2: Prejudice, Discrimination, and Health

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  • Carty, Denise C.
  • Key, Kent D.
  • Caldwell, Cleopatra
  • French-Turner, Tonya
  • Brownlee, Shannon
  • De Loney, E. Hill


Racism is a system of beliefs and structures that denigrate and disadvantage members of racial groups who are categorized and regarded as inferior. This chapter describes racism and summarizes its impact on health inequities for African Americans and other racial and ethnic groups in the United States. After describing key dimensions of racism, it explains mechanisms through which each dimension of racism is associated with health inequities. Next, drawing from the public health literature, the chapter highlights empirical support for how racism is associated with health outcomes in racialized population groups in the United States. It ends with a case study of what one community has done to address racism as a fundamental determinant of racial disparities in infant mortality. Multiple frameworks for addressing the effects of racism exist, and frameworks that approach health equity from an intersectional lens are particularly important.

  • Define racism, prejudice, and discrimination, and identify the levels at which they operate

  • Describe the ways in which racism directly impacts health

  • Discuss the ways in which racism affects different racial/ethnic groups

  • Identify strategies that can be used to address racism and health

  • Describe how community-based interventions can be designed to impact racism at multiple levels


In this chapter, we describe racism and summarize its impact on health inequities for African Americans and other racial and ethnic groups in the U.S. We use “racism” as an umbrella term that encompasses racial ideology, racial prejudice, internalized racism, racial discrimination, and racism-related structures in institutions and society. After describing key dimensions of racism, we explain mechanisms through which each dimension of racism is associated with health inequities. Next, drawing from the public health literature, we highlight empirical support for how racism is associated with health outcomes in racialized population groups in the U.S. We end with a case study of what one community has done to address racism as a fundamental determinant of racial disparities in infant mortality. Throughout this chapter, we use “inequities” and “disparities” interchangeably. We prefer the term “inequities” to connote that health differences fueled by racism are inherently unjust, unfair, and avoidable.

Definitions of Racism

Racism is a system of beliefs and structures that denigrate and disadvantage members of racial groups who are categorized and regarded as inferior. A definition of racism is “beliefs, attitudes, institutional arrangements, and acts that tend to denigrate individuals or groups because of phenotypic characteristics or ethnic group affiliation” (Clark, Anderson, Clark, & Williams, 1999, p. 805). Racism has been operationalized at intrapersonal, interpersonal, and structural levels (Bonilla-Silva, 1997; Jones, 2000; Williams, Lawrence, & Davis, 2019).

The major components or levels of racism can be visualized as intersecting circles rather than discrete classifications. Intrapersonal racism is the ideology of racism internalized in people’s thoughts, and it consists of both prejudice and internalized racism. Racial prejudice is operationalized as racist beliefs and attitudes, and it is often subtle or unconscious (Dovidio, 2001; Quillian, 2006), whereas internalized racism is acceptance of negative stereotypes about one’s racial group (Jones, 2000). Interpersonal racism, indicated as discrimination, refers to actions or behaviors that unfairly target individuals based on their race. Discrimination can occur between individuals or across institutions, and the differential impact by race can be deliberate or unintentional (Williams et al., 2019). Institutional and structural racism are often described interchangeably. Institutional racism refers to discriminatory policies and practices within institutions such as healthcare, education, and housing (Bailey et al., 2017). Structural racism refers to totality of ways that stratified social systems result in differential opportunities and distribution of societal resources by race (Bonilla-Silva, 1997).

Regardless of the definitions or conceptualizations used, it is essential to understand that racism is multidimensional and systemic. The different levels or dimensions of racism represent differences in the actors, victims, settings, or mechanisms through which each dimension contributes to health inequities. However, each dimension has interactional components. Racism is a pervasive phenomenon that negatively impacts marginalized groups even in the absence of explicitly perceived or reported acts of racism. Individual “acts” of racism rarely operate in isolation, but are driven, often unthinkingly, by ideologies of racial superiority and inferiority and a self-replicating system of disadvantage and oppression for subordinated populations (Bonilla-Silva, 1997).

Four key concepts illustrate racism: (a) prejudice; (b) discrimination; (c) structural racism; and (d) internalized racism. Each concept is listed and described based on the degree to which the concept has been discussed and studied in the medical and public health literature.

Racial prejudice. Racial prejudice refers to negative beliefs, attitudes, or assumptions held about individuals or groups based on their race. Racial prejudice is rooted in ideology and reflects collective biases and misunderstandings that are perpetuated in societies. Hence, prejudice is both an individual and collective phenomenon (Blair & Brondolo, 2017). More nuanced descriptions of prejudice include aversive racism which refers to prejudice at the hands of liberal actors who are not viewed as ostensibly racist (Pearson, Dovidio, & Gaertner, 2009). Racial prejudice perpetuates stigma, which can be a major source of stress for individuals in racially-stigmatized groups (Meyer, Schwartz, & Frost, 2008). Consequences of this stigmatization include stereotype threat and internalized racism that are negative psychological responses to pervading stereotypes about one’s racial group (Aronson, Burgess, Phelan, & Juarez, 2013). Prejudice can occur based on race, sex, disability, and other stigmatized social statuses, and prejudice can ultimately lead to interpersonal and systemic discrimination and violence against people in stigmatized social groups (Stuber, Meyer, & Link, 2008). Acknowledging prejudice in multiple forms is important to understanding additional burdens and disadvantages due to the intersections of race and gender, race and class, or race and sexual orientation, for example (Schulz & Mullings, 2006).

