Racism’s Insidious Effect on Black Lives and Health

Health Letter, November 2015

By Sammy Almashat, M.D., M.P.H.

The series of unarmed black men and women who have died at the hands of local police has laid bare the gaping inequalities in justice that separate white communities from those of people of color in America. The killings of Eric Garner, Michael Brown Jr., Ezell Ford, Tanisha Anderson, Tamir Rice, Eric Harris, Walter Scott, and Freddie Gray[1] spawned a wave of protests that coalesced into the grass-roots Black Lives Matter (BLM) movement.

BLM highlights not only the devastating impact of the criminal justice system on young black men and women but also the broader impact of racism on every aspect of black life and communities.[2] An insightful commentary in the August American Journal of Public Health (AJPH) discussed the pervasive influence of racism on health and ended with a call to the public health community to advocate for changes to address racism and health inequity.[3]

Highly unequal health outcomes: The central role of structural racism

In 2013, the Centers for Disease Control and Prevention released the Health Disparities & Inequalities Report, which found that blacks have the highest rates, among all racial groups, of heart disease, stroke, high blood pressure, colon cancer, obesity and infant mortality, in addition to twice the rate of diabetes as whites.[4] The findings extended beyond disease, with the report noting that homicide rates are far higher for blacks than any other ethnic group, a reflection of the endemic crime in poor inner- city communities.[5]

The authors of the AJPH article explained that such stark disparities in major health outcomes are a manifestation of structural racism. Structural racism has been defined as “the normalization and legitimization of an array of dynamics — historical, cultural, institutional and interpersonal — that routinely advantage whites while producing cumulative and chronic adverse outcomes for people of color.”[7] The definition expands beyond overt, interpersonal racism to describe the societal and institutional roots of the income, wealth, educational and health inequalities between whites and people of color.

So how, exactly, does racism lead to the poorer health outcomes for blacks mentioned above?

Racist criminal justice system

As evident in the origins of BLM, the most immediately apparent institutional hazard to black life is the racist criminal justice system. A 2015 study found that young black males are more than twice as likely as their white counterparts to die at the hands of police (although the study could not determine how many of these deaths represented wrongdoing on the part of police).[8]

In addition to the police brutality that has taken so many black lives, the dramatic growth in mass incarceration over the past four decades[9] has been accompanied by the imprisonment of nearly 1 million blacks, who make up over 40 percent of all inmates[10] despite representing just 15 percent of the U.S. population.[11] This increase is in part due to the decadeslong War on Drugs, which has sent blacks to prison for drug offenses at 10 times the rate of whites,[12] even though both groups report using illicit drugs at roughly similar levels.[13] A school-to-prison pipeline has imprisoned mostly black and Hispanic students for relatively minor offenses.[14]

Increasingly overcrowded prisons[15] present clear mental and physical hazards. A 2006 survey by the Bureau of Justice Statistics estimated that, although 45 to 64 percent of inmates had a mental health problem — with 15 to 24 percent reporting symptoms that met the criteria for a psychotic disorder — only 24 percent of federal and 34 percent of state prisoners had received mental health treatment since admission.[16] A lack of adequate care for medical emergencies, such as asthma attacks, has led to deaths while in custody.[17] The ever-present threat of prison rape can result in sexually transmitted diseases and both physical and psychological trauma.[18] Solitary confinement longer than 15 days — which the U.N. Special Rapporteur on Torture considers a form of torture that should be prohibited due to its potentially severe psychological consequences[19] — is disproportionately inflicted as punishment on black and Hispanic prisoners.[20]

Economic oppression

BLM makes clear that its focus extends “beyond extrajudicial killings of Black people by police and vigilantes” to the various other causes of the systematic oppression of blacks in this country.[21] In a similar vein, the authors of the AJPH article “recognize[d] that the adverse health effects of structural racism are not limited to the criminal justice system.”[22]

Poverty is endemic in the black and Hispanic communities, with 27 percent of blacks and 24 percent of Hispanics, compared with 10 percent of whites, falling below the federal poverty line in 2013.[23] In 2013, the median household wealth of whites was 13 times greater than that of blacks and 10 times greater than that of Hispanics.[24] In 2007, 28 to 46 percent of black households had zero or negative wealth compared to 15 to 23 percent for white households.[25] Blacks have the highest unemployment rate of any racial group,[26] with unemployment rates consistently around twice as high as those for whites for the past 60 years.[27] Blacks also generally have more precarious[28] and lower-wage[29] jobs than whites. The far lower rate of social mobility among blacks[30] ensures that these inequities are passed on to subsequent generations.[31]

