Section 3.16: Racism as a Determinant of Health

Start with the basics: defining race and ethnicity

We hear and discuss the terms and experiences of ‘race’ and ‘racism’ frequently in the media, in our classrooms, professionally and especially in the fields of Public and Global Health.

But if you were asked to actually define race, what would you say? 

Is race biological, related to genetics? 

Or, is it a social construct — rooted in historical actions meant to justify divisions, discrimination and inequities?

If you said ‘social construct’ — you are correct.

We also often hear the term ethnicity mentioned next to or interchangeably with race.

Are these concepts the same?

The answer is — not necessarily.

Sometimes this definition can be confusing — we are saying that race is not associated with genetics, but is associated with biological characteristics such as skin color, facial features and hair type. But we are also saying that most importantly race is a social construct. Racial categories, based on physical/biological features such as skin color, facial features and hair type, were created by humans throughout history. 

These racial categories have often been used to justify divisions between groups, unequal power dynamics and violence — and not just in the distant past. Slavery, the Holocaust, neo-colonial policies, the Rwanda genocide and contemporary examples of direct and institutional or systemic racism are all examples of how socially constructed racial categories have been used to justify marginalization, oppression and violence by certain groups against certain groups.

A person or group of people’s ethnicity is not necessarily the same as their race, though individuals may choose to identify their race and ethnicity as the same.

Ethnicity depends on cultural and social factors such as family origin, language, diet and religion to classify humans. Your ethnicity is the group you belong to, or are perceived to belong to, in the light of such factors.

(Bhopal, 2016)

Watch the video clip below for a comprehensive discussion and definition of race and ethnicity.

Remember moving forward that ethnicity can also be used as a means to discriminate against particular groups. Certain beliefs and cultural practices can also come from ethnicity and ethnic identity. Therefore, ethnicity can also be considered a structural and/or social determinant of health.

Race or racism as a determinant of health?

Let’s also remember to correctly distinguish race from racism. While race refers to socially constructed categories and we see health inequities between races within and between countries, race itself is not a social determinant of health.

Racism, however, is.

The fact that an individual is born with black or white skin is not, alone, a determinant of health. What makes race a determinant of health are the histories and systems of oppression, marginalization and systemic racism which exist within certain contexts that make having black or white skin a determinant of health.

Let’s once again think back to the images we have used to understand the structural and social determinants of health, and the different social and systemic levels on which these determinants can be located.

Consider racism at the roots, feeding the systems that influence, shape and distribute the social determinants of health. For those individuals and communities which have been systematically racialized and marginalized within systems that are founded on racism, it is easy to see how racism becomes a structural and, indirectly, social determinant of health.

If racist systems did not exist and resources and opportunities were truly distributed equally between all groups of people, race would not act as a determinant of health outcomes. 

While race is a social category based on physical attributes, racism is an organized system based on an ideology of inferitority that categorizes, ranks and differentially allocates desirable society resources [and opportunities] to socially defined ‘races.’

(Smedley et al, 2010)

It is important to recognize this distinction between race and racism. Race in and of itself is not a determinant of health; being born a certain race in a racist system, however, is.

There are different ways of understanding where and how racism is present and experienced by individuals who identify as or are perceived as belonging to a particular race.

Racism can happen at the interpersonal level or at the systemic level.

Racism at the interpersonal level is the most recognized form of racism. Also known as relational or individual racism, it happens when individuals experience discriminatory behaviour from other people. These behaviours are based on the long-standing ideology of racism (i.e. racial superiority). Interpersonal racism is expressed explicitly or implicitly through prejudice, stereotyping and discrimination.

(Canadian Medical Association and the Government of the Northwest Territories, 2021)

Also referred to as institutional racism, systemic racism occurs when mainstream institutions and organizations formalize and condone long standing racist ideologies into policies, practices and norms. This reinforces racial hierarchies that inherently privilege the ideas and needs of the dominant white population while disadvantaging non-white racial groups. Systemic racism permits interpersonal racism in the workplace through direct racist policies or the absence of policy and accountability measures to address it.

(Canadian Medical Association and the Government of the Northwest Territories, 2021)

Linking race to health outcomes

For centuries, medical providers, researchers, public health professionals, politicians and historians believed, assumed and taught that race was genetic.  Supposed ‘genetic differences’ between races were used to explain why certain races were more susceptible or more immune to certain diseases.

