The murder of George Floyd at the hands of Minneapolis police officers reveals a long time truth that our society has tried to hide: racism is a public health crisis. Racism can occur on an individual level or a systematic level, and can be intentional or unintentional. It has continued to plague our country long after the civil rights movement in the 1960s, and has produced a wealth of symptoms we have not yet addressed. We need health equity and we need it from our law enforcement officers, government leaders, health care providers, researchers, professors, community members, friends, and family. We must address society’s discomfort with race discussions in order to improve health outcomes for all Americans.
“Racism is a system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call "race"), that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources."
-- APHA Past-President Camara Phyllis Jones, MD, MPH, PhD
The health field has been aware of health disparities for decades. As Dr. Camara Jones states in a 2002 interview: ”Racism is one of the fundamental causes of racial disparities in health outcomes”. It is now 2020, yet some people are still unaware of this same message: racism is a public health crisis. See the full interview with Dr. Camara Jones on institutionalized racism and its impacts on health.
If you find yourself safe at home and the constant stream of protest coverage is weighing on you, we have a solution: turn it off, show up or donate what you can to support your BIPOC (Black, Indigenous, and People of Color) community members who cannot just turn off the tv to get away from the injustice they face at the hands of those who are meant to protect them. Action and support for the black and brown lives in your community is needed. You don’t need to be a ‘type’ of person to be an activist or a voice for change. You just need to be willing to step out of your comfort zone and enter new spaces with a willingness to amplify BIPOC voices and to listen. Once you do, you will find a community of support and renewed hope for a better, more equitable future.
It’s long overdue that we acknowledge race as a social determinant of health. This post collects public health research on the impact of racism on health disparities.
NOTE: As a public health blog, we want to bring attention to the fact that COVID-19 is still a threat to the safety of all our communities. Especially as you may be entering spaces that belong predominantly to BIPOC communities who are also at higher risk of severe COVID-19 burdens, please be aware of CDC guidelines in place to prevent the spread of COVID-19. Wash your hands, wear a cloth face mask, keep 6 feet of distance, and check out the Vox infographic (below) on keeping risk levels low based on where you gather:
COVID-19 DISEASE BURDEN
“In Chicago, more than 50% of COVID-19 cases and nearly 70% of COVID-19 deaths involve black individuals, although blacks make up only 30% of the population. Moreover, these deaths are concentrated mostly in just 5 neighborhoods on the city’s South Side. In Louisiana, 70.5% of deaths have occurred among black persons, who represent 32.2% of the state’s population. In Michigan, 33% of COVID-19 cases and 40% of deaths have occurred among black individuals, who represent 14% of the population.”
-- Clyde W. Yancy, MD, MSc[1]
Dr. Yancy identifies these preliminary numbers as indicators of health care disparity not just because of comorbidities, but also due to a lack of structure in place to address barriers to access. Black/African Americans make up a larger percentage of essential workers and therefore have less of an opportunity to social distance.[2]
“The most effective strategy known to reduce COVID-19 infection is social distancing, but herein lies a vexing challenge. Being able to maintain social distancing while working from home, telecommuting, and accepting a furlough from work but indulging in the plethora of virtual social events are issues of privilege. In certain communities these privileges are simply not accessible.”
--Clyde W. Yancy, MD, MSc[1]
The COVID-19 pandemic has revealed the disparities and burdens upon the African-American, Native American, and Hispanic/Latinx populations.[3] There is no one explanation for the high disease burden in these populations, but the following concepts may all contribute to risk factors that have exacerbated racial inequity in the United States. The push to create COVID-19 racial disparities task forces have been proposed or enacted on a state (Michigan, Oakland, CA, Indiana, & potentially more!) and a federal level (efforts led by Senator Kamala Harris).
MATERNAL MORTALITY
The maternal mortality rate has been rising in the United States: maternal death rates have nearly doubled, while decreasing elsewhere around the world.[4] Maternal mortality rates in the United States have risen from 7.2 deaths per 100,000 live births in 1987 to 16.9 deaths per 100,000 live births in 2016.[5] In addition, a 2018 report from Maternal Mortality Review Committees determined that 60% of the maternal deaths in this country were preventable.[6]
Breaking these numbers down even more, we can see a clear race-based inequality. Data from 2011-2016 shows the pregnancy-related mortality ratio for African American women is 42.4 deaths per 100,000 live births. While much higher than the US average, this rate also stands in stark comparison to the 13.0 deaths per 100,000 live births for non-Hispanic white women.[5] This racial inequity is unwarranted and unacceptable.
