The Role of Racism in Health Inequalities

Nicole Kravitz-Wirtz and Margaret Hicken introduce “Social Science & Medicine” journal’s Special Issue on Racism and Health Inequalities.

In the United States and around the world, racial inequalities in health have been and continue to be well-documented in academe and public discourse. Yet there are markedly few empirical studies examining the root causes of these inequalities, with ongoing resistance to identifying racism as a key determinant of racial health inequalities. APHA Past President Camara Jones defines racism as “a system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call ‘race’)”. (See here for more discussion on the definition of racism.)

While important and necessary research has been done, it tends to emphasize discrimination or prejudice experienced by individuals (interpersonal racism). There remains a critical need for more (and more nuanced) research on cultural and structural forms of racism and health, which is the focus of a recent special issue of Social Science and Medicine on Racism and Health Inequalities. Together, the collection underscores the potential for innovative population health research on cultural and structural racism, but also highlights recommendations as scholars move toward a reconstruction of knowledge about the root causes of racial health inequalities and then work toward their elimination.

Recommendation One: Research on racial health inequalities should be situated within a framework of cultural and structural racism

In the introduction to the special issue, we, along with our colleagues, propose that all research on racial health inequalities (even research focused on interpersonal processes or using individual-level measures) should be rooted in a framework of cultural and structural racism.

Very broadly speaking, a society’s culture — or its collective values and belief systems — maintains its structure, or the composite of its formal and informal institutions such as the media and criminal justice, education, economic, and political systems. Cultural racism is collective acceptance of the values and belief systems of the racially dominant group. Non-dominant groups are identified by visible characteristics such as skin tone, clothing, or accent (called racialization) and stigmatized with crude, implicitly-accepted stereotypes (called stigmatization). These stereotypes then facilitate the implementation of institutional policies and practices that disadvantage non-dominant (non-White) racial groups — and because these stereotypes often operate on our shared social subconscious, it appears that these policies and practices are simply neutral and rational and for the good of a society. Then, because our apparently neutral and rational institutions actually systematically disadvantage non-White racial groups, the racial social and health inequalities that are continually documented reinforce cultural racism.

Several papers in the special issue outline different ways that racialized institutions (or institutions that have become dominated by certain racial groups) are shaped by cultural racism. Asad and Clair (2018), for example, illustrate how cultural racism based upon the racialization and stigmatization of Black Americans and certain immigrant groups drive institutions to enact policies that not only materially and symbolically exclude specific members within the racialized groups (e.g., Black Americans who have engaged in illegal activity, or undocumented immigrants), but also have “spillover effects” on those with social proximity to these specifically marked individuals.As the insidious nature of cultural racism can make institutions appear racially neutral and rational, future work explicating the role of cultural racism may clarify how we can intervene on racialized and racially hierarchical structures.

Even when a cultural and structural racism framework is not explicitly or immediately related to specific empirical questions, such a framework, too often absent, is crucial for understanding racial health inequalities, as it may facilitate study design, result interpretation, and ultimately clarify an ambiguous literature. Two systematic reviews (Heard-Garris et al. 2018 and Maina et al. 2018) in the special issue report on very different interpersonal processes — the link between caregiver-experienced discrimination and child health and healthcare provider implicit bias and patient health — but both report similarly equivocal literatures. By situating discrimination and implicit bias within a racism framework, scholars can better measure and model how these individual/interpersonal factors operate and clarify when they are important for health. For example, Colen and colleagues (2018) model discrimination as it pertains to the lower health gains with upward socioeconomic mobility experienced by Black compared to White Americans. Unlike other studies, this evidence supports the notion that discrimination explains some racial health inequalities, as upwardly-mobile Black adults likely need to increasingly navigate white spaces, increasing discriminatory experiences. In another example, Hicken and colleagues (2018) model discrimination, as a marker of individually-perceived unfair treatment, and vigilance, as a marker of the burden of broad racial stereotypes, within a framework of cultural racism. They report that vigilance, but not discrimination, is related to weight-related measures for Black women, providing clarity to an equivocal literature on the associations among race, discrimination, and obesity.

