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Institutional Racism and Health: a Framework for Conceptualization, Measurement, and Analysis

• Published: 22 August 2022
• Volume 10 , pages 1997–2019, ( 2023 )

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• Belinda L. Needham   ORCID: orcid.org/0000-0001-5939-2027 1 ,
• Talha Ali 2 ,
• Kristi L. Allgood 1 ,
• Annie Ro 3 ,
• Jana L. Hirschtick 1 &
• Nancy L. Fleischer 1  

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Despite growing interest in the health-related consequences of racially discriminatory institutional policies and practices, public health scholars have yet to reach a consensus on how to measure and analyze exposure to institutional racism. The purpose of this paper is to provide an overview of the conceptualization, measurement, and analysis of institutional racism in the context of quantitative research on minority health and health disparities in the United States. We begin by providing definitions of key concepts (e.g., racialization, racism, racial inequity) and describing linkages between these ideas. Next, we discuss the hypothesized mechanisms that link exposure to institutional racism with health. We then provide a framework to advance empirical research on institutional racism and health, informed by a literature review that summarizes measures and analytic approaches used in previous studies. The framework addresses six considerations: (1) policy identification, (2) population of interest, (3) exposure measurement, (4) outcome measurement, (5) study design, and (6) analytic approach. Research utilizing the proposed framework will help inform structural interventions to promote minority health and reduce racial and ethnic health disparities.

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While most prior research on racism and health has focused on interpersonal racism, public health scholars have begun to explore the ways in which institutional policies and practices—both historic and contemporary—contribute to minority health and health disparities [ 1 , 2 , 3 , 4 , 5 , 6 ]. This trend in public health scholarship reflects a broader societal shift toward thinking about racism as a structural problem rather than solely as an interpersonal phenomenon. The purpose of this paper is to provide an overview of the conceptualization, measurement, and analysis of institutional racism in the context of quantitative research on minority health and health disparities in the United States. Building on recent papers calling for greater conceptual clarity, increased consideration of historical context, and enhanced methodologic rigor in this area of research [ 7 , 8 , 9 , 10 ], we begin by providing definitions of key concepts, such as racialization, racism, and racial inequity, and explaining linkages between these ideas. Next, we discuss the hypothesized mechanisms that link exposure to institutional racism with health. Finally, we propose a framework to guide methodologic considerations for future studies, informed by a literature review of measures and analytic approaches used in prior research on institutional racism and health.

Framing the Problem

Definitions and conceptual model.

Although studies examining institutional racism as a determinant of health have become increasingly common in recent years for reviews, see 2, [ 11 , 12 , 13 ], conceptual ambiguity remains widespread. Thus, we begin by defining relevant concepts. First, racialization refers to the social construction of racial categories, such as White, Black, Latino, Footnote 1 and Asian [ 14 , 15 , 16 ]. While racial categories vary across place and time, they are typically based on phenotypic characteristics, such as skin color, eye shape, and hair texture, that reflect differences in continental ancestry [ 17 ]. Importantly, phenotypic differences are commonly believed to reflect other important differences between the so-called races, including differences in intelligence and morality [ 17 ]. Thus, in racialized social systems, the process of racial differentiation is inextricably intertwined with the process of racial stratification (i.e., the hierarchical ranking of people according to race), which results in differential access to power and other resources [ 18 , 19 ].

We use the general term racism to refer to both the ideology of racial superiority/inferiority (i.e., ideological racism , including internalized racism Footnote 2 ), as well as the resulting inequitable treatment of individuals according to race (i.e., actualized racism ). We distinguish between two forms of actualized racism: institutional and interpersonal. Institutional racism refers to racially discriminatory policies and practices Footnote 3 embedded in social institutions such as the government, the economy, the education system, the healthcare system, religious institutions, the family, and the media. Institutional racism is said to be systemic [ 20 ] or structural [ 2 , 21 ] when it operates as a system across multiple interconnected institutions. Interpersonal racism refers to discriminatory treatment by race among individual actors. Finally, racial inequity refers to inequitable, or unjust, outcomes by race, including inequities in education, economic mobility, and health outcomes. Relationships among these concepts are shown in Fig.  1 .

Conceptual model linking racialization to racial inequity via ideological and actualized racism

Racism and Health: Mechanisms

Racism may negatively impact health through both psychosocial and material pathways. For example, the internalization of ideological racism could affect mental health (e.g., depression, anxiety) by decreasing self-esteem among members of stigmatized minority groups [ 22 , 23 ], while repeated exposure to acts or threats of interpersonal racism could affect mental and physical health by triggering chronic activation of physiologic stress response systems [ 24 ]. Institutional racism is hypothesized to negatively affect health and well-being through material pathways by shaping access to health-promoting resources [ 25 , 26 ]. For example, the institutional practice of redlining drove residential segregation and depressed home values and homeownership rates in minority neighborhoods [ 27 ]. By restricting where Black families could live, redlining contributed to overcrowding, which was then used as a rationale for demolishing homes in Black communities to make way for interstate highways [ 27 ]. Along with dividing minority communities, the highways contributed to environmental injustice by increasing air pollution [ 28 ]. Additionally, while not explicitly racist, programs such as the GI Bill, which was designed to provide resources such as higher education and mortgage lending to those returning after World War II, had disparate impacts by race because the program relied upon racist institutional policies, including redlining and racially discriminatory college admissions processes [ 27 ]. Though redlining is no longer legal, residential segregation is firmly entrenched in the United States and is a powerful determinant of access to a broad range of health-promoting resources, including education, employment, housing, and healthcare [ 29 ]. In addition to its effects on material pathways, restricted access to socially valued resources resulting from institutional racism may further harm health through psychosocial mechanisms, such as perceived injustice or feelings of hopelessness [ 30 ].

While redlining is the most often cited racially discriminatory policy in health research, it is not the only racist policy or set of policies that have affected non-White populations in the USA. Other examples include the seizure of American Indian lands [ 31 ], Reconstruction era Black Codes/vagrancy laws [ 32 ], Jim Crow/American Apartheid policies [ 33 ], failure of Congress to protect Black Americans from lynching [ 34 ], exclusion of specific occupations in the receipt of social security benefits [ 35 ], internment of specific ethnic groups [ 36 ], the War on Drugs [ 32 ], removal of desegregation orders in public education [ 37 ], and public charge rules [ 38 ], among many others. It is important to note that institutional policies, including some of those listed above, are often enacted by individual agents of institutions, such as judges, poll workers, and police officers, who may or may not also engage in acts of interpersonal racism when interacting with racial or ethnic minorities. Thus, while we can distinguish between ideological, interpersonal, and institutional racism conceptually , they operate simultaneously and interactively, making it difficult to disentangle the effects of various forms of racism empirically .

Framework for Advancing Institutional Racism and Health Research

In this section we discuss key considerations in advancing institutional racism and health research. As shown in Fig.  2 , the framework outlines six conceptual and analytic considerations when empirically examining questions on institutional racism and health: (1) institutional racism policy identification, (2) population of interest, (3) institutional racism exposure measurement, (4) health outcome measurement, (5) study design, and (6) analytic approach. This framework aligns with research calling for a historical/contextual and theoretical link between historical racist policies and contemporary health outcomes [ 7 , 8 , 9 , 10 , 39 ], strong measurement of institutional racism [ 8 , 9 ], and methodological approaches that can strengthen the causal evidence base [ 9 ]. However, this framework builds on previous work [ 9 , 10 ] by incorporating and focusing on research methods such as linking the network of policies that created a racially disparate impact in resources, the exposure and outcome measurement, matching the timing and geographic region of the policy and outcome, and the design of the research. This framework for the study of institutional racism allows for modern racist policies (e.g., Muslim bans, modern voting restrictions, attacks on “Critical Race Theory”) and changing definitions of race (e.g., person of Hispanic/Latinx or Middle Eastern nationalities forming new racial groups), and is broad enough to incorporate research on any racial or ethnic group.

Conceptual framework to guide institutional racism and health research

To inform our framework, we conducted a systematic literature review, building on a recent review by Groos and colleagues [ 12 ], to summarize and critically assess current approaches to the measurement and analysis of institutional racism in quantitative health research. The Groos et al. review [ 12 ] includes articles published between January 1, 2007 and December 31, 2017. The authors searched PubMed and EMBASE databases to identify studies that included the terms “structural racism,” “systemic racism,” “institutional racism,” and/or “institutionalized racism” in the title or abstract. Footnote 4 Out of 255 abstracts identified in the search, 20 met the authors’ inclusion criteria: original research, conducted in the United States, explicitly measured an indicator of structural racism, included a health-related outcome, full-text available, and used quantitative methods. Given growing interest in research on institutional racism in recent years, we conducted an updated search using the methods described in Groos et al. [ 12 ]. As shown in Figure S1 , we identified 36 additional papers published between January 1, 2018 and December 15, 2020 that met the authors’ inclusion criteria. Table 1 summarizes the 20 papers included in the Groos et al. [ 12 ] systematic review, as well as the 36 papers from our updated search.

BN performed the initial review of each abstract to determine whether the paper met the Groos et al. [ 12 ] inclusion criteria. Next, BN extracted information on the measures used, domains examined, levels of measurement for exposures and outcomes, racial and ethnic groups examined, analytic approaches, and links to policy. A second coauthor (T.A or K A) then reviewed each paper to verify the accuracy of the information. In the event of a disagreement, a third coauthor reviewed the paper, and all three coauthors involved in the literature review met to make a final determination about the information in Table 1 .

Identifying Institutional Racism Policies

Making the links between policy and exposure measurement explicit can help advance empirical research on institutional racism and health. First, the closer research is tied to the harm of specific policies, including the enactment and the enforcement of policies, the stronger the evidence base for eliminating racist policies. Second, even if the exposure measurement is not explicitly tied to a specific policy, researchers can provide the past and present policy context of an institutional racism measure. This is important because, historically, institutional racism was enacted through overtly racist policies that were later modified to be covertly racist “color-blind” policies. Recently, scholars have emphasized the importance of better understanding and articulating the policy context in the measurement of institutional racism. For example, Dennis et al. provide a framework that details major periods of structural discrimination in the USA, including specific policies and domains that have affected different racial/ethnic populations [ 10 ]. Hardeman et al. also highlight the importance of understanding the historical context to better understand how structural racism impacts health [ 8 ].

