Structural Racism Costs Lives

Structural Racism Costs Lives

By Jim Windell

           Given the growing strength of the Black Lives Matter movement, there is also a growing recognition that racism is a durable feature of U.S. society – and that racism and that it has health consequences for people of color.

           Writing in a recent issue of the New England Journal of Medicine, Zinzi Bailey, Sc.D., M.S.P.H., Justin M. Feldman, Sc.D, and Mary T. Bassett, M.D., M.P.H., describe how structural racism works and why racist policies are a root cause of the health inequities in this country.

           The authors acknowledge that there is no official definition of structural racism — or of the closely related concepts of systemic and institutional racism — although many definitions have been offered. All definitions, they point out, make it clear that racism is not simply the result of private prejudices held by individuals, but is also produced and reproduced by laws, rules, and practices. And that these laws, rules and practices are sanctioned – and even implemented – by various levels of government, and embedded in the economic system as well as in cultural and societal norms. Confronting racism, the authors argue, therefore, requires not only changing individual attitudes, but also transforming and dismantling the policies and institutions that undergird the U.S. racial hierarchy.

           What are those policies and institutions that prop up racism? Bailey, Feldman and Bassett suggest that principally they are redlining and racialized residential segregation, mass incarceration, police violence, and unequal medical care. They then go on to discuss each of these in detail.

           In terms of redlining and racialized residential segregation, they point out that in the early 1930s, the federal government established the Home Owners’ Loan Corporation (HOLC) to expand homeownership as a part of recovery from the Great Depression. But HOLC created maps of at least 239 U.S. cities, drawing red lines (hence “redlining”) around communities with large Black populations. These areas were flagged as hazardous investment areas whose residents should not receive HOLC loans. That meant that mortgages were less accessible to minorities and, thus, prospective Black homebuyers were made vulnerable to predatory terms. In turn, that reduced their access to home ownership while depriving these communities of an asset that is central to intergenerational wealth transfer.

           Redlining, along with other government-sanctioned practices, created residential racial segregation, which to this day remains a powerful predictor of Black disadvantage. The authors point out that there is a direct legacy of redlining in health and wellbeing which includes preterm births, cancer, tuberculosis, maternal depression, and other mental health issues. These all occur at higher rates among residents of once redlined areas.

           We’ve all become much more aware of mass incarceration and police violence in the past several years. Most of us know that the U.S. has the world’s highest incarceration rate, and that police in this country kill civilians far more often than do police in other wealthy countries. A large body of scientific research documents both racially unequal outcomes and racial bias in virtually all aspects of the criminal legal system. Black people experience harsher outcomes in relation to police encounters, bail setting, sentence length, and capital punishment than do White people.

           The health outcomes of mass incarceration and police violence are significant for Black people. Obviously, some of these outcomes are direct; the police kill hundreds of Black people every year – and many more are injured. But incarcerated people — who are disproportionately Black — face a high risk of death after release, and prisons and jails have been major sites of disease transmission during the Covid-19 pandemic. The indirect effects are also devastating. For instance, police violence can harm the mental health for entire communities through constant surveillance and the ever-present threat of violence.

           The roots of racial inequities in health care go back generations and persist to this day. In its 2003 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the Institute of Medicine reviewed more than 100 studies and concluded that bias, prejudice, and stereotyping contributed to widespread differences in health care by race and ethnicity. Bailey, Feldman and Bassett note that that call to action went largely unheeded. Fifteen years later, the 2018 National Healthcare Quality and Disparities 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 the quality measures included, with little to no improvement from decades past.

           The reason for this unequal treatment, the authors contend, is based, at least in part, on enduring racist cultural beliefs and practices. For instance, in a 2016 study to assess racial attitudes, half of White medical students and residents held unfounded beliefs about intrinsic biologic differences between Black people and White people. These false beliefs were associated with assessments of Black patients’ pain as being less severe than that of White patients and with less appropriate treatment decisions for Black patients.

           A common response to the calls to action by Black Lives Matter or other community groups is to deny that structural racism exists or to minimize it by attributing things that are racial to a “few bad apples.” However, the authors of this article dismiss those explanations and suggest that actions to dismantle racism will necessarily involve the whole of society. We must, they say, move beyond individual education and personal insight to change policy and social norms. But that will require the engagement of many institutions. However, they state that the medical and public health communities can contribute directly in at least four key areas.

           Those areas and the recommendations are 1.) embracing the intellectual project of documenting the health impact of racism; that racism and inequities in social determinants of health more generally are topics that are valid for research; 2.) improving the availability of data that include race and ethnicity, and supporting the efforts to develop and improve measurement of structural racism; 3.) having the medical and public health communities looking at themselves, as individuals and as institutions, and better understanding how they continue to participate in racist practices; and 4.) acknowledging that structural racism has been challenged, perhaps most successfully, by mass social movements, and that meaningful change will require policies that restructure the chances for a healthy life for people of color, and actively working to right the wrongs done by the foundational racial hierarchy that continue to shape everyday life.

            To read the article in the New England Journal of Medicine, find it at:

Bailey, Z.D., Feldman, J.M. & Bassett, M.T. (December 16, 2020). How Structural Racism Works — Racist Policies as a Root Cause of U.S. Racial Health Inequities. The New England Journal of Medicine,DOI: 10.1056/NEJMms2025396

Share this post:

Comments on "Structural Racism Costs Lives"

Comments 0-5 of 0

Please login to comment