Structural Racism is a Public Health Crisis: Impact on the Black Community

  • Date: Oct 24 2020
  • Policy Number: LB20-04

Key Words:

Abstract

Racism has a long-standing history in the United States and across the world that permeates almost every institution. From the education system and the health care system to environmental issues, the criminal justice system, and the field of economics, Blacks and African Americans have suffered across multiple generations at the hands of the racist practices that plague each of these institutions. This policy statement calls on APHA to help support and fund research focused on addressing structural racism and help develop solutions to mitigate racism within the institutions in the United States.

Relationship to Existing APHA Policy Statements

The following APHA policy statements support the purpose of this statement by advocating on a range of social determinants and stressors related to structural racism and racial and ethnic discrimination. However, none of these policies holistically address structural racism as a public health threat. Although related to existing policies, the present policy statement addresses structural racism as a public health threat in a holistic way that no other policy has done.

  • Policy Statement 20178: Housing and Homelessness as a Public Health Issue
  • Policy Statement 20017: Research and Intervention on Racism as a Fundamental Cause of Ethnic Disparities in Health
  • Policy Statement201811: Addressing Law Enforcement Violence as a Public Health Issue
  • Policy Statement 20189: Achieving Health Equity in the United States
  • Policy Statement 20062: Reducing Racial/Ethnic and Socioeconomic Disparities in Preterm and Low Birthweight Births
  • Policy Statement 7424: Racism in the Health Care Delivery System
  • Policy Statement 20005: Effective Interventions for Reducing Racial and Ethnic Disparities in Health
  • Policy Statement 200311: Opposition to Eliminating or Compromising the Collection of Racial and Ethnic Data by State and Local Public Institutions
  • Policy Statement 20042: Reducing Health Disparities in People with Disabilities through Improved Environmental Programmatic and Service Access
  • Policy Statement 200412: Support for Community Based Participatory Research in Public Health
  • Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health
  • Policy Statement 20015: APHA Position Paper on the Health Status of American Indians and Alaska Natives
  • Policy Statement 9904: Federal Policies Impacting American Indians and Alaska Natives
  • 20197: Addressing Environmental Justice to Achieve Health Equity

Problem Statement
Structural racism is a public health crisis: Racism is a pervasive system of power based on the social construction of race, that is, ideological notions of the inherent superiority of non-Hispanic “Whites” and inherent inferiority of people of color (i.e., Native Americans or Alaska Natives, Native Hawaiians/Pacific Islanders, Latinx/Hispanic Americans, Blacks and African Americans [hereafter referred to as Black], and Asian Americans) that operate across multiple levels (internal, interpersonal, institutional) to unjustly advantage Whites and unjustly disadvantage persons of color.[1,2] The confluence of COVID-19’s devastating impact in the United States—disproportionately borne by people of color, especially Black individuals, who have the highest death rate of all racial/ethnic groups—and the viral videos of private and state violence against Black bodies has sparked massive public demands for racial justice. While racism oppresses all people of color, the unique 400-year history and ongoing perpetuation of Black racial subjugation in the United States is the undeniable focus of our country’s most recent social awakening.

In the words of a former APHA president, Dr. Camara Jones,[2] “racism saps the strength of our entire society through the waste of human resources” as the full potential of those it marginalizes goes unrealized.[3] Structural racism is a public health crisis that requires immediate, sustained, and comprehensive action. Structural racism is defined as “the totality of ways in which societies foster [racial] discrimination, via mutually reinforcing [inequitable] systems…(e.g., in housing, education, employment, earnings, benefits, credit, media, health care, criminal justice, etc.) that in turn reinforce discriminatory beliefs, values, and distribution of resources, reflected in history, culture, and interconnected institutions.”[4] In some cases, interventions that address structural racism directed toward the Black community will help to alleviate inequalities across other racial/ethnic groups. The consequences of structural racism targeting other communities in this country are equally important and must be addressed, and policies specific to other racial/ethnic minorities must also be written.