When policies can be measured directly, researchers can consider both the impact of the enactment of a policy as well as the potential for differential enforcement. For example, the Reagan Administration did not adequately enforce all aspects of the Civil Rights Act, such as employment discrimination [ 93 ], which may be important to consider when examining the impact of the policy over different time periods. However, we also recognize that it is not always possible to make direct links between historic policies that have laid the foundation for racial inequities, especially in cases when the legacy of past policies is omnipresent and difficult to measure or disentangle from concurrent policies. Nonetheless, by strengthening the theoretical linkage between specific policies and institutional racism exposure measurement in our framing of the research and interpretation of results, we can improve the quality of research.

In our literature review, few articles mentioned specific policies that form their basis of exposure measurement, and even fewer explicitly incorporated policies in their analyses. For example, only 15 out of 39 papers that used area-level indicators of institutional racism included more than a cursory discussion of discriminatory policies or practices related to the indicator(s), while 13 papers included a minimal or generic discussion of policy, and 11 papers did not discuss policy at all. Out of 18 papers that included at least one individual- or family-level indicator of institutional racism, only four included a detailed discussion of discriminatory policies or practices related to the indicator(s), while two included a minimal or generic discussion of policy, and 12 did not discuss policy at all. It is noteworthy that three of the four papers with detailed policy discussions were in the immigration domain, where overtly discriminatory policies remain legal. Only one paper that used individual- or family-level indicators of institutional racism directly measured exposure to a discriminatory policy [ 76 ].

Population of Interest

The population of interest should be well defined. Researchers must decide whether to take a minority health approach, in which people who identify as a specific racial/ethnic group are the focus of the analysis [ 94 ], or to compare differences in exposure to or effect of discriminatory policies for different racial/ethnic groups . Studies that include a single racial/ethnic group in the analytic sample are appropriate when the focus is on understanding the health effects of varied exposure to institutional racism for racial or ethnic minorities or when the focus is on identifying potential moderation in causal mechanisms between institutional racism and health. These kinds of analyses acknowledge that the experience of institutional racism can vary within the same racial/ethnic group, either in exposure or in moderating variables that mitigate its health effect. For instance, exposure to institutional racism may vary by geographic location, such as among Hispanic populations who reside in states that differ in their immigration enforcement policies. Researchers could also identify how coping strategies, such as social support through extended family or “fictive kin” networks, mitigate the health risks of institutional racism within Black Americans [ 95 ].

In contrast, studies on the extent to which differences in exposure to or effect of discriminatory policies or practices contribute to racial/ethnic health disparities require analytic samples with more than one racial/ethnic group. For example, a multi-racial/ethnic population would be needed to determine the differential impact of a specific criminal justice policy on health outcomes across racial/ethnic groups. Multi-racial/ethnic populations are also needed to test hypotheses on whether institutional racism can actually benefit Whites while being detrimental to racial/ethnic minorities [ 65 , 70 , 89 , 96 ].

In our literature review, we found that just over one third of papers took a minority health approach, examining a single racial/ethnic group, while approximately two thirds of papers took a health disparities approach, examining two or more racial/ethnic groups. Of the 21 papers that took a minority health approach, 17 included Black respondents only, three included Hispanic respondents only, and one included Chinese American respondents only. Of the 35 papers that took a health disparities approach, 27 included Black and White respondents, one included Black and Hispanic respondents, and seven included multiple racial/ethnic groups. Just 23 of the 35 papers that included more than one racial/ethnic group examined effect modification by race, which is important for understanding group differences in vulnerability to institutional racism. While neither the minority health approach nor the health disparities approach is inherently superior, we recommend that researchers employing a health disparities approach include as many racial/ethnic groups as possible and examine effect modification by race if the study is adequately powered to test interactions.

Finally, whether studies focus on a single racial/ethnic group or multiple groups, to best define their population of interest, researchers should also consider the timing and historic context of the research question (related to the policy discussion above, and Timing of Exposure Measurement , below). For example, policy impacts may compound across an individual’s life course, resulting in greater health impacts for older individuals, and may also compound across generations, resulting in the intergenerational transmission of poor health, beginning at birth. In addition, for specific racial/ethnic groups, immigration wave and immigration generation may be important considerations when defining the population of interest for a given study.

Institutional Racism Exposure Measurement

Improving exposure measurement for institutional racism is a key component of our framework. Below we consider five elements to specify for measures: (1) single vs. multiple domains, (2) area vs. individual level, (3) direct vs. proxy, and (4) timing of measurement.

Single vs. Multiple Domains

Institutional racism is considered structural or systemic when multiple institutions work together to produce and sustain a racist system [ 2 , 10 , 20 , 21 , 97 ]. As such, researchers must first determine whether to examine the relationship between one institutional domain, or multiple domains, and health. To capture the systemic, largely latent (i.e., covert and not directly observable) nature of structural racism, researchers should consider ways to incorporate multiple domains into their work.

The 56 papers from the literature review included measures of institutional racism in seven domains: criminal justice, economics and labor, education, healthcare, housing/residential segregation, immigration, and political participation/representation. Just over half of the papers measured institutional racism in a single domain, while slightly less than half included measures across multiple domains—an approach that is more consistent with the conceptualization of institutional racism as a “race discrimination system” that operates across many domains [ 20 ]. Housing-related measures, including residential segregation, were the most commonly used indicators of institutional racism (37 papers), followed by measures in economics and labor (22 papers), criminal justice (15 papers), education (13 papers), healthcare (4), political participation/representation (4), and immigration (3). We recommend that researchers focusing on a single domain identify causal mechanisms within that domain that impact health, while researchers examining measures from multiple domains incorporate theoretical and analytic approaches (e.g., latent models) that treat the measures as part of a connected system as opposed to discrete systems.

Complementary to focusing on a single or multiple domains is determining whether a single or multiple indicators will be used to represent a particular domain. Measurement approaches that combine multiple indicators across multiple domains have the potential to capture the systemic nature of institutional racism [ 2 , 20 , 21 ] but may obscure the effects of individual policies or practices that greatly influence health. In our literature review, we found that 17 papers included a single indicator of institutional racism, while 11 included multi-item scales assessing experiences of discrimination within institutional settings, and 28 included multiple indicators of institutional racism, either within a single domain or across multiple domains. We recommend using multiple indicators when trying to capture a more comprehensive measure of institutional racism that may be related to multiple historical policies, and thus difficult to isolate as a single policy measure (e.g., arrests, encounters, and probations to measure institutional racism in the criminal justice system). A single indicator may be appropriate when trying to isolate the effect of a specific policy or practice (e.g., presence/absence of a drug policy or drug-related arrests after implementation of a drug policy).

Area-Level vs. Individual-Level Measures

The level of exposure measurement is also critical. Researchers may consider measurement at the area level (e.g., state or Census tract) or individual level. In most cases, to capture the structural nature of institutional racism, we recommend using area-level exposure measures rather than individual-level measures, such as experiences of discrimination in institutional settings. There may be exceptions where the individual-level exposure represents a structural policy, such as immigration status for individuals from different countries, but these exceptions should consider the policies that led to the individual-level status.

When considering area-level measures, the geographic level of enactment or enforcement of the racially discriminatory policy should ideally match the geographic level of the exposure to minimize exposure misclassification. For example, if exposure is operationalized as racial disparities in police use of force, and policing policies regarding use of force are primarily made at the district or city level, then exposure should be measured at the district or city level rather than the county or state level. Other specific policies, such as voting rights restrictions, are often at the state level.

In our literature review, we found that 39 of the 56 papers we reviewed included at least one area-level measure of exposure to institutional racism, which is consistent with the conceptualization of institutional racism as a macro-level phenomenon. Area-level indicators in the housing/residential segregation domain included contemporary measures of residential segregation, such as the index of dissimilarity, the isolation index, and the index of concentration at the extremes [ 45 , 46 , 47 , 48 , 52 , 53 , 54 , 61 , 63 , 69 , 70 , 71 , 72 , 77 , 78 , 79 , 80 , 84 , 86 , 90 , 91 , 92 ]; historical measures of residential segregation based on Home Owner’s Loan Corporation (HOLC) redlining maps [ 44 , 60 , 62 ]; and contemporary measures of mortgage discrimination and redlining [ 49 , 54 , 67 , 69 , 70 , 71 , 92 ]. These measures were assessed at a variety of geographic levels, including HOLC-defined neighborhoods, Census tracts, zip codes, metropolitan areas, counties, and states. Other area-level measures of institutional racism included Black-White inequities in the domains of economics and labor, criminal justice, education, and political participation/representation [ 42 , 43 , 46 , 47 , 53 , 58 , 63 , 72 , 73 , 74 , 75 , 85 , 89 , 91 , 97 , 98 ]. These measures were assessed at the city, county, and state levels. In the criminal justice domain, two recent studies used the number of police killings of Black people in the county [ 51 ] and metropolitan statistical area [ 59 ] as an indicator of institutional racism. The measurement of area-level racism at different geographic scales makes it challenging to compare results across studies but may be justified based on theoretical or policy considerations. Thus, we recommend that researchers using area-level measures provide an explicit rationale for the geographic level examined.

Seventeen of the papers we reviewed included at least one individual-level measure of exposure to institutional racism. Most of these studies asked respondents to report experiences of discrimination in multiple institutional settings, such as schools, workplaces, and the criminal justice system [ 40 , 50 , 55 , 56 , 57 , 64 , 68 , 82 , 83 , 87 , 99 , 100 ]. One study asked parents to report concerns about their children’s exposure to racism in institutional settings [ 88 ], while two studies used individual-level characteristics like income and access to healthcare as indicators of exposure to institutional racism [ 41 , 85 ]. Studies in the immigration domain included individual-level measures of immigration status [ 76 ] and reports of sightings and interactions with immigration officials [ 81 ] as indicators of exposure to institutional racism, while one study measured fear of deportation at the family level [ 66 ].

