Structural Racism as a Root Cause of U.S. Racial Health Inequities
Medicine and Society: Structural Racism and U.S. Racial Health Inequities
Introduction to Structural Racism
Evolution of Recognition: In the five years since "#BlackLivesMatter — A Challenge to the Medical and Public Health Communities" was published in the Journal (reference 1), there has been a significant shift in recognizing racism as a persistent feature of U.S. society and acknowledging its severe cost in Black lives.
Widespread Adoption of "Black Lives Matter": The slogan has been adopted by elected officials, corporate leaders, academics, and millions of public protestors following the extrajudicial killing of George Floyd (reference 2).
Structural Basis of Racism: This growing recognition highlights that racism has a structural foundation, embedded in long-standing social policy, a concept encapsulated by the term "structural racism."
Definition of Structural Racism: While there is no single "official" definition, multiple definitions exist for structural racism and its related concepts (systemic and institutional racism) (references 3-7).
Key Insight: All definitions clarify that racism is not merely the product of individual prejudices (reference 8) but is actively generated and perpetuated by laws, rules, and practices. These are sanctioned and implemented by various levels of government and are deeply ingrained in the economic system, as well as cultural and societal norms (references 3, 8).
Required Action: Confronting racism necessitates not only changes in individual attitudes but also the transformation and dismantling of the policies and institutions that uphold the U.S. racial hierarchy.
Impact Domains: Structural racism, a legacy of African enslavement, impacts population and individual health across three interconnected areas:
Redlining and racialized residential segregation.
Mass incarceration and police violence.
Unequal medical care.
Cardinal Features of Harms: These examples share common characteristics: their harms are historically rooted, involve multiple institutions, and are sustained by racist cultural stereotypes.
Redlining and Racialized Residential Segregation
Origins: The federal government established the Home Owners’ Loan Corporation (HOLC) in 1933 to boost homeownership as part of Great Depression recovery efforts (reference 8).
Mechanism of Redlining: HOLC created maps for at least 239 U.S. cities to assess mortgage-worthiness. Staff used racial composition to literally "draw red lines" around communities with large Black populations, designating them as hazardous investment areas. Residents in these areas were denied HOLC loans, making mortgages inaccessible.
Consequences for Black Homebuyers: This practice made Black prospective homeowners vulnerable to predatory loan terms, increased lender profits, reduced access to homeownership, and deprived these communities of a crucial asset for intergenerational wealth transfer.
Systemic, Not Personal: Loan officers' individual racial views were irrelevant; the decline of federal mortgages was a government-sanctioned policy.
Validation of Other Racist Practices: Redlining legitimized other discriminatory tactics, including:
Restrictive Covenants: Legal agreements by previous owners that barred Black people from homeownership.
Undervaluing Real Estate: Property in Black neighborhoods was systematically undervalued.
Mob Violence: Against Black individuals who moved into historically White neighborhoods.
End of Official Redlining: Officially ceased with the Fair Housing Act of 1968.
Persistent Impact: Its effects are still evident in the social geography of cities today, serving as a basis for widespread social disinvestment:
Neighborhood Infrastructure: Deficiencies in green space, housing stock, and roads.
Services: Inadequate transport, schools, and garbage collection.
Employment: Limited opportunities.
Predictor of Disadvantage: Residential racial segregation remains a potent predictor of Black disadvantage (references 3, 5, 9).
Direct Health Legacy: A direct connection exists between redlining and diminished health and well-being, with higher rates of:
Preterm birth.
Cancer.
Tuberculosis.
Maternal depression and other mental health issues.
These health issues are concentrated in formerly redlined areas (references 3-5).
Mechanisms for Continued Health Impact: Plausible mechanisms include exposure to environmental toxins (e.g., teratogens, carcinogens, air pollutants) and the cumulative physical impact of concentrated psychosocial stressors (references 5, 9-11).
Evidence: Better HOLC neighborhood grades correlate with lower levels of airborne carcinogens and higher levels of tree-canopy coverage, which mitigates air pollutants and heat (reference 12).
Racial Disparity in Pollution: Predominantly White neighborhoods generally have lower air pollution levels (reference 13), while higher exposures in Black communities contribute to asthma and low-birth-weight outcomes (reference 14).
Cooperation for Redlining: Redlining required collaboration among government agencies, the banking, credit, and real estate industries, private developers, and homeowners.
Cultural Beliefs: This collective action fostered cultural beliefs that Black neighbors would reduce real estate values and increase crime.
Facilitation of Other Structural Racism: The structural racism embedded in segregation perpetuates other forms of injustice, including mass incarceration, police violence, and the unequal distribution of high-quality health care.
Police Violence and the Carceral State
U.S. Incarceration Rates: The United States has the highest incarceration rate globally, and U.S. police kill civilians significantly more often than police in other wealthy nations (references 15, 16).
Racial Bias in Criminal Legal System: Extensive scientific research documents racial bias and unequal outcomes across nearly all facets of the criminal legal system. Black individuals face harsher outcomes in police encounters, bail setting, sentence length, and capital punishment compared to White individuals (references 17, 18).
