The Health Consequences of Structural Racism: Implications for Anti-Racism Policy and Practices in Social Institutions

The main objective of this dissertation was to investigate the health consequences of structural racism operating implicitly as racist law enforcement practices and agency policies, and as explicit forms of racial discrimination that have become systematic, or normalized, for US Blacks. Public health interventions targeting proximal risk factors such as behaviors have effectively reduced overall morbidity, mortality, and high-risk behaviors yet Black-White differences in health persist even after adjusting for sociodemographic and health system factors, as well as health behaviors. Structural racism—ongoing interactions between macrosystems and institutions to constrain the opportunities, resources, and power of marginalized racial groups—likely functions to prevent the elimination of Black-White gaps in health by unfairly burdening Blacks with high-risk exposures. Epidemiologic studies examining structural racism have largely demonstrated Black-White health disparities associated with ecological exposures (e.g. educational attainment) and community or interpersonal predictors (e.g. segregation, racial bias and discrimination). Few studies have examined the health effects of underlying racist policies and practices. Evidence suggests that along with explicit racial discrimination, implicit racism operating within the criminal system is among the strongest drivers of racial inequalities by shaping exposures to health-promoting opportunities and burden-bearing liabilities over the life course and across generations, such as the disproportional police arrests and killings of Blacks. The negative health effects of pervasive racial discrimination are theorized to be cumulative over the life course potentially resulting in allostatic load—multisystem physiologic dysregulation due to chronic adaptation to stress. Allostatic load is highest among Black women though they may not be aware of being at an elevated risk (e.g. having high cholesterol). Consequently, three potential mechanisms that link structural racism to racial health disparities include (1) racial bias against Blacks in officer use of deadly force, (2) underlying racist law enforcement agency policies and practices, and (3) everyday and institutional-specific racial discrimination. Data are from The Guardian, The Washington Post, the Law Enforcement Management and Administrative Statistics (LEMAS), and the African American Women’s Heart & Health Study. This research was the first to estimate (1) interaction effects between race/ethnicity and being unarmed among men shot and killed by US law enforcement, (2) US law enforcement policies that contribute to Black-White disparities in police killings using The Guardian and LEMAS databases, and (3) the association between everyday versus institutional racial discrimination, allostatic load, and self-reported health among at-risk Black women. Study findings present novel approaches to examining mechanisms by which structural racism impacts health disparities and may help reduce several leading causes of US Black-White disparities in death and disease