Rationale as a late breaker: Recent grass-roots movements and community uprisings for racial justice are fueling policy change. Multiple city, county, and state governments in the United States now recognize structural racism as a public health crisis and are acting to address its insidious effects. The American Public Health Association can stand in solidarity with others who have named structural racism a public health crisis by actively working toward a more racially just future through holding government/health promotion agency officials accountable for addressing structural racism as an underlying threat to population health and well-being.

Structural racism as a fundamental cause of racial health inequities: Racism, particularly at the institutional/structural level, is a fundamental social determinant of long-standing, widespread racial disparities in population health.[5,6] Racism has been woven tightly into the fabric of American society to establish and reinforce the racial hierarchy.[7] From 1619, when the first enslaved Africans arrived to the land of America, to the deliberate failures of Reconstruction to Jim Crow and the Civil Rights Movement and beyond, racist beliefs about Black people have been codified into law and the policies and practices of social institutions.[5,8] Structural racism differentially distributes the goods, services, opportunities, and protections of society by race, including safe and affordable housing, quality education, adequate income and wealth building, employment, accessible quality health care, and healthy neighborhoods.[1,2] This legacy of racial oppression has resulted in pervasive social inequalities and health inequities across the life course.

The education system: Racial inequality in education can be illustrated in numerous ways; this policy highlights three of them regarding the impact of structural racism on the education and well-being of Black children. First, racial segregation in schools continues despite being illegal in the United States since 1954. The Brown v. Board of Education ruling did not end de facto segregation in schools or school segregation by income, and today more than half of U.S. students attend school in a “racially concentrated district where over 75% of students are either white or nonwhite.”[9] Second, the school-to-prison pipeline includes a host of policies that serve to disproportionately push Black children out of the education system and into the juvenile justice system. This pattern is most notable in urban schools and schools with inadequate resources. Factors include but are not limited to zero-tolerance rules that have resulted in increased suspensions for children of color and the increased policing of schools in which law enforcement officers or “school resource officers” are hired to patrol the students.[10]

A third example of racial inequality is a consistent pattern in which Black children are overrepresented in special education (SPED). Data show that Black children 6 to 21 years of age are 40% more likely than White children to be identified for SPED; Black children are also more than two times as likely to be labeled under the category of serious emotional disturbance as any other racial/ethnic group.[11] Once in SPED, there is evidence of significant racial differences regarding quality of education, educational outcomes, and discipline. Relative to their White counterparts, Black students are more likely to be taught a less rigorous SPED curriculum; moreover, these students are likely to receive instruction in segregated or restricted special education classes, to be taught by uncertified or provisionally licensed teachers, and to graduate with a certificate of attendance or completion instead of a high school diploma, and they have a higher dropout rate.[12] Many of these special education patterns are consistent across school districts, or even entire states, which indicates that this overrepresentation is a community-level problem and not isolated to specific schools.[13]

The health system: There are several occurrences that have led to the mistrust of medical practitioners by Black communities.[14] This issue of mistrust has a significant impact on how Black communities view health care and the provider-patient relationship.[15] Factors leading to mistrust of medical practitioners include the use of supposed “scientific evidence” of racial inferiority to justify racial discrimination while excluding the social and political issues perpetuating inequality, ethical violations targeting Black communities, and disparate medical resources, patient-provider interactions, treatments, and access to health care.[3]

Multiple examples of unethical practices targeting Black communities exist. These examples include but are not limited to excruciatingly painful experimental surgeries performed on enslaved Black/African American women without the use of anesthesia and little or no support for establishing and sustaining medical facilities and training opportunities to increase the workforce of Black practitioners treating Black patients for diseases that often resulted from imposed poor social conditions (e.g., the 1918 influenza epidemic).[16] Additional instances include the use of patient Henrietta Lacks’s cells to advance scientific knowledge without her or her family’s consent or financial compensation[17]; forcible sterilization of Black women, specifically those enrolled in government welfare programs, without their consent[18]; and denial of known effective syphilis treatment for Black male participants with syphilis for the research purpose of studying the natural history of the disease, resulting in severe pathology and participant deaths (the Tuskegee Syphilis Study). Awareness of the Tuskegee study fostered further distrust of the medical, public health, and social services sectors, which has led to low participation in public health programs, clinical trials, and organ donation related to Black communities.

