Structural Racism and Health Inequities
Understanding Racism in Health Care
Different Forms of Racism
Racism affects health care in many ways. It can be seen in policies, practices, and attitudes that disadvantage people based on their race. There are three main types of racism:
- Structural Racism: This is when policies and practices in institutions create and maintain racial inequality. For example, Black Americans have higher death rates from heart disease and cancer compared to White Americans (Hostetter & Klein, 2018).
- Personally Mediated Racism: This is when individuals show prejudice and discrimination based on race. For example, Black Americans are imprisoned for drug crimes at six times the rate of White Americans (Pearl, 2018).
- Internalized Racism: This is when people of a stigmatized race accept negative messages about their abilities and worth. This can lead to self-devaluation and hopelessness (David et al., 2019; Jones, 2000; Roberson & Pieterse, 2021).
Historical Context of Structural Racism
Racism in the United States has a long history, starting with the ill treatment and forced removal of Native Americans and the history of slavery. This history has led to ongoing structural racism that affects many aspects of life, including health care.
- Native Americans: They have faced violence and forced removal from their lands since the arrival of European settlers. Policies like the Indian Removal Act forced Native Americans to relocate, resulting in many deaths (Fixico, 2021).
- Black Americans: Slavery and segregation laws, such as the Black Codes and Jim Crow laws, have created long-lasting inequalities. These laws denied Black Americans basic rights and opportunities, leading to ongoing disparities (Shah & Adolphe, 2019).
Contemporary Structural Racism and Systemic Inequities
Structural racism continues to affect health care today. For example, redlining practices in the 1930s labeled neighborhoods with predominantly Black populations as high-risk, leading to disinvestment and poor health outcomes (Mitchell & Franco, 2018).
- Health Insurance: Many BIPOC (Black, Indigenous, and People of Color) individuals lack access to health insurance, leading to poorer health outcomes. Medicaid expansion has helped, but many states with high BIPOC populations have not expanded Medicaid (Yearby et al., 2022).
- Environmental Injustice: BIPOC communities often face higher levels of pollution and environmental hazards, leading to health issues like asthma and cancer (Bailey et al., 2021).
Addressing Structural Racism in Health Care
Nurses play a crucial role in addressing structural racism. This includes:
- Education: Nursing curricula should include content on structural racism, implicit bias, and the social determinants of health (Villarruel & Broome, 2020).
- Advocacy: Nurses should advocate for policies that promote health equity, such as Medicaid expansion and equitable funding for public schools (ANA, 2021).
- Workforce Diversity: Increasing diversity in the nursing workforce can improve communication and trust with BIPOC communities and help address health disparities (AACN, 2023).
This chapter is a summary of Chapter 6 of Ochs, J., Roper, S. L., & Schwartz, S. M. (2024). Population Health for Nurses. OpenStax. Microsoft Copilot was used in support of this effort. Note: Microsoft Copilot uses commercial data protection to ensure the security and privacy of user data. Prompts and responses are not saved, and data is not used to train the underlying large language model.
References:
American Association of Colleges of Nursing. (2023). Enhancing diversity in the nursing workforce.
American Nurses Association. (2021). The ethical responsibility of the nursing profession to address systemic racism.
Bailey, Z. D., Feldman, J. M., & Bassett, M. T. (2021). How structural racism works—racist policies as a root cause of U.S. racial health inequities. The New England Journal of Medicine, 384(8), 768–773.
David, E. J. R., Schroeder, J. H., & Fernandez, R. (2019). Internalized racism: A systematic review of the psychological literature. Journal of Counseling Psychology, 66(3), 303–318.
Fixico, D. L. (2021). American Indians and the urban experience. Routledge.
Hostetter, M., & Klein, S. (2018). Structural racism and health inequities: Evidence and interventions. American Public Health Association.
Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener’s tale. American Journal of Public Health, 90(8), 1212–1215.
Mitchell, R., & Franco, P. (2018). HOLC “redlining” maps: The persistent structure of segregation and economic inequality. National Community Reinvestment Coalition.
Pearl, B. (2018). Report to the United Nations on racial disparities in the United States criminal justice system. The Sentencing Project.
Roberson, Q. M., & Pieterse, A. L. (2021). The complexities of racism and implications for clinical practice. Journal of Clinical Psychology, 77(10), 2136–2149.
Shah, N., & Adolphe, J. (2019, August 19). The history of racism in America, from the colonial era to the Trump campaign. Vox.
Villarruel, A. M., & Broome, M. E. (2020). Reclaiming our legacy: Structural racism in nursing research, education, and practice. Journal of Nursing Scholarship, 52(6), 597–608.
Yearby, R., Mohapatra, S., & Wen, H. (2022). Structural racism, the Affordable Care Act, and health disparities in the USA: What has changed and what has not? The Lancet Regional Health–Americas, 7, 100135.