In its review of racism and health, the AJPH article alluded to the well-documented evidence on the impact of poverty. In addition, two comprehensive reviews of previous studies strongly suggested that greater income inequality within a population adversely affected the population’s health and well-being.[32],[33] Researchers have proposed several explanations for how inequality may lead to worse health outcomes, including lack of access to resources necessary to maintain health, insufficiently protective health and welfare policies, a general lack of trust within society, and the chronic psychological and social stresses faced by those at the bottom of the income ladder.[34]

Access to and treatment in the health care system

Racism also affects health in more direct ways. In a country where health insurance is not a right but a commodity, higher rates of poverty mean that more blacks are uninsured (12 percent) than whites (7 percent), despite the Affordable Care Act.[35] A lack of health insurance has been found to be associated with a 40 percent increased risk of death.[36]

And even people of color with health insurance often encounter a discriminatory health care system, as shown by a 2003 Institute of Medicine (IOM) report.[37] Citing the IOM report’s findings, authors in a recent New England Journal of Medicine piece noted that for almost every disease studied — including heart disease, cancer, HIV infection, diabetes and kidney disease— “black Americans received less effective care than white Americans.”[38] This substandard treatment, in turn, fuels distrust,[39] avoidance of and noncompliance with[40] the system by black patients. Only around 5 percent of American physicians are black, compounding the problem. [41]

From research to advocacy

What can be done? Health professionals clearly have a responsibility to change the status quo. The authors of the AJPH article called on the public health field to integrate structural racism into public health training programs and research agendas, but it also urged “public health professionals to go beyond merely documenting health disparities and disseminating findings in scientific forums, and expand our professional responsibility to include community advocacy.”[42]

This advocacy must support political and social policies that increase health equity. Tens of thousands of physicians[43] and nurses[44] have called for a universal, single-payer health insurance system, which would go a long way toward ensuring equal access to health care for people of all income levels, races and ethnicities. The IOM report recommended a series of measures to eliminate the unequal treatment of black and other minority populations within the health care system, including increasing the number of black health professionals.[45]

Since the rise of BLM, more health professionals have spoken out about the health impacts of racism. Among others, New York City’s health commissioner[46] and academic physicians writing in the New England Journal of Medicine[47] have signaled the need to recognize and combat structural racism as a root cause of poor minority health outcomes. In San Francisco, a group of medical students founded the White Coats 4 Black Lives campaign in solidari ty with BLM, based on the observation that “the same prejudice and systemic bias that tarnishes our education, housing, employment, and criminal justice systems, also tarnishes medicine.”[48]

Given the pervasive societal and economic factors responsible for the health injustices faced by black communities, however, any long-term solutions must arise from broader movements to confront the political, economic and institutional power structures that perpetuate racism within U.S. society.


References

[1] Quah N, Davis LE. Here’s a timeline of unarmed black people killed by police over past year. BuzzFeed News. May 1, 2015. http://www.buzzfeed.com/nicholasquah/heres-a-timeline-of-unarmed-black-men-killed-by-police- over#.psZ5bVXMdo. Accessed October 12, 2015.

[2] Smith MD. A Q&A with Opal Tometi, co-founder of #BlackLivesMatter. The Nation. June 2, 2015. http://www.thenation.com/article/qa-opal-tometi-co-founder-blacklivesmatter/. Accessed September 28, 2015.

[3] Jee-Lyn García J, Sharif MZ. Black Lives Matter: A commentary on racism and public health. Am J Public Health. 2015;105(8):e27-e30.

[4] Centers for Disease Control and Prevention. Black or African American populations. . Accessed September 24, 2015.

[5] Thompson HA. Inner-city violence in the age of mass incarceration. The Atlantic. October 30, 2014. http://www.theatlantic.com/national/archive/2014/10/inner-city-violence-in-the-age-of-mass-incarceration/382154/. Accessed September 28, 2015.

[6] Jee-Lyn García J, Sharif MZ. Black Lives Matter: A commentary on racism and public health. Am J Public Health. 2015;105(8):e27-e30.

[7] Lawrence K, Keleher T. Structural Racism. Race and Public Policy Conference. 2004. https://www.citizen.org/sites/default/files/definitions_of_racism_0.pdf. Accessed September 24, 2015.