Historical Role of Institutions: Understanding the deeply punitive and racially unequal nature of the U.S. criminal legal system requires acknowledging the historical role of courts, prisons, and police as institutions designed to maintain racial hierarchy. This has critical, lasting implications for Black communities' health.
Roots in Slave Patrols: Contemporary U.S. policing originated from 18^{th}-century colonial Virginia slave patrols, created to capture runaways and suppress uprisings.
Post-Slavery Reassertion of White Dominance: After the abolition of slavery and the brief progress of the Reconstruction Era, police and prisons became essential instruments for reasserting White dominance, particularly in the South.
Lynching: Law enforcement sanctioned, enabled, and participated in lynching of Black people, often carried out by White mobs under the guise of punishment for crimes, but frequently driven by broader economic and political motives (reference 19).
"Slavery by Another Name": Police and prisons were used by Southern White people to enforce vagrancy laws and the convict-leasing and sharecropping systems, compelling formerly enslaved people back to forced labor (reference 20).
Post-Civil Rights Era Escalation: While lynching and convict-leasing declined by the Civil Rights Acts of 1964:
President Lyndon Johnson declared a "War on Crime" shortly thereafter.
President Richard Nixon followed with a "War on Drugs" in the next decade.
Both initiatives exploited fears about perceived Black criminality.
Mass Incarceration Growth: These developments led to a sevenfold increase in the incarcerated population, with Black people incarcerated at five times the rate of White people (references 21, 22).
Economic Dimensions: Similar to the post-Reconstruction era, mass incarceration had economic benefits, such as expanding prisons to provide employment in White, deindustrialized rural areas (reference 23).
Escalation of Police Violence (Late 1960s): The late 1960s saw a massive surge in police killings of Black men (reference 24).
Modest Restrictions: It wasn't until the 1980s that the U.S. Supreme Court imposed minimal restrictions on police use of force, like ruling it unconstitutional to shoot a fleeing civilian who poses no harm (reference 25).
Entanglement with Segregation: Policing has long been intertwined with other structures that perpetuate racism, such as residential segregation.
Historical Enforcement: Police once enforced racial restrictions in "sundown towns" that excluded Black people after working hours.
Contemporary Targeting: They now disproportionately target Black people who enter White neighborhoods (reference 26).
Example: The police activity leading to Breonna Taylor’s fatal shooting was linked to an "urban revitalization" plan (reference 27).
Adverse Health Consequences: Policing and incarceration have severe adverse impacts on the health of Black individuals:
Direct Effects:
Police use of force kills hundreds of Black people annually and injures thousands non-fatally.
Incarcerated individuals (disproportionately Black) face a high risk of death upon release (reference 28).
Prisons and jails were major sites of disease transmission during the Covid-$19$ pandemic (reference 29).
Indirect Effects:
Police violence can harm the mental health of entire communities due to constant surveillance and threat (reference 30).
The cycle of incarceration can lead to community spread of sexually transmitted infections or other infectious diseases like Covid-$19$ (reference 31).
Critique of Police Reform Alone: The idea that police reform alone will resolve police violence is incomplete and misleading.
Structural Racism Lens: A structural racism perspective reveals that policing and prisons have historically served their intended purpose of social control over the Black population, enforced through violence.
Effective Change: Requires involving other sectors (e.g., mental health, social services) in equitably addressing public safety without necessarily requiring a police response.
Unequal Health Care
Historical Roots in Scientific Racism and Eugenics:
Scientific Racism: Modern American medicine has historical ties to scientific racism and the eugenics movements. Scientific racism solidified the concept of race as an intrinsic biological (and later genetic) attribute, using culturally biased scientific theories (reference 32).
American Scientists: Figures like Samuel Morton perpetuated this, using anatomical features (e.g., skull size) to categorize races, thereby entrenching White superiority (references 32, 33).
Eugenics Movement: Swept the U.S. in the early 20^{th} century, leading to laws against "miscegenation" and forced sterilization of "undesirable races" to create a "better, more intelligent, Whiter nation" (reference 32).
Medical Dehumanization of Black People:
Innately Diseased Narrative: Respected medical doctors portrayed Black people as inherently diseased and dehumanized their suffering, using scientific arguments to create an illusion of neutrality.
Samuel Cartwright (1851): A Southern physician, described "drapetomania," a "mental illness" he claimed caused enslaved Africans to run away. He argued it could be prevented by enforced submission and "cured" by whippings (reference 34).
Dysaesthesia Aethiopica: Cartwright also "discovered" this "disease" in Black people, characterized by reduced intellectual ability, laziness, and partial skin insensitivity (reference 34).
J. Marion Sims: Hailed as the father of modern gynecology, he achieved his advancements in vesicovaginal fistula repair through repeated, anesthetic-free operations on enslaved Black women, who could not provide informed consent (reference 35).
Persistent Racialized Susceptibility: Racialized beliefs about disease susceptibility endure to this day.
