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Population Health for Nurses

6.3 Contemporary Structural Racism and Systemic Inequities in the United States

Population Health for Nurses6.3 Contemporary Structural Racism and Systemic Inequities in the United States

Learning Outcomes

By the end of this section, you should be able to:

  • 6.3.1 Describe the relationship between structural racism and systemic inequities.
  • 6.3.2 Discuss contemporary manifestations of structural racism.
  • 6.3.3 Examine current persistent systemic inequities.
  • 6.3.4 Explain how structural racism intersects with the social determinants of health.

To illustrate the concept of structural racism, Gee and colleagues (2009) utilize the analogy of an iceberg. The visible part of the iceberg above the water represents overt racism, which is easily recognizable. The larger, mostly hidden base of the iceberg represents structural racism, the often invisible social systems and structures that result in harm of and discrimination against BIPOC individuals (Gee et al., 2009). Structural racism may pose barriers to opportunities that would otherwise promote health and well-being, such as access to high-paying jobs with benefits, safe neighborhoods, quality schools, quality health care, and equitable treatment in the criminal justice system (Braveman et al., 2022). Just as the unseen base of an iceberg is more dangerous to a ship than its tip, structural racism can be more dangerous than overt racism, as it positions BIPOC individuals at a significant disadvantage across several domains of living, impacting health in ways that are not as easily discernable (Braveman et al., 2022). Political disempowerment, residential segregation, unequal financial practices, unfair treatment in the criminal justice system, and environmental health injustice are all examples of current structural racism and persistent systemic inequities.

The Relationship Between Structural Racism and Systemic Inequities

As discussed, structural racism results in institutional policies, systems, laws, and practices that limit the opportunities, resources, and power of individuals based on race (Braveman et al., 2022), resulting in systemic inequities. Inequities create inequalities in health care, education, housing, and employment opportunities. Structural racism and systemic inequities are partners, existing together and creating unequal systems across all of society. Put simply, structural racism creates unequal opportunities to achieve positive outcomes.

Structural racism results in systemic inequities even when controlling for income level. College-educated Black individuals are more likely to experience unemployment and have lower levels of income and accumulated wealth than their White counterparts (Churchwell et al., 2020).

The Race Gap: Black White

The Reuters Graphics slideshow “The Race Gap: Black White” explores the gap between Black and White Americans from birth to death, highlighting the systemic disadvantages still present in American life more than 150 years after the abolishment of slavery.

View the slideshow, and then respond to the following questions.

  1. The slideshow mentions that disparities persist despite policies and laws intended to address them. Why do you think these policies and laws have failed to eliminate these disparities?
  2. In what ways did structural racism create these disparities?
  3. How do redlining policies have lasting effects on many of the disparities mentioned in this slideshow, including food insecurity, quality of education, and access to health care?

Political Disempowerment

Since the passage of the 15th Amendment in 1870 secured the right to vote for all men—including non-White men—groups of White Americans have engaged in voter suppression efforts to politically disenfranchise people of color. During the Jim Crow era, voter suppression was prevalent in many states, with White supremacist groups engaging in violent intimidation and governments selectively applying restrictions and laws such as a poll tax and literacy tests. As recently as 2023, many states were considering restrictive voting legislation, such as requiring voter identification, eliminating Sunday voting, limiting mail-in voting, and consolidating polling places. A voting bill or law is considered restrictive when it includes one or more stipulations that make it more difficult for eligible citizens to register to vote, stay on the voter rolls, or cast a vote as compared to existing state law (Brennan Center for Justice [BCJ], 2022). Requiring photo identification, decreasing available times to vote, and creating longer wait times to vote due to consolidated locations disproportionately affect low-income and BIPOC voters due to inflexibility of work schedules, transportation difficulties, and difficulty in obtaining photo identification (Braveman et al., 2022; BCJ, 2022).

Residential Segregation

Residential racial segregation in the United States remains high despite the Fair Housing Act of 1968, which outlawed racial discrimination in housing. Almost three-quarters of the neighborhoods that HOLC graded as hazardous in the 1930s are now considered neighborhoods of color with low-to-moderate income (Mitchell & Franco, 2018). These federal policies kept BIPOC communities living in low-income areas, ensuring systemic inequities in health care access, educational opportunities, employment opportunities, transportation, and health outcomes. For example, the Boston neighborhoods redlined in 1938 still rely on limited bus service, while better-funded commuter rail and subway systems serve other portions of the city (Hostetter & Klein, 2018).

