Structural Racism in

Healthcare
Jeffrey M. Samuel, PharmD, MPHc
Purdue University
Health Equity Fellow
Objectives
1. Define race, racism and structural racism
2. Describe historical examples of structural racism in health
3. Differentiate the three levels of racism and how they affect health
4. Identify three strategies to combat structural racism
Outline
1. Introduction
2. Definition of terms
3. A History of Racism
4. Impact on Healthcare
5. Three Levels of racism
 Why are we talking
about this?

SAVI. (2015, July 15). Worlds apart: Gaps in Life Expectancy in the Indianapolis Metro Area. from
https://www.savi.org/wp-content/uploads/2020/09/Worlds_Apart_Gaps_in_Life_Expectancy.pdf.
 Why are we talking
about this?

A – “Best” areas
B – “Desirable” areas
C – “Declining” areas
SAVI. (2021). The Polis Center at IUPUI, from https://www.savi.org/2021/06/24/lasting-
impacts-of-segregation/ D – “Hazardous” areas
 Why are we talking
about this?

A – “Best” areas
B – “Desirable” areas
C – “Declining” areas
D – “Hazardous” areas

SAVI. (2021). The Polis Center at IUPUI, from https://www.savi.org/2021/06/24/lasting-impacts-of-segregation/

SAVI. (2015, July 15). Worlds apart: Gaps in Life Expectancy in the Indianapolis Metro Area. from https://www.savi.org/wp-content/uploads/2020/09/Worlds_Apart_Gaps_in_Life_Expectancy.pdf.
 Dual reality: A restaurant saga

Jones, C. P. National Campaign Against Racism. 2019-2020 Evelyn Green Davis Fellow Radcliffe Institute for Advanced Study Harvard University. American Public Health Association.
 Dual reality: A restaurant saga

Jones, C. P. National Campaign Against Racism. 2019-2020 Evelyn Green Davis Fellow Radcliffe Institute for Advanced Study Harvard University. American Public Health Association.
 Dual reality: A restaurant saga

Racism structures “Open/Closed”

signs in our society

Jones, C. P. National Campaign Against Racism. 2019-2020 Evelyn Green Davis Fellow Radcliffe Institute for Advanced Study Harvard University. American Public Health Association.
 Dual reality: A restaurant saga

Jones, C. P. National Campaign Against Racism. 2019-2020 Evelyn Green Davis Fellow Radcliffe Institute for Advanced Study Harvard University. American Public Health Association.
 What is Race?
The classification of humans into groups based on
physical traits, ancestry, and social relations, or the
relationships between them
● The idea of "race" originated in the 18th century Photo credit: Photo: Amy Swan, Washington Monthly
● Used geographical location and phenotypic traits (skin color)
to place people into different racial groupings
● Formed the notion of separate racial "types"
● Fueled the idea that these differences had a biological basis.

Jones, C. P. National Campaign Against Racism. 2019-2020 Evelyn Green Davis Fellow Radcliffe Institute for Advanced Study Harvard University. American Public Health Association.
Bryce, E. (2020, February 8). What's the difference between race and ethnicity? LiveScience. Retrieved October 24, 2021
 What is Racism?
A system
of structuring opportunity and assigning value
based on the social interpretation of race (or how one looks)
• Unfairly disadvantages some individuals and communities
• Unfairly advantages other individuals and communities
• Saps the strength of the whole society through the waste of human resources

Jones, C. P. National Campaign Against Racism. 2019-2020 Evelyn Green Davis Fellow Radcliffe Institute for Advanced Study Harvard University. American Public Health Association.
 What is Colorblind Ideology?

● Racial equality will be achieved by the absence of

accounting for race

● Reject all racial categorizations, record-keeping

and make no distinctions based on race

● Relies on the idea that race no longer matters

Photo credit: Doctor Eye Health

Rose, T. (2015, December 2). How Structural Racism Works. The Office of the Provost | Brown University. Retrieved October 24, 2021, from
https://www.brown.edu/about/administration/provost/initiatives/inaugural-lecture-how-structural-racism-works.
 What is Implicit Racial bias?
• Associations made by individuals in the
unconscious state of mind.
• Can unknowingly act in discriminatory ways
• Shaped by experiences
• Likely not aware of the biased association
• Result in biased thoughts or actions
● Take an Implicit Association Test (IAT): Photo credit: Yes! Solutions Journalism
https://implicit.harvard.edu/implicit/selectatest.html

Maryfield, B. (2018, December). Implicit Racial Bias . Justice Research and Statistics Association. Retrieved October 21, 2021, from https://www.jrsa.org/pubs/factsheets/jrsa-factsheet-
implicit-racial-bias.pdf.
 A History of Racism
1861 - 1865: American Civil War

1865 – 1877: Reconstruction Era

● Attempts to fix inequalities cause by racism and slavery
● Amendments were added to the U.S. Constitution to promote equal rights
○ 13th – Ended slavery
○ 14th – The right to be American citizens
○ 15th – The right to vote
● Could also earn a paycheck, own land, and receive an education
● Did not last – hate groups (KKK) used violence to force black people from their homes and jobs
and to prevent them from voting.

