In 2020, the pandemic and widely publicized racial injustices reinforced the importance of overcoming health disparities. Health disparities are the preventable “differences in health outcomes and their determinants between segments of the population”1(pS1) caused by the social determinants of health.1–4 Including educational attainment, housing, and safety, the social determinants of health describe the setting where one is “born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”1(pS1)
The social determinants of health were described as a product of circumstance but recently have been associated with practices and policies created by structural racism.2 Structural racism is defined as the “totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice.”5(p1454) These ills create systems that directly impact the availability of resources, laws, and public policies and thus the social determinants of health.1–6 As conquering health disparities remains an unachieved health measure from Healthy People 2020, noting the impact of structural racism, and its impacts on health disparities, is an important step in this fight.
The literature describes “residential segregation”5(p1456) as a key example of structural racism noting the connection to poor environmental health standards such as air and water pollution and adverse health outcomes including those surrounding birth, chronic disease, life expectancy, and safety.4,5 This is magnified in communities described as hypersegregated, or metropolitan areas that predominantly comprise of one minority group by way of structural racism through housing and lending discrimination.5 The current 29 hypersegregated communities were classified by measuring the difference in racial population metrics to create equal racial percentages between the minority group and White citizens, the physical area that the population occupies, and the presence of other minority communities nearby among other criteria.7 The greatest impact on mortality in these communities was correlated with increases in measures associated with population density8 and are secondary to the creation of opportunity poor areas that lack access to health care and resources through “redlining”5(p1455) and Jim Crow era policies.5,8,9
Structural Racism and Health Disparities
As nearly 2 out of 3 Black Americans live in hypersegregated communities, hypersegregation allows for undisputable observation of the impacts of structural racism on health disparities.9 From infant mortality and low birth weight to chronic disease and mental health outcomes, there are staunch racial disparities across access to care, outcomes, and medical interventions offered.4,5,8–12 Studies specifically note the chronic stress hypothesis or “the cumulative effects of psychosocial and environmental hazards associated with population-level patterns of racial and social inequity,”10(p1296) as a further consequence of structural racism.5,10 This presents increased risks to both physical and mental health through long-standing physiological stress responses that perpetuate disease.10–12
When examining the impact of hypersegregation on index counties, Montgomery County and Summit County, Ohio, the hypersegregated Montgomery County exhibited lesser financial and educational attainment for Black citizens as well as disparities in infant mortality, type 2 diabetes, and heart disease.13 All health outcomes examined for both White and Black citizens were worsened in Montgomery County showing that structural racism and its impacts on the social determinants of health are mutually amplified for minorities and detrimental to the health of all living in hypersegregated communities.13 Therefore, addressing the impacts of structural racism on the health of patients and communities is imperative as without it, health equity will be impossible to achieve.5
Targeting Structural Racism in Fighting Health Disparities
Approaches to solving health disparities are complicated and multifactorial.4 This only becomes more complicated when addressing disparities from the wide lens of structural racism. Studies suggest that a focus on community partnerships, equitable policy interventions, and trainings involving all stakeholders are necessary to make an impact on health disparities caused by structural racism.4,5,13
Hardeman and colleagues submit that “it's crucial to ‘center at the margins’—that is, to shift our view point from a majority group's perspective to that of the marginalized group or groups.”4 As public health practitioners, one cannot know the nuances of the community that they serve like the community members themselves. Welcoming and employing citizen input yield great benefits when building programming for the community5,13 including creating opportunities for programs to meet the demonstrated needs of community members, ensuring cultural relevance of initiatives, and allowing the community the administrative power to both run and alter the program as needs change.4 Franklin County Public Health (FCPH) in Ohio has created Community Health Action Teams (CHATs) that directly connect community members to public health leaders. Community members attend monthly neighborhood meetings where they view local health outcomes data, choose outcomes to improve upon, and then partner with FCPH to create action items striving for improvement. When this included access to healthy foods, CHATs worked with the local food bank to create easily accessible and free monthly produce markets. In an area with a higher refugee population, cultural representation ensured culturally relevant produce options.14 Likewise in Atlanta, the Save 100 Babies initiative was implemented to fight infant mortality in the Black community. More than 100 community members participated in discussing personal experiences, followed by building actionable steps against infant mortality in the area.15
Public policy and government institutions present additional challenges when creating solutions to health disparities. Not only do policies determine where funding is allocated but also policies can directly create inequities.5 The militarization of police forces, mandatory minimums for incarceration, and zoning for environmental hazards in vulnerable communities can be targeted by political advocacy to increase health outcomes.5,16 However, when in existence, the inequitable enforcement of protective policies can emphasize the impacts of the social determinants of health and yield unsafe environments for citizens.