It is evident that the aforementioned historical events and ethical violations have fueled mistrust. To remedy the systemic and longitudinal abuse of the medical system on black bodies, it is imperative that we educate health care providers on this history and take practical actions to combat their personal biases and establish trust with their Black patients. Additional investments must be made to recruit and train people of color in the medical profession.

The stark racial health inequities evident with COVID-19 are not new. People of color, particularly Blacks, have long experienced disproportionately higher rates of morbidity and mortality across the life course than non-Hispanic Whites.[19] Racism worry,[20] self-reported[21] and vicarious racism exposure,[22] and structural racism[23] have been linked, primarily in Blacks/African Americans, to a host of negative mental, physical, and behavioral health outcomes net of potential confounders. For example, evidence that racism is an independent predictor of pregnancy and birth outcomes such as prenatal depression, preterm birth, and low birthweight, as well as Black-White disparities in these outcomes, continues to mount.[22,24,25] Framed within a life course perspective, racism’s deleterious effects on health result from the cumulative impact of chronic exposure to the toxic stressors that racism produces.[26] Operating through stress pathways, racism can affect mental and behavioral health and “weather” the body by compromising the immune, vascular, and hormonal systems, thereby increasing physical health risk.[27,28]

Scientists widely agree that race is a social rather than genetic construct.[27,29] Racial disparities are evident across a wide range of health indicators spanning the life course, and they fluctuate over time and across geographic regions. Foreign-born women exhibit better pregnancy outcomes than their U.S.-born counterparts; however, this reproductive advantage dissipates with subsequent U.S.-born generations.[8] The genetic differences hypothesis also includes the idea that Black people are inherently intellectually inferior to White people. This idea was promoted in The Bell Curve,[30] in which it was argued that differences in IQ scores among Asian Americans, Whites, and Black Americans were not due to biased IQ tests. Rather, it was posited that properly administered IQ tests are not demonstrably biased against social, economic, ethnic, or racial groups and that a genetic explanation for racial differences must be considered.[30]

Racism contributes to psychological and physiological stress processes, which are hypothesized to explain in part the deleterious effects of racism on poor physical and mental health outcomes across the life span.[23] To date, extant research has focused primarily on perceived racial discrimination and has shown negative effects on mental health[31] and physiological markers of stress including inflammation, cellular aging,[32] blood pressure,[19] and allostatic load.[33] Although research on the health effects of structural racism is more limited, studies have revealed significant linkages between racial residential segregation and high blood pressure[15] and inflammation among adults.[34]

The environment: Structural racism is pervasive in our environment, evident in the persistent residential segregation and restricted access to safe housing, water, air, and green space as well as healthy foods that disproportionately affect people of color in the United States.[23,31,35] Black individuals have experienced and continue to experience a particularly heavy burden from discriminatory environmental policies and practices.[23,31,35] Exposure to deleterious environmental conditions is linked to infectious and chronic disease and premature mortality.[23,31] Environmental injustices were established in and are perpetuated through unfair policies and practices (e.g., Jim Crow laws, redlining, predatory lending),[10] and they need to be abolished.

The criminal justice system: Incarceration is a recognized social determinant of health. Mass incarceration refers to the dramatic increase in the number of people under the surveillance of the criminal justice system that began in the late 1970s. Black and Brown Americans have borne the brunt of mass incarceration, a system that has been identified as the next form of structural racism and racial injustice.[36] In 2017, young Black men 18 to 19 years of age were 12 times more likely to be in prison than their White peers.[37] That same year, the rate of imprisonment for Black women (92 per 100,000) was almost double that of White women (49 per 100,000).[37] The jail incarceration rate for Black adults (616 per 100,000) was more than three times that of White adults (187 per 100,000) in 2017.[38] Contributing factors to the mass incarceration of Black Americans are the war on drugs that disproportionately targeted Black communities, a 100:1 sentencing disparity between crack and cocaine possession that did not end until the 2010 Fair Sentencing Act reduced it to 18:1, and stop and frisk policies that entailed police surveillance based on racial profiling.

