Understanding Racism and Health

State Health Policy Leadership Health Equity

Tiffany Ford

Jamila Michener

Racial disparities in health outcomes are well documented, but less is known about the role of racism in health disparities. In this Q&A, Jamila Michener, PhD, of Cornell University and Tiffany Ford, MPH, PhD, of the University of Illinois at Chicago discuss their contribution to The Milbank Quarterly’s centennial issue. Their article defines racism and describes three core principles to guide an understanding of the connections between racism and health. They are: 1) racism operates in conjunction with interlocking forms of oppression; 2) racism catalyzes processes of cumulative disadvantage, and 3) racism is a function of power relations. The authors offer recommendations for integrating these principles into health research, action, and policy.

This piece is the sixth in a series of Q&As with authors from The Milbank Quarterly’s special issue, The Future of Population Health: Challenges and Opportunities.

You identify three core principles to guide our understanding of how racism affects health. Why is understanding these connections so essential for health practitioners and policymakers?

Ford: It’s critical that we situate health where it belongs, which is in a larger conversation of power in this nation [as addressed by the third principle]. The first two principles explain how racism operates alongside other systems of oppression, and how racism and health operate across a myriad of domains along the life course. All three principles direct our attention toward how inequality operates, the questions we need to be asking, the data we need to be collecting, and the approach that we need to be taking.

Michener: Racism isn’t freestanding; it intersects and interlocks with a lot of other processes.

Racism is cumulative. Racism is about power. These are touchpoints to understand the nature of the complexities of racism.

How do you define racism? And why is it important to consider racism as a set of processes that can lead to disparities?

Ford: We define racism as the interconnected social, political, economic, and ideological systems that create, maintain, and exacerbate stratification, so that access to opportunities and resources is based on a group’s or individual’s location in a socially constructed racial hierarchy. Racism is produced and reproduced by laws, rules, and practices sanctioned and implemented by various levels of government and embedded in the economic system.

Michener: We’re explicitly not talking about race; we’re talking about racism. One of the traps that policymakers, ordinary people, and academics fall into is talking in terms of race. Race is ostensibly a demographic characteristic that we correlate with outcomes like racial disparities. Focusing on racism forces us to think about processes. Racism is not rooted in individuals. It’s a process that pervades our social, political, and economic systems. It doesn’t have a genetic or biological basis, but it is a social fact that shapes our society and comes to be a basis of stratification and hierarchy. A process-oriented view of racism points us towards change because we can alter our processes.

Can you describe interlocking systems of oppression and health equity?

Ford: Black feminist scholars long before us have made these points about intersectionality. Racism hits different depending on how you’re gendered in society. There are different sets of stereotypes for folks who are racialized as Black and gendered as men relative to folks who are racialized as Black and gendered as women, for example. Racism doesn’t operate alone. Directing our attention to how racism is operating alongside other systems of oppression focuses attention to distinct mechanisms that might encourage intervention.

Health equity means everyone has a fair and just opportunity to be as healthy as possible. Health equity is a process, just as racism is a process. Engaging in a process through which everyone has a fair and just opportunity to be as healthy as possible means attending to interlocking systems of oppression and understanding how racism operates along the life course and attending to power differentials.

Michener: I grew up in New York City with three older brothers in a neighborhood that a newspaper referred to as the “killing zone,” because somebody was killed there every 63 hours. That neighborhood was a product of the processes of racism. The neighborhood was a consequence of White flight. It was hyper segregated and very poor. I experienced disadvantage very differently than my brothers did.  Any of us could get caught in the crossfire of violence, but they were much more likely to be victims of violence. They were much more likely to be pressured into selling drugs and affiliating with a neighborhood gang. At that time, my biggest risk was getting pregnant and being stuck in the cycle of poverty. We were in the same neighborhood, in the same family, but because we’re gendered in different ways, we experienced those processes of racism in very different ways.

What is the role of cumulative disadvantage in racism?

Michener: The cumulative nature of the disadvantage is brought into sharp relief with the example of Medicaid work requirements. Medicaid work requirements premise health care upon getting a job, which is more difficult for certain groups of people because of cumulative, systemic disadvantage.

Black and Latinx Americans are more likely to encounter the criminal legal system. Police officers spend more time in highly segregated neighborhoods that are disproportionately Black and brown, so living in one of those neighborhoods increases the chances of an encounter with the police, which increases the likelihood of having a criminal record. Criminal records make it substantially harder to find a job.

When policy decisions connect these problems to each other more deeply, they’re essentially making a decision that says: anyone who has one of these problems is more likely to have all of them. When talking about Medicaid work requirements, people need to know that means something different for people of color than it does for people racialized as White. Work requirements are bad for everyone, but they’re disproportionately going to harm people of color.

Why is it important to consider power relations when discussing racism?

Michener: We can’t solve a process problem like racism or address a process issue like health inequity without attending to power, because power is what structures the processes. We must think about who’s central in these systems, who has a voice and who has influence. Voice without influence is just tokenism.

Power is the medium through which change operates. When we enable the people who are most affected by a set of processes to have a role in identifying the problems and implementing and designing the solutions, the promise of change is most real. Power is important because power gets us to change.

What is the problem with deficit-based framings of racism?

Michener: The vast majority of health outcomes have racial disparities. A deficit-oriented framing looks at all the things that are wrong, which can be compelling but can also reinforce stereotypes. We have to think about the processes that account for the disparities and the possibilities for changing them, which require changing our power dynamics and understanding the interlocking forces of oppression and cumulative processes of disadvantage. An emphasis on power is what moves us from a deficit-oriented perspective to an action-oriented perspective.

How can policymakers integrate the principles that you discuss into policy?

Michener: People love asking me the question: If there’s one policy you could implement, what would it be? The whole point is there isn’t one policy that’s going to change all of this. We need to be thinking broadly in terms of systems, how they’re integrated, and how to intervene at various points. Policymakers should consider how they are thinking about problems. Are they understanding racism as a process and not just identifying racial disparities as outcomes? What processes are creating the outcomes they seek to change? And how can they alter those processes in ways that might address multiple outcomes across the life course that are connected to each other? Policymakers should also consider who has power and who doesn’t, what constituents they are engaging and serving, and if there are additional constituents to attend to and center.

Ford: Thinking about racism and interlocking systems of oppression helps to shape the questions about data, how inequality is operating, and who is disproportionately negatively impacted. Policymakers should focus on partnerships and ensuring there are adequate resources to include people that are traditionally excluded from the policymaking and decision-making process. Redistributing power oftentimes requires the redistribution of resources in a very concrete way, like providing money to the most impacted people to attend meetings so they can take off work or extend childcare or elder care. It’s about ensuring that people can engage in this process of answering the larger question: What is the process that’s created these outcomes?