Structural Racism: A Call to Action for Health and Health Disparities Research

Introduction

Racism matters, and matters profoundly, to understanding the persistent and pervasive disparities in health experienced by racialized populations in the United States and throughout the world.1-3 An ideology of inferiority and organized system of oppression, racism created “race” as a powerful form of social stratification and means of differentially allocating power, resources and opportunities – advantaging and privileging those considered superior and disadvantaging and excluding those considered inferior.4-6

Since colonization, racism has been deeply embedded in the structures, systems and institutions of society in the United States and in other colonized states, with vast and severe consequences for health and health disparities.6-8 Yet, overwhelmingly, empirical research on racism, health and health disparities has focused on interpersonal discrimination as a psychosocial stressor.6,9 Understanding the disproportionate burden of stressor exposure experienced by racialized groups as a result of interpersonal discrimination is important, as is attending to how such discrimination impacts health and health disparities throughout the lifecourse and across generations. However, such discrimination can only be fully understood – and addressed – as an expression of the insidious and pervasive structural racism that is tightly woven into the very fabric of society.6

We must turn far greater attention to this structural racism. Documenting the ways in which structural racism impacts health and health disparities, identifying key modifiable mechanisms, and critically, implementing and evaluating actions to dismantle systemic racism and address associated health effects are urgent and essential tasks. Radical shifts in ways of working in health and health disparities research, policy and practice will be required to achieve this. Without addressing systemic racism as a fundamental cause, health equity will remain an aspirational target not realized.

Structural Racism Illustrated by the Pandemic

Over the last year or so, the COVID-19 pandemic has profoundly changed the world as we knew it in many ways. It has also brought into even sharper view the stark disparities and the White supremacy and structural racism that have long existed.10,11 The pandemic has further highlighted the ways in which racism continues to create the racialized other and shapes the structures and systems of society to produce health disparities. White supremacy and systemic racism well precede COVID-19. They present a far greater and long-standing public health emergency than this recent virus, with a far greater health toll.10-14

Call to Action

This supplement of Ethnicity & Disease is both critical and timely. It provides space to attend to the multiple ways in which structural and systemic racism and discrimination impact minority health and health disparities. It also presents a call to action to reshape research, policy and practice on minority health and health disparities to ensure actionable efforts to address systemic racism are core motivators and outcomes.

This call to action is compellingly made by Gee and Hicken15 who clearly reinforce the limitations of a focus on interpersonal discrimination or on single, specific institutions. They demonstrate how, if health equity is to be achieved, attention must be directed to addressing the total system of structural racism and the underlying set of racialized rules that maintain White supremacy and reinforce racial disadvantage. Doing so is a key task for the field moving forward. Business as usual cannot continue.

Dennis et al16 and Volpe et al17 both provide insightful commentaries to assist in operationalizing the complexities of structural racism within health disparities research. Volpe et al17 show the complex and multiple ways in which online racism influences health and health disparities, reinforcing Gee and Hicken’s15 point that racism and the underlying racialized logic is always finding new forms and settings in which to reinvent and express itself, in this case, in new technologies.

Two empirical articles draw attention to the role of structural racism in child health disparities. Sewell18 finds area level associations between increased childhood illnesses and neighborhoods with less regulated mortgage markets. Stanhope et al19 draw attention to the impacts of immigration enforcement on very preterm birth among US-born and foreign-born Hispanic women across the United States and show that rates of very preterm birth were slightly increased in some counties, primarily in the Southeast (Virginia, North Carolina, South Carolina) although there was no evidence of a global effect of county participation in a 287(g) program. A third empirical paper from Fernández-Esquer et al20 highlights the under-researched issue of wage theft and mental health. Through a small community sample, the researchers demonstrate ways in which this prevalent issue is likely to contribute substantially to mental health for immigrant workers. There is an urgent need to replicate these findings in a broader range of contexts and assess the impact of wage theft on a broader range of health outcomes.

Building evidence for the implementation and effectiveness of interventions to address structural racism and discrimination remains an outstanding priority in the field. Shelton et al21 provide a helpful primer for integrating structural racism and discrimination within implementation science approaches. Two institutional racism interventions, one in a local health department and the latter in a school, are outlined by Duerme et al22 and Allen et al,23 respectively. The latter provides concrete examples of how taking structural racism seriously should transform the day-to-day operations of social organizations.

Conclusion

This special issue of Ethnicity & Disease helps to move the field forward by drawing attention to the multiple ways in which structural racism impacts health and health disparities across conceptual and empirical studies that span observational and interventional designs. It also highlights the critical work that still remains to be done to document and dismantle the powerful ways in which structural racism and White supremacy operate across institutions to create, reproduce and reinvent racialized oppression. We must urgently shift focus away from individuals and institutions in isolation to consider the interconnected nature and total system of racism and its racialized logic and rules.24 Redirecting efforts away from solely describing the problem of systemic racism to identifying key levers for intervention – and critically, implementing and evaluating comprehensive and sustained actions to address systemic racism – must be an urgent priority.