Relatedly, police violence disproportionately impacts the Black community: first, in terms of the victims it claims, and, second, in the absence of justice afforded to victims’ loved ones. From January to August 2020, 184 Black people were known to have been killed by the police.[32] In very few of these cases does an arrest or conviction of the officer(s) occur; only five officers have been convicted in the last 15 years for the death of a Black person.[39]

Economics: Socioeconomic status (SES) is a strong predictor of health status.[40] Racism structures socioeconomic opportunities by “race” through historical and enduring racist policies and practices (e.g., Jim Crow laws and continued discrimination in hiring, housing, and lending), resulting in socioeconomic inequities that contribute to inequities in population health.[6,8,41] Relative to non-Hispanic Whites, people of color, with the exception of some Asian subgroups, tend to have lower educational attainment and quality, less earned income for a given level of education (i.e., income incongruity), and less household income in both childhood and adulthood; also, they are less likely to reside in higher-income neighborhoods, to have favorable terms for insurance and bank loans, and to have upward mobility, wealth accumulation, and intergenerational wealth transfer.[42] These economic inequities relate to differential exposures that can harm health (e.g., environmental toxins, chronic stressors, violence, and inadequate access to safe housing and neighborhoods, healthy food, and quality health care services) as well as differential protections that support health.[33,43,44] Importantly, several studies have noted both wider racial disparities in health at higher SES levels[22,25,45–47] and better health outcomes among foreign-born than U.S.-born pregnant women (at times comparable to outcomes among non-Hispanic Whites) net of SES,[18,48] suggesting that racial health disparities are not reducible to population differences in SES.

Rather, SES is a major pathway by which racism operates to structure opportunity and pattern health along racial lines.[6,8] For example, a history of discriminatory economic policies and practices dating back to U.S. chattel slavery has restricted Black wealth accumulation, the foundation of economic stability and intergenerational socioeconomic mobility. According to a recent report released by the Brookings Institution, the net worth of White families is 10 times that of Black families ($171,000 vs. $17,150). Even in the top 10% income category, where Blacks represent only 3.6%, the racial gap is no less startling: the net worth for White families is $1,789,300, while the net worth for Black families is $343,160.[42]

In the case of higher SES Black women, who may be assumed to enjoy access to quality health care, income, and wealth to support material needs and aspirations, as well as knowledge and support for healthy birth and maternal outcomes, higher SES is not as protective as expected.[23,25,45–47] Claims have been made that SES differentials explain racial disparities, so SES inequalities rather than racism are the real crisis. While SES and health are strongly related, the relationship varies by race. For example, there is a wider racial gap in adverse pregnancy outcomes at higher SES levels. When SES is controlled, residual effects of race often remain, suggesting that SES does not fully account for racial disparities.[22,25]

Evidence-Based Strategies to Address the Problem
Additional research is needed on the effects of racism on health as well as on effective interventions to combat structural racism across the life course.[49] Such research could explore thought-provoking methodologies to promote self-education (e.g., critical race theory) as a means of better understanding and addressing the multiple forms of structural inequality and how these forms intersect and affect health; use an intersectional analysis to understand how racism is tied to other dimensions such as gender, socioeconomic status, and geography; and develop and use standardized measures of racism for questionnaire or administrative data.[49] Better measurements of racism and racial discrimination can increase understanding of clients’ or community members’ lived experiences, assess racial dynamics within organizations, or provide evidence of the need for resources to address racism as a social determinant of health.[49]

While more research is needed, our country cannot wait to respond to this ongoing crisis. Although there is a significant lack of evidence-based strategies that address structural racism, we need to identify, fund, and evaluate promising and emerging approaches.[49] While numerous pathways by which racism harms health have been identified, such as barriers to health care quality and access, residential segregation (including environmental and educational deficits), and discriminatory practices within the criminal justice system, more research is needed to disentangle and address interventions. Increased use of promising community-specific, multipronged interventions (e.g., purpose built communities) with ongoing evaluation is recommended.[23]

