Racism as a Structural Determinant of Health

Abstract

Racism refers to organized social systems within societies that simultaneously privilege dominant racial groups while disenfranchising nondominant racial groups through the differential allocation of power, prestige, opportunity, and flexible resources, according to assignment into socially constructed racial and ethnic groups. Unfair and unjust allocation of these domains is maintained through multiple mechanisms: cultural, interpersonal, and institutional racism. These mechanisms work synergistically to reinforce a racial hierarchy. Cultural racism promotes dominant group culture as the norm or superior to the culture of nondominant racial groups, evident in societal representations of history, stereotypes, and symbolic resources embedded in cultural institutions. In turn, these views and representations undergird interactions and discriminatory behaviors enacted by individuals and formal rules and procedures of social and political institutions, often in covert ways without mention of race. Discriminatory actions co-occur across institutional systems of housing, banking, politics, education, labor, criminal justice, and health care. The interconnections and totality of these mechanisms, coined structural racism, determines differential access to burdens and benefits that drive health. For example, colonialism, residential segregation, and disinvestment in communities of color influence access to essential needs and known health benefits (e.g., parks, quality schools and work opportunities, grocers, municipal and medical facilities) and burdens (e.g., substandard housing stock, elevated noise levels, air pollution). Removal of democratic representation in governance further stifles the capacity of communities of color to participate in decision making about policies that affect health (e.g., the Flint water crisis, neighborhood school closures). In order to endure under adverse circumstances, nondominant racial and ethnic groups resist negative stereotypes (e.g., illegality, lack of self-control) and take on added burdens (e.g., traveling further distances to access quality resources, entering spaces that devalue one’s existence, and employing high-effort coping strategies), all the while being on guard in anticipation of unfair treatment. Taken together, these racist mechanisms and the coping strategies employed to resist can induce stressful feelings, erode mental health, and result in dysregulation of physiologic systems that trigger accelerated deterioration of physical health. Resultant disparities in social and health outcomes are often referenced by the dominant racial groups to further justify cultural and institutional forms of racism. Importantly, these claims on how racism determines health and health inequities is a global argument—however, works cited in this annotated bibliography are primarily developed in the context of the United States.