Let’s take the COVID-19 pandemic in the city of Chicago as an example. As of June 2020, Black Chicagoans were dying from COVID-19 at a rate more than 2.5 times higher than white Chicagoans (Colvin and Murphy, 2020).

Are Black Americans genetically more susceptible to COVID-19 than white Americans?

Well, as we established above, race does not stem from genes. Racial categories are based on physical attributes — and those same racial categories were socially constructed and applied by humans throughout history.

By now, when you see an unequal health indicator like mortality rates from COVID-19 by race, your Public Health red lights should be flashing. Is this simply an inequality or an inequity? Inequity is right — avoidable, unfair and unjust. Your Public Health mind should also kick into gear and consider what historical, structural and social determinants of health might be responsible for such drastic inequities in mortality rates from COVID-19 by race in Chicago, especially at the beginning of the pandemic when health systems were overwhelmed and those who could were working from home with little contact with other people.

As anthropologist William Dressler has pointed out, “So many medical conditions are differentially distributed to African Americans – heart disease, diabetes, hypertension, low birth weight babies – are we to believe that Black people were so evolutionarily unlucky that they got all the genes that predisposed them to every malady?” (Smedley et al, 2010)

Across the United States and around the world, racial and ethnic minority populations experience higher rates of poor health and disease in a range of health conditions, including diabetes, hypertension, obesity, asthma, and heart disease, when compared to their White counterparts. The life expectancy among Black/African Americans is four years lower than that of White Americans (CDC, 2021b).

Now that you have a bit more context, watch this video clip that details why and how racism has been declared a Public Health crisis in the United States by some cities and the Centers for Disease Control and Prevention.

The following excerpts from an article on race, inequality and health inequities by Smedley and colleagues (2010) explores the intersection of determinants of health further, disproving the myth that racial differences in health outcomes can be attributed to genes alone.

‘Can trauma be inherited?’: Racism, intergenerational trauma and health

If a mother, father or community as a whole experience a traumatic event or ongoing traumatic events — such as war, genocide, violence or racism — will the next generation feel any effects of those experiences? 

The answer is in many cases yes. 

While individuals and communities can be incredibly resilient during and after traumatic events, the experiences and effects of trauma are often felt and passed down to subsequent generations often in subtle but significant ways. This is called intergenerational trauma, also sometimes referred to as generational trauma or historical trauma.

Intergenerational trauma is historic and contemporary trauma that has compounded over time and been passed from one generation to the next. The negative cumulative effects can impact individuals, families, communities and entire populations, resulting in a legacy of physical, psychological and economic disparities that persist across generations.

(Canadian Medical Association and Government of the Northwest Territories, 2021)

You should be able to think of many examples for potential intergenerational trauma that we have discussed throughout this course.

Think of the histories of violence — direct, structural and cultural — we have read about in Haiti and Rwanda in the book Mountains Beyond Mountains; colonial histories of oppression, exploitation and violence; the long-lasting effects of unethical medical experiments such as experiments carried out by Nazis during World War II against Jewish people, people identifying as LGBTQ and other ethnic minorities; the Tuskegee Syphilis Experiment, among others.

The Canadian Medical Association states that, “For Indigenous peoples, the historical trauma includes trauma created as a result of the imposition of assimilative policies and laws aimed at attempted cultural genocide and that continues to be built upon by contemporary forms of colonialism and discrimination (2021).”

Understanding racism and intergenerational trauma as determinants of health

As described in the Prelim Engagement section, residential schools were established beginning in the mid to late 1800s in Australia, Canada and the United States. These schools had the sole purpose of ‘assimilating’ Indigenous children into members of the white, settler cultures in each country. 

Indigenous children were taken from their families, sometimes literally ripped from their parents’ arms, and forced to stay at residential schools for months or even years at time without contact with their families. 

Some children who went to residential schools were never seen by their families again. Unmarked graves of children are still being uncovered near former residential schools in Canada as the country concludes a years-long, national ‘Truth and Reconciliation Process’ to “facilitate reconciliation among former [residential school] students, their families, their communities and all Canadians” (Government of Canada, 2021). September 30, 2021 was the first time Canadians observed a now-annual ‘National Day of Truth and Reconciliation’ to “focus the country’s attention on the victims and survivors of the residential school system and other genocidal acts against Indigenous peoples” (Atkins, 2021).