It is important to support the self-determination of communities through true community-based participatory research that addresses public health issues, including engaging community members in leading the planning, implementation, and evaluation of programs.[50]

Instituting anti-racism public health education campaigns to change attitudes with ongoing program evaluation (similar to anti-smoking interventions) is crucial.[49] Providing anti-racism training for all professionals in the health, social services, and educational sectors, including engagement in self-reflection and critical dialogue regarding implicit biases and stereotypes (e.g., Implicit Association Test), is essential.[49] Government entities can encourage anti-racism training by recommending that accrediting bodies adopt cross-cultural education standards based on implicit bias theory and evidence-based research and educational tools.[49] These efforts must be followed or complemented with larger scale efforts to help public health practitioners and policymakers use anti-racism principles in decision making, policy implementation, and interventions.[22]

Opposing Arguments/Evidence
Opposing arguments are not supported by evidence presented above, including the idea that racism does not exist and everyone has had to work hard to get ahead — White privilege does not exist. It has been argued that historical medical experiments were necessary to advance medical knowledge and science. Slaves were often willing participants because they had no other viable access to treatments or medicine.[51] This does not negate the inhumane, unethical abuse of Black medical subjects. Some argue that Black people are more likely to be violent, dangerous, or prone to criminal activity than White people based on arrest and incarceration statistics showing an overrepresentation of Black individuals in the justice system. As presented above, these statistics are explained by the structural racism embedded in the criminal justice system.

There are opposing arguments against ending structural racism and supporting racial equality. Many of these arguments are rooted in White supremacy and the belief that, after the end of Jim Crow and legal segregation, structural and institutional racism no longer exist. Those who oppose racial equality might argue that the United States is a meritocracy where everyone has equal chances to work hard to get ahead.

Action Steps
To achieve the goals of the evidence-based strategies listed, APHA urges comprehensive changes to address structural racism as a public health crisis. Therefore, APHA calls for:

  • Congress to pass and fully fund new and existing anti-racism legislation, such as the Anti-Racism in Public Health Act, that supports public health research and investment by creating a National Center of Anti-racism at the Centers for Disease Control and Prevention.
  • Congress to pass S.4019 and HR 7232 establishing Juneteenth as a national federal holiday. Juneteenth is already recognized by 47 states and the District of Columbia as a state holiday or observance.
  • Support of public health research investments that seek to examine the health effects of and structural interventions targeting structural racism.
  • Establishing collaboratives among federal, state, and local governmental agencies to develop evidence-based recommendations for the most effective policy changes that will address the underlying causes of structural racism.
  • Supporting federal, state, and local initiatives that acknowledge inequities and promote racial equity within federal, state, and local government agencies and other institutions.
  • Improving the evidence base by increasing data collection on racial inequities and mandating the use of measures of racism, especially within police violence, law enforcement, and criminal justice system data.
  • Increased economic investments in historically underresourced minority communities that will promote place-based interventions.
  • Supporting and transforming the federal Healthy Start program and maximizing its potential to reduce infant mortality, eliminate disparities, and increase health equity.
  • Supporting public awareness of racism by encouraging reexamination of history curricula for K–12 education.
  • Supporting increased funding of community-based organizations focused on promoting racial equity through human capital and organizational support.
  • Rescinding federal, state, and/or local policies and practices that prohibit diversity, equity, and anti-racism training for all professionals in the health, social service, educational, and public safety/law enforcement sectors.
  • Reassessing, revising, and evaluating policies to ensure that they are mitigating the impact of racism.

