Open Access Research Article
THE IMPACT OF RACISM ON HEALTH DISPARITIES.
Published Paper
Article Details
THE IMPACT OF RACISM ON HEALTH DISPARITIES.
AUTHORED BY
- PRAPTI JALPAN SHAH
Abstract:
Race functions as an essential health disparity creator between various
communities of different ethnicities. This study investigates the connection between system-based racism and health inequalities through research
about how institutional barriers and structural inequalities with interpersonal discrimination affect health
service access and healthcare delivery effectiveness and result outcomes. The
study conducts a literature review which emphasizes both socioeconomic position
and environmental contamination and stress-caused medical conditions in
addition to medical sector discrimination. The study presents policy solutions
for eliminating health inequalities alongside advancing racial health equality.
Racism is not always conscious, explicit, or readily visible— often it is
systemic and structural. Systemic and structural racism are forms of racism
that are pervasively and deeply embedded in systems, laws, written or unwritten
policies, and entrenched practices and beliefs that produce, condone, and
perpetuate widespread unfair treatment and oppression of people of colour, with
adverse health consequences. Examples include residential segregation, unfair
lending practices and other barriers to home ownership and accumulating wealth,
schools’ dependence on local property taxes, environmental injustice, biased
policing and sentencing of men and boys of colour, and voter suppression
policies. This article defines systemic and structural racism, using examples;
explains how they damage health through many causal pathways; and suggests
approaches to dismantling them. Because systemic and structural racism permeate
all sectors and areas, addressing them will require mutually reinforcing
actions in multiple sectors and places; acknowledging their existence is a
crucial first step.
Keywords: Racism; Discrimination; Health
Disparity; Race; Ethnicity; Immigrant; Social
Determinants; Inequity.
Introduction
Health discrepancies exist throughout worldwide societies because of the
long-lasting and structural social inequalities that persist. Racism,
as a social determinant of health, influences multiple facets of healthcare
access, delivery, and outcomes. This research examines how racism affects
health inequalities and proposes governmental approaches to lessen its negative
effects. Health inequities among racial minorities are pronounced, persistent,
and pervasive (Sondik et al., 2010). Racism may be one cause of these
inequities. Studies find that individuals
who report experiencing racism
exhibit worse health than people who
do not report it (Williams
and Mohammed, 2009). While this line of research has been invaluable in shifting the discussion from innate differences in biology or
culture to social exposures, it is limited by inadequate attention to the
multiple dimensions of racism, particularly structural racism. Theories of institutional
racism give preminence to racism that is embedded within normed and often
overlooked policies and practices of organizations and structures, and structural
racism expands upon this perspective to consider how the interactions among
institutions produce racialized outcomes (Bailey, Krieger, Agenor, Graves,
& Bassett, 2017; Williams and Collins., 1995;
Williams et al., 2019).
Despite evidence of narrowing
in recent years (Cunningham et al.,
2017), the racial mortality gap remains large, with life expectancies for black
males and black females 4.4 years and 2.9 years lower than their white
counterparts (NCHS 2018).
METHODS
Critical Review Methodology:
We conducted a broad-scope critical review of the extant health
disparities literature across three areas of clinical pathology interest:
communicable diseases; non-communicable conditions; and injuries. The review was conducted through
a race-conscious lens to examine the impact of race on health
outcomes and inform a conceptual framework for the development of actionable
steps and practice recommendations.
Critical reviews include “a degree of analysis and conceptual innovation”
resulting in a product capable of launching a new phase of evaluation.11 According to Grant
and Booth, the critical review does not call for a systematic evaluation
of all the literature related to a topic, but rather the emphasis is on the
contribution of each piece of evidence included to the review’s conceptual
product.11 As
described by the Search, Appraisal, Synthesis, and Analysis framework, critical reviews are designed to identify key findings in the field of interest (health disparities literature), evaluate the
evidence in accordance with its contribution (racial health disparities
attributable to SDoH), synthesize the evidence in organized fashion
(clinical pathology interests
relevant to EM), and provide
a conceptual output of
analysis that contributes to the literature (actionable steps and practice recommendations).
Results
Final structural racism model:
The model with the best fit was a single
factor model that contained seven indicators (one from each domain) and one
correlated error term. The final model is displayed in figure. The fit
statistics for the final model were excellent, with a root mean square error
of approximation of 0.049,
a confirmatory fit index of 0.984, a Tucker-Lewis fit index of 0.974,
and a standardized root mean square residual of 0.073. All factor loadings were
statistically significant at the p<0.06 level. The final standardized factor
scores can be interpreted as the number of standard
deviations a state's
structural racism score
is from the mean for all states.
Figure 1. Diagram of final factor analysis
model. Oval shape indicates the latent variable of structural racism.
Rectangular boxes represent the exogenous variables, in this case, indicators covering each of the seven domains of structural racism
considered in this model.