Discrimination. Racial discrimination is “differential treatment on the basis of race that disadvantages a racial group” (Blank, Dabady, & Citro, 2004, p. 4); similar definitions apply to discrimination based on sex, sexual orientation, gender identity, and other factors. Discrimination is often studied in public health based on retrospective, self-reported experiences of discrimination (Paradies et al., 2015; Williams & Mohammed, 2009). However, discrimination does not have to be personally recognized nor intentional to have negative consequences for health. Several studies show that implicit bias among health professionals contributes to biased decision-making and lower quality of care (Fitzgerald & Hurst, 2017). Neither the actors nor the targets are likely to perceive or articulate this bias. Institutionalized forms of racial discrimination such as housing discrimination and unequal treatment in healthcare impact individual and population health regardless of conscious perception or reporting.

Structural racism. Structural racism is a social system rooted in racial ideologies that maintains unequal distribution of and access to power and societal resources (Bonilla-Silva, 1997). Structural racism results in systemic racial group inequities that can impact health (Gee & Ford, 2011). Racism is manifested structurally via racial residential segregation (Williams & Collins, 2001), environmental injustice (Morello-Frosch, Zuk, Jerrett, Shamasunder, & Kyle, 2011), political disenfranchisement (Rodriguez, Geronimus, Bound, & Dorling, 2015), mass incarceration (Wildeman & Wang, 2017), and immigration policies (Martinez et al., 2015).

Structural racism is also represented by historical traumas such as African American enslavement (Gaskin, Headen, & White-Means, 2005; Prather et al., 2018), colonization and forced removal of Native Americans from their lands (Dunbar-Ortiz, 2014), internment of Japanese Americans (Gee, Ro, Shariff-Marco, & Chae, 2009), and social marginalization and criminalization of undocumented immigrants (LeBrón & Viruell-Fuentes, 2019). These historical experiences can have intergenerational effects on health (Brave Heart & DeBruyn, 1998; Gee & Ford, 2011). Racism, particularly its structural components, is viewed as a fundamental cause of health inequities (Phelan & Link, 2015).

Internalized racism, cultural racism, and implicit bias. A less frequently researched area in health is internalized racism, whereby members of stigmatized races accept negative stereotypes about their individual or group abilities and self-worth (Jones, 2000). Internalized racism can result in negative self-concepts, depression, and psychological distress for persons who internalize stereotypes of racial inferiority (Mouzon & McLean, 2017). A related concept is “cultural racism,” which highlights the ideological and cultural systems that propagate false notions of the superiority of Whites and “white” culture (Cogburn, 2019).

A consequence of cultural racism that has garnered attention in health disparities literature is the notion of implicit or unconscious bias. Implicit bias results from internalized perceptions about group inferiority that are subconsciously acted upon, often to the detriment of the stigmatized groups (van Ryn et al., 2011). Implicit bias among health professionals is associated with poor patient–provider communication and biased treatment recommendations (Fitzgerald & Hurst, 2017). A correlate of implicit bias is aversive racism, which refers to subtle biases in social interactions and decision-making, even among well-intentioned individuals, that contributes to disparities (Pearson et al., 2009).

Genetics, Race, and Racism

A sophisticated understanding of race and racism precludes genetic explanations for racial inequities in health. Science confirms that no genes exclusively or consistently map onto Black or White races, therefore it is misguided to attribute genetics as a primary explanation for racial disparities (Foster & Sharp, 2004; Goodman, 2000). Race is not real in the biogenetic sense. Rather, race is a social construct that categorizes groups based on ideologies of group superiority and inferiority relative to phenotype, group affiliation, and socially ascribed characteristics (Harawa & Ford, 2009). Racial classification in the U.S. maintains systems of power and privilege for persons racialized and socially accepted as White relative to all other racial/ethnic classes (Omi & Winant, 2015). Despite its genetic irrelevance, race remains an important social factor to consider when describing health inequities due to the close correlations between race and health. However, race is inappropriate to explain health inequities without discussion of co-occurring factors that systematically map onto race to produce differential health outcomes (LaVeist, 1996).

Racism is a peculiar system that both reifies and contradicts the notion of race. Racial classifications and group membership have shifted throughout U.S. history and are still evolving. For example, former Polish and other immigrants who were marginalized because of their ethnicity ultimately became accepted as White (Roediger, 2005). Ethno-religious groups such as Arab or Muslim are normatively racialized as non-White, although Arabs are classified as White in the U.S. Census (Garner & Selod, 2014). Many Latinos/Latinas of Mexican origin, although officially classified as White, are designated foremost as an ethnic group and routinely differentiated from non-Hispanic Whites (Viruell-Fuentes, Miranda, & Abdulrahim, 2012).

In this chapter, we acknowledge the primacy of racism, which transcends fluid conceptualizations of race. We use the terms African American, Black, Asian American, American Indian/Alaska Native, Native American, Latino/Latina/Latinx, and White as relevant to the sociopolitical or scientific context discussed. Racism in the U.S. has particular relevance for African Americans in terms of the intensity and scale of impact, and most studies of racism and health inequities focus on African Americans. Much of our discussion refers to African Americans to reflect the prevailing social, historical, and academic focus on this population. We also refer to Latinos/Latinas and Arab Americans during our discussion in light of the emergent racialization of these groups in the U.S. We acknowledge that there is vast heterogeneity within these broad racial categorizations. However, in-depth coverage of how racism impacts all of these groups is beyond the scope of this chapter. We contend that racism is a system that negatively impacts all groups who are conferred a subordinate racial status; hence, the definitions and discussions about racism in this chapter can be applied broadly to multiple racial groups and even further extended into constructs such as heterosexism and transphobia.


Racism operates through multiple pathways and has been associated with multiple health outcomes (Dominguez, 2008; Harrell et al., 2011; Phelan & Link, 2015; Williams & Mohammed, 2013). In this section, we present selected findings that support how racism impacts health for varying population groups. We highlight stress, racial residential segregation, and immigration policy as key pathways through which racism harms health. An emphasis on racism as a determinant of health does not negate interacting factors such as socioeconomic status that remain important drivers of health inequity. However, studies that have analyzed associations between various measures of racism and health have observed sustained effects of racism independent of socioeconomic, demographic, and other health risk factors. Most studies are cross-sectional, and therefore a cause-and-effect relationship between racism and the studied outcome cannot be established. Hence, we report associations. Each reported association implies that higher levels of racism are linearly and significantly associated with health in an unfavorable direction.