References
1. Jones CP. Levels of racism: a theoretic framework and a gardener’s tale. Am J Public Health. 2000;90(8):1212–1215. 
2. Jones CP. Toward the science and practice of anti-racism: launching a national campaign against racism. Ethn Dis. 2018;28(suppl 1):231–234.
3. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003.
4. Krieger N. Discrimination of health inequities. Int J Health Serv. 2014;44:643–710.
5. James SA. Confronting the moral economy of US racial/ethnic health disparities. Am J Public Health. 2003;93(2):189.
6. Phelan JC, Link BG. Is racism a fundamental cause of inequalities in health? Annu Rev Sociol. 2015;41:311–330.
7. Williams DR, Lawrence JA, Davis BA. Racism and health: evidence and needed research. Annu Rev Public Health. 2019;40:105–125. 
8. Darity W Jr, Hamilton D, Paul M, et al. What we get wrong about closing the racial wealth gap. Available at: https://socialequity.duke.edu/wp-content/uploads/2019/10/what-we-get-wrong.pdf. Accessed October 15, 2020.
9. Meatto K. Still separate, still unequal: still teaching about school segregation and inequality. Available at: https://www.nytimes.com/2019/05/02/learning/lesson-plans/still-separate-still-unequal-teaching-about-school-segregation-and-educational-inequality.html. Accessed October 15, 2020.
10. American Civil Liberties Union. School-to-prisons pipeline. Available at: https://www.aclu.org/issues/juvenile-justice/school-prison-pipeline/school-prison-pipeline-infographic. Accessed October 15, 2020.
11. U.S. Department of Education, Office of Special Education and Rehabilitative Services. 40th Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act. Washington, DC: U.S. Department of Education; 2018. 
12. Harry B, Klingner JK. Why Are So Many Minority Students in Special Education? Understanding Race and Disability in Schools. New York, NY: Teachers College Press; 2006.
13. Harper K, Fergus E. Policymakers cannot ignore the overrepresentation of black students in special education. Available at: https://www.childtrends.org/blog/policymakers-cannot-ignore-overrepresentation-black-students-special-education. Accessed September 27, 2020. 
14. Prograis L, Pellegrino E, eds. African American Bioethics: Culture, Race, and Identity. Washington, DC: Georgetown University Press; 2007.
15. Jacobs EA, Rolle I, Ferrans CE, Whitaker EE, Warnecke RB. Understanding African Americans’ views of the trustworthiness of physicians. J Gen Intern Med. 2006;21(6):642–647.
16. Gamble VN. “There wasn’t a lot of comforts in those days:” African Americans, public health, and the 1918 influenza epidemic. Public Health Rep. 2010;125(suppl 3):114–122.
17. Skloot R. The Immortal Life of Henrietta Lacks. New York, NY: Crown Publishers; 2010.
18. Pallotto EK, Collins JW, David RJ. Enigma of maternal race and infant birth weight: a population-based study of US-born black and Caribbean-born black women. Am J Epidemiol. 2000;151:1080–1085. 
19. Cunningham TJ, Croft JB, Liu Y, Lu H, Eke PI, Giles WH. Racial disparities in age-specific mortality among blacks or African Americans—United States, 1999–2015. MMWR Morb Mortal Wkly Rep. 2017;66(17):444–456.
20. Braveman P, Heck K, Egerter S, et al. The role of socioeconomic factors in black–white disparities in preterm birth. Am J Public Health. 2015;105(4):694–702. 
21. Paradies Y. A systematic review of empirical research on self-reported racism and health. Int J Epidemiol. 2006;35(4):888–901. 
22. Dominguez TP, Dunkel Schetter C, Glynn L, Sandman C, Hobel C. Racial differences in birth outcomes: the role of general, pregnancy, and racism stress. Health Psychol. 2008;27:194–203.
23. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453–1463. 
24. Alhusen JL, Bower K, Epstein E, Sharps P. Racial discrimination and adverse birth outcomes: an integrative review. J Midwifery Womens Health. 2017;61(6):707–720.
25. Braveman P, Heck K, Egerter S, et al. Worry about racial discrimination: a missing piece of the puzzle of black-white disparities in preterm birth? PLoS One. 2017;12(10):e0186151.