History.com Editors. (2021, April 27). Black history milestones: Timeline. History.com. Retrieved October 26, 2021, from https://www.history.com/topics/black-history/black-history-milestones.
 A History of Racism
1870’s – 1960’s: Jim Crow laws made segregation legal
● An era of racial terror
● Nearly 5,000 recorded lynching’s of black people in the U.S.
● Harder to get jobs, housing and education
● African Americans fled the Jim Crow South in a series of mass migrations

1960’s: Civil Rights movement made segregation illegal

● Many states sought to protect existing segregation patters
○ Discriminatory lending polices by banks
○ Closing of all public schools

History.com Editors. (2021, April 27). Black history milestones: Timeline. History.com. Retrieved October 26, 2021, from https://www.history.com/topics/black-history/black-history-milestones.
 A History of Racism

Tuskegee Study
● In 1932, the US Public Health Service began a study of black
men diagnosed with syphilis
● In 1947, penicillin became the recommended treatment for
syphilis, but doctors and nurses explicitly discouraged
treatment of syphilis in the participants
● This exploitation only ended in 1972
● Many of the men died from syphilis
● Wives and children were also infected

Photo credit: The American Society for Biochemistry

and Molecular Biology

Tuskegee University. (2021). About the USPHS Syphilis Study. Retrieved October 23, 2021, from https://www.tuskegee.edu/about-us/centers-of-excellence/bioethics-center/about-the-usphs-syphilis-study.
 A History of Racism

Tuskegee Study
● Researches looked at the erosion of trust and its consequences
● Less likely to seek medical care
● Health conditions were further advanced
● Distrust was linked to a higher likelihood of black men dying
before age 75
● This legacy is embedded in systemic racism

Photo credit: The American Society for Biochemistry

and Molecular Biology

Tuskegee University. (2021). About the USPHS Syphilis Study. Retrieved October 23, 2021, from https://www.tuskegee.edu/about-us/centers-of-excellence/bioethics-center/about-the-usphs-syphilis-study.
 States with jurisdictions declaring
“Racism is a public health crisis”
May 2019

Jones, C. P. (2020, October). Racism is a Public Health Crisis: Now That We See, What Do We Do? 2020 Bray Health Leadership Lecture. Oregon State University.
 States with jurisdictions declaring
“Racism is a public health crisis”
May 2020

Jones, C. P. (2020, October). Racism is a Public Health Crisis: Now That We See, What Do We Do? 2020 Bray Health Leadership Lecture. Oregon State University.
 States with jurisdictions declaring
“Racism is a public health crisis”
June 2020

Jones, C. P. (2020, October). Racism is a Public Health Crisis: Now That We See, What Do We Do? 2020 Bray Health Leadership Lecture. Oregon State University.
 States with jurisdictions declaring
“Racism is a public health crisis”
September 2020

Jones, C. P. (2020, October). Racism is a Public Health Crisis: Now That We See, What Do We Do? 2020 Bray Health Leadership Lecture. Oregon State University.
 Racism leads to Health Disparities
● Racism negatively affects mental and physical health
● Impacts where a person lives, learns, works and plays
● Creates inequities in access to social and economic
benefits
○ Housing
○ Education
○ Wealth
○ Employment
○ Food

● These “social determinants of health” are key drivers

of health inequities – increasing the risk for poorer
health outcomes

CDC. (2021, October 20). Racism and health. Centers for Disease Control and Prevention. Retrieved October 23, 2021, from https://www.cdc.gov/healthequity/racism-disparities/index.html.
CDC. (2017, May 2). African American Health. Centers for Disease Control and Prevention. Retrieved October 21, 2021, from https://www.cdc.gov/vitalsigns/aahealth/infographic.html#infographic.
 Racism leads to Health Disparities
● Racial and Ethnic minority
groups in the U.S. have
higher rates of illness and
death
○ Diabetes
○ Hypertension
○ Obesity
○ Asthma
○ Heart Disease

CDC. (2021, October 20). Racism and health. Centers for Disease Control and Prevention. Retrieved October 23, 2021, from https://www.cdc.gov/healthequity/racism-disparities/index.html.
CDC. (2017, May 2). African American Health. Centers for Disease Control and Prevention. Retrieved October 21, 2021, from https://www.cdc.gov/vitalsigns/aahealth/infographic.html#infographic.
 Racism and COVID
● Disproportionate impact of COVID-
19 among racial and ethnic minority
populations

CDC. (2020, December 10). Disparities in covid-19 deaths. Centers for Disease Control and Prevention. Retrieved October 23, 2021, from https://www.cdc.gov/coronavirus/2019-
ncov/community/health-equity/racial-ethnic-disparities/disparities-deaths.html.
A gardener’s tale
A gardener’s tale
 Fertile soil Dry, rocky soil

Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener's tale. American Journal of Public Health, 90(8), 1212–1215. https://doi.org/10.2105/ajph.90.8.1212
Schmelz, A. (2021, September). Racism and Health. Butler College of Pharmacy.
Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener's tale. American Journal of Public Health, 90(8), 1212–1215. https://doi.org/10.2105/ajph.90.8.1212
Schmelz, A. (2021, September). Racism and Health. Butler College of Pharmacy.
Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener's tale. American Journal of Public Health, 90(8), 1212–1215. https://doi.org/10.2105/ajph.90.8.1212
Schmelz, A. (2021, September). Racism and Health. Butler College of Pharmacy.
 Levels of racism
● Structural (institutionalized) racism

● Personally-mediated racism

● Internalized racism

Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener's tale. American Journal of Public Health, 90(8), 1212–1215. https://doi.org/10.2105/ajph.90.8.1212
 Structural (institutionalized) racism
● Differential access to the goods, services, and opportunities of society by race

● Examples
○ Housing, education, employment, income
○ Medical facilities,
○ Clean environment
○ Information, resources, voice

● Explains the association between social class and race

Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener's tale. American Journal of Public Health, 90(8), 1212–1215. https://doi.org/10.2105/ajph.90.8.1212
 Personally-mediated racism
● Differential assumptions about the abilities, motives, and intents of others, by race

● Differential actions based on those assumptions

● Prejudice and discrimination

● Examples
○ Chinese Exclusion Act
○ Incarceration of Japanese American during WWII
○ Asian Americans after SARS and during COVID-19

● Results in unequal treatment in healthcare and poor health outcomes

Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener's tale. American Journal of Public Health, 90(8), 1212–1215. https://doi.org/10.2105/ajph.90.8.1212
 Internalized racism
● Acceptance by the stigmatized races of negative messages about their own ability’s and intrinsic
worth

● Accepting the limitations to our full humanity

● Manifests as:
○ Self-devaluation
○ Resignation
○ Helplessness
○ Hopelessness

Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener's tale. American Journal of Public Health, 90(8), 1212–1215. https://doi.org/10.2105/ajph.90.8.1212
 Structural (institutionalized) racism
Differential access to the goods, services, and
opportunities of society by race

Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener's tale. American Journal of Public Health, 90(8), 1212–1215. https://doi.org/10.2105/ajph.90.8.1212
Schmelz, A. (2021, September). Racism and Health. Butler College of Pharmacy.
 Structural (institutionalized) racism
Historical insult: Gardener prefers red,
so plants red seeds in more fertile soil

Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener's tale. American Journal of Public Health, 90(8), 1212–1215. https://doi.org/10.2105/ajph.90.8.1212
Schmelz, A. (2021, September). Racism and Health. Butler College of Pharmacy.
 Personally-mediated racism
Differential assumptions (based on race) about
the abilities, motives, and intents of others and
differential actions based on those assumptions

Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener's tale. American Journal of Public Health, 90(8), 1212–1215. https://doi.org/10.2105/ajph.90.8.1212
Schmelz, A. (2021, September). Racism and Health. Butler College of Pharmacy.
 Internalized racism
Acceptance by the stigmatized races of negative
messages about their own ability’s and intrinsic worth

Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener's tale. American Journal of Public Health, 90(8), 1212–1215. https://doi.org/10.2105/ajph.90.8.1212
Schmelz, A. (2021, September). Racism and Health. Butler College of Pharmacy.
 Who is the gardener?
Has the power to decide, to act, and to control resources
● Government
● Media
● Corporations / Foundations
● Communities

Dangerous when:
● Allied with one group
● Not concerned with equity

Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener's tale. American Journal of Public Health, 90(8), 1212–1215. https://doi.org/10.2105/ajph.90.8.1212
 What can we do?

Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener's tale. American Journal of Public Health, 90(8), 1212–1215. https://doi.org/10.2105/ajph.90.8.1212
Schmelz, A. (2021, September). Racism and Health. Butler College of Pharmacy.
 What can we do?
● Knowledge
○ Mitigate unconscious bias
○ Understand the impacts of structural racism
○ Teach others!

● Take action!
○ Name Racism and be explicit
○ Engage people of color in equity initiatives
○ Measure and evaluate progress in reducing health disparities

APHA. (2021). Racial Equity & Public Health. American Public Health Association. Retrieved October 25, 2021, from https://www.apha.org/-
/media/Files/PDF/advocacy/SPEAK/210825_Racial_Equity_Fact_Sheet.ashx.
 Pharmacist Story: Barbershop Healthcare Study
● Uncontrolled hypertension is a leading cause of disability and
premature death in African-American men
● Pharmacists worked with the barbers to manage hypertension care
● Results:
○ 64% reduced their blood pressure to healthy levels in the intervention
group
○ At 12 months, the intervention group had an average reduction in SBP
by 28.6 mm Hg, compared to 7.2 mm Hg in the control group
Photo Credit: Cedars-Sinai
● One of the barbers was included as an author

Victor, R. G., Blyler, C. A., Li, N., Lynch, K., Moy, N. B., Rashid, M., Chang, L. C., Handler, J., Brettler, J., Rader, F., Elashoff, R. M., & Ferdinand, K. C. (2018, December 17).
Sustainability of blood pressure reduction in black barbershops. Circulation. Retrieved October 25, 2021, from https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.118.038165.
Thank you!