We note that it is not possible at the individual level to distinguish between experiences of institutional racism and experiences of interpersonal racism that occur within an institutional setting. For example, if an individual responds “yes” to the question, “Were you ever treated unfairly during the job hiring process because of your race?” it is hard to determine to what extent this unfair treatment was due to institutional policies/practices (e.g., institutional practice of asking job candidates about their conviction history — because non-Whites are disproportionately more likely to have a conviction history compared to Whites, this practice precludes non-Whites from having a fair chance at employment) versus interpersonal racism (e.g., an employer choosing not to call back non-White applicants for a job interview because of their subconscious bias that non-White persons are less competent or less professional than White persons, despite laws in place that make it illegal for an employer to discriminate based on someone’s race/ethnicity). The distinction between experiences of institutional racism and experiences of interpersonal racism that occur within an institutional setting is important to make in order to sufficiently address racism, which requires a multi-level approach. For instance, within employment, efforts to address interpersonal racism (e.g., anti-racism training for employers) may prevent individual employers from discriminating against non-White employees. However, without institutional policies in place (e.g., an amendment to the Civil Rights Act that prevents employers from discriminating against people with criminal records or requiring employers to delay a criminal background check until after an offer is made or addressing racism within the criminal justice system), non-White persons will not have a fair chance at employment and will continue to face institutional racism within employment and its subsequent health impacts. It is also not possible to determine the extent to which an individual’s education or income is the result of exposure to discriminatory policies or practices. Thus, we recommend against using such measures to assess exposure to institutional racism.

Direct vs. Proxy Measures

Another consideration is the use of direct or proxy measures of exposure to discriminatory policies or practices. In some cases, direct measures of exposure to specific policies may be preferable to strengthen the connection to a health outcome. For proxy measures, researchers must clearly articulate the conceptual link between institutional policies, whether historic or contemporary, and the exposure measurements. For example, a direct measure of a policy exposure would be living in a state with restrictive voter ID laws, whereas a proxy measure in the political participation/representation domain could be the Black:White ratio of the population proportion who voted in the last presidential election. In the immigration domain, a direct measure may be living in a county where local law enforcement work closely with immigration enforcement (e.g., Secure Communities [ 101 ]), whereas a proxy measure could be fear of deportation.

In our literature review, we found that, with the exception of three papers that used HOLC maps to measure exposure to a specific racially discriminatory policy [ 44 , 62 , 102 ], the studies in Table 1 that used area-level indicators of institutional racism relied on proxy measures, rather than direct measures of exposure to discriminatory policies or practices. Given the challenges inherent in measuring institutional racism in an era of color-blind policies, researchers have increasingly come to rely on measures of racial inequality in domains, such as education or political participation/representation, as proxies for exposure to institutional racism. Though rarely stated explicitly, the rationale for this approach is that contemporary racial inequalities are the result of discriminatory policies and practices and, therefore, are a reasonable proxy for exposure to the policies and practices themselves. Explicitly linking policies to proxy measures is crucial to support the claim that racial/ethnic inequalities in specific domains are due to institutional factors rather than individual choices. Recent work by Agenor et al. provides a template for considering specific state-level policies in different institutional domains, which can be examined in future health studies [ 103 ].

Timing of Exposure Measurement

Lastly, researchers should consider the timing of their exposure measures within the context of the disease processes for their health measures. Historic timing is critical in linking exposure to health outcomes. As researchers, in order to provide the strongest evidence for causal inference, we must ensure that the timing of the policy precedes specific health outcomes in ways that allow for any latency period in disease progression [ 104 ]. For example, prior empirical studies have incorporated administrative data on school quality from the Jim Crow South and linked it with later life cognitive functioning [ 105 , 106 ]. The historic timing of policies has further implications for measurement, as more proximal events will be easier to measure directly. For example, it may be easier to link recent immigration policies that vary across states in their design and implementation [ 107 ] to acute health outcomes (e.g., birth outcomes, heart attacks) than to link older policies like the 1984 Immigration Reform and Control Act to chronic health outcomes. It is useful to consider a few specific questions when thinking about the timing of exposure measurement: are contemporary exposure measure(s) appropriate to adequately capture the link between policy and the health outcome? Are historic measures during a particular period of the life course more appropriate? And, accordingly, are intergenerational measures needed to capture the relevant exposures for specific health outcomes? For example, sensitive periods, such as gestation, may require a particular timing for specific birth outcomes, as in research that examines the timing of immigrant raids during different trimesters of pregnancy on low birth weight [ 108 ].

Health Outcome Measurement

As in other areas of epidemiologic research, health outcomes are best measured at the individual level. Area-level health outcome data, analyzed in an ecologic framework, can provide initial evidence on the extent to which institutional racism measures affect health, but cannot be used to identify causal relationships [ 109 ]. Area-level health outcome measurement may mask the influence of the exposure on the health outcome for different racial/ethnic minority populations, depending on the distribution of race/ethnicity in a particular Census tract, state, or other geographic area. Moreover, measuring health outcomes at the individual level allows for an examination of effect modification of the institutional racism-health relationship by race/ethnicity, to help elucidate differences in the relationships across racial/ethnic populations.

Study Design

The study design will be determined by the type of data a researcher has, as well as the level of exposure and outcome measurement. Ecologic studies examine associations between area-level exposures and area-level outcome measures. Multi-level study designs can be used when the exposure measurement is at the area level, and the outcome measurement is at the individual level. Individual-level study designs are needed when both the exposure and outcome are measured at the individual level. Because institutional racism is a contextual phenomenon, the strongest study designs will be multi-level in nature to enable researchers to estimate the contextual effects of area-level institutional racism on individual-level health.

Study designs may be purely observational or quasi-experimental. Observational studies examine the relationship between existing exposures and outcomes, based on observed patterns within or between populations. When longitudinal observational data are available, researchers should take a counterfactual approach to isolate the impact of structurally racist policies over time and as they operate within and across domains to produce racial disparities in health. For instance, causal mediation approaches that model time-varying relationships between variables allow researchers to treat “race” as part of the time-varying reciprocal or mutually reinforcing processes of racialization and racial discrimination within and across various socioeconomic, political, and cultural systems [ 110 ]. These approaches also allow researchers to decompose racial health disparities into different types of cumulative life course effects of institutional racism including unobserved racism (i.e., operating through unmeasured pathways), racial discrimination (i.e., the effect of an underlying system that first racialized individuals and then discriminated against them based on those racial categories), and emergent discrimination (i.e., system-wide race discrimination arising from pervasive racial disparities collectively across multiple domains). For a detailed discussion of these approaches, see Graetz et al. [ 110 ]. Quasi-experimental designs take advantage of an intervention, such as a policy change, that disrupts the ongoing pattern of health [ 111 ]. In quasi-experimental designs, in contrast to experimental designs, the researcher does not define the intervention. However, quasi-experimental designs can enhance causal inference if adequate comparison groups can be identified to represent a counterfactual comparison of what would have happened if the intervention had not occurred [ 111 ]. Recent examples include evaluating the impact of immigration raids or the 2017 Executive Order of the travel ban targeting individuals from Muslim majority countries [ 108 , 112 ].

In our literature review, we found examples of multi-level, ecologic, and individual-level study designs. Among papers that included at least one area-level measure of institutional racism, 22 were multi-level studies, while 17 were ecologic studies. In both the multi-level and ecologic studies, institutional racism was measured at the group level (e.g., the state-level Black:White ratio of felony disenfranchisement). This is appropriate given that discriminatory policies and practices are a property of institutions, not individuals. In the ecologic studies, health outcomes were also measured at the group level, despite being a property of individuals. The lack of individual-level data necessary to control for confounding can introduce bias when estimating the contextual effect of institutional racism on health in ecologic studies [ 113 ]. Thus, we recommend that researchers use multi-level study designs when possible. We also found 16 papers that measured exposures and outcomes at the individual level, and one paper that measured exposure and outcome at the family level. As discussed in detail above, we recommend against measuring institutional racism at the individual level due to challenges inherent in measuring a macro-level phenomenon at the individual level.

Analytic Approaches

Finally, analytic approaches must incorporate the specific aspects of exposure and outcome measurement and study design. An important decision point will be whether to model indicators of institutional racism separately or together; the former allows researchers to better identify specific policies that matter for health, while the latter better captures the systemic nature of multiple interconnected policies. If the latter approach is chosen, researchers must decide if they want to pre-specify institutional racism domains of interest (e.g., criminal justice, economics and labor) or use data reduction techniques to generate profiles of institutional racism. One approach for pre-specifying indicators within given domains is confirmatory factor analysis (CFA), where each domain is treated as a latent construct. CFA is used to understand how each individual indicator of institutional racism loads onto the latent construct of the specified domain. CFA can also be used to generate single summary measures of institutional racism, as in a recent paper by Dougherty et al. [ 53 ]. Other data reduction techniques, such as latent class analysis, may be useful to generate profiles of institutional racism without pre-specifying domains of interest.

Importantly, if examining institutional racism and health through a health disparities lens, effect modification of the relationship by race/ethnicity should be incorporated. For example, if researchers are examining the relationship between redlining and cardiovascular disease, testing for effect modification by race/ethnicity will help the research community understand if redlining affected the health of Black individuals only and/or to a greater extent than White individuals, as we would hypothesize given the targeting of the policy. As highlighted in our review, testing for effect modification of the relationship between institutional racism and health by race/ethnicity has not always been incorporated into recent research. Testing these types of hypotheses are essential to provide evidence for differential effects of policy.

In this paper we defined key concepts relevant to the study of institutional racism and proposed a framework for advancing institutional racism and health research, supported by a review of recent literature examining the relationship between institutional racism and health. We hope this framework will inform future examination of the impacts of institutional racism on health, and that it will help promote the consideration of structural interventions to improve minority health and to reduce and eliminate health disparities [ 114 ].

Data Availability

Not applicable.

Code Availability

While the US government classifies Latino as an ethnic group rather than a racial group, we include it in this list to acknowledge that Latinos have been historically racialized as non-White through legislation, immigration enforcement practices, and media framing.

Internalized racism is a specific type of ideological racism in which members of stigmatized racial or ethnic groups accept negative stereotypes about their own group.

In the post-Civil Rights era, institutional policies or practices are considered racially discriminatory if they result in inequitable outcomes by race, regardless of intent.

