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Abstract
Racism is not always conscious, explicit, or readily visible—often it is systemic and structural. Systemic and structural racism are forms of racism that are pervasively and deeply embedded in systems, laws, written or unwritten policies, and entrenched practices and beliefs that produce, condone, and perpetuate widespread unfair treatment and oppression of people of color, with adverse health consequences. Examples include residential segregation, unfair lending practices and other barriers to home ownership and accumulating wealth, schools’ dependence on local property taxes, environmental injustice, biased policing and sentencing of men and boys of color, and voter suppression policies. This article defines systemic and structural racism, using examples; explains how they damage health through many causal pathways; and suggests approaches to dismantling them. Because systemic and structural racism permeate all sectors and areas, addressing them will require mutually reinforcing actions in multiple sectors and places; acknowledging their existence is a crucial first step.
TOPICS
RACISM
HEALTH EQUITY
ACCESS TO CARE
HEALTH DISPARITIES
HOUSING
PUBLIC HEALTH
CHILDREN'S HEALTH
EDUCATION
TAXES
When most people think about racism, they probably think of racial slurs, hate crimes, or other overtly racist actions. There are, however, other less obvious yet ultimately even more destructive forms of racism. Structural and systemic racism are often invisible—at least to those who are not its victims. This article defines structural and systemic racism, explains how they damage health, and provides illustrative examples. Although we focus on how structural and systemic racism can harm the health of people of color, they also may damage the health and well-being of a society overall1,2—including the health and well-being of White people.3
Definitions
People of color is a term used to refer to African Americans, American Indians/Alaska Natives, Asian Americans, Latinos/Hispanics, and Native Hawaiians/other Pacific Islanders. Racism is the relegation of people of color to inferior status and treatment based on unfounded beliefs about innate inferiority, as well as unjust treatment and oppression of people of color, whether intended or not. Racism is not always conscious, intentional, or explicit—often it is systemic and structural.4 Systemic and structural racism are forms of racism that are pervasively and deeply embedded in and throughout systems, laws, written or unwritten policies, entrenched practices, and established beliefs and attitudes that produce, condone, and perpetuate widespread unfair treatment of people of color.5 They reflect both ongoing and historical injustices. Although systemic racism and structural racism are often used interchangeably, they have somewhat different emphases. Systemicracism emphasizes the involvement of whole systems, and often all systems—for example, political, legal, economic, health care, school, and criminal justice systems—including the structures that uphold the systems.6Structuralracism emphasizes the role of the structures (laws, policies, institutional practices, and entrenched norms) that are the systems’ scaffolding.5 Because systemic racism includes structural racism, for brevity we often use systemic racism to refer to both; at times we use both for emphasis. Institutional racism is sometimes used as a synonym for systemic or structural racism, as it captures the involvement of institutional systems and structures in race-based discrimination and oppression;4,7,8 it may also refer specifically to racism within a particular institution.9
Gilbert Gee and Annie Ro depict systemic racism as the hidden base of an iceberg10 (see illustration in online appendix exhibit 1).11 The iceberg’s visible part represents the overt racism that manifests in blatant discrimination and hate crimes—explicitly racist treatment that may be relatively easy to recognize. The iceberg’s base—the much larger, usually unseen part—represents systemic and structural racism. It consists of the societal systems and structures that expose people of color to health-harming conditions and that impose and sustain barriers to opportunities that promote good health and well-being. The opportunities denied include access to good jobs with benefits; safe, unpolluted neighborhoods with good schools; high-quality health care; and fair treatment by the criminal justice system. Systemic racism is the iceberg’s more dangerous part: It places people of color at a disadvantage in multiple domains affecting health in ways often more difficult to recognize than explicit interpersonal racism.
Systemic racism is so embedded in systems that it often is assumed to reflect the natural, inevitable order of things.
Systemic racism is so embedded in systems that it often is assumed to reflect the natural, inevitable order of things. Slavery—explicitly supported by laws—endured for 250 years in the United States and was followed by almost 100 years of Jim Crow laws—often enforced by terror—that were deliberately designed to restrict the rights of African Americans, including the rights to vote, work, and get an education. Although civil rights legislation in the 1960s made it illegal to discriminate, enforcement of these antidiscrimination laws has been inadequate.12 Racial inequities, and their ensuing socioeconomic and health consequences, persist because of deeply rooted, unfair systems that sustain the legacy of former overtly discriminatory practices, policies, laws, and beliefs. At times, these systems and structures, which are rooted in beliefs in White supremacy, operate unconsciously or unintentionally, but nevertheless effectively, to produce and sustain racial discrimination. Systemic racism systematically and pervasively puts Black people, Indigenous people, and other people of color at compounded disadvantage within society. It often can be traced to deliberate acts of discrimination in the past, such as laws mandating residential segregation by race. Once in place, however, systemic racism is often self-perpetuating, with persistently damaging effects on health even after the explicitly discriminatory measures are no longer in effect.
