Racism and Health: Three Core Principles

Centennial Issue

Policy Points:

  • Racism operates in conjunction with interlocking forms of oppression, so it must be addressed relationally.
  • Racism catalyzes processes of cumulative disadvantage as it extends across multiple policy domains along the life course, so it necessitates multifaceted policy solutions.
  • Racism is a function of power relations, so the redistribution of power is a necessary precursor to health equity.

Profound racial inequities were entrenched in crucial domains of American life long before COVID-19. In the wake of the pandemic, these preexisting disparities deepened. Housing offers an arresting example. In 2019, just before the onset of the pandemic, 46% of renter households were paying more than 30% of their income toward rent, and nearly a quarter were spending more than half their income on housing.1 Black and Latinx renters were hit hardest: 54% of Black renters and 52% of Latinx renters were cost burdened (i.e.,spending disproportionate shares of their income on rent) compared with 42% of White renters.1 The pandemic exacerbated the financial struggles of renters. By September 2020, 9.7% of Black renter households and 8.7% of Latinx households (compared with 4.4% of White renter households) reported that they were “very likely” to be evicted in the next two months.2 By March 2021, one year after the COVID-19 pandemic was declared a national emergency in the United States, roughly 29% of Black renters and 21% of Latinx renters had fallen behind on rent compared with 11% of White renters.1

Similar dynamics unfolded across many domains. COVID-19 aggravated prepandemic racial chasms in arenas as varied as education, employment, nutrition, wealth, and health.3–8 Even as such gulfs were widening, the murder of George Floyd by Minneapolis police officers sparked historic nationwide (and global) uprisings against racial violence.9 This confluence of catastrophes brought racism to the forefront of American life. In response, health scholars and practitioners grappled more keenly with the health implications of racism. Many incisive essays and articles centered on the connections between racism and health.10–22 Even with this established and growing corpus of important research, the task of integrating theoretically nuanced and empirically grounded perspectives on racism into our understandings of health remains a work in progress. This essay contributes to the effort by elaborating three core principles. First, racism operates in conjunction with other forms of oppression. Second, racism extends across multiple policy domains, catalyzing cascades of disadvantage along the life course. Third, racism is a function of power relations. In the sections to follow, we explicate the logic and evidence undergirding these observations, and highlight their implications for research, practice, and policymaking.


