspective is particularly relevant for the field of global health, which holds up health equity as a fundamental goal.

Ultimately, global health practitioners, in collaboration with other advocates in the movement for health equity and racial justice, must work together to research, understand, and dismantle racism as a social determinant of health and inequity. By taking proactive steps to address how racist policies and structures undermine the ability of marginalized communities to experience healthy lives, public health – as a discipline – is better equipped to promote health and social justice for all.

— Claire M. Moore & Ashley L. Graham

Notes

1. Lewis JR. Scars and stains of racism are still deeply embedded in American society. Interview, CNN, November 6, 2018. https://thehill.com/homenews/house/415171-john-lewis-scars-and-stains-of-racism-are-still-deeply-embedded-in-american
2. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, & Bassett MT (2017). Structural racism and health inequities in the USA: evidence and interventions. The Lancet, 389 (10077), 1453-1463.
3. Walker RE, Keane CR, & Burke JG (2010). Disparities and access to healthy food in the United States: A review of food deserts literature. Health & place, 16(5), 876-884.
4. Berkovitz C. Environmental racism has left Black communities especially vulnerable to COVID-19. The Century Foundation, May 19, 2020. https://tcf.org/content/commentary/environmental-racism-left-black-communities-especially-vulnerable-covid-19/. Accessed July 20, 2020.
5. Balazs C, Morello-Frosch R, Hubbard A, & Ray I. (2011). Social disparities in nitrate-contaminated drinking water in California’s San Joaquin Valley. Environmental health perspectives, 119(9), 1272-1278.
6. Stillo F & MacDonald Gibson J. (2017). Exposure to contaminated drinking water and health disparities in North Carolina. American journal of public health, 107(1), 180-185.
7. Picheta R. Black newborns more likely to die when looked after by white doctors. CNN, August 20, 2020. https://www.cnn.com/2020/08/18/health/black-babies-mortality-rate-doctors-study-wellness-scli-intl/index.html. Accessed August 21, 2020.
8. Goldstein A & Guskin E. Almost one-third of Black Americans know someone who died of covid-19, survey shows. The Washington Post, June 26, 2020. https://www.washingtonpost.com/health/almost-one-third-of-black-americans-know-someone-who-died-of-covid-19-survey-shows/2020/06/25/3ec1d4b2-b563-11ea-aca5-ebb63d27e1ff_story.html. Accessed July 20, 2020.
9. Declarations of Racism as a Public Health Issue. APHA. https://www.apha.org/topics-and-issues/health-equity/racism-and-health/racism-declarations. Accessed August 24, 2020.
10. Dr. Camara Jones explains the cliff of good health. Urban Institute. https://www.urban.org/policy-centers/cross-center-initiatives/social-determinants-health/projects/dr-camara-jones-explains-cliff-good-health. Accessed July 20, 2020.

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