An important limitation of the search strategy, as noted by Groos et al., is that papers must have included the terms structural racism, systemic racism, institutional racism, or institutionalized racism in the title or abstract. It is likely that many more health-related papers measured similar constructs but failed to label them using these key terms.

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Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Number R01MD016046. T A was supported by a National Institute on Aging training grant (T32AG019134). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Needham, B.L., Ali, T., Allgood, K.L. et al. Institutional Racism and Health: a Framework for Conceptualization, Measurement, and Analysis. J. Racial and Ethnic Health Disparities 10 , 1997–2019 (2023). https://doi.org/10.1007/s40615-022-01381-9

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Institutional Racism and Health: a Framework for Conceptualization, Measurement, and Analysis

Journal of Racial and Ethnic Health Disparities

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Examples of Institutional Racism: What It Is and What You Can Do

Institutional racism is everywhere, from healthcare to housing to education to employment. Examples of institutional racism include instances of police brutality, reduced funding for predominantly Black schools, as well as racial gerrymandering.

The impact of institutional racism is far-reaching and a vicious cycle that takes a toll on people and society. Here's an overview of the historically prevalent discrimination that affects the Black community.

What Is Institutional Racism?

Policies and power structures rooted in White privilege maintain institutional racism, or systemic racism. Interpersonal racism shows up in biases for and against others based on race. Institutional racism, in contrast, is embedded into the structures of society. It leads people of different races to have different outcomes regarding housing , employment, health, finance, and education.

"Institutional racism is different and more implicit than interpersonal racism. It's come to the forefront of the national conversation after the murder of George Floyd and the protests for racial equity across the country [in 2020],"  Beth Beatriz, PhD , a researcher specializing in health equity, told  Health .

Legal segregation and Jim Crow laws previously publicly encoded institutional racism across the country. Modern policies and signage don't frequently identify institutional racism, but biases in favor of White people still exist in coded forms. These restrictions often have an unfair outcome in Black communities.

"Declaring certain hairstyles 'unprofessional' historically restricted qualified Black candidates from gainful employment," Nance Schick , an attorney and mediator based in New York, told  Health . "Despite the CROWN Act of 2020 [which prohibits discrimination based on hair texture or style], there are still employers who have restrictions on hair, particularly dreadlocks and natural hair." 

Examples of Institutional Racism in the U.S.

Institutional racism is prevalent in the United States across just about every sector. You may see examples of institutional racism in education, health, policing, and more.

School funding based on property values and residential taxes, combined with racial segregation in housing, has led to systemic underfunding of predominantly Black schools. Low-poverty districts that are primarily White spend almost $2,000 more per student than low-poverty districts where most students are people of color. This often results in poorer test scores and learning outcomes for Black students at underfunded schools.

The U.S. healthcare system has historically discriminated against non-White populations. Many healthcare facilities that predominately serve Black communities lack the funding, resources, and staff to deliver adequate healthcare. Poor healthcare services lead to adverse health outcomes.

Black women are as much as four times more likely than White women to experience a pregnancy-related death in the United States. Research has found that inadequate access to prenatal healthcare raises the risk of maternal mortality, in addition to healthcare providers' racial biases.

The COVID-19 pandemic also highlighted inequities in the U.S. healthcare system. Lack of access to healthcare services, such as COVID testing , led to a disproportionate number of infections and deaths among minority groups. Research has shown that COVID outcomes among non-White populations directly result from racist U.S. healthcare policies.

Where a person lives and the conditions of their neighborhood greatly impact their health outcomes. Residents of impoverished neighborhoods demonstrate a high risk of poor physical and mental health outcomes, such as:

• Depression or anxiety
• Heart problems

"The historical practice of 'redlining' is an example of a racist institutional policy still felt today," said Beatriz. Redlining happened when banks refused to lend money for mortgages in communities with large proportions of people of color. The banks considered these communities to be "hazardous."

The effects of redlining have persisted, despite it being outlawed in 1968. The Urban Institute reported in 2017 that the homeownership rate for White households was 71.9%. The rate for Black households, in contrast, was 41.8%.

This racial residential segregation is the cornerstone of Black and White disparities. "The inequities built into low-income housing is a fundamental cause of health disparities between [Black and White people]," Marsha Parham-Green, the executive director of the Baltimore County Office of Housing, told  Health .

"Concentrated poverty, safety, and segregation, as well as other social and community attributes, further contribute to stress and deterioration of health," said Parham-Green. "Those who are most vulnerable—children and the elderly—are most adversely affected by unstable housing conditions."

Law and Policing

Black people are roughly five times as likely as White people to report being unfairly stopped by the police. Black Americans are also more likely to suffer the ill effects of racial profiling. Racial profiling is stereotyping a person based on assumed characteristics of a racial or ethnic group rather than the individual.

Police brutality is an ongoing problem in the United States, disproportionally affecting Black communities. Black people face an adverse risk of poor health outcomes as a result, such as:

• Death from injuries sustained by the police
• Health complications that increase the risk of death
• Unfair arrest and incarceration

Economically-based discrimination goes hand-in-hand with interpersonal racism. Business loan officers may require Black applicants to have higher credit scores and income levels than White applicants. This discrimination may become an example of institutional racism if it's widespread.

An investigation in 2018 by the National Fair Housing Alliance found economic discrimination regarding car loans. Non-White applicants who experienced discrimination would have paid an average of $2,662.56 more over the life of the loan than less-qualified White applicants. The investigators also found that White applicants were offered more financing options than non-White applicants 75% of the time.

Some state elected officials denied early and mail-in voting for non-White voters. Black voters' ballots in North Carolina were rejected at more than three times the rate of White voters during the 2020 U.S. general election.

The U.S. Postal Service also removed hundreds of sorting machines, a form of institutional racism. "Mail delivery was slowed down, and residents over-indexing with a Black population couldn't get their mail," Lauren Raysor , an attorney and founder of the Mount Vernon Coalition for Police Reform, told  Health .

Another form of institutional racism in politics is gerrymandering. Gerrymandering determines electoral districts, which decide the outcomes of state and federal elections. There's one U.S. representative from each district. Census data, which the U.S. government collects every 10 years, influences redistricting.  

Racial gerrymandering happens when people in positions of power redraw district lines to suppress minority voices. Take, for example, a community largely made up of Black voters. The likelihood of Black voters being accurately represented decreases if lawmakers gerrymander that community into several districts.  

How To Be an Ally

Institutional racism hurts society, squashing innovation and creating an environment that breeds unhealthy stress and burnout. Those affected will continue to be a part of a cycle of despair and disenfranchisement if institutional racism continues as the status quo.

"Black Americans who call out institutional racism are often gaslighted,"  La Shawn Paul , mental health expert and diversity and inclusion strategist, told  Health . "To address any problem, you must first acknowledge its existence. Silence is complacency."

According to Schick, people can combat institutional racism by making the following changes:

• Don't stop with one Black friend and think you know enough about the Black experience. One person does not represent an entire group of people.
• Go to town halls, school board meetings, and other places where people are discussing solutions. Protests and books are great for creating awareness. But then, it's time for solutions at every level.
• Speak up when you see changes that can be made. Sometimes, the change is in a policy. Other times, change is as small as an individual's behavior.

"It's getting harder for all of us to claim ignorance. It's time to make a change," said Schick. "Perhaps that is where it begins, with pure intention. Adding courage and action, big changes can occur. We likely have to do some deep soul-searching first and accept that it will be uncomfortable. Nevertheless, this is where we must begin. Again."

A Quick Review

It's not as obvious as in previous generations, but institutional racism affects people of color profoundly. Examples can be as subtle as a lack of spending on public schools in economically disadvantaged areas serving minorities.

Institutional racism is pervasive and can affect every aspect of peoples' lives, from their finances to their education and physical and mental health. The best way to fight institutional racism is to become aware and active in changing the policies and behaviors perpetuating it.

EdBuild. Nonwhite school districts get $23 billion less than white districts despite serving the same number of students .

American Academy of Family Physicians. Institutional racism in the health care system .

Howell EA. Reducing disparities in severe maternal morbidity and mortality .  Clin Obstet Gynecol . 2018;61(2):387-399. doi:10.1097/GRF.0000000000000349

Gadson A, Akpovi E, Mehta PK. Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome .  Semin Perinatol . 2017;41(5):308-317. doi:10.1053/j.semperi.2017.04.008

Yearby R, Clark B, Figueroa JF. Structural racism In historical and modern US health care policy .  Health Aff (Millwood) . 2022;41(2):187-194. doi:10.1377/hlthaff.2021.01466

Pacheco CM, Ciaccio CE, Nazir N, et al. Homes of low-income minority families with asthmatic children have increased condition issues .  Allergy Asthma Proc . 2014;35(6):467-474. doi:10.2500/aap.2014.35.3792

Urban Institute. Breaking down the Black-White home ownership gap .

Pew Research Center. 10 things we know about race and policing in the U.S. .

Alang S, McAlpine D, McCreedy E, et al. Police brutality and Black health: Setting the agenda for public health scholars .  Am J Public Health . 2017;107(5):662-665. doi:10.2105/AJPH.2017.303691

Board of Governors of the Federal Reserve System. Availability of credit to small businesses .

National Fair Housing Alliance. Discrimination when buying a car .

ProPublica. In North Carolina, Black voters mail-in ballots much more likely to be rejected than those from any other race .

NAACP Legal Defense Fund. How redistricting works — and how you can get involved .

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Racism and Health: Evidence and Needed Research

David r. williams.

1 Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health

2 Department of African and African American Studies and of Sociology, Harvard University

3 Department of Psychiatry and Mental Health, University of Cape Town, South Africa

Jourdyn Lawrence

Brigette davis.

In recent decades, there has been remarkable growth in scientific research examining the multiple ways in which racism can adversely affect health. This interest has been driven in part by the striking persistence of racial/ethnic inequities in health and the empirical evidence that indicates that socioeconomic factors alone do not account for racial/ethnic inequities in health. Racism is considered a fundamental cause of adverse health outcomes for racial/ethnic minorities and racial/ethnic inequities in health. This article provides an overview of the evidence linking the primary domains of racism – structural racism, cultural racism and individual-level discrimination – to mental and physical health outcomes. For each mechanism, we describe key findings and identify priorities for future research. We also discuss evidence for interventions to reduce racism and needed research to advance knowledge in this area.

