This special issue, titled Public Health Interventions to Address Health Disparities Associated With Structural Racism, would not have been possible even a few short years ago. The phrase “structural racism” and its closely allied concept “systemic racism,” though hardly new, had not yet become part of the public discourse. Researchers who worked on this construct were in the main African American scholars, as well as other scholars of color, who typically worked with limited access to research funds and struggled to publish their work on the pages of peer-reviewed journals.1
Two events in 2020, not a sudden increase in knowledge, changed our perspectives on the enduring impact of racism. First, COVID-19 took, and continues to take, a deeply disparate toll by race and ethnicity. Then in May 2020 came the very public murder of George Floyd, triggering outrage across the county and around the globe. We now hear the phrase “structural racism” invoked by business leaders, academics, elected officials, advocates, and activists. Type these words into a search engine and tens of millions of “hits” come up. The medical literature has also changed. PubMed is an online database that comprises more than 32 million citations for biomedical literature. In 2000, “structural racism” as a key phrase yielded 5 citations. In 2021, a year not yet completed, the same search yields more than 100-fold more citations.
To this explosive adoption of new language, this special issue brings an important additional contribution: it grounds us in practice. It both unpacks what we mean when we say “structural racism harms health” and offers the practical experience of integrating structural racism into our work. I am especially pleased that two-thirds of the 15 articles that make up this collection are reports from the field, from local health departments and community organizations. Practice is hard, but it is the purpose of public health. It is important to share what we learn now, as we are learning. As it should, our learning may change over time. It is also important to test concepts and strategies with rigorous research as reported in the issue's research articles.
There is no “formal” definition of structural racism, though several have been proposed. As I wrote with colleagues nearly a year ago:
All definitions make clear that racism is not simply the result of private prejudices held by individuals, but is also produced and reproduced by laws, rules, and practices, sanctioned and even implemented by various levels of government, and embedded in the economic system as well as in cultural and societal norms. Confronting racism, therefore, requires not only changing individual attitudes, but also transforming and dismantling the policies and institutions that undergird the U.S. racial hierarchy.2(p768)
Lofty words. And true words. But of course the question is how to use them in practice. I suggest this process begins with learning more history. In a review of structural racism against Asians, Muramatsu points out that the first immigration law that used national origin was the 1882 Chinese Exclusion Act, setting in motion the dynamics of anti-Asian sentiment that would later include the World War II Japanese internment and, as COVID-19 has shown, persists to this day. We need also to learn how public health came to accept racialized groups, “race,” as a core demographic variable. Gomez and colleagues show us how US Census categories of Latinos have been mutable. Once the US Census simply counted “Mexicans.” The term “Hispanic” came later, with still more recently acknowledgment of “Latino.” The authors also explain how many Latino/Hispanic people consider that it is their ethnicity, not skin color, what sets them apart from people classified as White.
Which brings me to another point. Amidst the surge in use of “structural racism,” another phrase is seen far less often: “white supremacy.” The same PubMed search yielded zero citations in 2000, rising in 2021 to 49. It is a racial hierarchy that places White people at the top that extends to all people of color. Historically, white supremacy was embedded in the law, enforced by government. Johnson points out how the policy of hypersegregation, strongly associated with adverse health outcomes, was established as government policy including “redlining” that limited African American mortgage access in the 1930s. Weber and Penn make a compelling case that to dismantle racism, public health should take up one of the tools used to embed it: the law. And several authors also make clear that undoing racism requires guidance from the communities that have been most harmed.
Elevating community voices is a theme of the cluster of articles that focus on public health departments, including work to target 2 of the most enduring and tragic racial inequities, infant survival and maternal death related to pregnancy. Putting in place protocols and gaining community trust are time consuming and may make people impatient. Buncombe and Chatham, 2 North Carolina counties whose stories are reported by Gorenflo and colleagues, spent an entire year focusing on building community trust. This was rewarded in Buncombe by the emergence of a community organization as the lead on an effort to improved maternal infant health care. A very different approach worked in Chatham County. The New York City Health Department was similarly rewarded by a community process on expanding bike lanes.3 Central Brooklyn's traditional inhabitants considered bike lanes a leading edge of gentrification. After building trust, which took a year, and learning how these bike lanes would link their neighborhood to Prospect Park, a beloved Brooklyn asset, as well as provide health benefits, the community campaigned for more miles of bike lanes than had been initially proposed by the city. Does having an engaged community partner lower infant mortality? Do more bike lanes reduce obesity? This is not the first question to ask, although it often is. The first question is whether “Can evidence-informed intervention be delivered?” We need impact, but impact may take time. Are there data to support need? Has crafting the intervention benefited from community input? Can we tell whether what was planned actually has been delivered? After this comes replication and then scale-up and then consideration of whether the intervention “dose” has delivered impact.
For many, and for all of us who call these United States home, these issues are also personal. I was moved by Muramatsu's account of how anti-Asian racism affected the life of her family to recount a story of my own. My parents' marriage was illegal in my father's home state of Virginia because my mother is White. It was only with a 1967 Supreme Court decision on the Loving case, after which the state of Virginia exhausted its appeals, that my parents ceased to risk arrest by visiting his family. Until then, while visiting, my mother would instruct me to identify one of my aunts as my mother when we were in town. All these many years later, I can still recall the fear I felt that I might get my family into trouble by answering truthfully the question, “Where is your mother?”
The National Institutes of Health has acknowledged that it has failed to support diversity in who does science and in supporting research that addresses racism and released some $100 million to address this gap.4 That's good. Fortunately, we have researchers and practitioners who have persisted and we will benefit from their work and the promise of more to come.
It's a long road, and we have gotten started.
1. McFarling UL. “Health equity tourists”: how White scholars are colonizing research on health disparities. STAT News Special Investigation. September 21, 2021. https://www.statnews.com/2021/09/23/health-equity-tourists-white-scholars-colonizing-health-disparities-research
. Accessed September 23, 2021.
2. Bailey ZD, Feldman JM, Bassett MT. How structural racism works—racist policies as a root cause of U.S. racial health inequities. N Engl J Med. 2021;384:768–773.
3. Noyes P, Fung L, Lee KK, Grimshaw V, Maybank KA, DiGrande L. Cycling in Bedford-Stuyvesant: A Look at Cycling and Driving Behaviors. New York, NY: New York City Department of Health and Mental Hygiene; 2010. https://www1.nyc.gov/assets/doh/downloads/pdf/dpho/dpho-brooklyn-bike-bedstuy.pdf
. Accessed September 23, 2020.
4. Collins FS, Adams AB, Aklin C, et al. Affirming NIH's commitment to addressing structural racism in the biomedical research enterprise. Cell. 2021;184(12):3075–3079. https://www.cell.com/cell/fulltext/S0092-8674(21)00631-0?utm_source=EA
. Accessed Sep-tember 20, 2021.