[8] Krieger N, Kiang MV, Chen JT, Waterman PD. Trends in US deaths due to legal intervention among black and white men, age 15-34 years, by county income level: 1960-2010. Harvard Public Health Review. Volume 3, January 2015. http://harvardpublichealthreview.org/wp-content/uploads/2015/01/HPHRv3-Krieger-Trends-in-Deaths.pdf. Accessed October 7, 2015.

[9] National Academies Press. The Growth of Incarceration in the United States: Exploring Causes and Consequences (2014). http://www.nap.edu/read/18613/chapter/2. Accessed September 28, 2015.

[10] NAACP. Criminal Justice Fact Sheet. http://www.naacp.org/pages/criminal-justice-fact-sheet. Accessed September 28, 2015.

[11] Centers for Disease Control and Prevention. Black or African American Populations. http://www.cdc.gov/minorityhealth/populations/REMP/black.html. Accessed September 28, 2015.

[12] NAACP. Criminal Justice Fact Sheet. http://www.naacp.org/pages/criminal-justice-fact-sheet. Accessed September 28, 2015.

[13] Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. September 2014. http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf. Accessed September 28, 2015.

[14] Deeney J. How to discipline students without turning school into a prison. The Atlantic. January 9, 2014. http://www.theatlantic.com/education/archive/2014/01/how-to-discipline-students-without-turning-school-into-a-prison/282944/. Accessed September 28, 2015.

[15] Government Accountability Office. Growing Inmate Crowding Negatively Affects Inmates, Staff, and Infrastructure. September 2012. http://www.gao.gov/assets/650/648123.pdf. Accessed September 28, 2015.

[16] Bureau of Justice Statistics. Mental Health Problems of Prison and Jail Inmates. September 2006. http://www.bjs.gov/index.cfm’ty=pbdetail&iid=789. Accessed September 28, 2015.

[17] Alliance for a Just Society. Inadequate Healthcare in Prisons: A Death Penalty Conviction for Profit (3-Part Examination). August 8, 2013. http://allianceforajustsociety.org/2013/08/inadequate-healthcare-in-prisons-a-death-penalty-conviction-for-profit-3-part-examination/. Accessed October 7, 2015.

[18] Stoker Bruenig E. Why Americans don’t care about prison rape. The Nation. March 2, 2015. http://www.thenation.com/article/why-americans-dont-care-about-prison-rape/. Accessed October 6, 2015.

[19] United Nations News Centre. Solitary confinement should be banned in most cases, UN expert says. October 18, 2011. http://www.un.org/apps/news/story.asp?NewsID=40097#.VgmayvlVhBc. Accessed September 28, 2015.

[20] Eichelberger E. How racist is solitary confinement? The Intercept. July 16, 2015. https://theintercept.com/2015/07/16/rikers-study-black-inmates-250-percent-likely-enter-solitary/. Accessed September 28, 2015.

[21] Black Lives Matter. About the #BlackLivesMatter Network. http://blacklivesmatter.com/about/. Accessed October 6, 2015.

[22] Jee-Lyn García J, Sharif MZ. Black Lives Matter: A commentary on racism and public health. Am J Public Health. 2015;105(8):e27-e30.

[23] Kaiser Family Foundation. Poverty Rate by Race/Ethnicity. http://kff.org/other/state-indicator/poverty-rate-by-raceethnicity/. Accessed September 28, 2015.

[24] This represented a widening of the gap since 2007, when median white household wealth was 10 times and 8 times greater than black and Hispanic figures, respectively. Kocchar R, Fry R. Wealth inequality has widened along racial, ethnic lines since end of Great Recession. Pew Research Center. December 12, 2014. http://www.pewresearch.org/fact-tank/2014/12/12/racial-wealth-gaps-great-recession/. Accessed September 26, 2015.

[25] Insight Center for Community Economic Development. Lifting as we Climb: Women of Color, Wealth, and America’s Future. Spring 2010. https://www.citizen.org/sites/default/files/198_women_of_color_wealth_future_spring_2010.pdf. Accessed September 26, 2015.

[26] Bureau of Labor Statistics. Employment status of the civilian population by race, sex, and age. August 2013. http://www.bls.gov/news.release/empsit.t02.htm. Accessed September 26, 2015.