Public health practitioners have a special skill set to demonstrate the necessity and impact of policies by epidemiological and biostatistical means, potentially driving policy formation or modification. After the Family Smoking Prevention and Tobacco Control Act was passed in 2009, public health experts were able to identify how lower-income and minority communities were more likely to have stores that were noncompliant and thus encouraging tobacco use in specifically younger minority citizens and increasing health disparities in these communities. Following these findings, specific approaches were designed to assist the US Food and Drug Administration in protecting all citizens equitably.17 By creating standards for further analysis surrounding the implementation of policy, the field can monitor the impact of policies and protect vulnerable communities.
Medical professionals play an integral part in creating health equity through the care they provide, yet they are not often directly targeted in public health initiatives. Institutional biases within the medical field further complicate the ability to challenge structural racism. Known as the Social Categorization of Medicine, these biases are unintentionally taught alongside medical knowledge and negatively impact patient care.6 Incorporating health equity and cultural humility in educational opportunities for those caring for patients is imperative as this directly correlates to the care provided.2,3,5,6
Collaboration is a necessity when creating programming that will impact both public health practice and the practice of medicine. Current teaching models have centered on the personal responsibility of patients for health outcomes.2,3,5,6 Programming that shifts the discussion to learning about the structural and historical barriers for patients not only can improve empathy and individual understanding of the factors facing patients but can also improve the care that patients receive.2,4,5,6,18 Public health practitioners should partner with medical educators to assist in creating curriculum changes that further health equity. Beyond lectures, studies have shown narrative medicine to be very successful in dispelling the myths learned, thus improving their ability to better care for patients' individual needs.6 Imbedding the community's story in medical curricula underlines the importance of the relationship between public health and medicine and is one of the most memorable ways to highlight how structural racism can impact patients and one's responsibility to work toward health equity.6 One residency program worked alongside public health practitioners and community partners to create “resident-led care teams”2 where medical residents were directly involved in navigating the social determinants of health that patients regularly experience.2 The residents were able to learn about their community while developing the skills to care for underserved patients in their community and beyond.2
By conquering structural racism, public health practitioners have an opportunity to right the wrongs of yesterday and create a healthier tomorrow. To make tangible strides forward, the field must be actively striving to partner with community members and creating programming that is relevant to those it serves, advocating for and assessing equitable policy reform that encourages healthy and thriving communities, and leading the charge to create partnerships with medical education to ensure that all are prepared to fight for health equity. As further research will likely describe additional ways that structural racism has impacted the health of our patients and communities, it is important that the field begins to utilize best practices to strengthen our care, our resources, and our communities at large.
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9. Yang T, Matthews S. Death by segregation: does the dimension of racial segregation matter? PLoS One. 2015;10(9):1–26.
10. Osypuk T, Acevedo-Garcia D. Are racial disparities in preterm birth larger in hypersegregated areas? Am J Epidemiol. 2008;167(11):1295–1304.
11. Hu W, Lu J. Associations of chronic conditions, APOe4 allele, stress factors, and health behaviors with self-rated health. BMC Geriatr. 2015;15:137.
12. Howard BV, Gidding SS, Liu K. Association of apolipoprotein E phenotype with plasma lipoproteins in African American and White young adults. Am J Epidemiol. 1998;148(9):859–868.
13. Wright State University. Opportunity and life-long health outcomes: a review of the effects and proposed solutions of hypersegregation on health disparities. Core Scholar. https://corescholar.libraries.wright.edu/cgi/viewcontent.cgi?article=1193&context=mph
. Published 2017. Accessed April 11, 2021.
14. Franklin County Public Health. Community Health Action Team. Health systems planning. https://myfcph.org/health-systems-planning/community-health/chat
. Published 2021. Accessed July 21, 2021.
15. Jackson FM, Saran AR, Ricks S, et al. Save 100 Babies: engaging communities for just and equitable birth outcomes through photovoice and appreciative inquiry. Matern Child Health J. 2014;18(8):1786–1794.
16. Crear-Perry J, Maybank A, Keeys M, Mitchell N, Godbolt D. Moving towards anti-racist praxis in medicine. Lancet. 2020;396:451–453.
17. Lee JGL, Baker HM, Ranney LM, Goldstein AO. Neighborhood inequalities in retailers' compliance with the Family Smoking Prevention and Tobacco Control Act of 2009, January 2014-July 2014. Prev Chronic Dis. 2015;12(171):1–8.
18. Sklar DP. What would excellence in health professions education mean if it addressed our most pressing health problems? Acad Med. 2019;94(1):1–3.