Institute of Medicine Report (2003): "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care" reviewed over 100 studies and concluded that bias, prejudice, and stereotyping led to widespread racial and ethnic disparities in health care (reference 36).
Unheeded Call to Action: This report's recommendations were largely ignored.
National Healthcare Quality and Disparities Report (2018): Fifteen years later, this report documented that Black, American Indian and Alaska Native, and Native Hawaiian and Pacific Islander patients continued to receive poorer care than White patients on 40% of quality measures, with little to no improvement over decades (reference 37).
Underlying Racist Beliefs: This unequal treatment is partly rooted in persistent racist cultural beliefs and practices.
2016 Study on Racial Attitudes: Half of White medical students and residents held unfounded beliefs about intrinsic biological differences between Black and White people. These false beliefs correlated with assessing Black patients' pain as less severe and providing less appropriate treatment (reference 38).
Systemic Disinvestment: Individual prejudice alone cannot explain substandard care.
Under-resourced Facilities: Systematic disinvestment in public and private sectors within segregated Black neighborhoods has led to under-resourced facilities with fewer clinicians, making it challenging to recruit experienced primary care providers and specialists.
Impact on Access: This directly affects access to and utilization of healthcare services (reference 3).
American Medical Caste System: Black communities historically became medical training grounds and sources of profit, reinforcing the current American medical caste system.
Widespread Contribution to Inequity: Regardless of intent, actions by medical schools, providers, insurers, health systems, legislators, and employers have collectively ensured that racially segregated Black communities receive limited and substandard care (reference 3).
Acceptance as "Normal": The acceptance of this inequitable treatment as "normal" is historically entrenched and supported by the belief that Black people are inherently disease-prone and implicitly or explicitly undeserving of high-quality care.
Beyond "Bad Apples": Dismantling structural racism's impact on health care means moving beyond blaming a few individuals. It requires critical reflection on how everyday, accepted practices reify race (treating the social construct of race as an intrinsic biological difference), thereby exemplifying and contributing to a broader system of structural racism.
Our Role in Dismantling Structural Racism
Pervasiveness of Structural Racism: Structural racism dates back to the origins of U.S. history, permeates its institutions and economy, and resides within American culture.
Perception of Black Disadvantage: Its durability fosters the perception that Black disadvantage is intrinsic, permanent, and therefore normal.
Measurable Impact: Structural racism is not an amorphous "miasma"; it harms health in ways that can be described, measured, and dismantled.
Societal Effort Required: Actions to dismantle racism necessarily demand the engagement of all society.
Beyond Individual Education: Moving beyond individual education and personal insight to change policy and social norms requires the involvement of many institutions, but the medical and public health communities have a direct role in at least four key areas:
Embracing the Intellectual Project of Documenting Racism's Health Impact
Marginalized Research: Despite a long history, empirical research demonstrating racism's health impact is rarely published in major medical journals.
Convincing Evidence: The authors find the evidence of structural racism's health effects convincing, supported by over a century of scholarship, yet it remains marginalized by other research priorities (references 3-6, 39).
Limited Publication: When major medical journals address structural racism, it's often in commentaries or editorials, treating it as a discussion topic rather than a subject for discovery.
Broad Agreement Needed: Funders, editors, and reviewers must agree that racism and health inequities linked to social determinants are as valid for research as biological markers (and can be combined with them).
Improving Data Availability and Measurement of Structural Racism
Enhanced Data: Efforts to improve data collection, including race and ethnicity, are essential.
Support for Measurement Development: Initiatives to develop and refine measurements of structural racism, especially using administrative databases, need support and encouragement (references 6, 40-44).
Self-Reflection for Medical and Public Health Communities
Comprehensive History: Faculty and students require a more complete understanding of U.S. history and how medicine and public health have participated in and continue to perpetuate racist practices.
Critical Use of Racial Categories: Reflection includes acknowledging the harms of uncritical use of racial categories, which reinforces implicit assumptions of genetic origins for racial differences.
Measuring Success: Interventions should be evaluated based on how effectively they narrow inequitable health gaps (specifically between Black and White people), rather than solely focusing on overall population improvements.
Research Standards: Rigorous standards for publishing research on racial health inequities have been proposed (reference 45).
Address Underrepresentation: Actions to address the increasing underrepresentation of Black students in medical school (reference 46) and the disadvantages Black researchers face in securing National Institutes of Health awards (reference 47) should not be delayed.
Challenging Claims: Claims regarding an inadequate pool of qualified Black applicants for recruitment, hiring, and promotion should be questioned.
Acknowledging the Role of Mass Social Movements
Catalyst for Change: Structural racism has been most successfully challenged by mass social movements.
Policy Restructuring: Change requires policies that fundamentally restructure opportunities for a healthy life for people of color, correcting the historical injustices of foundational racial hierarchy that still shape daily existence.
Medical Community's History: Organized medicine and public health have a history of opposing desegregation and broader access to care (e.g., Medicare), barring Black physicians, advocating scientific racism, and codifying race as a biological variable.
Rectifying Wrongs: These fields have much to regret but also much to offer in rectifying historical wrongs and should actively engage in this work.