Structural Racial Health Inequity: The US is the Exposure
“For all of the technological advancement, we are still without adequate measures of structural racism. Of course, that makes perfect sense if we accept the commonness of racism.”
Public health has developed a consensus that structural racism is a major driver of persistent and chronic racial health inequity in the United States. Yet, research has infrequently treated the United States as a whole as the “exposure.” More than 100 years of biomedical and social science research has supported that racial disparities persist and intersect with broad domains of social and economic life to include measures of clinical outcomes, health care access, income, education, and community determinants. Turn-of-the-century African American scholars including W.E.B. DuBois and Benjamin Brawley described social and environmental conditions that are still relevant to contemporary discussions about violence against Black bodies, economic marginalization, and criminal justice. Before we begin developing any tool, it is important that we have conceptual and ontological clarity.
Science has not caught up with the consensus. It is rare to see researchers account for community factors such as neighborhood poverty or segregation.The structural influence of racism is almost negligible in the body of public health literature. In fact, there are no measures of structural racism that capture its multi-level and temporal dimensions, much less how to apply it in analytic models. Individuals, groups, or communities can be exposed to racism sporadically or chronically. Experiences with racism can vary considerably depending on education, income, occupation, neighborhood characteristics, geography, admixture or colorism, within-race ethnicities, source, context, geography, assimilation or covering, and social capital. For many African Americans, heightened racism can persist for a lifetime. Even one-time encounters with racism can carry lifelong emotional or physical injury. We recently hosted a webinar to share the story of Board member Linda Brown’s harrowing experiences over 25 years ago when having her daughter. We could see that Ms. Brown was re-living a painful memory that had a profound impact on her and shaped her perceptions of the US health care system. One story that she shared was when when she was shunned by providers because she and her husband engaged with understanding all aspects of her daughter’s condition and hospitalization. They would ask questions about the necessity of tests and the treatment plan. A form of Public Health Liberation, her questions were challenged by an arrogant provider who brushed off such questions. She felt that her race and gender were key reasons why.
Still, many may not perceive their experiences as forms of racism because of internalized stigma, acceptance of “one’s lot in life,” norming, and its commonness. Racism can operate in explicit or easily recognizable forms such as hatred or violence, but most commonly interacts alongside factors involving classism, legal violence, coercive power, economic exploitation, diminished opportunity, and the perceived or actual threat against liberation expression. Individuals or groups who exercise their inherent right to speak about their own human suffering and seek relief (Public Health Liberation) can be subjected to counter-resistant racial violence. This violence varies from bodily harm (e.g. murder of George Floyd) to structural violence (e.g. workplace retaliation against allegations of racial discrimination). Insidious racial violence is vastly understudied in the United States. This, of course, makes sense if we accept the commonness of racism.
To accelerate racial health inequity, we must not only address the experiences of victims of racial violence through a Public Health Liberation framework, but also gain greater insight into agents of that system. We defined public health liberation theory in a prior article. These agents fall along a continuum of individual action to structural functioning. Public discourse on racism tends to fixate on the individual narrative rather than the cultural, institutional, and policy role in racial inequity. These highly visceral cases of misconduct or violence can lead the public to believe that racism is largely the result of a single or limited set of bad actors. If the full extent of American racism cannot be freely and openly revealed, then we can expect yawning chasms in racial health inequity indefinitely.
We need more honesty about all of the sources of structural racism. We begin by discussing two areas that have flown under the radar. Future articles on structural racism will appear in The Hub - the Public Health Liberation platform. First, public health educational institutions have deprived generations of public health students of a full account of social determinants of racial health. There is a lack of interdisciplinary inquiry to accurately define racism in the US, discussion of past and contemporary challenges, and teaching of all of the legal, political, and community levers to eliminate structural racism - the latter is what we mean by Public Health Liberation. Students may find the classroom and interpersonal experience to be racially unwelcoming, even hostile, given the noted lack of diversity among public health educators and curricular blind spots.
Many public health scholars that we surveyed were unaware of the lead crisis in Washington, DC in the early 2000s that was “20 to 30 times larger” than the Flint lead crisis. It was regarded as one of the most egregious examples of environmental racism in recent memory. Academic-based public health educators generally do not have any licensing requirements, so it can be challenging to ensure that public health education stays current and culturally and socially relevant. Public health is one of few social sciences aligned with a social contract similar to American medicine. Yet, it has deep undercurrents of conservatism and interest group domination, particularly when it comes to allocation of funding dollars. Public health curricula can also suppress educating students about the past or present role of their institutions in perpetuating racism within a local community. Such taboo topics are common in public health education. Future PHL Hub articles will look at public health funding and lobbying as other major barriers.
Another taboo in public health discourse is racial violence within African American communities. Here, we must emphasize that race and racism are not mutually exclusive. Members within a racial group can and do perpetuate racism and should be held to the same standard of accountability as non-concordant groups. If we aim to make meaningful gains in health equity, then all barriers standing in the way must be on the table of discussion. Too often, we overlook inconvenient truths in equity discussion. Self-harming and racial violence within minority communities is one such area that public health has tended to avoid. These include when African American or Black political leaders support policies that reinforce inequity, often through unconditional support of corporate enterprises. It can also occur when a minority employee through self-hating or coercive practices follow procedures that have a racially disparate impact. It is a mistake to assume this is a defining feature of Black leadership. The alliance between elected officials and capitalists can often function as a shadow form of government with little regard for minority interests regardless of political persuasion or background.
In keeping with the mission of the Public Health Liberation, this article seeks to draw attention to limitations in current approaches for racial health equity. We need better measures. We need honest conversations that open the door to “third rails.” Then and only then can we open new pathways for accelerating health equity. Come back to Public Health Liberation for more articles.