There has been steady and sustained growth in scientific research on the multiple ways in which racism can affect health and racial/ethnic inequities in health. This article provides an overview of key findings and trends in this area of research. It begins with a description of the nature of racism and the principal mechanisms -- structural, cultural and individual -- by which racism can affect health. For each dimension, we review key research findings and describe needed scientific research. We also discuss evidence for interventions to reduce racism and needed research to advance knowledge in this area. Finally, we discuss crosscutting priorities across the three domains of racism.

The patterning of racial/ethnic inequities in health was an early impetus for research on racism and health ( 139 ). First, there are elevated rates of disease and death for historically marginalized racial groups, blacks (or African Americans), Native Americans (or American Indians and Alaska Natives) and Native Hawaiians and Other Pacific Islanders, who tend to have earlier onset of illness, more aggressive progression of disease and poorer survival ( 5 , 134 ). Second, empirical analyses revealed the persistence of racial differences in health even after adjustment for socioeconomic status (SES). For example, at every level of education and income, African Americans have lower life expectancy at age 25 than whites and Hispanics (or Latinos), with blacks with a college degree or more education having lower life expectancy than whites and Hispanics who graduated from high school ( 15 ). Third, research has also documented declining health for Hispanic immigrants over time with middle-aged U.S.-born Mexican Americans and Mexican immigrants resident 20 or more years in the U.S. having a health profile that did not differ from that of African Americans ( 56 ).

Racism and Health

Racism is an organized social system, in which the dominant racial group, based on an ideology of inferiority, categorizes and ranks people into social groups called “races”, and uses its power to devalue, disempower, and differentially allocate valued societal resources and opportunities to groups defined as inferior ( 13 , 140 ). Race is primarily a social category, based on nationality, ethnicity, phenotypic or other markers of social difference, which captures differential access to power and resources in society ( 133 ). Racism functions on multiple levels. The cultural agencies within a society socializes the population to accept as true the inferiority of non-dominant racial groups leading to negative normative beliefs (stereotypes) and attitudes (prejudice) toward stigmatized racial groups which undergird differential treatment of members of these groups by both individuals and social institutions ( 13 , 140 ). A characteristic of racism is that its structure and ideology can persist in governmental and institutional policies in the absence of individual actors who are explicitly racially prejudiced ( 7 ).

As a structured system, racism interacts with other social institutions, shaping them and being re-shaped by them, to reinforce, justify and perpetuate a racial hierarchy. Racism has created a set of dynamic, interdependent, components or subsystems that reinforce each other, creating and sustaining reciprocal causality of racial inequities across various sectors of society ( 106 ). Thus, structural racism exists within, and is reinforced and supported by multiple societal systems, including the housing, labor and credit markets, and the education, criminal justice, economic and healthcare systems. Accordingly, racism is adaptive over time, maintaining its pervasive adverse effects through multiple mechanisms that arise to replace forms that have been diminished ( 99 , 140 ).

Racism: A Fundamental Cause of Racial/Ethnic Inequities in Health

The persistence of racial inequities in health should be understood in the context of relatively stable racialized social structures that determine differential access to risks, opportunities, and resources that drive health. We conceptualize this system of racism, chiefly operating through institutional and cultural domains, as a basic or fundamental cause of racial health inequalities ( 74 , 99 , 133 , 136 ). According to Lieberson, fundamental causes are critical causal factors that generate an outcome while surface causes are associated with the outcome but changes in these factors do not trigger changes in the outcome ( 73 ). Instead, as long as the fundamental causes are operative, interventions on surface causes only give rise to new intervening mechanisms to maintain the same outcome. Sociologists argued that socioeconomic status (SES) is a fundamental cause of health ( 53 , 132 ), with Link and colleagues ( 74 , 100 ) providing considerable evidence in support of this perspective. In 1997, Williams argued that alongside SES and other upstream social factors, racism should be recognized as a fundamental cause of racial inequities in health ( 133 ). Evidence continues to accumulate highlighting racism as a driver of multiple upstream societal factors that perpetuate racial inequities in health for multiple non-dominant racial groups around the world ( 99 , 140 ).

Structural or Institutional Racism

We use the terms institutional and structural racism, interchangeably, consistent with much of the social science literature ( 13 , 55 , 106 ). Institutional racism refers to the processes of racism that are embedded in laws (local, state, and federal), policies, and practices of society and its institutions that provide advantages to racial groups deemed as superior, while differentially oppressing, disadvantaging, or otherwise neglecting racial groups viewed as inferior ( 13 , 104 ). We argue that the most important way through which racism affects health is through structural racism. We highlight evidence of the health impact of residential segregation but acknowledge that there are multiple other forms of institutional racism in society. For example, structural racism in the Criminal Justice System ( 84 , 130 , 142 ) can adversely affect health through multiple pathways ( 37 , 130 ).

Racial Residential Segregation

Racial residential segregation remains one of the most widely studied institutional mechanisms of racism and has been identified as a fundamental cause of racial health disparities due to the multiple pathways through which it operates to have pervasive negative consequences on health ( 7 , 38 , 60 , 136 ). Racial residential segregation refers to the occupancy of different neighborhood environments by race that was developed in the U.S. to ensure that whites resided in separate communities from blacks. Segregation was created by federal policies as well as explicit governmental support of private policies such as discriminatory zoning, mortgage discrimination, red-lining and restrictive covenants ( 107 ). This physical separation of races in distinctive residential areas (including the forced removal and relocation of American Indians) was shaped by multiple social institutions ( 83 , 136 ). Although segregation has been illegal since the Fair Housing Act of 1968, its basic structures established by the 1940s remain largely intact.

In the 2010 Census, residential segregation was at its lowest level in 100 years and the decline in segregation was observed in all of the nation’s largest metropolitan areas ( 43 ). However, the recent declines in segregation have been driven by a few blacks moving to formerly all-white residential areas with the declines in segregation having negligible impact on the very high percentage black census tracts, the residential isolation of most African-Americans, and the concentration of urban poverty ( 44 ). Although segregation is increasing for Hispanics, the segregation of African Americans remains distinctive. In the 2000 census middle class blacks were more segregated than poor Hispanics and Asians ( 81 ), and the segregation of immigrant groups has never been as high as the current segregation of African Americans ( 83 ).

Segregation and Health: Pathways

Segregation affects health in multiple ways ( 136 ). First, it is a critical determinant of SES, which is a strong predictor of variations in health. Research has found that segregation reduces economic status in adulthood by reducing access to quality elementary and high school education, preparation for higher education, and employment opportunities ( 136 ). Schools in segregated areas have lower levels of high-quality teachers, educational resources, per-student spending and higher levels of neighborhood violence, crime and poverty ( 91 ). Segregation also reduces access to employment opportunities by triggering the movement of low skill, high pay jobs from areas where racial minorities are concentrated to other areas and by enabling employers to discriminate against job applicants by using their place of residence as a predictor of whether or not the applicant would be a good employee ( 136 ) One national study found that the elimination of segregation would erase black-white differences in income, education and unemployment and reduce racial differences in single motherhood by two-thirds ( 28 ). Thus, segregation is responsible for the large and persistent racial/ethnic differences in SES. In 2016, for every dollar of income that white households received, Hispanics earned 73 cents and blacks earned 61 cents ( 110 ). And racial differences in health are stunningly larger. For every dollar of wealth that white households have, Hispanics have 7 pennies, and blacks have 6 pennies ( 120 ).

Segregation can also adversely affect health by creating communities of concentrated poverty with high levels of neighborhood disadvantage, low quality housing stock, and with both government and private sector demonstrating disinterest or divestment from these communities. In turn, the physical conditions (poor quality housing and neighborhood environments) and the social conditions (co-occurrence of social problems and disorders linked to concentrated poverty) that characterize segregated geographic areas lead to elevated exposure to physical and chemical hazards, increased prevalence and co-occurrence of chronic and acute psychosocial stressors, as well as, reduced access to a broad range of resources that enhance health ( 60 , 87 , 128 , 136 ). The living conditions created by concentrated poverty and segregation make it more difficult for residents of those contexts to practice healthy behaviors ( 7 , 60 , 128 , 136 ). Segregation also adversely affects the availability and affordability of care, contributing to lower access to high quality primary and specialty care and even pharmacy services ( 129 ).

Epidemiological Evidence Linking Segregation to Health

A 2011 review found nearly 50 empirical studies which generally found that segregation was associated with poorer health ( 128 ). A 2017 review and meta-analysis focused on 42 articles that examined the association between segregation and birth outcomes found that segregation was associated with increased risk of low birth rate weight and preterm birth for blacks ( 85 ). Other recent studies show that segregation is associated with increased risk of preterm birth for U.S.-born and foreign-born black women ( 79 ) and of stillbirth for blacks and whites, with the effects being more pronounced for blacks than for whites ( 131 ). A systematic review of 17 papers examining segregation and cancer, found that segregation was positively associated with later-stage diagnosis, elevated mortality and lower survival rates for both breast and lung cancers for blacks ( 65 ). Recent studies highlight variation in the association between segregation and health for population subgroups. One national study found that segregation was associated with poor self-rated health for blacks in high but not lower poverty neighborhoods ( 31 ). It was unrelated to poor health for whites but benefited whites indirectly by reducing the likelihood of their location in high poverty neighborhoods ( 31 ). And a 25 year longitudinal study found that cumulatively higher exposure to segregation was associated with elevated risk of incident obesity in black women but not black men ( 101 ).

Recommendations for Research on Institutional Racism

Several strategies should be implemented to further understanding of how institutional racism adversely affects health. First, there is a need to broaden our conceptualization and assessment of the multiple domains and contexts in which these structural processes are operative and empirically assess their impact on health. In a study of structural racism and myocardial infarction, Lukachko and colleagues ( 75 ) utilized four state-level measures of structural racism: political participation, employment, education and judicial treatment. The analyses revealed that state level racial disparities that disadvantaged blacks in political representation, employment and incarceration were associated with increased risk of MI in the prior year. Among whites, structural racism was unrelated to or had a beneficial effect on the risk of MI.