[27] Desilver D. Black unemployment rate is consistently twice that of whites. Pew Research Center. August 21, 2013. http://www.pewresearch.org/fact-tank/2013/08/21/through-good-times-and-bad-black-unemployment-is-consistently-double-that-of-whites/. Accessed October 6, 2015.

[28] Wilson V. The crisis of black unemployment: Still higher than pre-recession levels. American Prospect. April 2, 2015. http://prospect.org/article/crisis-black-unemployment-still-higher-pre-recession-levels. Accessed September 26, 2015.

[29] Quane JM. The urban jobs crisis. Harvard Magazine. May-June 2013. http://harvardmagazine.com/2013/05/the-urban-jobs-crisis. Accessed September 28, 2015.

[30] White GB. How black middle-class kids become poor adults. The Atlantic. January 19, 2015. http://www.theatlantic.com/business/archive/2015/01/how-black-middle-class-kids-become-black-lower-class-adults/384613/. Accessed September 28, 2015.

[31] Cook L. U.S. education: Still separate and unequal. U.S. News and World Report. January 28, 2015. http://www.usnews.com/news/blogs/data-mine/2015/01/28/us-education-still-separate-and-unequal; Dewan S. Discrimination in housing against nonwhites persists quietly, U.S. study finds. New York Times. June 11, 2013. http://www.nytimes.com/2013/06/12/business/economy/discrimination-in-housing-against-nonwhites-persists-quietly-us-study-finds.html; and Dunn C. Black graduates from top colleges face discrimination in job search, salaries, study finds. International Business Times. March 15, 2015. http://www.ibtimes.com/black-graduates-top-colleges-face-discrimination-job-search-salaries-study-finds-1847590. All accessed October 21, 2015.

[32] Wilkinson RG, Pickett KE. Income inequality and population health: A review and explanation of the evidence. Soc Sci Med. 2006;62(7):1768-1784.

[33] Pickett KE, Wilkinson RG. Income inequality and health: A causal review. Soc Sci Med. 2015;128:316-326.

[34] Ibid.

[35] Marken S. U.S. Uninsured Rate at 11.4% in Second Quarter. Gallup. July 10, 2015. http://www.gallup.com/poll/184064/uninsured-rate-second-quarter.aspx. Accessed September 27, 2015.

[36] Wilper AP, Woolhandler S, Lasser KE, et al. Health insurance and mortality in US adults. Am J Public Health. 2009;99(12):2289-2295.

[37] Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2003. http://www.nap.edu/catalog/10260/unequal-treatment-confronting-racial-and-ethnic-disparities-in-health-care. Accessed October 6, 2015.

[38] Ansell DA, McDonald EK. Bias, black lives, and academic medicine. N Engl J Med. 2015;372(12):1087-9.

[39] Armstrong K, McMurphy S, Dean LT, et al. Differences in the patterns of health care system distrust between blacks and whites. J Gen Intern Med. 2008;23(6):827-833.

[40] Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2003. http://www.nap.edu/catalog/10260/unequal-treatment-confronting-racial-and-ethnic-disparities-in-health-care. Accessed October 6, 2015.

[41] Tweedy D. The case for black doctors. New York Times. May 15, 2015. http://www.nytimes.com/2015/05/17/opinion/sunday/the-case-for-black-doct…. Accessed September 28, 2015.

[42] Jee-Lyn García J, Sharif MZ. Black Lives Matter: A commentary on racism and public health. Am J Public Health. 2015;105(8):e27-e30.

[43] Physicians for a National Health Program. About PNHP. http://www.pnhp.org/about/about-pnhp. Accessed October 6, 2015.

[44] National Nurses United. About NNU. http://www.nationalnursesunited.org/pages/about. Accessed October 6, 2015.

[45] Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2003. http://www.nap.edu/catalog/10260/unequal-treatment-confronting-racial-and-ethnic-disparities-in-health-care. Accessed October 6, 2015.

[46] Firger J. Dr. Mary Bassett: Why #BlackLivesMatter to public health. CBS News. February 23, 2015. http://www.cbsnews.com/news/dr-mary-bassett-why-black-lives-matter-to-public-health/. Accessed September 28, 2015.

[47] Ansell DA, McDonald EK. Bias, black lives, and academic medicine. N Engl J Med. 2015;372(12):1087-1089.

[48] WhiteCoats4BlackLives. Origins. http://www.whitecoats4blacklives.org/origins. Accessed September 28, 2015.