Racism as a Structural Determinant of Health

by

Linnea Evans

• LAST MODIFIED: 23 August 2022
• DOI: 10.1093/obo/9780199756797-0215

Introduction

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.

Fundamental Writings on Theories of Race and Racism

Theories of race and racism have largely been developed in the social sciences, namely sociology, to outline how racial classification and racism operates and changes over time. Early theories emphasized racist ideologies, and individual behaviors, often overt in nature, compared to newer work that theorizes ways in which racism is structural and clandestine. In this section, theory is discussed and related to developments in public health. Omi and Winant 2014 emphasized in their theory of racial formation how racial identities are created and take on meaning via cultural representations and structures that allocate resources along racial lines. Bell 1993 delivered an essential reminder that racism is an enduring feature of society, so long as the dominant group does not see their own fate threatened by the hierarchical racial system. Bell’s writings laid the groundwork for theoretical approaches that characterize racism as a fundamental cause of health inequities via enduring inequalities in power, prestige, and flexible resources that ensure intervening mechanisms between race and health are reliably replaced. Initial measures of racial discrimination in health studies were grounded in the work Essed 1991, which detailed how racism shows up in everyday interactions. Black feminist scholarly works, especially Collins 1990, critiqued early conceptualizations of how racism occurs, adding that oppressions of race intersect with other systems of power in a matrix of domination to differentially shape the lives of people at the intersection of race, class, gender, and sexuality. Collins and Crenshaw are frequently invoked in calls for intersectional approaches to health. Bonilla-Silva 1997 advances a structural theory of racism, where racist ideas are just one part of a larger racial system. Under this perspective, the structure of society itself is racist. Golash-Boza 2016 weaves together writings on racial ideologies and racial structures to articulate the mutually reinforcing effect—racist ideologies lead to racist practices on the micro- and macro-level, which in turn reinforce racist ideologies and discourse. The totality of these synergistic effects, structural racism, is a growing focus in health literature. Analyzing racial ideology over time, Bobo, et al. 2012 shows a move toward a more covert form termed “laissez-faire racism.” Bonilla Silva 2013 characterizes the contemporary arguments to account for racial inequalities and deny the continuance of structural racial advantage “color-blind racism.” Another important contribution can be found in writings on how race, place, and power are intertwined. Lipsitz 2011 introduced the “White spatial imaginary” to describe the spatial dimensions of White privilege that maintains the relegation of people of color to different spaces with different opportunity structures. Resistance forms in a “Black spatial imaginary” that counters with democratic ideals, as evidenced in political movements examined in Carmichael and Hamilton 1967 and creation of alterative prestige hierarchies discussed in Collins 1990 and Essed 1991. Spatial dimensions of racism are increasingly captured in public health’s approach to assessing the role of structural racism on health.

• Bell, D. 1993. Faces at the bottom of the well: The permanence of racism. New York: Basic Books.

  Bell uses allegory and historical example to argue that racism is a permanent fixture of American society. A central tenet to his argument: the fight for equity inevitably will fail so long as the dominant group does not see their own well-being threatened by the status quo.

• Bobo, L. D., C. Z, Charles, M. Krysan, and A. D. Simmons. 2012. The real record on racial attitudes. In Social trends in American life: Evidence from the General Social Survey since 1972. Edited by P. V. Marsden, 38–83. Princeton, NJ: Princeton Univ. Press.

  DOI: 10.1515/9781400845569-005

  This chapter details mid-20th-century trends in the General Social Survey to show a move away from overt racialized ideology. However, Bobo cautions against concluding that the United States is post-racial. Trends show an enduring racial hierarchy, with Whites expressing social distance preferences; endorsement of negative traits towards racial and ethnic minoritized groups; and strong reluctance to support government intervention to redress racial inequality.

• Bonilla-Silva, E. 1997. Rethinking racism: Toward a structural interpretation. American Sociological Review 62.3: 465–480.

  DOI: 10.2307/2657316

  In this pivotal piece, Bonilla-Silva challenges race scholars to move beyond defining racism as a set of ideas, and presents an alternative framework that advances a structural theory of racism based on the notion of racialized social systems.

• Bonilla Silva, E. 2013. Racism without racists: Color-blind racism and the persistence of racial inequality in the United States. 4th ed. Lanham, MD: Rowman and Littlefield.

  Bonilla-Silva details the phrases and arguments used by Whites to account for racial inequalities and deny the continued existence of structural racial advantage. This book is an essential tool to challenging color-blind thinking in America.

• Carmichael, S., and C. V. Hamilton. 1967. Black power: The politics of liberation. New York: Vintage Books.

  This book is frequently credited for both documenting and labeling the depths of racism in US institutions as systemic racism. Insights into the civil rights movement and the Black Power movement are presented with in-depth discussions on the struggles toward political participation and representation that remain highly relevant in the 21st century.

• Collins, P. H. 1990. Black feminist thought: Knowledge, consciousness, and the politics of empowerment. London: Routledge.

  Collins weaves together Black feminist ideas to advance two major points on the study of racism: (1) oppressions of race, class, gender, and sexuality are intersecting systems of power (matrix of domination); and (2) Black women’s lives exist at these intersections, confining their movement and labor, yet also prompting resistance and adaptations, such as the creation of alterative prestige hierarchies by which to judge oneself and derive satisfaction.

• Crenshaw, K. 1991. Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Review 43.6: 1241–1299.

  Crenshaw coined the term intersectionality to challenge the legal treatment of racial and sex discrimination as separate issues. This paper elaborates on the ways in which race and gender intersect in shaping structural, political, and representational aspects of violence against women of color. From this conceptual groundwork emerged research and interventions addressing the ways in which intersecting identities (e.g., race, gender, class, sexuality, disability status) matter to health disparities.

• Essed, P. 1991. Understanding everyday racism: An interdisciplinary theory. London: SAGE Publications.

  DOI: 10.4135/9781483345239

  Conducts a cross-comparative study with Black women in the United States and the Netherlands to detail how racism is expressed in everyday interactions. Essed builds a theory of everyday racism that lays the foundational groundwork upon which measurement scales of everyday experiences of discrimination were formed.

• Golash-Boza, T. 2016. A critical and comprehensive sociological theory of race and racism. Sociology of Race and Ethnicity 2.2: 129–141.

  DOI: 10.1177/2332649216632242

  Golash-Boza weaves together theories of race and racism under one theoretical framework by articulating the mutually reinforcing relationship between racist ideologies and racist structures. Reference to empirical examples serves to illustrate how empirical research has helped advance our theoretical understanding of racism, acts that move us toward the goal of explicating and ending racial oppression.

• Lipsitz, G. 2011. How racism takes place. Philadelphia: Temple Univ. Press.

  Lipsitz introduces what he terms the “White spatial imaginary,” White Americans’ understanding of place in the context of longstanding segregation and unequal access to education, employment, and housing. In response, the “Black spatial imaginary” is the resistance by Black Americans to survive policies of racial segregation via the reimagining of segregated spaces.

• Omi, M., and H. Winant. 2014. Racial Formation in the United States. 3d ed. New York: Routledge.

  DOI: 10.4324/9780203076804

  First written in 1994, this book remains an essential reader about how concepts of race are created and transformed across time and space, and how race is a master category that permeates every aspect of our lives. In the third edition, Omi and Winant revise their theory of racial formation to address the changing political and social landscape, and to incorporate intersectionality theories.