The murder of George Floyd by a white police officer kneeling on his neck for nearly nine minutes, with three other officers enabling the death, was both a heinous act and a vivid metaphor for what racism is doing to the health outcomes of racialized persons in the United States, and how we as a country have been responding. The burgeoning public health research examining the differential impact of racism on Americans’ health has established beyond doubt that racial discrimination, in multiple forms, leads to higher levels of disease and shorter lifespans for people of color. If we are to end this pattern, we need to grasp the complexities of how racism has these impacts, and understand which interventions will have lasting effects versus which will simply prompt new mechanisms for racist outcomes.
Structural racism and health
Racism is a structured system that interacts with other social institutions, shaping them and being reshaped by them, to reinforce, justify, and perpetuate a racial hierarchy. This interconnectivity yields structural or systemic racism, in which “multiple societal systems, including the housing, labor, and credit markets, and the education, criminal justice, economic, and health care systems all support and reinforce racism. In the context of health, this means that not only does racism lead to poorer health outcomes for racialized individuals, but the healthcare system itself bolsters and perpetuates the racist superstructure.
Consider these findings:
- 40% of the healthcare equality measures from the Agency of Healthcare Research and Quality report are worse for African Americans.
- Black men experiencing chest pain wait longer for an initial EKG than white men.
- Black women are two to six times more likely to die from complications of pregnancy than white women.
- Doctors are less likely to prescribe pain medication and appropriate treatment to Black patients than to white.
- Black men are 50% more likely to get prostate cancer than white men and twice as likely to die from it.
- 31% of white children with mental health problems receive mental health services while only 13% of minorities do.
- Black infant mortality rate is 2.5x that of their white counter parts.
- Higher levels of chronic stress response are present in communities of color, which can contribute to a vast array of negative health outcomes, from depression and migraines to heart disease and hypertension.
Daily occurrences of micro-aggressions, residual effects of intergenerational trauma, and blatant acts of racism are all harmful to the health of people of color.
Sociologists have convincingly argued that socioeconomic status (SES) is a key factor for health. It intuitively makes sense that if we are better off economically, we will have access to better food, housing, employment, and medical care than if we were poor; and if we are higher up the social hierarchy, we will be more likely to have access to the education and opportunities that will lead to economic wealth and security. It’s a tidy feedback loop, and SES certainly plays a role in health. Yet recent studies have yielded a more complex picture, in which racial and ethnic inequities in health persistent across the SES spectrum. For example, at age 25, African Americans have a lower life expectancy than whites, and Hispanics, at every level of income and education. Further, African Americans with a college degree or beyond still have a lower life expectancy than whites and Hispanics who did not go beyond high school. Clearly, additional factors are at work. Research is increasingly showing that these factors are also tied to and underpinned by racism.
Segregation has been increasing in America since 2010, when it was at a 100-year low. We know that segregation is a driver of disparities in SES, which in turn affect health outcomes. A national study of segregation found that its elimination would remove black–white differences in education, unemployment, and income, and would reduce by two-thirds racial differences in single motherhood.
In 2011, a review of almost 50 empirical studies found an association between segregation and poorer health. A few years later, a 2017 meta-analytical review of 42 articles on birth outcomes and segregation determined that for Blacks, segregation was associated with a greater rick of preterm birth and low birth weight. Reviewers of 17 papers on links between cancer and segregation found it to be positively associated with later-stage diagnosis, higher mortality, and lower survival rates for lung and breast cancers in Black patients. A 25-year longitudinal study of incident obesity in African Americans found that cumulatively higher exposure to segregation was associated with a higher risk of obesity for Black women than Black men.
Cultural racism refers to a belief that intrinsic and insurmountable cultural differences exist between races. As the scientific validity of biological racism has been undermined by empirical proof, cultural racism has taken its place, with highly negative consequences for the health of minority groups.
Cultural racism can fuel social policies that lead to differential access to opportunities. It can reinforce segregation when, for example, white residents who hold negative stereotypes about Blacks choose not to live in “mixed” neighborhoods. This form of racism can also manifest as unconscious bias at the individual level. In a clinical healthcare setting, this may result in white patients receiving better medical care than people of color. The 2019 review cited earlier found that “across virtually every type of diagnostic and treatment intervention blacks and other minorities receive fewer procedures and poorer-quality medical care than do whites.” Further, physicians with higher implicit bias scores made biased treatment recommendations and engaged in poorer verbal and nonverbal communication when caring for Black patients.
The stereotypes resulting from cultural racism can generate anxieties and negative expectations in those being stigmatized; this is referred to as “stereotype threat.” When the person who is stigmatized accepts these stereotyped beliefs about their own inferiority, internalized racism results. As studies of stereotype threat increase, some evidence indicates that it can cause anxiety, problems with self-regulation, compromised decision making, and unhealthy choices that may cascade into substance abuse, depression, and obesity. Further research is needed to understand when and how internalized racism adversely affects health, what negative health outcomes it can have, and what groups are most vulnerable to it.
Research to develop effective interventions
To develop effective, lasting interventions, we need more research into how structural racism adversely affects health. A 2014 study of structural racism and myocardial infarction (MI) used four state-level measures of structural racism: political participation, employment, education, and judicial treatment. The researchers found that racism-based disparities that disadvantaged African Americans in political representation, employment, and incarceration were associated with a higher risk of MI; in the case of whites, structural racism was unrelated to or even had a beneficial effect on their risk of MI.
Immigration policy is emerging as another vehicle for structural racism, with adverse effects on health outcomes. Anti-immigrant policies can catalyze hostility in the public, generating psychological distress and, potentially, physical harm for those directly and indirectly affected by the policies. A study that examined the effect of a large federal immigration raid on a community found, in the year after the raid, an increased risk of low birth weight among infants of Latina mothers but no increase for infants of white mothers.
We also need to look at why elevated levels of racial prejudice in communities can be associated with poorer health not just for racial minorities but for all persons who live in that community.
The bottom line is that racism in America is leading to poorer health, unequal healthcare treatment, lower quality of life, and shorter lifespans for people of color. African Americans are still at risk for the same level of unemployment in 2020 as they were in the 1960s, with all of the cascading negative effects that joblessness and poverty bring. If our nation continues to aid and abet structural racism, or turn a blind eye to it, then we are as complicit in the undermining of minority health and lives as the four ex-Minneapolis police officers awaiting trial.