Racism limits people’s ability to attain their highest level of health. As a major cause of health inequity, racism violates a core mission of public health professionals: creating conditions that give all people the opportunity to achieve their best health.
The impact of racism on public health has not always been widely acknowledged or understood, but awareness is growing. The American Medical Association recently described racism as “an urgent threat to public health, the advancement of health equity, and a barrier to excellence in the delivery of medical care.”
Racial Disparities in Health Outcomes
Racism endangers the health and well-being of people of color and other marginalized groups and communities. Those effects are starkly apparent in the disparities in health outcomes suffered by Black Americans:
- Black women suffer pregnancy-related deaths at more than three times the rate of white women, according to the Centers for Disease Control and Prevention (CDC).
- Compared to white Americans, Black Americans are 2.6 times more likely to contract COVID-19, 4.7 times more likely to be hospitalized for the disease, and 2.1 times more likely to die from it, according to the CDC.
- Black men are about 2.5 times more likely to be killed by police than are white men, and Black women are about 1.4 times more likely to be killed by police than are white women.
- Compared to white Americans, Black Americans suffer higher rates of heart diseases, stroke, cancer, asthma, influenza and pneumonia, diabetes, HIV/AIDS, and homicide, according to the U.S. Department of Health and Human Resources.
How Racism Affects Health
Racism takes a direct toll on people of color, causing unhealthy stress levels, feelings of powerlessness, and countless other negative impacts to mental and physical health. The accumulation of daily stressors associated with exposure to racism and discrimination can cause toxic stress beginning at an early age.
Such stress affects children’s physical, mental, and behavioral health throughout their lives, according to the American Academy of Pediatrics. Racism, discrimination, and bias also limit access to economic and social resources that influence health outcomes.
How Racism Affects Social Health Determinants
The correlation between socioeconomic adversities and poorer health outcomes is well documented. Healthy People, a health promotion and disease-prevention initiative of the U.S. Department of Health and Human Services, groups social determinants of health into five categories.
- Economic stability. Having a low or unstable income affects the ability of individuals and families to afford health care, healthy foods, and housing.
- Education access and quality. Individuals with lower levels of education are generally less healthy and live shorter lives than those with higher levels of education.
- Health care access and quality. Factors including lack of insurance make some individuals less likely to have a primary care provider and to be able to afford treatments and medication.
- Neighborhood and built environment. Individuals who live in neighborhoods with high rates of violence and unsafe air or water, as well as those who work in dangerous work environments, face greater health and safety risks than others.
- Social and community context. A lack of support from family, friends, coworkers, and community negatively impacts health and well-being.
A system that assigns value to individuals based on their race puts marginalized groups at a disadvantage for the structural opportunities that support health. This could take the form of overt racism that would deny a Black person a job, or structural racism that makes a Black person more likely to be incarcerated than a white person for the same crime.
The inherent challenges associated with joblessness or raising a child in a single-parent household might affect Black and white individuals equally. Racism, discrimination, and bias, however, make it more likely that Black individuals will face those challenges than white individuals.
A Deeper Problem
Socioeconomic disparities –– and disparities that occur along racial lines –– help explain differences in health outcomes experienced by Black Americans. However, health disparities are not simply a factor of social and economic forces:
- Black Americans have worse health outcomes than white Americans, even accounting for class and poverty.
- Studies have shown that health disparities between wealthy Black Americans and wealthy white Americans are even more pronounced than disparities between Black and white Americans who are not wealthy.
- Disparities in maternal mortality rates suffered by Black women exist across geographic locations, including in states with the lowest pregnancy-related mortality ratios, and they are also consistent among groups with higher levels of education.
These facts speak to the complexity and severity of the negative impact that racism has on public health. Examining ways racism affects healthcare services can shed light on this concerning issue.
Manifestations of Racism in Health Care
Instances of racism, discrimination, and bias that contribute to negative health outcomes occur on both individual and systemic levels.