Second, immigration policy has been identified as a mechanism of structural racism ( 38 ) and systematic attention should be given to understanding how contemporary immigration policies adversely affect population health. Recent research suggests that anti-immigrant policies can trigger hostility toward immigrants leading to perceptions of vulnerability, threat, and psychological distress for both those who are directly targeted and those who are not ( 46 ). One study found that a large federal immigration raid was associated with an increase in low birthweight risk among infants born to Latina but not white mothers in that community a year after the raid ( 90 ). Immigration polices can also adversely affect health by leading to reduced utilization of preventive health services by both documented and undocumented immigrants ( 80 , 117 , 127 ).

Third, some of the methodological limitations of the current literature need to be addressed. Research on structural racism has been limited by the availability of data on structural levels and ecological analyses are limited in capturing the underlying processes. The available evidence suggests that the associations between segregation and health tend to vary based on the choice of a geographic unit of analysis ( 7 , 38 , 60 , 128 ). While smaller units tend to produce the most reliable estimates, the appropriate geographic level may not be consistent across all health outcomes. These analytic challenges are further exacerbated by difficulties disentangling the potential mediating and moderating effects that contribute to observed patterns. Many studies adjust for variables like poverty or other indicators of low SES and the social context which are likely a part of the pathway by which segregation exerts its effects ( 60 , 128 ). Future research needs to identify the proximal mechanisms linking segregation to health by using longitudinal data to establish temporality, and leveraging new statistical techniques ( 60 , 128 ). There is also a need for more complex system modeling approaches that seek to capture the impact of all of the dynamic historical processes that influence each other over time, at multiple levels of analysis ( 30 , 92 ).

Fourth, greater attention should be given to similarities and differences across national and cultural contexts. For example, segregation levels are rising in Europe and are positively associated with darker skinned nationalities and being Muslim but there has been little analysis of the effects of this segregation on SES and health ( 82 ). A study that compared a national sample of Caribbean blacks in the U.S. to those in the U.K. found that, in the U.S., increased black Caribbean ethnic density was associated with improved health while increased black ethnic density was associated with worse health but the opposite pattern was evident for Caribbean blacks in England ( 10 ). Comparative research could enhance our understanding of the contextual factors such as variation in the racialization of ethnic groups that could contribute to the observed associations.

Finally, we need a better understanding of the conditions under which group density can have positive versus adverse effects on health ( 86 ). A national study of Hispanics found that segregation was adversely related to poor self-rated health among US born Hispanics but it had a salutary effect on the health of the foreign-born ( 32 ). We need a clearer understanding of when and how segregation can give rise to health enhancing versus health damaging factors.

Cultural Racism

Cultural racism refers to the instillation of the ideology of inferiority in the values language, imagery, symbols and unstated assumptions of the larger society. It creates a larger ideological environment where the system of racism can flourish, and can undergird both institutional and individual level discrimination. It manifests itself through media, stereotyping and within institutions, and norms ( 49 , 140 ). It can yield inconspicuous forms of racism, such as implicit bias, as a result of the commonplace and continuous negative imagery about racial and ethnic minorities ( 140 ). Cultural forms of racism may serve as the conduit through which views regarding the limitations, stereotypes, values, images and ideologies associated with racial/ethnic minority groups are presented to society, and are consciously or subconsciously adopted and normalized ( 105 , 113 ).

The internalization of racism yields a tendency to focus on individual pathology and abilities rather than examining structural components that give rise to racial inequities. This internalization affects most members of the dominant group and a nontrivial proportion of the marginalized group as well, given that both groups are exposed to key socializing agents of the larger society that perpetuate racist beliefs ( 105 ). Research indicates that negative racial and ethnic stereotypes persist in entertainment, media, and fashion ( 18 , 140 ). A recent national survey of adults who work with children found that whites had high levels of negative racial stereotypes (lazy, unintelligent, violent and having unhealthy habits) towards non-whites, with the highest levels towards blacks followed by Native Americans and Hispanics ( 103 ).

Cultural Racism and Health

Cultural racism can affect health in multiple ways. First, cultural racism can drive societal policies that lead to the creation and maintenance of structures that provide differential access to opportunities ( 140 ). For example, a study of white residents revealed that their negative stereotypes about blacks influenced their housing decisions in ways that would maintain residential segregation ( 64 ). In this study whites rated an all-white neighborhood more positively (on the cost of housing, safety, future property value, and quality of schools) than an identical neighborhood if a black person were pictured in it.

Second, cultural racism can also lead to individual level unconscious bias that can lead to discrimination against outgroup members. In clinical encounters, these processes lead to minorities receiving inferior medical care compared to whites. Research indicates that across virtually every type of diagnostic and treatment interventions blacks and other minorities receive fewer procedures and poorer quality medical care than whites ( 112 ). Recent research documents the persistence of these patterns and reveals that higher implicit bias scores among physicians are associated with biased treatment recommendations in the care of black patients ( 123 ). Providers’ implicit bias is also associated with poorer quality of patient provider communication including provider nonverbal behavior ( 25 ).

Stereotype threat is a third pathway. This term refers to the anxieties and expectations that can be activated in stigmatized groups when negative stereotypes about their group are made salient. These anxieties can adversely affect academic performance and psychological functioning ( 114 ). Some limited evidence indicates that stereotype threat can lead to increased anxiety, reduced self-regulation and impaired decision-making that can lead to unhealthy behaviors, poor patient-provider communication, lower levels of adherence to medical advice, increased blood pressure and weight gain among stigmatized groups ( 6 , 114 , 141 ). Relatedly, a study documented that exposure of American Indian students to Native American mascots, leads to declines in self-esteem, community worth and achievement aspirations ( 35 ). Fourth, as noted, some members of stigmatized racial populations respond to the pervasive negative racial stereotypes in the culture by accepting them to be true. This endorsement of the dominant society’s beliefs about their inferiority is called internalized racism or self-stereotyping. Research indicates that it is associated with lower psychological well-being and higher levels of alcohol consumption, depressive symptoms and obesity ( 139 ).

Recommendations for Research on Cultural Racism

Future research should aim to understand how and why cultural racism, when it is measured as elevated levels of racial prejudice at the community level, is associated with poorer health for racial minorities, and sometimes all persons, who live in that community. Recent studies have found that residing in communities with high levels of racial prejudice is positively associated with overall mortality ( 20 , 67 ), heart disease mortality ( 68 ), and low birthweight ( 21 ). Community-level prejudice against immigrants has also been associated with increased mortality among US-born immigrant adults ( 89 ). However, these studies are ecological in nature and lack adjustment for individual-level factors

Second, we need to better understand how internalized racism can affect health. There is limited understanding of the conditions under which internalized racism has adverse consequences for health, the groups that are most vulnerable, and the range of health and health-related outcomes that may be affected ( 140 ). The optimal measurement of internalized racism is also a challenge. Studies have used scales of internalized racism, minority group endorsement of negative stereotypes and African Americans’ scores on anti-black bias on the IAT. It is currently unclear how these measures correlate with each other and the extent to which they may capture different aspects of internalized racism. Beyond the individual, future work should also examine internalized racism in a more collective form that could facilitate understanding of the cultural and structural pervasiveness of racism at the societal level racial ( 105 ). Research should also assess if and how racist ideologies and oppression become internalized among immigrants in the United States and how these are associated with health outcomes.

Discrimination

Discrimination is the most frequently studied domain of racism in the health literature. It exists in two forms: 1) where individuals and larger institutions, deliberately or without intent, treat racial groups differently, resulting in inequitable access to opportunities and resources (e.g., employment, education, and medical care) by race/ethnicity, and 2) self-reported discrimination, a sub-set of these experiences that individuals are aware of. These latter incidents are a type of stressful life experience that can adversely affects health, similar to other kinds of psychosocial stressors. Considerable scientific evidence, supports of the first pathway, much of it captured through audit studies (those in which researchers use individuals who are equally qualified in every respect but differ only in race or ethnicity) that document the persistence of discrimination in many contexts including employment, education, housing, credit, and criminal justice systems ( 93 ). This discrimination in social institutions contributes to the differential access to resources and opportunities and results in SES and other material disadvantages.

A large proportion of the discrimination literature focuses on the second pathway with the evidence indicating that stigmatized racial and ethnic populations and other socially marginalized groups around the world report experiences of discrimination that are inversely related to good health ( 109 , 139 , 140 ). Researchers refer to these experiences as self-reported discrimination, perceived discrimination, and racial discrimination, and we use these terms interchangeably. Self-reports of discrimination can adversely affect health through triggering negative emotional reactions that can lead to altered physiological reactions and changes in health behaviors, that can increase the risk of poor health ( 41 ). We highlight key patterns and trends in this research on discrimination and health.

A 2015 meta-analysis assessed the scientific evidence for the association between self-reported racial discrimination and health from over 300 articles published between 1983 and 2013 ( 95 ). Eighty one percent of studies were from the U.S. followed by the U.K., Australia, Canada, the Netherlands and 15 other countries. The analyses found that the association between discrimination and mental health was stronger than for physical health. This was inconsistent with a prior review that found similar effect sizes for physical and mental health ( 96 ). Interestingly, ethnicity moderated the effect of self-reported racial discrimination on health with the association between perceived racial discrimination and mental health being stronger for Asian Americans and Latino Americans compared to blacks and the association with physical health being stronger for Latinos than for blacks.

While the review by Paradies and colleagues ( 95 ) is the most comprehensive one published to date, it excluded many studies that are included in other reviews. Because of its focus on experiences of “racism”, it excluded studies using measures of discrimination, bias and unfair treatment where race or ethnicity were not explicitly noted as the reason for discrimination. This included many studies using the Everyday Discrimination Scale and the Major Experiences of Discrimination Scale ( 137 , 143 ) which use a two-stage approach where respondents are first asked about generic experiences of bias and then a follow-up question ascertains the main reason. Many studies that have used these measures have not asked or analyzed the follow-up question. Relatedly, studies were also excluded that used a version of these two instruments that were utilized in the national MIDUS study ( 59 ). It explicitly asked respondents to report only instances where they had been “discriminated against” because of their race or other specific social characteristics ( 59 ). It appears that the use of “discrimination” does not affect the reports of bias by blacks but depresses reports by whites ( 8 ). Importantly, multiple reviews have concluded that the deleterious health effects of discrimination are generally evident with the generic perception of bias or unfair treatment irrespective of which social status category the experience is attributed to ( 70 , 96 , 139 ).