Perceived Racism and Health Outcomes

Racism has received considerable attention in public health research as a contributing cause of adverse health outcomes. Overall, racism is associated with poor mental and physical health, although studies are most frequent and the effects are more robust for measures of perceived or self-reported discrimination and mental health outcomes (Paradies et al., 2015; Williams & Mohammed, 2013). Racism has been linked to mental distress and psychiatric disorders in African American, Asian, and Latino/Latina populations (Lewis, Cogburn, & Williams, 2015). A meta-analysis of racism and mental health outcomes that included over 300 studies indicated that self-reported racism was associated with depression, psychological distress, anxiety, post-traumatic stress disorder, and other negative mental health outcomes in addition to decreased positive mental health indicators such as self-esteem, life satisfaction, and overall well-being (Paradies et al., 2015).

Racism is associated with overall physical health, but the association with discrete health outcomes is mixed. Cardiovascular disease risk factors are commonly studied in research that examines racism and physical health. Perceived racism has a positive association with ambulatory blood pressure across multiple studies (Brondolo, Love, Pencille, Schoenthaler, & Ogedegbe, 2011; Dolezsar, McGrath, Herzig, & Miller, 2014), but the relationship to hypertension and other cardiovascular disease risk factors is mixed (Lewis, Williams, Tamene, & Clark, 2014; Paradies et al., 2015). A meta-analysis of perceived racism and physical health outcomes in 50 studies found consistent associations with perceived racism and overweight measures (Paradies et al., 2015). National studies have found that self-reported racism is associated with obesity in Black women (Cozier et al., 2014) and men (Thorpe, Parker, Cobb, Dillard, & Bowie, 2017). Perceived racial discrimination has also been associated with smoking (Borrell et al., 2007; Corral & Landrine, 2012; Landrine & Klonoff, 2000) and alcohol use (Borrell, Kiefe, Diez-Roux, Williams, & Gordon-Larsen, 2013) in African Americans. Most studies of racism and health have examined African American populations, but there is growing attention to documenting how perceived racism influences health in other racial and ethnic groups. Additional discussion of health equity among African American populations can be found in Chapter 5, African American Health Equity.

Asian Americans. Although Asian Americans may be stereotyped as a “model minority,” they are not immune to the effects of racism. In a nationwide survey, Asian Americans (including Filipino, Chinese, and Vietnamese subpopulations) were more likely to report discrimination due to race, ethnicity, or skin color than discrimination due to other causes such as gender, age, or income (Gee, Spencer, Chen, & Takeuchi, 2007). In addition, perceived discrimination among Asian Americans was positively associated with the number of reported chronic health conditions including cardiovascular and respiratory diseases, other chronic illnesses, and chronic pain (Gee, Spencer, Chen, & Takeuchi, 2007). Asian Americans who self-reported discrimination were two to three times more likely to have a mental health disorder, including depression and anxiety, controlling for sociodemographic, cultural, and co-occurring health factors (Gee, Spencer, Chen, Yip, & Takeuchi, 2007).

Some studies have highlighted coping styles used by Asians to buffer discrimination experiences. Perceived racial discrimination was associated with depression among Southeast Asian refugees (Noh, Beiser, Kaspar, Hou, & Rummens, 1999) and Korean immigrants (Noh & Kaspar, 2003) in Canada. Passive coping and high ethnic identity among Southeast Asians and active, problem-focused coping among more established Korean immigrants moderated the effect of perceived racism on depression. In another study, Asian Americans who reported high levels of racial/ethnic discrimination were less likely to be current smokers if they had high levels of ethnic identity (Chae et al., 2008). These studies demonstrate variation by national origin, refugee or immigrant status, and ethnic identity, and suggest that culturally-concordant coping may help to buffer the deleterious health effects of racism at the individual level.

Additional discussion of health equity among Asian populations can be found in Chapter 7, Asian American Health Equity.

Latinos/Latinas. In the U.S., Latinos/Latinas are designated as an ethnic group, and they are primarily enumerated in the White racial category according to the U.S. Census (U.S. Census Bureau, 2019). However, Latinos/Latinas hold a subordinate racial position relative to non-Hispanic Whites, and they are often viewed as “foreigners” regardless of nativity or immigration status (LeBrón & Viruell-Fuentes, 2019). This marginalization makes Latinos/Latinas subject to racial/ethnic discrimination, and there is a growing body of work examining racism and health among Latinos/Latinas (Viruell-Fuentes et al., 2012). In a multi-site study, perceived ethnic discrimination was prevalent among Central Americans, Cubans, Dominicans, Mexicans, Puerto Ricans, South Americans, and Other Latino/Latinas (Arellano-Morales et al., 2015). Perceived racial discrimination has also been associated with self-reported mental health (Stuber, Galea, Ahern, Blaney, & Fuller, 2003) and physical health (Finch, Hummer, Kolody, & Vega, 2001) in Latino/Latina populations. Among Puerto Ricans in Boston, Massachusetts, perceived discrimination due to ethnicity, race, or language was associated with more reported chronic medical conditions, past smoking, and higher diastolic blood pressure (Todorova, Falcon, Lincoln, & Price, 2010). Oza-Frank and Cunningham (2010) observed that increasing body mass index (BMI) was associated with longer duration of U.S. residence for Latino/Latina immigrants. Additional discussion of health equity among Latinx populations can be found in Chapter 6, Health Equity in U.S. Latinx Populations.