Racial segregation is directly associated with an economic disadvantage, as many individuals gain wealth through equity in their homes. The new homes built in suburban areas during the time of the white flight sold for twice the national median income in the 1940s and 1950s; those same homes sell for almost eight times the national median income today, illustrating how home ownership can create wealth (Gross, 2017). Denying Black Americans the opportunity to own a home denied them this wealth-creation opportunity, contributing to economic and social inequities. Racial segregation is also associated with limited opportunities for upward mobility due to lack of employment options and poor-quality schools. BIPOC individuals are more likely than their White counterparts with similar incomes to live in areas with concentrated disadvantage (Braveman et al., 2022). Today, once-redlined neighborhoods are more likely to have a majority BIPOC population with lower incomes and overall lower home values (Perry & Harshbarger, 2019).

The Racial Disparities of Mortgage Lending

In this Good Morning America video, reporter David Scott shares his investigation highlighting racial disparities in mortgage lending in the United States.

Watch the video, and then respond to the following questions.

  1. Why do you think there are still widespread racial disparities in mortgage lending?
  2. Why do you feel the Fair Housing Act hasn’t been more effective in reducing disparities in home ownership?
  3. Do you see a path forward to changing these behaviors? If so, describe what you see; if not, explain why.

Financial Practices

Current financial practices continue to perpetuate structural racism, with echoes of the HOLC redlining scheme. Federal loan programs from the mid-1900s through today have greatly increased homeownership among White Americans, while BIPOC neighborhoods have largely experienced disinvestment. While redlined maps are no longer in use, their legacy continues as home values in racially segregated neighborhoods do not appreciate at the same rate as homes in mostly White neighborhoods (Braveman et al., 2022; Lynch et al., 2021; Yearby et al., 2022). Differences in homeownership, home values, and credit scores by race persist in areas that were formerly redlined. Current examples of discriminatory public and private financial practices include check cashing services and payday lenders. Businesses that offer check cashing services afford their clients the ability to get cash immediately from their checks for a fee. While individuals with bank accounts are able to deposit checks into their account and withdraw the money without any fees after the check clears, often in 2–3 days, individuals who use check cashing services must pay a fee–perhaps 2 percent of a check’s face value, or $2 for every $100 cashed (Davies, 2017). Payday lenders offer short-term payday loans with high interest rates that are due the next pay day. These types of loans are often considered predatory as they are expensive, can damage credit scores if they are not paid back in full, and can lead to debt collection issues (National Association of Consumer Advocates, n.d.). Such services have a history of disproportionately targeting BIPOC communities, further contributing to the inability of the people in these communities to accumulate wealth (Braveman et al., 2022; Lynch et al., 2021).

The Surprising Logic Behind the Use of Check Cashers and Payday Loans

This PBS News Hour video investigates the business of check cashers and payday lenders. Check cashers are often considered predatory, as they charge a fee to cash paychecks, but for many Americans who are living in poverty without any savings, check cashers are often the only way to get cash the same day. This video discusses arguments for and against these services.

Watch the video, and then respond to the following questions.

  1. Do you think check cashing and payday lending practices are predatory? Why or why not?
  2. Are check cashing services helpful or harmful? What about payday loans?
  3. Is expensive credit better than no credit? Why or why not?
  4. What solutions to larger issues could help alleviate the need for check cashing and payday lending services? How would this relate to the social determinants of health?

The Social Security Act (SSA) of 1935 created a system of employment-based insurance and income compensation to care for adults in retirement age (Bailey et al., 2017). To secure congressional votes in the South, the SSA deliberately excluded agricultural workers and domestic servants as these occupations were largely filled with Black men and women (Bailey et al., 2017). Because it excluded Black individuals, the SSA afforded the primarily White recipients more opportunity to acquire wealth and transfer it to future generations, whereas those without the benefit of the SSA often become dependent on adult children after retirement, further relegating BIPOC communities and families to lower wealth accumulation (Bailey et al., 2017).