In October 2021, President Joe Biden issued a proclamation commemorating Indigenous People’s Day in the United States on what is also known as Columbus Day (celebrated on a Monday each October) (Judd, 2021). President Biden’s proclamation does not end the federal government’s celebration of Columbus Day, though a number of cities in the U.S. have opted to replace Columbus Day with Indigenous People’s Day (Judd, 2021).

In September 2021, Senator Elizabeth Warren revealed a bill called The Truth and Healing Commission on Indian Boarding School Policies in the United States Act (Bendery, 2021). 

“The commission would provide a forum for Native people to speak about their families’ personal experiences with boarding school atrocities, and would come up with recommendations for Congress to help Indigenous people heal from the “historical and intergenerational trauma” passed down in their families.

The Indian Boarding School Policies are a stain in America’s history, and it’s long overdue that the federal government reckon with this history and its legacy,” Warren said in a statement. “These policies and practices caused unimaginable suffering and trauma for survivors, victims, and the thousands of Native families who remain impacted by them (Bendery, 2021).” For the full article on Senator Warren’s propose legislation follow the link here.

As you watch the following video clips of a detailed history, timeline and description of the residential school system in Canada and the stories of residential school survivors, reflect on how the beliefs and policies driving residential school system and Indigenous children’s and families’ experiences of residential school systems illustrate the key concepts we have discussed in this course and this section in particular, including:

• Direct, structural and cultural violence
• Interpersonal racism
• Systemic racism
• Cultural genocide
• Intergenerational trauma
• Historical, structural and social determinants of health

It is highly recommended you view both of the following video clips.

The way forward: What can be done to combat the negative effects of racism and intergenerational trauma on health?

We’ve seen how inequities in various arenas of our lives—in our neighborhoods, schools, jobs, housing and income—along with discrimination and internalized racism, can produce inequities in health outcomes. But research suggests many public policies that can improve the status and thus the health and well-being of peoples of color while advancing us further down the road to a non-racial society. Importantly, these policies don’t assume that U.S. society is “color-blind;” rather, they acknowledge that race, while not a biological reality, too often shapes life opportunities and health because of the lived experience of race.

How, then, can policy ameliorate the effects of racism on health? The United States has made great progress in improving race relations and attitudes toward racial diversity in the four-plus decades since landmark federal civil rights and voting rights legislation. But laws alone have not created equal opportunity for all, nor have they eliminated implicit racial bias and stereotyping. Below are just a few examples of innovative policies that can expand opportunity for all, while creating structures that root out implicit bias and more subtle forms of discrimination.

Because one of the fundamental determinants of racial and ethnic health disparities is segregation and unequal living conditions in majority-white and majority-minority neighborhoods, housing mobility strategies are a promising approach to reducing health inequities and expanding opportunity. Research suggests that helping poor people of color relocate to lower poverty neighborhoods can improve health outcomes, although more research is needed to understand how and under what conditions programs work best. Portable rent vouchers and tenant-based assistance are the most common housing mobility strategies, but legal efforts that challenge residential and school segregation have also produced results. Rigorous enforcement of antidiscrimination and equal opportunity laws remains critical to prevent redlining and ensure fair lending practices, including protection from sub-prime home loans. One obstacle, however, remains white flight from middle class destination communities.

While increasing housing options for people of color is one important strategy, policies should not ignore the needs of majority-minority communities. Many such communities, as noted above, are segregated from opportunity in ways that ultimately harm the health of their residents. To address these problems, policies should be examined that reduce geographic barriers to opportunity. For example, new job creation is increasingly taking place in suburban and exurban communities, far from segregated communities of color in urban cores and inner-ring suburbs; many of the residents in these communities don’t have cars or other opportunities to get to these jobs. A range of public policies – including public transportation, economic empowerment zones, housing mobility, and zoning – can reduce the distance between people and employment opportunities. Most of these policies require regional planning and coordination across local jurisdictions, and can be supported by state and federal incentives.