Case study: negative race-exposure interaction terms
The four examples
provided in are not exhaustive of all
possible race-exposure interaction scenarios. These relatively
simplistic examples miss other nuances that health disparities researchers may
encounter. Consequently, we will discuss a particular scenario we have observed
in the literature that often confuses researchers investigating racial health disparities.
When the more socially advantaged group is
the referent, presence of negative interaction indicates that a deleterious
exposure-outcome relationship is stronger among the more advantaged group,
as was the case in scenario
C (interaction present,
but exposure does not
contribute to the disparity). However,
the higher exposure
and outcome burden
may still be carried by the disadvantaged group.
One such example of this has emerged from the cardiovascular health
literature. In a sample of 6134 individuals recruited from 50,844, Liu et al.
aimed to evaluate the relationship between diabetes mellitus and uncontrolled blood pressure. Although this study
contrasted Mexican Americans, blacks, and whites, for consistency with our
previous examples, we will focus specifically on the black and white
comparison. In this article, the authors introduced an interaction term between
diabetes and race into their
model and found
a significant interaction; the association between diabetes and uncontrolled blood pressure was stronger among whites than
among blacks. From these results, the authors concluded that “health providers
need more efforts to weaken the association of diabetes
with uncontrolled blood pressure outcomes
by further improving
care for diabetes and blood
pressure in non-Hispanic whites.” In a health disparities context, such a
suggestion should give one pause and warrants further investigation.
Using our initial guiding questions, Tables 1
and 2 provided by Liu et al., and outside literature regarding uncontrolled
blood pressure, we see that uncontrolled blood pressure is more prevalent among
blacks than whites, diabetes prevalence is higher among blacks than whites, and
there is an overall association between diabetes and
uncontrolled blood pressure that is positive in both race groups but varies in
magnitude. The information gained from asking
these questions illustrates the scenario depicted
in. Although the presence of negative
interaction indicates that the association may be stronger in non-Hispanic
whites, blacks suffer the greater burden of both exposure and outcome. Thus,
from a health disparities standpoint, the assertion that the white sample
population should be targeted over the black sample population is troubling as it
could lead to inappropriate redistribution of intervention
resources and widening of racial disparities in uncontrolled blood pressure
prevalence. This example further demonstrates the danger of drawing conclusions regarding health disparities based on interaction term
significance alone and highlights the importance of additionally considering
the exposure and outcome distributions in a health disparities context.
Case study of a
racial health disparity interaction analysis found in the literature, examining
the relation between diabetes mellitus and uncontrolled blood pressure and
whether this association varies by race. This represents a scenario
where the interaction term
indicates that the exposure-outcome
relationship is stronger among the more advantaged group (captured by the
steeper slope of the dashed line), yet the high exposure prevalence among the
more disadvantaged group suggests that the exposure may be disparity-producing nonetheless. The exposure is indicated along the x-axis and the outcome
along the y-axis. The simplified, dichotomous race classification is denoted by
a solid line for the black sample and a dashed line for the white sample. The
circles represent the proportion of each racial group at each level of exposure
so that equally sized circles indicate that equal proportions of the racial
group are exposed and unexposed. Larger circles represent a larger proportion
exposed (or unexposed).
Discussion
To our knowledge, this is just the second
paper to use a latent measure of structural racism at the state level and to examine
the relationship between this measure and a wide array of racial health disparities.
It expands on the previous paper by
examining the association of structural
racism with Black-White racial disparities in documented mortality outcomes,
rather than subjective measures of general and mental health. It
also advances our own previous research that examined the link between
structural racism and racial health disparities at the state level, but used an index
that merely averaged
indicators across domains of structural racism, arbitrarily
assuming equal weights for each indicator. We found a significant relationship
between higher levels of the latent structural racism measure and greater
disparities between non-Hispanic Black and non-Hispanic White people in age-
adjusted death rates from firearm homicide, infant mortality, HIV, obesity, and
asthma, but not in death rates from hypertension, stroke, diabetes, and kidney
disease.
These results are consistent with our
previous paper, which found a significant relationship between structural
racism and state-level racial disparities in death from firearm homicide,
infant mortality, HIV, obesity, and asthma, but not for diabetes or kidney disease.
However, that paper did find
a small but significant relationship for hypertension and stroke which we
do not find here.
The magnitude of the
observed association between structural racism and Black-White racial health disparities was greatest
for firearm homicide
and HIV mortality. Our regression model predicts that holding all other variables constant, as a
state's structural racism factor score increases from one standard deviation
below the mean to one standard deviation above the mean, its Black-White
firearm homicide rate ratio increases from approximately 5 to 15.
Similarly, as a state's structural racism
factor score increases from one standard deviation below the mean to one standard
deviation above the mean, its Black-White HIV death rate ratio increases from approximately 7
to 10.