The terms systemic, structural, and institutional racism, or closely related concepts, were first used by social scientists. Sociologist David Williams13 and others6,14 have traced the key concepts back to the distinguished social scientist W. E. B. Du Bois, who wrote (around 1900) about how racial discrimination was institutionalized within multiple sectors of society and was self-perpetuating.8 Douglas Massey and Nancy Denton noted the institutionalization of racial discrimination “within large sectors of the American society, including the labor market, the educational system, and the welfare bureaucracy…and racial segregation.”7(p8)
Joe Feagin and Kimberley Ducey wrote: “Systemic racism includes the complex array of antiblack practices, the unjustly-gained political-economic power of whites, the continuing economic and other resource inequalities along racial lines, and the white racist attitudes created to maintain and rationalize white privilege and power. Systemic here means that the core racist realities are manifested in each of society’s major parts…—the economy, politics, education, religion, the family—[reflecting] the fundamental reality of systemic racism.”6(p6)
Eduardo Bonilla-Silva discussed how persistent racial inequality reflects the “continued existence of a racial structure” in society.5(p476) He noted that, in contrast with the Jim Crow period, the structures maintaining contemporary racial oppression “are increasingly covert, are embedded in normal operations of institutions, avoid direct racial terminology, and are invisible to most Whites.”
Examples Of Structural And Systemic Racism
Several examples of systemic racism are presented here. They have been selected on the basis of their importance in perpetuating racial injustice with health implications and for diversity of the sectors and systems involved. Health implications are generally discussed later.
Political Disempowerment
Political disenfranchisement and disempowerment through voter suppression and gerrymandering are an important historical and contemporary manifestation of systemic racism. The legal right for all men to vote was secured in 1870. During the nearly 100-year era of Jim Crow laws, however, voter suppression of Black people was maintained in many states through violent intimidation and selectively applied laws. The Civil Rights Act of 1964 did not eliminate requirements that continue to differentially affect people of color. Even in 2021 many states recently passed or were considering legislation disproportionately restricting the voting rights of people of color,15 including by gerrymandering, the deliberate redrawing of electoral district boundaries to favor the political party in power. Gerrymandering makes some people’s votes count less than others’ do, depriving them of full representation.16
Segregation
Another historical and current example of systemic racism is racial residential segregation, initially created by the deliberate and explicit racism codified in Jim Crow laws. Although segregation has declined since the Fair Housing Act of 1968 outlawed racial discrimination in housing, the United States remains highly segregated. Racial segregation is almost always accompanied by concentrated economic disadvantage and limited opportunities for upward mobility, such as good employment options and good schools.17 Because of segregation, African American and Latino people are more likely than White people with similar household incomes to live in neighborhoods with concentrated disadvantage, whose adverse health effects have repeatedly been demonstrated, yet most health and medical studies do not include variables representing neighborhood conditions.
Financial Practices
Widespread discriminatory public and private lending policies and practices are another salient instance of systemic racism and have created major obstacles to home ownership and wealth for people of color. Home ownership is the principal form of wealth for most Americans of modest means. Beginning in the 1930s bank lending guidelines from the federal Home Owners’ Loan Corporation were later adopted by private banks. The guidelines explicitly used neighborhood racial and ethnic composition and income data in assessing mortgage lending risks.18 During decades when federal loan programs greatly expanded Whites’ homeownership (and thus, wealth), non-White and low-income areas were disproportionately “redlined”—a practice whose name refers to the red shading on Home Owners’ Loan Corporation maps of neighborhoods that were deemed hazardous for lending. Racial and ethnic differences in homeownership, home values, and credit scores in formerly redlined areas persist.19 Predatory financial services disproportionately target communities of color, adding to the obstacles to their accumulating wealth.20 These include payday lenders and check cashing services, which typically charge excessive fees and usurious interest rates.20 Even when mainstream banking services are available in a segregated community, people of color are often subjected to higher service costs.20 Similar to redlining, these practices create obstacles to home ownership, starting or expanding businesses, accumulating wealth, financing college education, and generating property tax revenues to fund schools.
In addition, the dependence of public schools on local property taxes results in schools in segregated areas often being poorly resourced,21 making it difficult for children to escape from poverty and, as a consequence, ill health as adults