Public schools in the United States depend on local property taxes as a large part of their budgets. In racially segregated areas, the lower-income neighborhoods, largely composed of BIPOC individuals and low-income White individuals, have lower property tax revenues that result in resource-poor public schools. Property taxes are lower in these neighborhoods due to redlining. While low-income White individuals are affected by this issue, it disproportionately affects BIPOC individuals because structural racism has resulted in higher levels of household and community poverty (Braveman et al., 2022).

Criminal Justice System

Structural racism in the U.S. criminal justice system manifests in racial patterns of incarceration. The disproportionate burden of incarceration on BIPOC individuals reflects pervasive prejudicial policing and biased sentencing practices (Braveman et al., 2022). Incarceration carries a negative stigma that perpetuates a cycle of disadvantage, with fewer employment and economic opportunities affecting incarcerated persons’ families and communities. As discussed, police violence continues to be among the leading causes of death in Black men. Evidence comparing Black victims and White victims killed by police suggests inequitable treatment between the two races with a fatality rate three times higher among Black victims than White victims and Black victims more likely to be unarmed than their White counterparts (Braveman et al., 2022; DeGue et al., 2016; Laurencin & Walker, 2020). Systemic racism includes laws and policies but also the norms that guide routine practices. In the case of police, implicit biases play a role in the assumption that Black men are dangerous, creating distrust and disparities in police use of force between Black and White individuals (Braveman et al., 2022; Hinton et al., 2018; DeGue et al., 2016). At the intersection of the police and educational systems, the practice of schools involving law enforcement more often for misbehaving Black students than for misbehaving White students, increasing the risk that Black students will be incarcerated, reflects systemic racism. Additionally, school systems discipline Black students with more suspensions and expulsions than they do other students. These practices are based not on law but on prevalent, deeply rooted discriminatory attitudes (Braveman et al., 2022).

Lavette’s Choice

This ACLU video highlights the story of Lavette Mayes, a single mother arrested after a fight, who serves 14 months in jail because she is unable to afford her pretrial bail of $25,000. The video explores how the cash bail system has transformed into a for-profit system where higher-income individuals can avoid serving pretrial jail time while lower-income individuals are unable to afford to stay out of pretrial jail.

Watch the video, and then respond to the following questions.

  1. How do police profiling, poverty, and incarceration intersect with the social determinants of health?
  2. Do you feel pretrial detention is an equitable practice? Why or why not?

Environmental Health Injustice

Like many other facets of systemic racism in the United States, environmental injustices and disparities affecting BIPOC communities often stem from federally sponsored, racially motivated residential segregation. When HOLC and FHA redlined and labeled neighborhoods as hazardous, business disinvestment occurred, followed by a lack of insurable mortgages in these neighborhoods. Such changes made the way for industry to move in with coal-fired power plants, bus garages, and hazardous waste disposal plants, mostly in low-income BIPOC communities (Bailey et al., 2017; Braveman et al., 2022). In addition, most redlined neighborhoods were in urban areas where widespread community disinvestment resulted in less green space and tree canopies and increased urban heat exposure. The Flint, Michigan, water crisis is an example of both systemic racism and environmental injustice affecting a town that is largely composed of BIPOC individuals, reflecting the history of segregation. In April 2014, the city of Flint switched to an untreated water source that ultimately corroded the water pipes, resulting in high levels of lead leaching into the city’s drinking water. Despite months of complaints, it was well over a year before the city took any action. The city changed the Flint water supply, but this was ineffectual since the pipes were already corroded; they continue to leach contaminants into the residents’ water (Ruckart et al., 2019). See Social Determinants Affecting Health Outcomes for more information. The Flint water crisis demonstrates the disinvestment in infrastructure and officials’ lack of attention to the concerns of BIPOC individuals, resulting in negative long-term health impacts (Braveman et al., 2022).

Highways and associated traffic pollutants running through neighborhoods and the introduction of hazardous waste disposal plants and coal-fired power plants have resulted in significant environmental injustices in majority-BIPOC communities. These exposures are linked to adverse health outcomes such as asthma, adverse birth outcomes, and cancer (Swope et al., 2022). The legacy of redlining and the 1956 Federal-Aid Highway Act continue to shape the environmental exposures of BIPOC communities (Kowalski, 2019; Lane et al., 2022). The pollutant gradients within urban areas for nitrogen dioxide and particulate matter, both markers of air pollution, are significantly higher in former redlined neighborhoods than they are in other neighborhoods (Bose et al., 2022; Lane et al., 2022).