A number of works in the special issue are situated within a broader context of cultural and structural racism (e.g., Barber et al. 2018; Creary 2018; Jacoby et al. 2018; Logan et al. 2018), but because there are still challenges in measuring structural and cultural racism, there is still a need in future research to develop innovative measures (e.g., using “big data”). Three papers in particular highlight the potential for innovation when examining the link between cultural or structural racism and racial health inequalities. Chae and colleagues (2018) use geospatially located Google search terms to capture area-level racial prejudice and its relationship to birth outcomes among Black mothers. Morey and colleagues (2018) use the General Social Survey to link area-level measures of US attitudes toward immigration to individual-level mortality. McCluney and colleagues (2018) use standardized measures from the US Department of Labor to assess racial inequalities in workplace environments, such as in opportunities for advancement or autonomy, and their relationship to racial health inequalities.

Recommendation Two: Scholars studying racial health inequalities should use a critical race lens

Beyond a framework of cultural and structural racism, we recommend that scholars studying racial health inequalities use a critical race lens when developing  frameworks and conceptual and analytical models. Critical race theory (CRT) is a constellation of principles outlined for public health by Ford and Airhihenbuwa 2010 that forms an approach to scientific inquiry of racial health inequalities. CRT challenges scholars to understand that while specific aspects of racism may shift and adapt to fit the sociopolitical climate, cultural and structural forces continue to ensure that a new equilibrium is reached that normalizes racism and favors the dominant racial group.

Malat and colleagues apply a critical race lens to help explain how the dominant cultural racism of whiteness in the US drives White Americans to reject safety net policies from which they would benefit, while Hogan and colleagues (2018) use CRT to understand the ways race, gender, and class intersect in the lives of Brazilian women of childbearing age. Several papers in the special issue also use CRT to uncover the relationship between cultural and structural racism. Came and colleagues (2018) highlight the persistence and ubiquity of racism in the New Zealand healthcare system despite efforts to address historical inequities that privileged Whites over Maori. Kerrison (2018) documented how an apparently neutral prison-based drug rehabilitation program in fact privileged White values, ideologies, and behaviors, making it relatively easy for White participants to achieve the “rehabilitated” label (and access to beneficial resources conferred by that label) while Black participants could not.

Inherent in CRT approaches is moving from documentation to action on cultural and structural racism. In an international collaboration, Came and Griffith (2018) use CRT approaches to discuss the ways that those who are not the targets of racism can change their institutions to redress racialized and unequal policies and practices. Two papers empirically test interventions within the healthcare education system from pre-health training (Metzl et al. 2018) to medical training (Chapman et al. 2018) and report that it is possible to increase individual-level knowledge and understanding of the cultural and structural roots of racial health inequalities, though it remains a challenge to overcome the continual cultural processes that shape our implicit biases.

A call to action for the future of research on racial health inequalities

Woven throughout our introduction to the special issue is a call for population health scholars to continually scrutinize our field and to ask which voices are privileged when discussing racial health inequalities: Are the dominant voices from the West? The US? Are they primarily White?

Furthermore, we must continually name racism (with precision) and clarify and show the mechanisms that maintain the link between racism and health inequalities. Finally, we urge researchers to reconstruct the knowledge around racial health inequalities so that it can be used as a tool to dismantle racism and eliminate racial inequalities in health.

About the authors

Nicole Kravitz-Wirtz

Nicole Kravitz-Wirtz is an Assistant Professional Researcher at the University of California, Davis Violence Prevention Research Program. She is a sociologist and epidemiologist whose research has focused broadly on the social determinants and consequences of population health and health disparities, with a particular emphasis on neighborhood effects and urban poverty, race/ethnicity, and the transmission of inequality over the life span and across generations. Her current work addresses the social epidemiology and prevention of firearm violence and substance use, including intersections with trauma, race/ethnicity, and policing.

Margaret Hicken

Margaret Hicken is a Research Assistant Professor at the University of Michigan Institute for Social Research. Trained as a social demographer and social epidemiologist, her work focuses on the biological markers and mechanisms linking structural exposures to population racial health inequalities. In one of her research programs, she focuses on the social psychology of cultural and structural racism through vigilant coping thoughts and behaviors. Then, in another of her programs, she examines racial residential segregation and the interactions between chemical and non-chemical exposures on health inequalities.