The implications of these findings
can perhaps be appreciated best by
a comparison between New Jersey (the state with the highest
standardized structural racism
factor score [+2.2])
and Georgia (the continental state with the lowest standardized
structural racism factor score [- 1.2]). Although compared to Black people in
Georgia, Black people in New Jersey have a higher median household income
($55,453 vs. $46,964), a lower poverty rate (16.4% vs.
20.1%), and a lower incarceration rate (673 vs. 866),
the Black firearm homicide rate in
New Jersey is nearly five times higher than in Georgia, and the Black
HIV death rate is twice as high.
Connecticut has the second highest
standardized structural racism score at +2.04. This is primarily a result of
its extremely high incarceration ratio of 10.1 and its voter felony
disenfranchisement ratio of 11.6. In fact, Connecticut has the highest
Black-White ratio of felony disenfranchisement of any state along with the
fourth highest Black-White incarceration ratio. The ACLU of Connecticut writes
that: "Because of systemic racism, Connecticut's incarceration and policing
systems most harm Black and Latinx people, its budgets invest in over-policing
and prisons at the expense of opportunity, and barriers to voting access
most disenfranchise Black and Latinx voters." Connecticut has a long history of disenfranchisement of people who are
Black. The original state Constitution in 1818 only allowed voting by white
males. Connecticut did not in fact grant the right to vote to Black people
until 1876, after the 15th Amendment was ratified. This stands in
contrast to laws in every other New England state, which allowed Black people
to vote as of 1855. Connecticut has the highest incarceration rate of any New
England state, and three-fourths of its inmates are either Black or Latinx.
The ‘subjectivist’ way of dealing with the topic of racism in discussions
leads to problems because the objective
existence of racism is called
into question when habitual expectations for clear-cut textbook
knowledge, criteria and definitions are not met. Additionally, the empirical
findings connected to the ‘subjectivist’ approach point to several difficulties
that medical students encounter regarding the understanding and use of racialised categorisations such as ‘Rasse’, ‘race’. Problems
connected to the wide range,
vagueness and inadequacy of human categorisations are not specific
to medical students but are also described for the general context of life
sciences in Germany [127]. Regarding the relation of racialised categorizations
and racism, the use of racialised categorisations such as ‘race’ or ‘Morbus
mediterraneus’ is seen as somehow problematic and vaguely associated with
racism.
However, due to uncertainty
about what racism is, who is affected by racism
and how to deal with
racialised categorisations in the clinical environment, the evaluation of the
whole topic is afflicted with uncertainty and subjectivism. This mirrors
knowledge gaps among medical students about the concept of racism and other
forms of discrimination.
Furthermore, our results can help to understand difficulties that may
arise when different ways of dealing with the topic interact in medical
students’ discussions of racism. Opposing or
even conflicting orientations can lead to controversial discussions. However, they may also impede the development of a
collective conclusion or even the achievement of a mutual understanding.
Discussions then take more parallel patterns of shared opinions and lack true
interaction between participants. In our groups, we observed that some medical
students were not used to being considerate regarding potentially
discriminating or devaluing effects of their
statements on people
who personally experience racism. In particular, this holds true for
objectivistic views on racialised
groups like the ones promoted by ‘scientistic’ arguments,
or the handy heuristics employed in the ‘pragmatic’ approach. The somewhat
naïve do-gooder attitude of the ‘interculturalist’ perspective can also effectively prevent critical self-reflection and a considerate habitus in discussions of racism. Such ways of dealing with the
topic often caused indignation and
were vehemently criticised by other participants in our groups.
However, there were also insecure
students who were self-conscious and had difficulties expressing their thoughts
about racism out of fear of saying
something wrong or hurting somebody. Especially in interactions between
‘subjectivist’ and ‘critical’ attitudes, the inhibitions of the former can be
intensified. Students displaying a ‘critical’ approach sometimes claimed for
themselves a superior moral ground and referred to unconscious and structural
aspects of racism that are often beyond the reach of individual (self-)awareness and intentional change. This way of dealing with the topic of
racism can intimidate other participants in discussions. Yet, there might also
be a productive aspect in the irritations that arise when habitual ways of
dealing with racism collide. Especially the ‘subjectivist’ wish to learn more
and reduce uncertainty and ambivalence about the topic of racism points to the
potential of anti-racist medical education.
Limitations
Several important limitations of this study
should be noted. First, in order to generate stable rate estimates for the health outcomes, we had to combine data for multiple
years. In addition, we measured structural racism
based on its consequences, as manifested currently. We did not measure structural racism over time
nor use variables that directly measure historical structural racism (such as redlining maps, for example).
Therefore, the study is cross- sectional, precluding us from establishing a causal relationship between
structural racism and racial
health disparities. An important area for future research is to examine the
longitudinal relationship between structural racism and racial
health inequities. In fact, our current work is attempting to
do this by measuring changes in levels of racial segregation over time and
relating those patterns to changes in the magnitude of racial health
disparities over time.