Arab Americans. Arab Americans are at heightened risk of experiencing racial hostility due to the social and political climate that associates Arabs and Muslims with terrorism. Arab Americans who are of Middle Eastern descent are formally classified as White (Office of Management and Budget, 1997). However, for many Arab Americans, the racialization of Islam ascribes to them a marginalized social position and they are subject to significant discrimination and associated health effects (Abuelezam, El-Sayed, & Galea, 2017; Samari, Alcala, & Sharif, 2018). California and Michigan have the largest populations of Arab Americans in the U.S., and most population health studies of Arab Americans are based in those states. In a Detroit study, Arab Americans were more likely to report perceived discrimination if they identified as non-White, but they were more likely to experience psychological distress associated with discrimination if they identified as White (Abdulrahim, James, Yamout, & Baker, 2012). In a population-based study in Michigan, Arab Americans who perceived ethnic discrimination and individual or family abuse after 9/11 reported higher levels of psychological distress and worse self-reported health status (Padela & Heisler, 2010). In California, women who had Arab surnames had increased rates of preterm birth and low birth weight 6 months after 9/11 compared to baseline rates in the previous year (Lauderdale, 2006). Similar results were not replicated among Arab American women in Michigan who experienced no change in preterm birth or low birth weight before and after 9/11 (El-Sayed, Hadley, & Galea, 2008). A number of studies have documented increased psychological distress for Muslim populations related to discrimination based on their religious or ethnic identity (Samari et al., 2018). Finally, Arab Americans are increasingly the victims of hate crimes and hence subject to direct physical and psychological trauma which impact their health (Arab American Institute Foundation, 2018).

Native Americans. There is a well-documented history of racial inequities experienced by Native Americans in the U.S. (Brave Heart & DeBruyn, 1998; Jones, 2006). Much of the public health literature addresses how social disadvantage and psychological trauma influence health behaviors such as alcohol and substance use (Skewes & Blume, 2019). There is also a large literature on health conditions such as cardiovascular diseases, diabetes, and other chronic diseases and risk factors (Hutchinson & Shin, 2014). Published research on measured racism or racial discrimination in relation to specific health outcomes for Native Americans is less common. In a small sample of American Indians in the Northern Plains, perceived racial discrimination was associated with elevated diastolic blood pressure (Thayer, Blair, Buchwald, & Manson, 2017). Perceived racial discrimination was also associated with smoking in a multi-site urban American Indian/Alaska Native LGBT population (Johnson-Jennings, Belcourt, Town, Walls, & Walters, 2014). Reported racial discrimination was also associated with illicit substance use in a sample of American Indian youth residing in the Cherokee Nation (Garrett, Livingston, Livingston, & Komro, 2017). Greater availability of public health data on American Indian/Alaska Native populations (Bauer & Plescia, 2014) and expanded use of standardized self-report measures of discrimination with this population may improve findings on perceived discrimination and health among Native Americans (Gonzales et al., 2016). Additional discussion of health equity among Native American populations can be found in Chapter 8, American Indian and Alaska Native Health Equity.

Racism and Stress

Stress is an important mechanism through which racism harms health. As a chronic stressor, racism can cause biological dysfunction at the cellular level and health deterioration over the life course (Gee, Walsemann, & Brondolo, 2012; Harrell et al., 2011). One marker of chronic stress is allostatic load, a maladaptive biological response to frequent and cumulative stress which impairs normal neuroendocrine and inflammatory mechanisms and results in accelerated wear-and-tear on body systems (McEwen & Wingfield, 2003). Racial discrimination has been shown to affect stress pathways by dysregulating the hypothalamic-pituitary-adrenal (HPA) axis and producing elevated stress hormones such as cortisol, which causes inflammation and precipitates disease (Berger & Sarnyai, 2015). Another stress-related mechanism is the shortening of cellular telomeres—an indicator of premature aging (Liu & Kawachi, 2017).

Although findings are mixed, there is plausible support that racism-related stress is associated with physiologic changes that precipitate poor health. Studies indicate greater cardioreactivity in African American women in response to simulated stressors (Lepore et al., 2006; McNeilly et al., 1995) as well as greater allostatic load (Chyu & Upchurch, 2011) and hypertension prevalence (Hicken, Lee, Morenoff, House, & Williams, 2014) in relation to stress. Other studies have found associations with racial discrimination and shortened telomeres in African American men and women (Chae et al., 2014; Lu et al., 2019). Alternatively, studies have also demonstrated no direct association between racism-related stress and adverse physiologic responses (Albert et al., 2008; Krieger et al., 2013).

Racism is one of multiple “stressors” that humans can experience, alongside other stressors such as death of a family member, divorce, job loss, and other stressful events. Nonetheless, racism is not merely a life event, but a total lived experience. The pervasiveness of racism makes it a particularly noxious stressor that impacts health over the life course (Gee et al., 2012). Racism operates as microaggressions (Lewis, Williams, Peppers, & Gadson, 2017), unfair treatment (Chae et al., 2008), and major events (DeVylder et al., 2018; Lopez et al., 2017; Padela & Heisler, 2010). Racism can be direct or vicarious (Heard-Garris, Cale, Camaj, Hamati, & Dominguez, 2018). Structural racism produces inequities in education, employment, housing, and healthcare (Gee & Ford, 2011). All of these experiences contribute to chronic, cumulative stress for racially marginalized individuals and communities. Racism is thus a “mega” stressor that encapsulates multiple stressful experiences.

Actions employed by individuals to counter racism-related stress can also harm health. One such mechanism is high-effort coping, whereby individuals persist doggedly to counteract social stereotypes and resist social and structural barriers. James (1994) coined the term “John Henryism” to describe this phenomenon with reference to African American or Black populations. Other researchers have described this concept as “vigilance” (Himmelstein, Young, Sanchez, & Jackson, 2015) with applicability to diverse racial/ethnic groups. Overall, the findings on vigilant, high-effort coping are mixed, with evidence of limited effect or differential impact on health across populations by race, sex, and socioeconomic status (Felix et al., 2019; Subramanyam et al., 2013).