26. Verbiest S, ed. Moving Life Course Theory into action. Washington, DC: American Public Health Association; 2018.
27. Fine MJ, Ibrahim SA, Thomas SA. The role of race and genetics in health disparities research. Am J Public Health. 2005;95(12):2125–2128.
28. Hogue CJR, Bremner JD. Stress model for research into preterm delivery among black women. Am J Obstet Gynecol. 2005;192(suppl 5):S47–S55.
29. Krieger N. Stormy weather: race, gene expression and the science of health disparities. Am J Public Health. 2005;95(12):2155–2160.
30. Herrnsten RJ, Murray C. The Bell Curve: Intelligence and Class Structure in American Life. New York, NY: Free Press; 1994. 
31. Williams DR. Stress and the mental health of populations of color: advancing our understanding of race-related stressors. J Health Soc Behav. 2018;59(4):466–485. 
32. CBS News. Police in the U.S. killed 164 black people in the first 8 months of 2020. These are their names. Available at: https://www.cbsnews.com/pictures/black-people-killed-by-police-in-the-u-s-in-2020/. Accessed October 15, 2020.
33. Lorch SA, Enlow E. The role of social determinants in explaining racial/ethnic disparities in perinatal outcomes. Pediatr Res. 2015;79(1–2):141–147. 
34. Crimmins EM, Kim JK, Alley DE, Karlamagla A, Seeman T. Hispanic paradox in biological risk profiles. Am J Public Health. 2007;97(7):1305–1310.
35. Mikati I, Benson AF, Luben TJ, Sacks JD, Richmond-Bryant J. Disparities in distribution of particulate matter emission sources by race and poverty status. Am J Public Health. 2018;108(4):480–485.
36. Alexander M. The New Jim Crow. New York, NY: New Press; 2017.
37. Bronson J, Carson EA. Prisoners in 2017. Washington, DC: Bureau of Justice Statistics; 2019.
38. Bureau of Justice Statistics. Jail Inmates in 2017. Washington, DC: Office of Justice Programs; 2019.
39. Egelko B. Why it’s so hard to convict a cop of murder: just 5 in 15 years. Available at: https://www.sfchronicle.com/nation/article/Why-it-s-so-hard-to-convict-a-cop-of-murder-15327778.php. Accessed September 27, 2020.
40. Adler NE, Stewart J. Health disparities across the life span: meaning, methods, and mechanisms. Ann N Y Acad Sci. 2010;1186:5–23.
41. Nazroo JY. The structuring of ethnic inequalities in health: economic position, racial discrimination, and racism. Am J Public Health. 2003;93(2):277–285. 
42. McIntosh K, Moss E, Nunn R, Shambaugh J. Examining the Black-White Wealth Gap. Washington, DC: Brookings Institution; 2020. 
43. Hanks A, Solomon D, Weller CE. Systematic Inequality: How America’s Structural Racism Helped Create the Black-White Wealth Gap. Washington, DC: Center for American Progress; 2018. 
44. Shapiro T, Meschede T, Osoro S. The Roots of the Widening Racial Wealth Gap: Explaining the Black-White Economic Divide. Waltham, MA: Institute on Assets and Social Policy, Brandeis University; 2013.
45. Jackson FM, Rowley DL, Owens TC. Contextualized stress, global stress and depression in well-educated pregnant African American women. Womens Health Issues. 2012;22(3):e329–e336.
46. Owens TC, Jackson FM. Examining life-course socioeconomic position, contextualized stress and depression in well-educated African American pregnant women. Womens Health Issues. 2015;25(4):382–389.
47. Petersen EE, Davis NL, Goodman D, et al. Racial/ethnic disparities in pregnancy-related deaths—United States, 2007–2016. MMWR Morb Mortal Wkly Rep. 2019;68:762–765. 
48. David RJ, Collins JW Jr. Differing birthweight of infants of US-born blacks, African-born blacks, and US-born whites. N Engl J Med. 1997;337:1209–1214.
49. Ford CL, Griffith DM, Bruce MA, Gilbert K. Racism: Science and Tools for the Public Health Professional. Washington, DC: American Public Health Association; 2018.
50. Susser M. The tribulations of trials—intervention in communities. Am J Public Health. 1995;85(2):156–158.
51. Wall LL. The medical ethics of Dr J Marion Sims: a fresh look at the historical record. J Med Ethics. 2006;32(6):346–350.