REDLINING
Redlining refers to the impact of racial discrimination from 1930s mortgage loans that have come to shape demographic and wealth patterns today (75% of cities ‘redlined’ by the Home Owners’ Loan Corporation - HOLC - are struggling economically to this day).[7] Read more here about the long standing impact of redlining. According to a 2018 report by Dr. Bruce Mitchell of the National Community Reinvestment Coalition, the HOLC’s racist policies resulted in racial and economic divides that have widened over the past 80+ years.[8]
“Eighty years ago, a federal agency, the Home Owners’ Loan Corporation (HOLC), created “Residential Security” maps of major American cities. These maps document how loan officers, appraisers and real estate professionals evaluated mortgage lending risk during the era immediately before the surge of suburbanization in the 1950’s. Neighborhoods considered high risk or “Hazardous” were often “redlined” by lending institutions, denying them access to capital investment which could improve the housing and economic opportunity of residents.”
--Mitchell 2018, Executive Summary[8]
In the 1930s, the HOLC assigned ‘grades’ to represent ‘residential security’ for the four regions in the United States. Neighborhoods that were categorized as higher risk would be where lending was discouraged. The figure below demonstrates how the relationship between “residential security” correlates with a racial divide between predominantly white and minority group residents.
As evidence has increasingly shown, “your ZIP Code matters more than your genetic code” in determining health outcomes.[9] Your lifespan may vary by approximately 20-30 years based upon the community in which you live. [9] In this way, the impact of redlining trends from previous generations continue to impact both the demographic differences and racial health disparities we see today.
WEATHERING
The weathering hypothesis was coined by Dr. Arline T. Geronimus, a professor at the University of Michigan School of Public Health. This hypothesis postulates that the lived experience of systemic racism has biological impacts on black bodies. Ultimately, racism imposes a psychological and physical toll on the health of an individual.[10] This describes that racism not only has a psychological effect, but also takes a toll on the physical health of the body.
In 2006, Geronimus et al. found that non-Hispanic Black Americans had a greater probability for higher allostatic load scores than non-Hispanic White Americans at all ages - even when controlling for poverty level.[11] Allostatic load is measured across physiological systems and includes “subclinical indicators of the body’s response to stress”, in other words, it is a proxy measure for morbidity.
The results of this study indicate that the predicted probability of a higher allostatic load (or higher risk for comorbidities) is higher for black men and women compared to white men and women, with the greatest difference between the ages of 35 to 64. This finding was consistent with the weathering hypothesis that “blacks experience earlier deterioration than whites do” on a cellular level.
POLICE BRUTALITY AND THE CRIMINAL JUSTICE SYSTEM
Police brutality towards Black Americans has been occurring far too frequently and for far too long. According to a 2018 study by DeGue et al., Black Americans comprised 34% of the deaths by lethal force at the hands of law enforcement, yet they comprise only 13% of the American population.[12] “The rise of mass incarceration begins with disproportionate levels of police contact with African Americans”, states a report from The Sentencing Project to the UN.[13] See the following projects mapping police violence across the nation:
In addition to more frequent encounters, implicit biases play a role in how law enforcement officials react and perceive black community members.[12] Studies have shown that most people hold implicit biases - defined as “automatic, unconscious stereotypes that favor some groups and disfavor others” - and implicit biases in the United States consistently associate favorable concepts (i.e. the demonstration of a positive attitude such as voting for a candidate) with whites and less favorable concepts (i.e. the demonstration of an unfavorable attitude such as voting against a candidate) with blacks.[14]
Curious to explore more on implicit biases? Take these tests designed by the non-profit Project Implicit to explore implicit biases you may hold (click on the "take a test" tab).
For more guidance and action items regarding what you can do to address racial bias in the justice system, read former President Barack Obama’s Facebook post which also includes links to resources on Human Rights Leadership toolkits.
WHAT DOES THIS ALL THIS MEAN?
For those who identify as Black and/or African American and are reading these numbers and health outcomes, know that you are not a statistic. The limitation of epidemiology is that we must examine data as a whole set, from a population level view. This does not mean your life or your experience can be summed up by this view nor are these findings equivalent to a diagnosis or a prediction.
THE BIG TAKEAWAY: racism is at the core of these racial health disparities. In order for institutional change (and we need institutional change), we must start with ourselves. In health delivery systems and in all other social systems, we focus less on being “not racist”, but rather actively work to be ANTI-Racist, a concept described by Ibram X. Kendi.
Kendi has described being anti-racist is more powerful because few, if any, are entirely free of racism. In fact, racism has roots in policies of political power, rather than on the individual level. Read “How to be an Antiracist” by Ibram X. Kendi or check out his interview with the New York Times. Ibram X. Kendi also put together a reading list and urges readers to “Think of it as a stepladder to antiracism, each step addressing a different stage of the journey toward destroying racism’s insidious hold on all of us.”
WHAT CAN I DO, TODAY?
Start reading, thinking, and working towards becoming Anti-Racist.
Another good starting point: “Anti-Racism Resources for White People” resource list
Support local, national #BlackLivesMatter movements. All lives CANNOT matter until Black Lives Matter.