Several recent reviews provide additional evidence of the pervasive negative health effects of exposure to discrimination. A 2015 review indicated that self-reported discrimination is related not only to indicators of mental health symptoms and distress but also to defined psychiatric disorders ( 70 ). Moreover, there is growing evidence that self-reported discrimination is associated with preclinical indicators of disease, including increased allostatic load, inflammation, shorter telomere length, coronary artery calcification, dysregulation in cortisol and greater oxidative stress ( 70 ). Linkages between self-reported racial discrimination and physical health outcomes have been documented in multiple recent reviews with research indicating positive associations between reports of discrimination and adverse cardiovascular outcomes ( 72 ), BMI and incidence of obesity ( 12 ), hypertension and nighttime ambulatory blood pressure ( 33 ), engaging in high-risk behaviors ( 40 ), alcohol use and misuse ( 42 ), and poorer sleep ( 111 ). Research also indicates that experiences of discrimination can shape healthcare seeking behaviors and adherence to medical regiments. A 2017 review and meta-analysis of studies on discrimination and health service utilization revealed that perceived discrimination was inversely related to positive experiences with regards to healthcare (e.g., satisfaction with care or perceived quality of care) and reduced adherence to medical regimens and delaying or not seeking healthcare ( 11 ).

Research on stress and health reveals that in addition to stressful experiences affecting health through actual exposure, the threat of exposure as captured by responses of vigilance, worry, rumination and anticipatory stress can prolong the negative effect of stressors and exacerbate the negative effects of stressful experiences on health ( 17 ). Increased attention has been given to capturing vigilance with regards to the threat of discrimination. Several recent studies have used the Heightened Vigilance scale ( 23 ) or a shortened version of it and have found that vigilance about discrimination was positively associated with depressive symptoms ( 66 ), sleep difficulties ( 50 ), and hypertension ( 52 ) and contributed to racial differences for these outcomes. Another recent study with the same measure also found that heightened vigilance was associated with increased waist circumference and BMI among black but not white women ( 51 ). However, these studies have all been cross-sectional and future research using longitudinal study designs would strengthen the evidence for vigilance as a risk factor for health.

Another trend in recent research on discrimination and health is increasing attention to its negative effects on the health and wellbeing of children and adolescents. A 2013 review of discrimination and the health of persons age zero to 18 years old found 121 studies that had examined this association ( 102 ). There were consistent positive associations between self-reported discrimination and indicators of mental health problems, negative health behaviors and physical health outcomes. There is also accumulating evidence that the adverse health effects of discrimination in childhood and adolescence are evident early in life and are a likely contributor to racial inequities in health in young adulthood. For example, a study of black adolescents found that those who reported high levels of discrimination at age 16, 17, and 18 had elevated levels of stress hormones (cortisol, epinephrine and norepinephrine), blood pressure, inflammation and BMI by age 20 ( 16 ).

Research has documented cumulative effects of discrimination on health with greater negative impact evident with increasing levels of exposure to the stress of discrimination. A longitudinal study of ethnic minorities in the United Kingdom identified a dose-response relationship between the accumulation of experiences of discrimination with the deterioration in mental health, with the greatest degree of mental health deterioration evident among those who reported two or more experiences of discrimination at both time points ( 125 ).

Recommendations for Research on Discrimination and Health

As noted, audit studies and other field experiments document the existence of discrimination in many societal institutions and contexts. More concerted efforts are needed to apply knowledge and insights from these studies on the structuring and persistence of discrimination within institutional settings to understand how such discrimination sustains racial disadvantage in ways that shape health outcomes and impact racial health inequities. More generally, despite the burgeoning literature on self-reported discrimination and health, there are some fundamental questions that remain unanswered, including the conditions under which particular aspects of discrimination are related to changes in health status for specific indicators of health status. Such analyses might shed light on findings where the pattern is not uniform. For example, cohort studies have found a positive association ( 9 ), no association ( 2 ) and an inverse association between discrimination and all-cause mortality ( 34 ). The contribution of differences in the assessment of discrimination and in the populations covered to the observed patterns is not well understood.

Prior reviews indicate that the literature on self-reported discrimination and health has been plagued with multiple measurement challenges that probably lead to an underestimation of the actual effects of discrimination on health ( 62 , 135 ). These challenges include identifying the optimal approaches for accurately and comprehensively measuring discrimination and ensuring adequate assessment of key stressful components of discriminatory experiences such as their chronicity, recurrence, severity and duration and distinguishing incidents that are traumatic from those that are not. These challenges remain urgent issues to address in future research.

A limitation of most prior research on discrimination and health is the focus on singular identities of the study participants. Emerging evidence suggests that utilizing an intersectionality framework that examines associations between discrimination and health, with the simultaneous consideration of multiple social categories (e.g., race, sex, gender, SES), leads to larger associations than when only a single social category is considered ( 71 ). Experiences of discrimination should also be considered both for an individual’s self-identified race, as well as for one’s socially assigned race ( 124 ). Recent studies also provide striking evidence of the persistence of discrimination based on skin color within multiple Latino ethicities ( 97 ) and for blacks ( 88 ) suggesting that skin color should be an essential domain of assessing discrimination in future research.

An enhanced understanding of how discrimination combines with other stressors to shape health and racial/ethnic inequities in health is also needed. Self-reported experiences of discrimination do not fully encompass psychosocial stressors linked to non-dominant racial/ethnic status nor the full contribution of racism-related stressors. A study that measured multiple dimensions of discrimination (everyday, major experiences and work discrimination) along with brief measures of childhood adversity, lifetime traumas, recent life events and chronic stressors in the domains of work, finances, relationships and neighborhood, found a graded association between the number of stressors and multiple indicators of morbidity, with each additional stressor associated with worse health ( 115 ). Moreover, stress exposure explained a substantial portion of the residual effect of race/ethnicity after adjustment had been made for SES. Fully capturing stressful exposures for vulnerable populations should also include the assessment of stressors linked to the physical, chemical, and built environment ( 139 ).

Attention should also be given to understanding the contribution of stressors that, at face value, are not linked to racism but that reflect the effects of racism on health. Research on community bereavement shows that structural conditions linked to racism lead to lower life expectancy for blacks compared to whites ( 122 ). As a result, compared to whites, black children are three times as likely to lose a mother by age 10, and black adults are more than twice as likely to lose a child by age 30, and a spouse by age 60. This elevated rate of bereavement and loss of social ties is a stressor that adversely affects levels of social ties and physical and mental health of blacks across the life course ( 119 ). The death of loved ones is included on standard assessments of life events, but its links to racism typically recognized.

Another priority for future research is to better identify the conditions under which vicarious experiences of discrimination can affect health, The term, vicarious discrimination, refers to discriminatory experiences that were not directly experienced by an individual but were faced by others in their network or with whom they identify ( 47 ). A recent systematic review of 30, mainly longitudinal, studies found that that indirect, secondhand exposure to racism was adversely related to child health ( 47 ). The range of contexts in which vicarious discrimination occurs is broad. Recent studies suggest that online discrimination through social media and frequent reports and visualization of incidents of police violence directed towards black, Latino, and Native American communities may also have negative health consequences ( 121 ). A recent, nationally-representative, quasi-experimental study found that each police killing of an unarmed black male Americans worsened mental health among blacks in the general population ( 14 ).

Increased hostility and resentment towards racial and ethnic minority groups and immigrants in the U.S. as well as political polarization associated with the recent presidential election and its aftermath also deserve more research attention ( 138 ). A recent longitudinal study of high school juniors interviewed before and after the presidential election found that many reported concern, worry or stress regarding the increasing hostility and discrimination of people because of their race, immigrant status, religion, or other social factors. A year later, higher concern about discrimination was associated with increases in cigarette smoking, alcohol use, substance use, and greater odds of depression and ADHD ( 69 ).

Future research also needs to better document the role of discrimination, and other dimensions of racism, in accounting for racial disparities in health. Studies from Australia, New Zealand, South Africa and the U.S. have found that self-reports of discrimination make an incremental contribution over and above income and education in accounting for racial/ethnic inequities in health ( 139 ). However, most studies of discrimination neglect to empirically quantify the contribution of discrimination to the patterns and trends of inequities in health.

Interventions

Future research on racism and health needs to give more sustained attention to identifying interventions to reduce and prevent racism, as well as, to ameliorate its adverse health effects. Research on interventions to address the multiple dimensions of racism is still in its infancy ( 94 , 141 ).

Addressing Institutional Racism

Reskin ( 106 ) emphasizes that because racism is a system that consists of a set of dynamically related components or subsystems, disparities in any given domain is a result of processes of reciprocal causality across multiple subsystems. Accordingly, interventions should address the interrelated mechanisms and critical leverage points through which racism operates, and explicitly design multi-level interventions to get at the multiple processes of racism simultaneously. The systemic nature of racism implies that effective solutions to addressing racism need to be comprehensive and emphasize upstream/structural/institutional interventions ( 142 ). The civil rights policies of the 1960s are prime examples of race-targeted policies that that improved socioeconomic opportunities and living conditions, narrowed the black-white economic gap between the mid 1960s and the late 1970s and reduced health inequities ( 3 , 4 , 26 , 45 , 58 ). Interventions to improve household income, education and employment opportunities, and housing and neighborhood conditions have also demonstrated health benefits ( 141 ).

