Bower and LaFave, 2020 JHSON

1. Structural Racism: a “Cause of Causes”
Kelly Bower, PhD, MSN, MPH, RN
Sarah LaFave, PhDc, MPH, RN
August 7, 2020

2. 2
Why this lecture?

3. 3
Objectives
► Describe how structural racism has persisted in policies and
structures throughout United States history
• Define the levels of racism
• Define white privilege
• Highlight specific examples of the relationship between racist
policies/practices and health outcomes

4. 4
Race is a social construct
- Author Unknown

5. 5
Racism Defined
Interpersonal

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Racism Defined
Interpersonal
Internalized
Institutional
Adapted from Gee, G. C., Ro, A., Shariff-Marco, S., & Chae, D. (2009). Racial discrimination and health among Asian Americans: evidence, assessment, and directions for
future research. Epidemiologic reviews, 31, 130–151. doi:10.1093/epirev/mxp009

7. 7
Defining Structural Racism
Interpersonal
Internalized
Institutional
Adapted from Gee, G. C., Ro, A., Shariff-Marco, S., & Chae, D. (2009). Racial discrimination and health among Asian Americans: evidence, assessment, and directions for
future research. Epidemiologic reviews, 31, 130–151. doi:10.1093/epirev/mxp009
Structural
Structural
Structural
Structural
Structural

8. 8
Defining Structural Racism
► Racial discrimination is perpetuated systematically, rather
than depending on one individual or institution
► Inequities between groups in income, health, employment,
education, incarceration, and housing are perpetuated by
intentionally or unintentionally discriminatory policies and
practices that compound one another
Bailey, Z., Krieger, N., Agenor, M., Graves, J., Linos, N. & Bassett, M.T. (2017). Structural racism and health inequities in the USA: Evidence and interventions. The Lancet, 389, 1453-1453. doi:
https://doi.org/10.1016/S0140-6736(17)30569-X

9. 9
Defining White Privilege
► The unquestioned and unearned set of advantages, entitlements, benefits
and choices bestowed on people solely because they are white. Generally
white people who experience such privilege do so without being conscious
of it.
► Institutional White Privilege: Policies, practices and behaviors of
institutions -- such as schools, banks, non-profits or the Supreme Court --
that have the effect of maintaining or increasing accumulated advantages
for those groups currently defined as white, and maintaining or increasing
disadvantages for those racial or ethnic groups not defined as white.
Peggy McIntosh. 1988. White Privilege and Male Privilege: A Personal Account of Coming to See Correspondences Through Work in Women’s Studies.
Transforming White Privilege: A 21st Century Leadership Capacity, CAPD, MP Associates, World Trust Educational Services, 2012.

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Structural Racism & United States History
► 1865 – slavery outlawed in the United States
► 1870 – racially integrated schools are outlawed
► 1887 – 90 million acres of land stolen from American Indians
► 1890-1908 – overtly racist voting laws passed in several states
► 1923 – Supreme Court rules that Indian immigrants cannot become US citizens because they are not “White”
► 1935 – domestic and agricultural workers excluded from Social Security Act
► 1942-1945 – 110,000 Japanese Americans forcibly removed from homes/jobs and imprisoned in internment camps
► 1944 – black veterans excluded from many of the educational and housing benefits of the GI bill
► 1955 - Maryland legislature passes a law that imprisoned any white woman who birthed a mixed-race child
► 1959 - An Arkansas law required all state buses to designate whites-only seating areas
► 1986 – Reagan mandates minimum drug sentences – higher for crack than powder cocaine
► 2010 – Arizona SB 1070 requires police to check immigration status of people suspected of being undocumented (based on
how they look/are dressed)
► 2019 – analysis of millions of records shows that Black and Latinx applicants are more often denied loans or charged higher
interest rates than white loan applicants, controlling for other factors

11. 11
Ecosocial Theory of Racism
Key Points
► Lifecourse accumulation
► Racism is not inevitable
► We embody our environments & social
context
► Pathways between structural racism and
health
• Differential exposure to resources, opportunities,
stressors, and toxins.
• Differential treatment.
• Stress response.
Krieger, N. (2012). Methods for the scientific study of discrimination and health: An ecosocial approach. American Journal of Public Health, 102(5), 936-945.

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Pathways Between Structural Racism & Health
►Differential exposure to resources, opportunities, stressors,
and toxins: greenspace as an example
Grove, Morgan; Ogden, Laura; Pickett, Steward; Boone, Chris; Buckley, Geoff; Locke, Dexter H.; Lord, Charlie; Hall, Billy. 2018. The Legacy Effect: Understanding How Segregation and Environmental
Injustice Unfold over Time in Baltimore. Annals of the American Association of Geographers. 108(2): 524-537. https://doi.org/10.1080/24694452.2017.1365585.

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Pathways Between Structural Racism & Health
►Differential exposure to resources, opportunities, stressors,
and toxins: length and quality of school as an example
• African Americans more likely to develop Alzheimer’s & dementia than
non-Hispanic White Americans
• Disparity in cognitive decline narrows when comparing people who
had access to the same quality of education
Manly, J.J., Jacobs, D.M., Touradji, P., Small, S.A. & Stern, Y. (2002). Reading level attenuates differences in neuropsychological test performance between African
American and White elders. Journal of the International Neuropsychological Society, 8, 341-348. doi: 10.1017.S135561770102015X

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Pathways Between Structural Racism & Health
► Differential treatment: healthcare system as an example
• Controlling for other demographic and risk factors:
– Paramedics more likely to transfer black and Hispanic patients to safety-net
hospitals compared to white patients in the same zip code
– Black nursing home residents more likely to develop pressure ulcers than
white residents
Hanchate AD, Paasche-Orlow MK, Baker WE, Lin M, Banerjee S, Feldman J. Association of Race/Ethnicity With Emergency Department Destination of
Emergency Medical Services Transport. JAMA Netw Open. 2019;2(9):e1910816. doi:10.1001/jamanetworkopen.2019.10816
Li, Y., Yin, J., Cai, X., Temkin-Greener, J., & Mukamel, D. B. (2011). Association of race and sites of care with pressure ulcers in high-risk nursing home
residents. JAMA, 306(2), 179–186. https://doi.org/10.1001/jama.2011.942

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Pathways Between Structural Racism & Health
► Racism and discrimination contribute
to stress and inflammation
Harrell, C. J., Burford, T. I., Cage, B. N., Nelson, T. M., Shearon, S., Thompson, A., & Green, S. (2011). Multiple Pathways Linking Racism to Health
Outcomes. Du Bois review: social science research on race, 8(1), 143-157. doi: 10.1017/S1742058X11000178
Goosby, B.J., Cheadle, J.E. & Mitchell, C. (2018). Stress-related biosocial mechanisms of discrimination and African American health inequities. Annual Review
of Sociology, 44, 319-340. doi: https://doi.org/10.1146/annurev-soc-060116-053403

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Nursing Implications
►Addressing the nursing mandate to “treat” the root causes of
disease and inequality in research, policy, and practice