  1. Joint Center for Housing Studies. The state of the nation’s housing 2021. Harvard University. 2021. Accessed [March 24, 2023]. https://www.jchs.harvard.edu/state-nations-housing-2021
  2. Wedeen, S. Black and Hispanic renters face greatest threat of eviction in pandemic. Harvard University: Joint Center for Housing Studies. 2021. Accessed March, 24, 2023. https://www.jchs.harvard.edu/blog/black-and-hispanic-renters-face-greatest-threat-eviction-pandemic
  3. Feldman JM, Bassett MT. Variation in COVID-19 mortality in the US by race and ethnicity and educational attainment. JAMA Netw Open. 2021;4(11):e2135967. https://doi.org/10.1001/jamanetworkopen.2021.35967
  4. Gemelas J, Davison J. 2022. Inequities in employment by race, ethnicity, and sector during COVID-19. J Racial Ethn Health Disparities. 2022;9(1):350-355. https://doi.org/10.1007/s40615-021-00963-3
  5. Hardy BL, Logan TD. Racial economic inequality amid the COVID-19 crisis. The Hamilton Project. August 13, 2020. Accessed March 24, 2023. https://www.brookings.edu/wp-content/uploads/2020/08/EA_HardyLogan_LO_8.12.pdf
  6. Morales DX, Morales SA, Beltran TF. 2021. Racial/ethnic disparities in household food insecurity during the COVID-19 pandemic: a nationally representative study. J Racial Ethn Health Disparities. 2021;8(5):1300-1314. https://doi.org/10.1007/s40615-020-00892-7
  7. Selden TM, Berdahl TA. COVID-19 and racial/ethnic disparities in health risk, employment, and household composition: study examines potential explanations for racial-ethnic disparities in COVID-19 hospitalizations and mortality. Health Aff (Millwood). 2020;39(9):1624-1632. https://doi.org/10.1377/hlthaff.2020.00897
  8. Tai DBG, Sia IG, Doubeni CA, Wieland ML. 2021. Disproportionate impact of COVID-19 on racial and ethnic minority groups in the United States: a 2021 update. J Racial Ethn Health Disparities. 2022;9(6):2334-2339. https://doi.org/10.1007/s40615-021-01170-w
  9. Putnam L, Chenoweth E, Pressman J. The Floyd protests are the broadest in US history-and are spreading to White, small town America. Washington Post. June 6, 2020. Accessed March 24, 2023. https://www.washingtonpost.com/politics/2020/06/06/floyd-protests-are-broadest-us-history-are-spreading-white-small-town-america/
  10.  Andrews K. Racism is the public health crisis. Lancet. 2021;397(10282):1342-1343. https://doi.org/10.1016/S0140-6736(21)00775-3
  11. Bailey ZD, Feldman JM, Bassett MT. How structural racism works—racist policies as a root cause of US racial health inequities. N Engl J Med. 2021;38(8):768-773. https://doi.org/10.1056/NEJMms2025396
  12. Bailey ZD, Moon JR. Racism and the political economy of COVID-19: will we continue to resurrect the past? J Health Polit Policy Law. 2020;45(6):937-950. https://doi.org/10.1215/03616878-8641481
  13. Bassett MT. Tackling structural racism. J Public Health Manag Pract. 2022;28(suppl 1):S1-S2. https://doi.org/10.1097/PHH.0000000000001457
  14. Dean LT, Thorpe RJ Jr. What structural racism is (or is not) and how to measure it: clarity for public health and medical researchers. Am J Epidemiol. 2022;191(9):1521-1526. https://doi.org/10.1093/aje/kwac112
  15. Garcia MA, Homan PA, García C, Brown TH. The color of COVID-19: structural racism and the pandemic’s disproportionate impact on older racial and ethnic minorities. J Gerontol B Psychol Sci Soc Sci. 2021;76(3):e75-e80. https://doi.org/10.1093/geronb/gbaa114
  16. Krieger N. Structural racism, health inequities, and the two edged sword of data: structural problems require structural solutions. Front Public Health. 2021;9:655447. https://doi.org/10.3389/fpubh.2021.655447
  17. Lynch EE, Malcoe LH, Laurent SE, Richardson J, Mitchell BC, Meier HCS. The legacy of structural racism: associations between historic redlining, current mortgage lending, and health. SSM Popul Health. 2022;14:100793. https://doi.org/10.1016/j.ssmph.2021.100793
  18.  Michener J, LeBrón AMW. Racism, health, and politics: advancing interdisciplinary knowledge. J Health Polit Policy Law. 2022;4 (2):111-130. https://doi.org/10.1215/03616878-9517149
  19. Neblett EW Jr. Racism measurement and influences, variations on scientific racism, and a vision. Soc Sci Med. 2023;316:115247. https://doi.org/10.1016/j.socscimed.2022.115247
  20. Yearby R. Structural racism and health disparities: reconfiguring the social determinants of health framework to include the root cause. J Law Med Ethics. 2020;48(3):518-526. https://doi.org/10.1177/1073110520958876
  21. Yearby R, Mohapatra S. Law, structural racism, and the COVID-19 pandemic. J Law Biosci. 2020;7(1):lsaa036. https://doi.org/10.1093/jlb/lsaa036
  22.  Zambrana RE, Williams DR. The intellectual roots of current knowledge on racism and health: relevance to policy and the national equity discourse. Health Aff (Millwood). 2022;41(2):163-170. https://doi.org/10.1377/hlthaff.2021.01439

Michener J, Ford TN. Racism and Health: Three Core Principles. Milbank Q. 2023;101(S1): 333-355.