Additional income to households with modest economic resources suggests that added financial resources are associated with improved health ( 141 ). The Great Smoky Mountains Study was a natural experiment that assessed the impact of extra income received by American Indian households due to the opening of a Casino, on the health of Native youth ( 27 ). The study found declining rates of deviant and aggressive behavior among adolescents whose families received additional income; and increases in formal education and declines in the incidence of minor criminal offenses in young adulthood, and the elimination of Native American-white disparities on both of these outcomes ( 1 ). The Abecedarian project that randomized economically disadvantaged children, birth to 5 years of age, most of them Black, to an early childhood nurturing program also illustrates that interventions efforts at an early age can be beneficial ( 19 ). By their mid 30s, the intervention group had lower levels of multiple risk factors for cardiovascular disease than the controls. Community initiatives and efforts to build community capacity around racism may also have the potential to improve health ( 140 , 141 ). One study demonstrated that cultural empowerment among Native communities, in the form of civil and governmental sovereignty and the presence of a building for cultural activities, had a strong inverse relationship with youth suicide ( 22 ).

Addressing Cultural Racism

Most interventions aimed at reducing cultural racism focus on addressing implicit biases or enhancing cultural competence. A recent review found that cultural competency interventions can lead to improvements in provider knowledge, skills and attitudes regarding cultural competency and health care access and utilization, but there is little evidence that these interventions affect health outcomes and health equity ( 118 ). While extensive evidence documents that healthcare students and professionals have an anti-black there are no effective interventions to reduce this bias among providers ( 76 ). However, Devine and colleagues documented that a comprehensive program that deployed multiple strategies to reduce implicit biases found a sustained reduction in implicit biases in nonblack undergraduate students three months after the program began ( 29 ). Future research needs to assess the generalizability of the effects of this intervention to other groups.

Interventions, targeted at individuals, that seek to neutralize cultural racism have shown positive socioeconomic and health benefits. Values affirmation interventions (in which youth enhance their sense of self-worth by reflecting on and writing about their most important value) and social belonging interventions (which create a sense of relatedness) have been shown to markedly improve academic performance and health of stigmatized racial groups ( 24 ). There is an emerging body of evidence that suggests that similar self-affirmation strategies can enhance an individual’s capacity to cope with stressful situations and lead to improved health behaviors ( 24 ).

Addressing Discrimination

Effective strategies can be deployed to reduce discrimination against individuals that occur within institutional contexts. For example, in the employment domain, research reveals that discrimination can be reduced and the proportion of under-represented groups markedly increased through organizational policy changes that require mandatory programs, or programs with explicit authority and accountability that are supported by organizational leadership and rigorously monitored ( 57 ). Discrimination can also be minimized in employment decisions by having applications reviewed with the names of the applicants removed from the application package ( 61 ). Many interventions targeting interpersonal discrimination focus on reductions in prejudice and stereotyping through increased interracial contact. However, evidence in support of the contact theory of prejudice indicates that reductions in prejudice and discrimination are observed only when groups meet specific conditions: they are equivalent in status, have shared goals, cooperate to achieve shared goals, and have the support of authority figures ( 98 ).

Research on interpersonal discrimination also suggests that coping strategies and resources (such as social ties, religious involvement and optimism) can mitigate at least some of the detrimental effects of racial discrimination on health ( 70 ). Racial identity is another promising strategy but studies have found both protective and exacerbating effects of identity ( 144 ). At the present time, we do not clearly understand the determinants of discrepant findings and the conditions under which specific aspects of identity have positive or negative effects for particular indicators of health for specific population subgroups.

Needed Research On Interventions

Although there is emerging evidence that a broad range of strategies may reduce certain aspects of racism and enhance racial equity, there is still a lot that we do not understand. For example, interventions that have improved neighborhood and housing conditions have been implemented on a small scale and they have yet to seriously address either residential racial segregation or the concentration of poverty in the metropolitan areas in which they have been implemented. Residential segregation has been identified as a leverage point or fundamental causal mechanism by which institutional racism creates and sustains racial economic inequities ( 106 , 136 ). Thus, dismantling the core institutional mechanisms of segregation will require scaling up interventions that address its key underlying mechanisms. Relatedly, we lack the empirical evidence to identify which mechanisms of segregation (e.g., educational opportunity, labor market, housing quality) should be tackled first, would have the largest impact, and is most likely to trigger ripple effects to other pathways.

Research also needs to identify if and when observed health effects of reducing racism would be larger if comprehensive, multi-level intervention strategies (instead of interventions targeted at a single level) were deployed to neutralize the negative impact of the pathogenic effects of racism. For example, we are unaware whether we would observe larger positive effects if interventions focused on upstream interventions (e.g., in housing, education and additional income) were combined with an individual-level targeted strategy such as a self-affirmation intervention ( 24 ). Relatedly, interventions need to be evaluated for the extent to which they may be differentially effective across various subgroups of the population. The cost-effectiveness of interventions also needs to be assessed for population subgroups.

Taking the systemic nature of racism seriously also highlights that it is deeply embedded in other political, economic and cultural structures of society and that many powerful societal actors are likely to be resistant to change because they currently benefit from the status quo. Research to advance an agenda to dismantle racism and its negative effects must invest in studies that delineate how to overcome societal inertia, increase empathy for stigmatized racial/ethnic populations, build political will and identify optimal communication strategies to raise public and stakeholder awareness of the societal benefits of racial equity agenda ( 142 ).

Cross-Cutting Issues

Much of the research described in this review has focused on a single mechanism of racism (structural/institutional, cultural, discrimination) through which racism may influence health. Differentiating between these mechanisms allows researchers to clarify potential pathways, measure outcomes, and explore interventions. However, the impact of addressing a single dimension of racism will be diminished by the system of racial oppression which interacts across sectors and domains of racism. Tying together interconnected data on health and racism will be critical for health disparities researchers moving forward. Some emerging topics lend themselves to this multi-dimensional, cross-cutting research—allowing investigators to better understand and address the systemic nature of racism. Priority topics include studying the effects of racism throughout the life course, understanding the potential intergenerational effects of racism, and the impact of racism on white people.

Understanding Racism across the Life Course

Life course research aims to examine how early exposures, such as lead poisoning in utero, or adversity in early childhood, can impact health in adulthood. This perspective can incorporate early context, sensitivity and latency periods, the accumulation of risk over time, and etiologic origins of disease ( 39 ). When examining racism as an exposure, understanding how individuals encounter racism across the life course is one example of a cross-cutting issue in need of more research ( 38 , 39 , 128 ). A life course approach can begin to unpack how exposures to interpersonal, cultural, and structural racism may evolve and relate to each other across developmental stages, as individuals interact with their neighborhoods and educational systems, and health care systems ( 106 ). A recent study, for example, documented a relationship between early childhood lead exposure and adult incarceration ( 108 ). It is likely that multiple mechanisms of racism could have combined, additively and interactively over time, to undergird this association ( 78 ). Life course approaches are also important for determining how and when it is most opportune to intervene on racism. The Great Smoky Mountains Study found that providing additional income to Native American households led to a reduction in adolescent risk behaviors, but only among those who were the youngest when the income supplements began, and who thus had the longest period of exposure ( 27 ). A life course approach can identify key periods of increased risk as well as opportunities for intervention and resilience.

Intergenerational Transmission of Racism’s Effects

An extension of the life course perspective is a focus on the impact of intergenerational transmission of the effects of racism, from parent to offspring. Though still in its infancy, research on the intergenerational transmission of racism could enhance and clarify observational research which posits that descendants of survivors of mass and targeted trauma experience grief and other mental, behavioral, and somatic symptoms akin to what would might be expected if the trauma was witnessed directly ( 48 ). Long-term adverse health impacts linked to Jim Crow laws illustrate the long reach of institutional racism ( 63 ). Studies of children of Holocaust survivors and multiple generations of Native Americans suggest a link between these racialized traumatic experiences and the well-being of future generations ( 119 ). Possible pathways include the effects of parenting and community norms, the transfer of resources (i.e. wealth, land), and potentially, heritable and non-heritable epigenetic changes caused by external stressors ( 126 ). Differential DNA methylation is one type of epigenetic difference that has been found among adult children of holocaust survivors, which may affect gene expression at the methylated loci ( 119 ). Concerted new research efforts are needed to provide a more nuanced understanding of how racialized experiences are embodied for future generations.

Racism and the Health of Whites

There is growing scientific interest in how the system of racism can have both positive and negative effects on the health of whites ( 77 ). Whites as a whole have better health than the historically oppressed groups in the U.S., but they are less healthy than whites in other advanced economies. Inadequate attention has been given to delineating the ways in which racism could simultaneously advantage whites compared to other racial groups in the U.S. while creating conditions that are inimical to the health of all groups, including disadvantaging large segments of the white population, and imposing ceilings that prevent many middle class whites from attaining a level of good health seen elsewhere ( 77 ). For example, racial animus towards blacks has led to white opposition to a broad range of social programs, including the Affordable Care Act, which would benefit a large proportion of whites ( 116 ). In addition, while research on internalized racism has heavily focused on its potential negative health effects on members of racial and ethnic minority groups, whites also have high levels of internalized racism (that is, internalized racial superiority) that could affect how whites respond to economic adversity perhaps contribute to increasing rates of “deaths of despair” among low SES whites ( 77 , 105 ). Research on self-reported discrimination and hqealth has also observed negative effects of such experiences among whites ( 70 ). It is not clear that all whites are equally vulnerable. One study found that discrimination adversely affected only whites who were male and who belonged to ethnic subgroups with a history of discrimination (Polish, Irish, Italian or Jewish) ( 54 ). Another study found that discrimination based on class helped to explain SES differences in allostatic load in a sample of white adolescents ( 36 ). Concerted attention should be given to the myriad ways in which various aspects of racism can have positive and negative effects on the health of whites and particular subgroups of whites.

Conclusions

The study of contemporary racism and its impact on health is complex, as manifestations of structural, cultural, and interpersonal racism adapt to changes in technology, cultural norms, and political events. This body of research illustrates the myriad ways in which the larger social environment can get under the skin to drive health and inequities in health. While there is much that we yet need to learn, the quality and quantity of research continues to increase in this area and there is an acute need for increased attention to identifying the optimal interventions to reduce and eliminate the negative effects of racism on health. Understanding and effectively addressing the ways in which racism affects health is critical to improving population health and to making progress in reducing large and often intractable racial inequities in health.

Acknowledgments

Preparation of this paper was supported by grant U19 AG 051426 from the National Institute of Aging. We wish to thank Sandra Krumholz for her assistance with preparing the manuscript.

Literature Cited