Communities of color can also benefit from improving community resources for health and reducing environmental risks. Several strategies can improve the health of communities, such as improving coordination of key federal and state agencies involved in arenas that affect health (e.g., education, housing, and employment), creating incentives for better food resources in underserved communities (e.g., major grocery chains, farmer’s markets), developing community-level interventions for the promotion of healthy behavior (e.g., smoking cessation, exercise), and addressing environmental health threats (e.g., aggressive monitoring and enforcement of environmental laws).

In addition to providing housing mobility options and improving health and life opportunity conditions in communities of color, it’s important to consider all aspects of opportunity when fashioning new policies and programs that will affect Americans’ life chances. To that end, government can use a new policy tools, such as an “Opportunity Impact Statement” (OIS) as a requirement for publicly funded or authorized projects like school, hospital, or highway construction, or the expansion of the telecommunications infrastructure. Like an environmental impact report, an OIS would predict, based on available data, how a given effort would expand or contract opportunity in terms of equitable treatment, economic security and mobility, and shared responsibility, and it would require public input and participation. Government can also make expanding opportunity a condition of its partnerships with private industry by requiring, for example, public contractors to pay a living wage tied to families’ actual cost of living, insisting on employment practices that promote diversity and inclusion, and ensuring that new technologies using the public electromagnetic spectrum include public interest obligations and extend service to all communities.

Importantly, however, government policies should also restore a commitment to human and civil rights in ways that acknowledge how bias and discrimination play out at interpersonal levels, often in subtle ways that neither party may recognize. Some of the greatest strides in advancing American opportunity emerged from the twentieth century movements for racial equality, women’s rights, and workers’ rights, and new policies are needed to build upon these. This work is not yet complete; what is needed is both vigorous enforcement of existing anti-discrimination protections and a new generation of human rights laws that address evolving forms of bias and exclusion. 

These include:

• Increasing the staffing and resources that federal, state, and local agencies devote to enforcing anti-discrimination laws in voting, employment, housing, education, lending, criminal justice and other spheres. This includes using data more effectively to better detect potential bias, for instance, by comparing workforce diversity with the composition of an area’s qualified workforce.
• Assisting employers and other institutions committed to providing a fair and diverse environment, for example, by promoting model performance evaluation practices, greater cultural fluency, and other tools to counter bias and exclusion.
• Crafting new human rights laws that complement existing civil rights protections by addressing subconscious and institutional biases more effectively, protecting economic and social rights like the right to education, and correcting exclusion based on socioeconomic status and other characteristics not fully covered by current laws (Smedley et al, 2010).

Another example of actions and interventions to address and eliminate the negative impact of historic and systemic racism comes from the Canadian Truth and Reconciliation Commission (TRC). The Canadian TRC completed its process with specific calls to action within different domains to address racism and its effects on Indigenous people; a number of those calls to action are specifically focused on health. 

The following are taken from TRC documents and were reported in The Unforgotten Toolkit (Canadian Medical Association and the Government of Northwest Territories, 2021).

The TRC Calls to Action 18-24 are focused on health and include:

• Federal, provincial and territorial governments acknowledging that health care inequities between Indigenous and non-Indigenous Canadians exist due to previous Canadian government policies, including Residential Schools.

• The federal government, in consultation with Indigenous peoples, establishing measurable goals to close the gap in health outcomes between Indigenous and non-Indigenous Canadians, and publishing annual reports and assessing long-term trends.

• The federal government recognizing and addressing the distinct needs of urban Indigenous populations.

• The federal government providing funding for existing and new Indigenous healing centres.

• All those who can effect change in health care systems recognizing the value of Indigenous healing practices.

• All levels of government increasing the number of Indigenous professionals working in health care, increasing retention of Indigenous professionals working in health care, and providing

cultural competency training for all health care professionals.

• Development of a mandatory course on Indigenous history for all medical and nursing schools.

There have been incremental changes as institutions take steps to implement the calls to action and recommendations outlined in these reports and inquiries. 

For example, the Northern Ontario School of Medicine addressed 19 of the calls to action linked to health care and education training through a series of commitments, including the establishment of an Indigenous health lead to support all programs in incorporating Indigenous health in their clinical and academic curriculum.