Social–psychological responses such as internalized racism have been associated with major depression and psychological distress in African Americans (James, 2017; Mouzon & McLean, 2017). Internalized racism has also been linked to adverse birth outcomes (Chae et al., 2018) and hypertension (Chae, Nuru-Jeter, & Adler, 2012) in Blacks.

Stress-induced unhealthy behaviors can be a potential pathway through which racism influences health outcomes. Perceived racial discrimination has been associated with smoking and alcohol consumption in African Americans (Borrell et al., 2013) and heavy drinking in Latinos/Latinas (Borrell et al., 2010). Race-related stress was also associated with emotional eating in Black women (Longmire-Avital & McQueen, 2019). However, in a longitudinal analysis, racial discrimination did not predict unhealthy eating behaviors over time in a cohort of Black Americans monitored for hypertension and related risk factors (Forsyth, Schoenthaler, Ogedegbe, & Ravenell, 2014).

Residential Segregation

Racial residential segregation refers to the relative concentration and geographic separation of racial groups in residential areas (Massey & Denton, 1988). Historical policies and practices such as redlining and mortgage discrimination helped to create the current conditions of racially segregated communities with concentrated neighborhood disadvantage (Massey & Denton, 1993; Williams & Collins, 2001). Residential segregation dictates the quality of schools (Kozol, 1991) and employment opportunities (Dickerson, 2007), which are known predictors of health via educational attainment and income.

Racial segregation also influences the built environment in ways that lessen or promote health risks. Neighborhood factors that promote obesogenic environments in Black and Latino/Latina communities are low availability of supermarkets, parks, and exercise facilities, and safety issues related to crime and traffic which deter physical activity (Lovasi, Hutson, Guerra, & Neckerman, 2009). Kwate (2008) conceptualized that concentrated poverty, permissive zoning regulations, commercial targeting, and relative lack of political power promoted the proliferation of fast food establishments in predominantly Black neighborhoods and consequential risks for obesity. Racial inequities in poverty, unemployment, and home ownership at the county level were also associated with a higher prevalence of obesity in communities (Bell, Kerr, & Young, 2019).

Racially segregated neighborhoods have increased exposure to environmental toxins (Morello-Frosch et al., 2011) and lack structural supports for health-promoting activities such as walking and other recreational activities (Kramer & Hogue, 2009; Williams & Collins, 2001). Residents of racially-segregated neighborhoods may also have limited access to quality healthcare facilities and less use of health services (Gaskin, Price, Brandon, & LaVeist, 2009). In terms of measurable effects, racial segregation has been associated with preterm birth and low birth weight (Mehra et al., 2017), cancer disparities (Landrine et al., 2017), and cardiovascular disease risks (Kershaw & Albrecht, 2015).

Immigration Policy

Immigration policy can be conceptualized as structural racism to the extent that it negatively targets and disadvantages racialized groups. Historically, immigration and citizenship-related policies gave preference to White populations and European-origin nationalities, to the exclusion of non-European immigrants, including persons from Asian countries, the Pacific Islands, Africa, the Caribbean, and South and Central America (Gee & Ford, 2011). Racist theories about non-White people as diseased, unclean, morally corrupt, and inferior contributed to these policies (Gee & Ford, 2011). Although the 1965 Immigration and Naturalization Act repealed many of the explicit national-origin restrictions, there has been a resurgence of exclusionary immigration policies targeting immigrants from Central and South America and from Arab countries in the Middle East (Abuelezam et al., 2017; Gee & Ford, 2011).

The process of social stratification of immigrant groups impacted by immigration policies contributes to the “racialization” of these groups. Racialization refers to the construction of race in the larger society (Omi & Winant, 2015). Inherent in the racialization process is not just the assigning of a racial category, but the social ranking ascribed to that category. In the U.S. context, White is presumed to be racially dominant, and all other groups are ranked lower in the racial hierarchy. The racialization process would render Mexican immigrants and Arabs as non-White despite their official categorization as White by federal standards (Office of Management and Budget, 1997). Although Latinos/Latinas are considered an ethnic group by federal standards, in practice they are marginalized along racial/ethnic lines (LeBrón & Viruell-Fuentes, 2019; Omi & Winant, 2015).

The marginalization and exclusion of immigrant groups as a result of immigration policy constricts opportunities for immigrant groups, in turn creating health inequities. Documented and undocumented immigrants have restricted access to safety nets such as Medicaid, housing and education subsidies, and other public support programs (Gee & Ford, 2011). The barring of undocumented workers from legal employment increases the chances for inequitable pay and working conditions. These conditions can help to concentrate poverty and have other indirect and direct effects on health.

Other consequences of racialization and “othering” of immigrant groups include social stress in relation to discrimination and immigration policies. The threat of deportation can create heightened vigilance and chronic stress in immigrant communities. Latinos/Latinas in states and communities with more exclusionary immigrant policies have reported more perceived discrimination (Almeida, Biello, Pedraza, Wintner, & Viruell-Fuentes, 2016), poorer self-rated health (Vargas, Sanchez, & Juarez, 2017), and more frequent poor mental health days (Hatzenbuehler et al., 2017) than their counterparts in communities with less restrictive immigration policies. Immigration raids have also been associated with lower self-rated health and increased risk of low birth weight among Latinos/Latinas in affected communities, regardless of immigration status (Novak, Geronimus, & Martinez-Cardoso, 2017; Vargas et al., 2017). Moreover, enforcement of federal immigration laws by local authorities have resulted in greater mistrust of health services and delayed healthcare seeking among immigrant Latinos/Latinas (Rhodes et al., 2015).

