Measuring racism's impact on public health

It’s not enough to note disparities affecting Black communities, Rachel Hardeman says. It’s time to quantify how racism affects health policy in order to make changes.

Healthcare leaders are talking more about health equity and addressing disparities in Black communities.

Rachel Hardeman said that’s a sign of progress but it’s not enough. There’s been little research quantifying structural racism and its impact on public health, said Hardeman, associate professor and Blue Cross endowed professor of health and racial equity at the University of Minnesota.

In a study in Health Affairs, Hardeman and other researchers make the case for the necessity of measuring how structural racism has damaged public health. She said it's essential in developing health policies that aren't racist.

“We have to be able to measure how structural racism is being perpetuated in our society in order to change it,” Hardeman said in a phone interview.

“We don’t value what we don’t measure.”

The Health Affairs study documents the dearth of research on structural racism. Nancy Krieger and colleagues found 64 articles in top medical journals that mentioned racism in 2020, but only 10% of those included any measures of racism. A 2018 study found only 20 articles measuring structural racism between 2007 and 2017.

Hardeman said measuring structural racism is complex but crucial in developing healthcare policies that are truly equitable. It includes understanding state and local government policies, the availability of resources, and how lack of economic opportunity and mass incarceration affect the health of communities.

Hardeman lives only a few miles from where George Floyd was murdered. She’s been studying racism and its effects on public health for years before Floyd’s murder, but she acknowledged that it helps fuel her passion for her work today.

“Certainly, George Floyd’s murder and the visceral impact it has had on communities of color in the Twin Cities has been an important driver for the work that I do and the questions that we ask,” she said.

Hardeman said there is progress with more people acknowledging how racism affects public health.

“When I started this work, we weren't even naming racism as a public health issue,” Hardeman said.

Now, she added, “We are at a point where we’re having more robust conversations about the measurement of structural racism.”

The Health Affairs study said historical context is critical in understanding the contemporary effects of healthcare policy. The study notes that areas with higher percentages of Black people held in slavery continue to have more poverty and less economic mobility.

In evaluating health in certain communities, it’s important to consider the impact of segregation in housing policies that have forced Black people to live in areas that are less safe and with lower housing values. The study notes that prior research identifying health inequities in geographic areas doesn’t always account for that greater context.

Hardeman and researchers also point to understanding the impact of state policy, particularly as states have enacted more laws impacting public health. “Many of these policies and practices are not race-neutral in their intentions, implementation, or effects,” they wrote in the study.

“An emerging line of research finds that state-level structural racism is associated with higher rates of infant mortality, myocardial infarction, functional limitations, depression, higher body mass index, and worse self-rated health among Black people,” the study stated.

Hardeman pointed to state policies in determining eligibility for Medicaid as a key example of state policies affecting the health of citizens.

Mandatory minimum sentences, which lead to mass incarceration, have a direct impact on the public health of communities, and not just on those behind bars. Hardeman notes areas with mass incarceration have been found to have higher levels of premature birth. Those who are incarcerated face barriers to housing and job opportunities, which also has implications on their health.

“Mass incarceration is one of the oldest forms of structural racism,” Hardeman said. “It’s not just impacting people who are incarcerated. It has these ripple effects across families and communities.”

Hardeman and her fellow researchers suggest remedies for capturing structural racism in the Health Affairs study. She calls for a multi-faceted approach to study structural racism, which incorporates understanding inequities in educational opportunities, for example, are going to lead to disparities in public health.

They call for studies at the neighborhood level, examining zip code tabulation areas and geographica data from the Centers for Disease Control and Prevention to analyze structural racism. In addition, data from the U.S. Census Bureau, specifically its Census of Governments, shows how public money is spent across all levels of government, which could offer insight on how government policies and spending affect public health.

Critically, Hardeman and other researchers also call for community-based participation in studies of structural racism.

“Folks who are typically marginalized and left out of the conversation should be the ones leading the work,” Hardeman said. She said community members may have different and worthwhile ideas on evaluating racism and its impact on public health policy.

“I don’t want to assume I know all the ways structural racism should be measured,” she said.

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