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Tackling Structural Racism In Health

Press Release - ICB Launch

Alan R. Weil, Health Affairs

Oct 24, 2023

The October issue of Health Affairs, building on the February 2022 issue that explored racism and health, focuses specifically on structural racism. Articles published in this issue describe different types of structural racism and explore efforts to address its harms.

Politics And Policy

“Housing is a key determinant of health and health equity,” says Jamila Michener, who examines tenant organizing as a source of political power to address poor housing. Based on interviews with tenants from racially and economically marginalized communities, she identifies direct action and local policy change as “ways organizing can contribute to creating healthier, more racially equitable communities.”

Jaquelyn Jahn and coauthors use latent class analysis to divide states into groups based on thirteen structural racism–related legal domains, such as fair housing and racial profiling. They find that “age-adjusted premature mortality rates overall were highest in [the twenty-nine] states with predominantly harmful laws.”

Jason Semprini and coauthors categorize census tracts by the degree of redlining that occurred in them. Tracts with the highest rates of historical redlining had the highest proportion of the population without health insurance as of 2014. The Affordable Care Act helped close the gap, as the authors found that “Medicaid expansion had its greatest impact on uninsurance rates in the highest redline category.”

Simon Haeder and Donald Moynihan use national survey data to explore public beliefs about the acceptability of administrative burdens imposed by states that impede enrollment in Medicaid and the Supplemental Nutrition Assistance Program. They find “varying levels of support for state actions that would either create or mitigate burdens” and note that racial resentment is one of the major predictors of favoring administrative burdens. Leighton Ku and Carolyn Barnes offer perspectives on the article.

Using Data

Michael P. Cary Jr. and coauthors conduct a scoping review of literature related to mitigating racial and ethnic bias in clinical algorithms. They find that studies “tended to be either highly specific technical guidance or high-level, nontechnical surveys of strategies,” with limited evidence of the multidisciplinary approaches needed to overcome algorithmic bias.

In a Commentary regarding clinical algorithms, Tina Hernandez-Boussard and coauthors call for “striking the right balance between the race-neutral approach, which avoids using race as a risk factor in clinical decision making, and the race-aware approach, which incorporates data on disparities in an effort to advance health equity.”

Noting the need to address inequities across multiple dimensions (such as race and rurality), Denis Agniel and coauthors describe how assigning quantitative goals for each dimension of equity, or “equity weighting,” can yield more optimal results than traditional quality improvement incentives.

Zachary Dyer and coauthors identify forty-two variables available at the census tract level that they combine into a Structural Racism Effect Index. Deciles of the index are monotonically related to life expectancy, diabetes prevalence, and the percentage of residents identifying as people of color.

Responses To Racism

Community health workers (CHWs) are front-line public health workers who are also members of the marginalized communities they serve. Drawing on a series of interviews, Chidinma Ibe and coauthors conclude: “Efforts to embed CHW-delivered resources within health care delivery and public health organizations must be accompanied by CHW-centered policies and practices anchored in the centrality of these workers’ unique intersectional backgrounds.”

Shekinah Fashaw-Walters and Cydney McGuire propose a “racism-conscious” approach to policy making. In contrast to race-neutral or race-based policies, their approach involves examining current inequities and identifying prevalent health issues experienced by minoritized groups, identifying inequity-related policies, dissecting policy mechanisms and consequences, elucidating the impact of racism, and creating new policies that consider implementation strategies.

Based on discussions with members of Indigenous communities, Arielle Deutsch and coauthors find that “funding policies for the grants that [Indigenous-led community-based organizations] attain are incompatible with their needs to thrive,” leaving these organizations with inadequate infrastructure to compete with larger, White-led ones.

Joel Weissman and coauthors survey hospital health equity officers and find that most of them “recognized both systemic and institutional racism as obstacles to their work.”


Health Affairs thanks Gilbert Gee of the University of California Los Angeles and Ruqaiijah Yearby of the Ohio State University, who served as theme issue advisers. We thank the Robert Wood Johnson Foundation, the California Wellness Foundation, and the Episcopal Health Foundation for their financial support of this issue.


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