Other racial/ethnic groups are not immune to the deleterious effects of anti-immigration policies or public sentiment on health. In theory, racialization would be a normative experience for all migrant groups to the U.S. with varying impact by immigration cohort period, national origin, and racial phenotype together with moderators such as socioeconomic status, time in the U.S., and psychosocial orientations such as ethnic identity. However, studies are mixed with no generalized pattern of positive or negative adaptation and related health effects across immigrant groups to the racialization process in the U.S. (Cobb et al., 2019; Gee et al., 2009; Landale & Oropesa, 2002; Mouzon & McLean, 2017; Read & Emerson, 2005; Samari et al., 2018).


A 2003 Institute of Medicine Report and subsequent federal reports on inequalities in healthcare have documented differences in the access to, and quality of, care for racial and ethnic minorities that are associated with poorer health outcomes (Agency for Healthcare Research and Quality, 2019; Smedley, Stith, & Nelson, 2003). In general, African Americans receive lower quality healthcare (Fiscella & Sanders, 2016) and report more racial discrimination in health encounters (Smedley et al., 2003) than Whites. It has been shown that implicit bias in the healthcare system results in healthcare that is perceived more negatively by African Americans than Whites (Johnson, Saha, Arbelaez, Beach, & Cooper, 2004; van Ryn & Burke, 2000). Implicit bias and perceived racism are associated with less patient-centered communication, patient mistrust of the healthcare system, delayed entry into care, and lower adherence to prescribed treatment (Ben, Cormack, Harris, & Paradies, 2017; Blair et al., 2013). However, the weight of the evidence does not associate implicit bias with differential medical treatment or patient health outcomes (Hall et al., 2015). Feagin and Bennefield (2014) argue that the individual-level assessments and provider–patient interactions are insufficient to capture the effect of racism on health or healthcare inequalities, and they advocate for a more historical and structural analysis of how racism has structured ideology and healthcare institutions and left a legacy of extensive health inequities in communities.


Public health practitioners may be less likely to view structural factors, including racism, within the purview of professional intervention. However, addressing fundamental causes has been articulated as necessary for reducing health inequities (Ford & Airhihenbuwa, 2010; Link & Phelan, 1995). Accordingly, addressing racism is a critical approach to advancing health equity (Bailey et al., 2017). The public health literature is replete with observational studies testing various associations of racism (particularly self-reported discrimination) with health, but the field is lacking in interventions to remedy structural and other forms of racism (Carty et al., 2011; Castle, Wendel, Kerr, Brooms, & Rollins, 2019; Hardeman, Murphy, Karbeah, & Kozhimannil, 2018). In this section, we explore specific tools and interventions to address racism to reduce health inequities.

On an intrapersonal level, there are some orientations that people use, consciously or subconsciously, to counter the effects of racism. James (1993) offered a unique cultural perspective that highlighted indigenous cultural strengths within communities that could be employed to buffer against racism. Another orientation is racial or ethnic identity (Caldwell, Kohn-Wood, Schmeelk-Cone, Chavous, & Zimmerman, 2004). The interaction of racial/ethnic identity with other social identities (i.e., gender, age, economic status) highlights the intersectional approach to understanding and working with racially identified groups.

To delineate the meaning of racialized experiences for the mental health of ethnically diverse Black adolescents, Caldwell, Guthrie, and Jackson (2006) examined the intersectional nature of ethnicity and gender as social identities in the face of racial discrimination. They found that African American and Caribbean Black youth shared a number of characteristics related to discriminatory experiences, the meaning of racial identity, and mental health, regardless of ethnicity or gender, perhaps because of the strong ethnic homogenizing forces that are prevalent in American society. There were, however, unique findings that demonstrated the complexity of race/ethnicity and gender as embedded social identities. Multiple aspects of racial identity (e.g., centrality of race, public regard or the views of others, racial pride) were protective factors, but in different ways. Centrality of race to identity was associated with fewer depressive symptoms for Caribbean Black females, while believing that other groups had favorable views about Blacks related to fewer depressive symptoms for Caribbean Black males. Less racial pride was associated with more depressive symptoms for females, regardless of ethnicity. Further, African American and Caribbean Black females who reported more experiences with racial discrimination also reported higher levels of depressive symptoms, while discriminatory experiences were associated with lower self-esteem for all youth.

Seaton, Caldwell, Sellers, and Jackson (2010) also used an intersectional approach to examine ethnicity, gender, and age as moderators of perceived discrimination and mental health. They determined that older Caribbean Black female adolescents exhibited higher depressive symptoms and lower life satisfaction when faced with higher levels of discrimination compared with older African American male adolescents.

These nuanced findings are essential for developing services for ethnically diverse Black youth for whom different racial identity attitudes are critical to consider in efforts to reduce intrapersonal distress due to racial discrimination. For example, Miller and colleagues conducted a review of psychological practice recommendations to address racism (Miller et al., 2018). They categorized eight general approaches that counselors used. Approaches included psychoeducation, validation, critical consciousness, examination of privilege and racial attitudes, culturally responsive social support, developing a positive identity, minimizing self-blame, and outreach/advocacy. Framed with an intersectionality lens, approaches to intervention should incorporate multiple social identities to reflect the meaning of racialized experiences for ethnically diverse Black populations (Caldwell et al., 2006).

Community-Based Approaches

Socio Ecological Model and Undoing Racism

The Genesee County/Flint, MI Racial and Ethnic Approaches to Community Health (REACH) team was guided by the Socio-Ecological Model (SEM) that recognizes the need for engagement at all levels (individual, interpersonal, organizations/institutions, community, providers/healthcare systems, and policy). This model provided a broad platform for addressing social determinants of health associated with racial disparities in infant mortality. Guided by the SEM, the REACH team, comprised of public health, community, academic, and other institutional partners, developed and implemented interventions with a focus on “undoing” racism at the individual, institutional, and systems levels. In addition, REACH adopted principles of the People’s Institute for Survival and Beyond (PISAB), which holds that racism has been consciously and systematically erected, and it can be undone only if people understand what it is, where it comes from, how it functions, and why it is perpetuated (PISAB, n.d.). The REACH team adopted the PISAB working definition of racism, “racism = racial prejudice + power,” which was easy to adopt and understand among various stakeholders (PISAB, n.d.). Clear distinctions between racism, prejudice, bigotry, and associated terms were also necessary to move the work forward. The REACH team developed a shared understanding of racism, acknowledged its multi-faceted manifestations and health impacts, and worked collaboratively to mitigate those negative effects to reduce disparities in African American infant mortality.