Implicit Bias and Personal Racism
Conscious and unconscious biases can lower the quality of health care that people of color and other marginalized groups receive. Unconscious biases based on race and ethnicity can readily lead to prejudicial behavior. Implicit racial bias in the health care system can affect interactions between healthcare providers and patients, treatment decisions, and ultimately patient health outcomes.
For example, unconscious negative attitudes and stereotypes based on race can affect the way that physicians and other healthcare providers communicate and interact with patients of color. It can also influence recommended treatment and pain management options.
Systemic racism refers to established institutions and practices that create and maintain racial inequity. Examples of systemic racism that impact the health of Black Americans can be found throughout society:
- Residential segregation. Housing policies that discriminate against people of color can limit access to safe neighborhoods. For example, state-sponsored housing policies during the 1930s that refused to insure mortgages in predominantly Black neighborhoods and denied the sale of new homes to Black buyers created racial segregation that persists today.
- Police brutality. Violent actions by police disproportionately impact people of color. Black people account for only 12 percent of the population but 22 percent of fatal police shootings, according to the NAACP.
- Inequities in the criminal justice system. Inequities make it more likely for a Black person than a white person to be arrested and incarcerated for the same crime. The NAACP notes that Black Americans account for only 5 percent of illicit drug use but 29 percent of those arrested and 33 percent of those incarcerated for drug offenses.
- Food insecurity. Black communities are more likely to lack access to full-service grocery stores and other sources of healthy food than other communities, according to Healthline.
- Education disparities. Predominantly nonwhite school districts receive significantly less funding than predominantly white school districts. Underfunded schools are more likely to be under-resourced and have hazardous infrastructure, such as outdated HVAC systems or plumbing.
Harm caused by the continued legacy of slavery is immeasurable, but multiple research projects have established that current-day health disparities related to racism are rooted in the historical oppression of Black individuals and communities in America.
A study led by researchers at the University of North Carolina at Chapel Hill examined the role of implicit bias that is associated with racial disparities in life outcomes. The study found that higher rates of pro-white bias currently exist in counties and states that were more dependent on slavery. The researchers theorize that historical oppression is perpetuated through current structural inequalities, including disparities in poverty and upward mobility.
A separate study conducted by epidemiologists with Emory University and others examined declines in heart disease mortality in the U.S. South. It found that mortality rates of Black individuals declined more slowly in counties where enslavement of Black individuals had been higher.
The public health legacy of the Slave South can also be seen in the disproportionate impact of the COVID-19 virus on Black Americans. Data compiled by The Pew Charitable Trust reveals striking disparities:
- Black residents make up 28 percent of Alabama’s population, but account for 44 percent of COVID-19 deaths in the state.
- Black residents make up 34 percent of the populations of Georgia and Louisiana, but account for 49 percent and 55 percent, respectively, of COVID-19 deaths in those states.
- Black residents make up 28 percent of South Carolina’s population, but account for 53 percent of COVID-19 deaths in the state.
The Role of Public Health in Combating Racism
Public health professionals face a difficult challenge in combating racism in health care. The effects and manifestations of racism are complex. Health disparities related to race defy simple solutions.
For example, in the case of disproportionately high pregnancy-related mortality rates suffered by Black women, the CDC notes that an average of three to four contributing factors can be identified for each pregnancy-related death.
Causes of death among Black women can reflect differences in access to care (like, access to specialist care during preconception, pregnancy, and the postpartum periods); the quality of care they receive; and the prevalence of chronic diseases such as hypertension.
The CDC also acknowledges systemic factors such as gaps in healthcare coverage and preventive care, as well as lack of coordinated health care and social services. Given the issue’s complexity, any strategies to address racial disparities in pregnancy-related deaths require coordination at the community, industry, health system and facility, patient and family, and healthcare provider levels.
Public health professionals are uniquely qualified to address racism in health care systems because they are trained to work with individuals, institutions, and communities, and to coordinate services across all of these domains.
Representation and Education
One of the issues that perpetuates racial inequity in health care is the lack of representation for people of color in the field. Black people account for 12 percent of the U.S. population but only 5 percent of active physicians, according to the Association of American Medical Colleges.
The American Medical Association has acknowledged that “segregation and racism within the medical profession have, and continue to, profoundly impact the African American community.”
