Elsevier

The Lancet

Volume 389, Issue 10077, 8–14 April 2017, Pages 1453-1463
The Lancet

Series
Structural racism and health inequities in the USA: evidence and interventions

https://doi.org/10.1016/S0140-6736(17)30569-XGet rights and content

Summary

Despite growing interest in understanding how social factors drive poor health outcomes, many academics, policy makers, scientists, elected officials, journalists, and others responsible for defining and responding to the public discourse remain reluctant to identify racism as a root cause of racial health inequities. In this conceptual report, the third in a Series on equity and equality in health in the USA, we use a contemporary and historical perspective to discuss research and interventions that grapple with the implications of what is known as structural racism on population health and health inequities. Structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. These patterns and practices in turn reinforce discriminatory beliefs, values, and distribution of resources. We argue that a focus on structural racism offers a concrete, feasible, and promising approach towards advancing health equity and improving population health.

Introduction

Racial and ethnic inequalities, including health inequities, are well documented in the USA (table),1, 2, 3, 4, 5 and have been a part of government statistics since the founding of colonial America.6, 7, 8 However, controversies abound over explanations for these inequities.6, 7, 8 In this report, we offer a perspective not often found in the medical literature or taught to students of health sciences, by focusing on structural racism (panel 1)9, 10, 11 as a key determinant of population health.9, 10, 12, 13 To explore this determinant of health and health equity, we examine a range of disciplines and sectors, including but not limited to medicine, public health, housing, and human resources. Our focus is the USA.

Although there is growing interest in understanding how social factors drive poor health outcomes,14 and directed investigation in social science and social epidemiology into the interconnected systems of discrimination,9, 10, 12, 13 many academics, policy makers, scientists, elected officials, and others responsible for defining and responding to the public discourse remain resistant to identify racism as a root cause of racial health inequities.9, 10, 13 For example, in a Web of Science search done on Sept 7, 2016, with the term “race” in conjunction with “health”, “disease”, “medicine”, or “public health”, 47 855 articles were retrieved. However, when “race” was replaced by “racial discrimination”, only 2061 articles were located, and only 1996 articles were found when it was replaced by “racism”. Furthermore, when “race” was replaced by “structural or systematic racism”, only 195 articles were identified (ie, 0·4% of those identified with the search term “race”).

To date, the small body of empirical research on racial discrimination and health has focused primarily on the stress of perceived unfair treatment as experienced by individuals (interpersonal racism).9, 10, 12, 15, 16, 17, 18 Such inequitable suffering matters, but a broad, societal view—one that identifies and seeks to alter how such racism contributes to poor health—is required to understand, prevent, and address the harms related to structural racism. There is a rich social science literature conceptualising structural racism,8, 9, 10, 19 but this research has not been adequately integrated into medical and scientific literature geared towards clinicians and other health professionals.9, 10, 12, 13 In this report, we examine what constitutes structural racism, explore evidence of how it harms health, and provide examples of interventions that can reduce its impact. Our central argument is that a focus on structural racism is essential to advance health equity and improve population health.

Section snippets

Structural racism: a brief introduction

Any account of structural racism within the USA must start with the experiences of black people and the Indigenous people of North America. It was on these two groups that the initial colonisers of North America (the English, French, Dutch, and Spanish) first promulgated genocide and enslavement, and created both legal and tacit systems of racial oppression.8, 20, 21 Our report focuses primarily on the experiences of black Americans, since most research on racism and health has focused on this

Health consequences of structural racism: evidence and evidence gaps

Contemporary scholarship has established multiple pathways by which racism harms health, involving adverse physical, social, and economic exposures, as well as maladaptive coping behaviours and stereotype threats (panel 2).9, 12, 13, 15, 16, 17, 18, 21, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50 Typically concurrent, these exposures can accumulate over the life course and across generations.

To date, research on racial discrimination and health has focused

Addressing structural racism to advance health equity

Although efforts to counter institutional racism and residential segregation in the housing market and medical care system require initiatives focused on these institutions, such initiatives are not sufficient. Also needed is intersectoral work, especially that which is guided by transdisciplinary frameworks and action. Analytical insights derived from a systems perspective suggest several avenues for efficacious solutions, including the use of a focused external force that acts on multiple

Conclusion

Since the American colonial period, public and private institutions have reinforced each other, maintaining racial hierarchies that have allowed white Americans, across generations, to earn more and consolidate more wealth than non-white Americans, and maintain political dominance. This structural racism has had a substantial role in shaping the distribution of social determinants of health and the population health profile of the USA, including persistent health inequities. The stark reality

Search strategy and selection criteria

An overarching search strategy was not used; instead, we drew on our collective experience and specific searches for different sections to update or amplify the completeness of our review of the published literature. To identify review articles on racism and health, we searched Web of Science, PubMed, and Google Scholar using the search terms “racism AND health” or “racial discrimination AND health” or “structural racism AND health”. Only review articles published in English between Jan 1,

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