Racism is a stressor on multiple levels for African Americans and other racial and ethnic minorities. Racism has been shown to negatively impact one’s health, including depressive symptoms, serious psychological distress, decreased self-esteem, and poorer overall physical and mental health (Williams & Mohammed, 2013). More specifi cally, the health impacts of racism on African American women of childbearing age include maternal stress, low birth weight, preterm delivery, and damaging effects on women’s reproductive health and that of their unborn infants (Dominguez, 2011; Giurgescu, McFarlin, Lomax, Craddock, & Albrecht, 2011).

To address these health disparities, multiple community-based interventions working simultaneously can be effective in reducing racial and ethnic health inequities and improving health outcomes for affected individuals and populations. Racial and Ethnic Approaches to Community Health (REACH) in Flint, Michigan was one such program (Carty et al., 2011; Kannan, Sparks, Webster, Krishnakumar, & Lumeng, 2010; Kruger, Carty, Turbeville, French-Turner, & Brownlee, 2015; Kruger, French-Turner, & Brownlee, 2013; Pestronk & Franks, 2003; Selig, Tropiano, & Greene-Moton, 2006). An overarching strategy for the program was the adoption of the socio-ecological model (SEM), which allowed the Flint REACH team to address racism on multiple levels.

This case study will describe a community’s (Flint/Genesee County, MI) efforts to address racism and its effects on health disparities in maternal and infant health. Quotes from REACH program participants, general community residents, and REACH program coordinators are highlighted as we share what we did and what we learned.

Table 2.1 illustrates interventions that were created and strategically aligned with all levels of the SEM using PISAB principles and describes the impact at each level.

Community Voices

Individual/interpersonal level

Just hearing a different perspective probably opened a door to me wanting to learn even more about the physical impacts of racism and the impact that can have on a pregnancy and on the infant.

Organizational/institutional level

It has been difficult for organizations to get involved because everyone has their own agenda. But focusing on those shared issues that affect infant mortality is a way to bring some of those organizations into this forum. It’s about highlighting how infant mortality is connected to violence, to the community, to unity, to familial responsibility.

Health system/providers level

REACH is one of the unique places where the community actually gets to talk to the people in healthcare. Oftentimes, healthcare is just thrown at us without our input. But this is a place where we actually get to talk to those people who were in charge of it, and who were making some decisions and also voice our opinions and concerns.

Societal/policy level

I think it’s strategically important that REACH is housed in the health department, which is a policy-making agency within the community for healthcare and health service delivery. As it relates to mortality and other health-related issues, you have the community people who help make policy as part of the process, as opposed to institutions making policy before engaging the community.

Community-Based and Community-Engaged Approaches

Community engagement (CE) is defined as the process of working collaboratively with groups of people who are affiliated by geographic proximity, special interests, or similar situations with respect to issues affecting their well-being (CDC, 1997). The CE approach involves improving population health by building trust, utilizing effective communication strategies, creating long-standing collaborations, and enlisting new allies and resources. Community-based participatory approaches (CBPA) fall on the spectrum of CE, and necessitate CE throughout the process (Key et al., 2019).

The REACH team adopted CBPA/CE principles to guide the project approach in engaging community-based organizations, faith-based organizations, and other institutions within the African American community in creating culturally specific interventions. This provided the opportunity to utilize community expertise in the design and implementation of these interventions. In addition, these principles framed the project’s work by bringing to bear the value the community partners’ knowledge of knowing what will and will not work within the community’s context. This model was a true representation of community being an equal and equitable partner.

Socio-Ecological Model and Related Interventions and Impact for Genesee County/Flint, MI Racial and Ethnic Approaches to Community Health (REACH) Program
  • Undoing Racism Workshops Birth Brothers and Birth Sisters

  • Black Men for Social Change

  • Women Taking Charge of Their Health Destiny

  • African Culture Education Development Center

  • Middle Passage Experience

  • African American Healthy Eating Curriculum

  • African Health Navigators

  • Maternal and Infant Health Advocacy Service

  • Undoing internalized racial oppression

  • Teaching African history and culture; promoting cultural pride; self-love

  • Individual and family advocacy and support

  • Peer mentorship

  • Promoting healthy behaviors

  • Engaged, educated, and empowered community residents concerning racism, health disparities, and infant mortality.

  • Interventions provided self- and cultural empowerment to inform health consciousness and decision-making.

  • Windshield Bus Tours

  • Undoing Racism Workshops

  • Middle Passage Experience

  • African Culture Education Development Center

  • Interactive community driving tours with students, professionals, and executive leaders to highlight social determinants influencing maternal and infant health

  • Educating and reforming institutional “gatekeepers”

  • Raised awareness of historical, cultural, social, and environmental barriers that negatively affect the health outcomes of African Americans in Flint/Genesee County.

Healthcare Systems and Providers
  • Undoing Racism Workshops

  • Windshield Tours

  • African Culture Education Development Center

  • Cultural Competence Training

  • Programs to Reduce Infant Death Effectively

  • Fetal-Infant Mortality Review

  • Undoing institutionalized racism

  • Provider bias

  • Quality healthcare

  • Explored the role of “unconscious racism” within institutions and systems.

  • Highlighted the role providers and systems play in perpetuating racism and understanding how it can be “undone” to provide those services necessary to reduce racial disparities in infant mortality.