Having more doctors of color decreases the likelihood that patients of color will encounter bias. If those patients have more trust in their healthcare provider, they are more likely to follow the medical guidance they receive.
The institutions that train medical and health professionals can do their part by making cultural competency and health equity core values in their programs. Schools of public health have led efforts to raise awareness about racism as a public health issue, and many health and medical schools now include the concept of implicit bias in their curricula.
These steps can help new practitioners recognize and address their own biases. By doing so, schools can develop healthcare providers who practice and promote equitable care.
Advocating for Equity in Public Health
Tulane University’s Online Master of Public Health program teaches students to promote health equity, give a voice to people in need, and create healthier communities for all. With six primary areas of impact ––biostatistics and data science, environmental health science, epidemiology, global community health and behavioral science, health policy and management, and tropical medicine ––the program provides a holistic perspective across various health practices.
Ranked No. 13 among public health schools in the U.S., Tulane’s School of Public Health and Tropical Medicine offers an Online Master of Public Health (MPH) in Community Health Sciences degree, and multiple online graduate options in the area of environmental health sciences:
- Online Master of Public Health (MPH) in Disaster Management
- Online Master of Public Health (MPH) in Occupational and Environmental Health
- Online Master of Public Health (MPH) in Occupational Health and Safety Management
- Online Master of Science in Public Health (MSPH) in Industrial Hygiene
Tulane’s innovative curricula and field-tested faculty give students the tools they need to help underserved communities and promote health equity. Visit Tulane University’s Online Master of Public Health program to learn more about promoting better health for everyone.
Advocating for LGBTQ Health Access
What Is Environmental Justice? An Introduction to Fair Treatment
What Is Health Equity? Ensuring Access for Everyone
American Academy of Pediatrics, “‘Dismantle Racism at Every Level’: AAP President”
American College of Emergency Physicians, ACEP Statement on Structural Racism and Public Health
American Heart Association, “Why Are Black Women at Such High Risk of Dying from Pregnancy Complications?”
American Medical Association, AMA Board of Trustees Pledges Action Against Racism, Police Brutality
American Medical Association, The History of African Americans and Organized Medicine
American Public Health Association, Racism and Health
Association of American Medical Colleges, Diversity in Medicine: Facts and Figures 2019
Association of American Medical Colleges, “How We Fail Black Patients in Pain”
Center for American Progress, “Fighting Systemic Racism in K-12 Education: Helping Allies Move from the Keyboard to the School Board”
Center for American Progress, Health Disparities by Race and Ethnicity
Centers for Disease Control and Prevention, COVID-19 Hospitalization and Death by Race/Ethnicity
Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, “Racial/Ethnic Disparities in Pregnancy-Related Deaths –– United States, 2007-2016”
Healthline, “Healthy Food Is a Right for Black People, Not a Privilege”
NAACP, Criminal Justice Fact Sheet
The National Academies of Sciences, Engineering, and Medicine, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care”
National Academy of Medicine, Racism and Associated Health Impacts
NPR, “A ‘Forgotten History’ of How the U.S. Government Segregated America”
Pediatrics, “The Impact of Racism on Child and Adolescent Health”
The Pew Charitable Trusts, “COVID-19 Is Crushing Black Communities. Some States Are Paying Attention.”
The Pew Charitable Trusts, “Racism Is a Public Health Crisis, Say Cities and Counties”
Proceedings of the National Academy of Sciences, “Historical Roots of Implicit Bias in Slavery”
Proceedings of the National Academy of Sciences, “Risk of Being Killed by Police Use of Force in the United States by Age, Race–Ethnicity, and Sex”
Social Science & Medicine, “Racial Disparities in Health Among Nonpoor African Americans and Hispanics: The Role of Acute and Chronic Discrimination”
SSM ––Population Health, “The Legacy of Slavery and Contemporary Declines in Heart Disease Mortality in the U.S. South”
U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Quality of Housing
U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Social Determinants of Health
U.S. Department of Health and Human Services, Office of Minority Health, Profile: Black/African Americans