Donate, show up, care for your community:
If you’re looking to donate to the Minnesota Freedom Fund (MFF): think about also donating to other local organizations. MFF has released a statement saying they have been humbled by the support and have received $20 million. Read more or visit to donate to MFF here.
Donate to George Floyd’s family.
Reclaim the Block (and their suggested local organizations they recommend you consider supporting in addition, here)
Make calls: Call County Attorney Mike Freeman at 612-348-5550 to demand justice, accountability and/or policing changes. Call Minnesota Attorney General Keith Ellison at 651-296-3353. Call Gov. Walz at 651-201-3400.
Educate yourself. This is not the first case of police brutality. #SayTheirNames:
Trayvon Martin
Eric Garner.
Terence Crutcher.
Tamir Rice.
Mike Brown.
Freddie Gray.
Philando Castille.
Breonna Taylor.
George Floyd.
Alton Sterling.
Rekia Boyd.
Antonio Martin.
Walter Scott.
Jamar Clark.
Sandra Bland
And more.
Start at home. Conversations with family can be the most difficult, but setting boundaries and making your values clear can be a strong starting point.
Reach out to friends and family who can join and support you in being active in this movement.
Every day is a new day to push yourself and those around you to be better. We all start in different places on the activism spectrum (below), but with the right support and the right encouragement, we can all work towards a better society. If you have nowhere else to start or no one else to encourage you to work to improve yourself, message us. We can be that starting point of encouragement for you.
Let us know what ways you have been getting involved with the #BlackLivesMatter movement and if this content was helpful for you. Check out our ‘Ask Ivy’ feature on the website to send a message directly to our team. Now go - get out there and, as Obama stated, “Let’s get to work”.
Primary Author:
Minda Liu
B.A. Biology | Carleton College
MPH Candidate | Dartmouth College
Contributors:
Monica Nguyen, Shruthi Patchava, Arushi Krishnan, Divya Chawla
MPH Candidates | Dartmouth College
REFERENCESDorn A van, Cooney RE, Sabin ML. COVID-19 exacerbating inequalities in the US. Lancet. 2020;395(10232):1243-1244. doi:10.1016/s0140-6736(20)30893-x
Laurencin CT, Mcclinton A. The COVID-19 Pandemic: a Call to Action to Identify and Address Racial and Ethnic Disparities. doi:10.1007/s40615-020-00756-0
Yancy CW. COVID-19 and African Americans. JAMA. 2020;323(19):1891–1892. doi:10.1001/jama.2020.6548
Kozhimannil KB, Hernandez E, Mendez DD, Chapple-McGruder T. Beyond The Preventing Maternal Deaths Act: Implementation And Further Policy Change.; 2019. doi:10.1377/hblog20190130.914004
Pregnancy Mortality Surveillance System | Maternal and Infant Health | CDC. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm. Accessed April 15, 2020.
Brantley MD, Callaghan W, Cornell A, et al. Report from Nine Maternal Mortality Review Committees.; 2018. http://reviewtoaction.org/Report_from_Nine_MMRCs. Accessed April 15, 2020.
Jan T. Redlining was banned 50 years ago. It’s still hurting minorities today. - The Washington Post. https://www.washingtonpost.com/news/wonk/wp/2018/03/28/redlining-was-banned-50-years-ago-its-still-hurting-minorities-today/. Accessed June 1, 2020.
Mitchell B. HOLC “redlining” maps: The persistent structure of segregation and economic inequality » NCRC. https://ncrc.org/holc/. Accessed June 1, 2020.
Graham GN. Why Your ZIP Code Matters More Than Your Genetic Code: Promoting Healthy Outcomes from Mother to Child. Breastfeed Med. 2016;11:396‐397. doi:10.1089/bfm.2016.0113
Malcom K, Sawwani J. Racial Disparities in the Time of COVID-19. https://labblog.uofmhealth.org/rounds/racial-disparities-time-of-covid-19. Accessed May 31, 2020.
Geronimus AT, Hicken M, Keene D, Bound J. "Weathering" and age patterns of allostatic load scores among blacks and whites in the United States. Am J Public Health. 2006;96(5):826‐833. doi:10.2105/AJPH.2004.060749
DeGue S, Fowler KA, Calkins C. Deaths Due to Use of Lethal Force by Law Enforcement: Findings From the National Violent Death Reporting System, 17 U.S. States, 2009-2012. Am J Prev Med. 2016;51(5 Suppl 3):S173‐S187. doi:10.1016/j.amepre.2016.08.027
Report to the United Nations on Racial Disparities in the U.S. Criminal Justice System | The Sentencing Project. https://www.sentencingproject.org/publications/un-report-on-racial-disparities/. Accessed June 1, 2020.
Greenwald AG, Krieger LH. Implicit bias: scientific foundations. Calif Law Review. 2006:945–967. 10.2307/20439056.