  • Provided the services necessary to optimize maternal health and reduce infant mortality risks.

  • Billboard Media Campaign

  • Community Outreach and Engagement

  • Advocate for improvements in social and built environment

  • Engagement and outreach to communities

  • Foster community strengths and resources

  • Community-based participatory approaches

  • Successfully advocated to improve the built environment by adding a new bus stop in an underserved community to improve transportation access to community resources such as clinics and grocery stores.

  • Community Outreach and Engagement

  • Community Leadership Strategies

  • SWOT analysis

  • Identify priority systemic changes needed to improve health equity

  • Identified systemic changes needed in education, healthcare, and social service institutions.

  • Transformed the role of gatekeepers.

SWOT, strengths, weaknesses, opportunities, and threats.

Community Voices

In order to address any disparity – and I’m talking disparities across the board, across all races – you really have to involve the community. The community has to be top priority. They have to be equal players at the table, and I mean equal in their voice, equal in the resources, equal in the implementation, in the decision-making and everything. They have to be equal partners. We can’t just rely on our specialties, our public health training, and think that we know what works for the people out in the community. We need to talk to the people and have them on board with us every step of the way.

Community Outreach and Engagement

Utilizing multiple engagement strategies, the REACH team was able to garner community buy-in and provide education through outreach events. Through citywide media campaigns (i.e., billboards, educational information on city buses) and numerous events, the REACH project was well-received by the community. REACH also held annual events to report on the progress of the project and gain valuable feedback and input from community residents. This feedback was collected and integrated into the work plans.

Community Voices

We went out to a selective area that had most of the infant mortality cases in the neighborhood, and we canvassed the whole area with information and resources. We passed out bags for people with cleansing supplies and information letting women know how to connect to one of the major hospitals. We addressed food issues and directed them to fresh fruit that they could pick up at a church around the corner. It was really informative. We did that four years in a row.

Lessons Learned

Addressing Racism Using the Socio-Ecological Model

Addressing racial and ethnic infant mortality from an “undoing” racism perspective is complex. There is no “one size fits all” model to do this type of work. The impact that racism has on racial and ethnic health disparities is multi-faceted. Therefore, multi-faceted approaches were most effective in addressing the issue. The SEM worked well for the Genesee County REACH project. This approach allowed for community participation on multiple levels to address the impact of racism on health disparities. Specifically-tailored work plans with activities and expected outcomes were developed at each SEM level to gauge effectiveness. Most importantly, community partners were extensively involved with the design and adaptation of the work and ongoing community engagement at all levels was a key component to the success of the project.

Community Voices

One of the things that appeals to us is looking at all of the different variables that go into infant mortality. It really is about the big picture.

Bidirectional Education

Early in the development of the REACH project, it was clear that bidirectional education was warranted given the diversity of the REACH team. Trust and transparency were of the utmost importance. In order to achieve this, communication was crucial in ensuring equal and equitable contributions to the processes. Health department, academic, and institutional partners also understood the necessity of being culturally sensitive to the needs, beliefs, and approaches for effectively engaging community residents. In turn, community residents and REACH program participants often remarked on bidirectional transfer of information to and from their households and neighborhoods as central to creating the capacity for community to discuss the multi-levels of racism, its impact on community health, and REACH program interventions designed to undo racism. Engaging in dialogues on multiple levels in the community was a strength for the project.

Community Voices

The REACH program involves people of African descent, people who look like me. And they show how we can work together in the community to help us with our own health and environment and how to live comfortably and engage my children and my grandchildren. So, I’m learning and teaching at the same time.

Community-Developed Interventions

Interventions that were co-developed and co-created by the African American community were most effective in garnering community buy-in. This bolstered the confidence of community members, which was particularly important when they needed to engage with powerful systems such as governmental bodies and healthcare systems. This sense of co-ownership generated community buy-in and provided a sustainable model for many of the REACH project interventions.

For example, character development and mentorship strategies were employed to enhance mental and physical health and promote pregnancy prevention among youth. Character development began with fostering an understanding of the history and culture of African Americans and Ancient Africans (how the village model worked, how they ate, how they lived, and what they believed). Next, the program explored how African Americans value themselves and others who look like them. This was followed by instilling an understanding of cultural pride and identity which began with an individual focus and expanded to embrace the family and broader community.

Community Voices

Character development teaches young men and women that they are valuable because they’re intelligent, because they have character, because they have purpose, and because their life has meaning. How does this connect to infant mortality? If I can get young ladies and young men to start to value who they are, then sex is not the only thing that they think they have of value. Each sees themselves as a full, complete person who has inner value, as opposed to only seeing their value to someone else. And so that’s where we see that connection and we feel very strongly that is a valid connection.


As described previously, racism is a system of beliefs, actions, and structures that oppresses members of minority racial groups. The impact that historical and current racism has upon the health of minority groups within the United States is profound, and operates on intrapersonal, interpersonal, and structural levels. Each level has similar but also unique elements impacting health that require multiple levels of intervention to adequately address. Increasing evidence directly connects experiences of racism to biological processes in the body (such as allostatic load), providing new avenues for quantifying its effects on health. Multiple frameworks for addressing the effects of racism exist, and approaches that address health equity from an intersectional lens are particularly important.

  • Why is it important to distinguish between prejudice and discrimination? Which is related more closely to implicit bias, and why?

  • How do social and biological bases for health inequities (e.g., racism, allostatic load) help to counter erroneous assertions regarding a genetic basis for inequities?

  • Why is it important to take an intersectional lens when examining the effects of racism on different racial/ethnic groups?

  • Consider the case of the role of healthcare discrimination in receipt of needed painkiller medication. What are intervention targets at each level of the socio-ecological model?

  • Why is it important to have the voice of communities affected by racism at the heart of efforts to ameliorate its effects?


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