The Roots of Health Inequities


The history of redlining and its resultant domino effect of social disinvestment resulted in higher levels of air pollution in BIPOC and low-income communities and higher rates of asthma in individuals living in those communities. The racial and ethnic disparities in asthma are a result of a complex interplay of factors including structural racism, residential segregation, discriminatory policies, and the SDOH, along with lifestyle and biological determinants. Black, Hispanic, and Indigenous people disproportionately bear the burden of asthma in the United States with the highest rates and numbers of deaths and hospitalizations. Black Americans are:

  • one and one-half times more likely to have asthma,
  • five times more likely to visit an emergency department due to asthma, and
  • three times more likely to die from asthma.

(See Asthma and Allergy Foundation of America, 2020; Bose et al., 2022; Lane et al., 2022; Perez & Coutinho, 2021.)

The Congress for the New Urbanism (CNU) is a strong advocate for replacing aging highways that run through neighborhoods with city boulevards, housing, and green spaces, transforming the urban highway corridors of the past (CNU, n.d.-b). Examples of the kinds of completed projects for which Highways to Boulevards advocates include the Big Dig in Boston, Massachusetts; the Mandela Parkway in Oakland, California; and the Riverfront Parkway in Chattanooga, Tennessee (CNU, n.d.-b). For a complete listing of completed Highway to Boulevard projects, visit this website.

How Racism Shaped the Interstate

In this NPR Morning Edition news episode, “A Brief History of How Racism Shaped Interstate Highways,” reporter Noel King speaks with Professor Deborah Archer about the history of racism and redlining in creating the interstate highways.

Listen to the episode, and then respond to the following questions.

  1. Do you think these highway projects were purposefully designed to keep residential populations segregated? Why or why not?
  2. How would you describe the relationship between these highway projects, racism, and environmental health?

Intersection of Structural Racism and the Social Determinants of Health

The social determinants of health (SDOH) are the nonmedical factors that impact health outcomes (CDC, 2022b). Social Determinants Affecting Health Outcomes discusses the SDOH in detail. Examples of SDOH include access to safe housing, exposure to discrimination or violence, income level, and language and literacy skills (ODPHP, 2020d). Healthy People 2030 names structural racism as one of the SDOH given its pervasive and often invisible reach into all social practices (Bailey et al., 2017; ODPHP, 2020b). The historical roots of structural racism tie directly into the SDOH, as this racism has consigned BIPOC communities to an inferior or second-class status (Braveman et al., 2022). Put more succinctly, structural racism is further upstream than the SDOH (Churchwell et al., 2020; Lynch et al., 2021). The following are key examples of the ways in which structural racism intersects with the SDOH.

  • Safe housing: Structural racism negatively affects income level due to the far-reaching and lasting implications of historical residential segregation. HOLC and FHA redlining are examples of structural racism that limited opportunities for BIPOC families to purchase homes and to benefit from intergenerational wealth transfer, contributing to the lower-than-average income and wealth of BIPOC families. Black Americans have approximately one-tenth of the wealth of White Americans, have fewer assets, and are less likely to own their homes, own a business, or have a retirement account (Hanks et al., 2018). Because of structural racism, residential segregation in America continues, with more BIPOC families living in lower-income neighborhoods (Lynch et al., 2021; Ray et al., 2021; Zonta, 2019). For all of these reasons, structural racism presents a barrier to safe housing for BIPOC families.
  • Exposure to discrimination or violence: Structural racism exposes people to discrimination or violence in the form of biased policing practices, biased sentencing policies, and the mass incarceration of BIPOC individuals. This exposure results in a myriad of adverse outcomes for those affected (Bailey et al., 2021; Braveman et al., 2022), touching upon the SDOH in discrimination, violence, lower income, and barriers to safe housing.
  • Language and literacy: Structural racism negatively affects language and literacy skills due to the lack of access to quality schools in predominantly BIPOC neighborhoods and due to the biased treatment of BIPOC students within the educational system (Quick & Kahlenberg, 2019; Williams et al., 2019).

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