Conversely, health care institutions can apply some of these calls to action by:

• Acknowledging health care inequities between Indigenous and non-Indigenous Canadians;

• Addressing the distinct needs of urban Indigenous populations in their practices;

• Recognizing the value of Indigenous healing practices;

• Enrolling staff in mandatory courses on Indigenous history, and

• Reviewing hiring practices to encourage hiring more Indigenous professionals.

(Canadian Medical Association and the Government of Northwest Territories, 2021).

Racial and ethnic health disparities are real and persistent. Although today’s problems may be deeply rooted in the past, what’s important is that they threaten our future health and well-being. Simply put, many people of color live shorter lives and suffer poorer health than white Americans. But this is not inevitable. We have the power to change health outcomes. The bad news is that our health problems cannot be solved overnight, with better health care or newer drugs. The good news is that the solutions have been with us all along: evidence suggests that if we work towards social justice, people’s health, everyone’s — not just for those on the bottom – will improve as a result (Smedley et al, 2010).

References

1. Atkins, CJ. (2021). Canada observes first ‘Reconciliation Day’ recognizing Indigenous genocide and oppression. People’s World. https://www.peoplesworld.org/article/canada-observes-first-reconciliation-day-recognizing-indigenous-genocide-and-oppression/
2. Barnshaw, J. (2008). In Richard T. Schaefer (ed). Encyclopedia of Race, Ethnicity and Society Vol 1. SAGE Publications. https://books.google.com/booksid=YMUola6pDnkC&pg=PT1217&dq=race+social+construction#v=onepage&q=race%20social%20construction&f=false
3. Bendery, J. (2021). Elizabeth Warren Unveils Bill to Document Indian Boarding School Atrocities. Huffpost. https://www.huffpost.com/entry/elizabeth-warren-native-boarding-schools_n_615605b2e4b0502542304b42?ncid
4. Bhopal, R. (2016). Book Summary: Migration, Ethnicity, Race and Health. Public Health Panorama. Vol 2: 4. https://www.euro.who.int/__data/assets/pdf_file/0017/330731/10-Migration-ethnicity-race-health.pdf
5. Bilsky, L. and Klagsbrun, R. (2018). The Return of Cultural Genocide? European Journal of International Law. Vol 29:2. https://academic.oup.com/ejil/article/29/2/373/5057075
6. Canadian Medical Association and the Government of Northwest Territories. (2021). The Unforgotten toolkit: an educational guide. https://theunforgotten.cma.ca/wp-content/uploads/2021/06/CMA-IFSToolkit-AODA-June-3-v2-EN.pdf
7. Centers for Disease Control and Prevention. (2021). CDC’s Efforts to Address Racism as a Fundamental Driver of Health Disparities. Health Equity. CDC.  https://www.cdc.gov/healthequity/racism-disparities/cdc-efforts.html
8. Centers for Disease Control and Prevention. (2021b). Impact of Racism on our Nation’s Health. Health Equity. CDC. https://www.cdc.gov/healthequity/racism-disparities/impact-of-racism.html
9. Colvin, R. and Murphy, Z. (2020). We’ve Been Failed. Washington Post. https://www.washingtonpost.com/graphics/2020/national/black-chicagoans-covid-19-high-death-rate-system-of-neglect/ 
10. Government of Canada. (2021). Truth and Reconciliation Commission of Canada. Crown-Indigenous Relations and Northern Affairs Canada. https://www.rcaanc-cirnac.gc.ca/eng/1450124405592/1529106060525
11. Judd, D. (2021). Biden becomes first president to issue proclamation marking Indigenous Peoples’ Day. CNN Politics.
12. https://www.cnn.com/2021/10/08/politics/indigenous-peoples-day-joe-biden/index.html
13. Novic, E. (2016). The concept of cultural genocide: an international law perspective. Cultural Heritage Law and Policy. Oxford University Press: New York. https://cadmus.eui.eu/handle/1814/43864
14. Rice, J. (2011). Indian Residential School Truth and Reconciliation Commission of Canada. Cultural Survival. https://www.culturalsurvival.org/publications/cultural-survival-quarterly/indian-residential-school-truth-and-reconciliation
15. Smedley, B., Jeffries, M., Adelman, L. and Cheng, J. (2010). Race, Racial Inequality and Health Inequities: Separating Myth from Fact. The Opportunity Agenda. https://unnaturalcauses.org/assets/uploads/file/Race_Racial_Inequality_Health.pdf