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The Evolution of Structural Racism in Health Research |
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Within epidemiological study design, one of the most fundamental concerns is to eliminate bias through the clear definition of terms, as well as measurement accuracy and standardization. This clear-eyed commentary highlights the dual absence of both an established, singular definition of structural racism, as well as the absence of a standard way to measure it, resulting in conceptual inconsistencies and wide-ranging measurements. The authors note that without precise definition or measurement, structural racism can be mismeasured as interpersonal racism, resulting in overestimation of the latter and, therefore, overemphasis on interventions at the interpersonal level. This commentary is relevant for public health researchers and practitioners in that is seeks to delineate—using the literature—what is and is not structural racism, and calls for more accurate measurement in this crucial area. The authors date the first structural racism paper appearing in PubMed as a 2006 publication on migrant worker health, which did not explicitly define the term, and then follow the evolution of the term through subsequent years and publications. Through the years, scholars differentiate structural racism from institutional racism, the latter of which is most commonly known from Dr. Camara Jones’ pivotal “Gardner’s Tale” paper originally published in 2000. Ultimately, the authors arrive at this definition based on Bailey and Bassett: “structural racism represents the totality of ways in which multiple systems and institutions interact to assert racist policies, practices, and beliefs about people in a racialized group.” The table below summarizes key definitions presented in the commentary.
From an epidemiological perspective, the distinguishing aspect of structural racism is that it captures the interactions of multiple forms or institutions of racism, which may be mutually reinforcing. The study of structural racism allows for a more robust approach compared to the study of single forms of racism, the latter of which may produce biased estimates by incompletely accounting for the full scope of what can be an interactive system. Having set forth a clear definition of structural racism, the authors move onto its measurement. Within the literature, the most frequent measure has been in the single domain of residential segregation, which, the authors submit, is better classified as institutional rather than structural racism, as it does not encompass the interactions of multiple domains or forms of racism. Instead, the current recommendation is to utilize index measures to capture the multiple domains and interactive effects comprising structural racism. Dean and Thorpe point to a 2020 study which exemplified this by utilizing a five-domain index to measure county-level structural racism across education, housing, employment, criminal justice and health care in reference to body mass index (BMI). Using this cross-sectional index measure, the results from this study demonstrated that county-level structural racism was associated with lower BMI among White adults but higher BMI among Black adults. Dean and Thorpe also underscore the importance of specifying geographic level—be it county, state, or otherwise—when measuring and treating structural racism as an exposure so as to appropriately consider the relevant laws, policies, practices, and programs. In this commentary Dean and Thorpe have masterfully documented and clarified the complex and sensitive area of structural racism. This article is a must-read for any epidemiologist or public health worker researching or seeking a deeper understanding of structural racism and relevant interventions.■ |
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