Being white raised the question of how we as white student/faculty can implement
effective anti-racism teaching that also addresses institutional and structural
aspects without reproducing racism. Impressions from clinical health care practice brought in by SG indicated
the need to study not only medical students’ theoretical views on racism but
also their ways of dealing with the
topic in practice-related situations such as discussions. The aims of our study
were shaped by our perspectives as a white medical student and as ethicists in
medical education because we are concerned with understanding the preconditions
and obstacles of teaching and learning about racism and anti-racism in medicine
and health care and their connections to professional socialization in the
medical context. We studied perspectives of diverse students with and without
personal experience of racism and their interactional dynamics in discussions
laden with power relations stratified by racism.
“Strategies to dismantle
systemic racism must give high priority
to addressing inequities in the key determinants of health”.
CONCLUSION
To investigate racism seriously as a fundamental determinant of health
disparities requires attending to the multiple manifestations of racism.
Structural racism operates on the macrolevel of the socioecologic framework;
therefore, it more fundamentally influences outcomes than do proximal factors.
To date, research has focused on the relatively narrow band that emphasizes
self-reported racism and residential segregation. We encourage research on additional forms of racism,
including other dimensions of social segregation, immigration policy,
and the intergenerational transfer of assets
and liabilities. There
are many other forms of racism
that we did not have space to discuss, including the prison industrial complex,
historical trauma, emotional rules, and media portrayals. Some of these ideas
are developed more fully elsewhere in this issue of the journal. Research on
structural racism should not only focus on independent effects but also should
address interactions among multiple forms
of racism. Further, it is likely
that forms of racism may reinforce one another, and
efforts to dismantle one system may yield little effect without simultaneous
efforts on another system. For example, part of the segregation that occurs
across and within occupations is related to immigration policy (Catanzarite
2000). The study of single forms of racism would lead to an incomplete understanding
and, potentially worse, biased estimates.
For instance, assume that five forms of racism fully account for health
disparities, but an intervention only
targets one form. That intervention may show no effect simply because
it is incomplete, and
potentially lead to the erroneous conclusion that anti-racism efforts fail.
Hence, it is absolutely critical
to consider the multiple forms of racism. Further, our analysis
highlights the importance of time and its dimensions—historical period, age,
cohort, and placement in the life course. Given this complexity, conventional
tools of regression analyses, and even their extensions such as multilevel
analysis, would likely be inadequate.
Such study may benefit from simulation models, such as agent-based
modeling (Bruch and Mare, 2006). We can, however,
look to history
as a guide. Notably, the handful of studies
on the impact of the abolition of Jim Crow laws have consistently shown
improvements in mortality in the black community, and converging mortality
between black and white communities in the 15 years after the passage of the
1964 Civil Rights Act.53–56 We recognise that efforts to implement reforms to
dismantle structural racism have repeatedly encountered serious obstacles and
backlash from institutions, communities, and individuals seeking to preserve
their racial privilege.8,20,26,30 However, as Frederick Douglass famously said
in his 1857 address on the struggle against slavery in the USA, the West India
emancipation, and the backlash that ensued: “Power concedes nothing without a
demand.” For example, ways of dealing with the topic that tend to normalise
racism may require a focus on teaching knowledge about racism and competencies
that help to identify racism in practice and in internalised habits and
thoughts . This might pose particular difficulties as thorough self-reflection
is required, and habitual perspectives on racism and the moral evaluation of one’s own habits may have
to change. The ‘subjectivist’ way may be addressed
by providing access to knowledge about racism, and by empowering critical
reflection to overcome feelings of ambivalence and ambiguity connected to the
topic of racism. The ‘critical’ way might benefit from expanded knowledge and discussions about
racism.
Acknowledgments
We would like to thank
Merle Webel for her important work in the design
and realisation of the research project and Houda Hallal
for her helpful comments on the manuscript.
Moreover, SG is grateful for the feedback that he received
on his presentation at the conference “Rassismus, Diskriminierung
und Gesundheit” in Berlin, March 2023. Many thanks to Lucas Rateitschak for his help in the transcription process
and to Emma Dierlamm and Maya
Heins for language editing. We gratefully
acknowledge the availability of the IPUMS National Historical Geographic
Information System, which we used to obtain U.S. Census data when the Census
data web site was down.
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Article Information
THE IMPACT OF RACISM ON HEALTH DISPARITIES.
Authors: PRAPTI JALPAN SHAH
- Journal IJLRA
- ISSN 2582-6433
- Published 2025/03/01
- Issue 7
About Journal
International Journal for Legal Research and Analysis
- Abbreviation IJLRA
- ISSN 2582-6433
- Access Open Access
- License CC 4.0
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