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Hence, it is not only the composition of students that may create health disparities but also the de of the curriculum. Health inequities among racial minorities are pronounced, persistent, and pervasive Sondik et al. They even encounter blatantly illegal actions by their employers, including not being paid for work and systematic manipulation of work hours to avoid compensation for overtime. This article reviews several ways of conceptualizing structural racism, with a focus on social segregation, immigration policy, and intergenerational effects.

Is this relationship due to exposure to physical hazards, psychosocial stress, diminished wages, lack of insurance, or some combination of these factors?

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The serious study of racism and health did not gain traction until the s, but now this body of work has become more commonplace. De Castro et al. As a general phenomenon, segregation influences health by simultaneously isolating racial groups from one another and by concentrating exposures and resources. Segregation in nursing care may also remain a ificant issue Smith et al.

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Since its inception, U. While this body of research has been invaluable in advancing knowledge on health inequities, it still locates the experiences of racism at the individual level. Structural mechanisms do not require the actions or intent of individuals Bonilla-Silva As fundamental causes, they are constantly reconstituting the conditions necessary to ensure their perpetuation Link Even if interpersonal discrimination were completely eliminated, racial inequities would likely remain unchanged due to the persistence of structural racism Jones In the next section, we describe a few examples of structural racism and their potential connections with health inequities.

The structural forms of racism and their relationship to health inequities remain under-studied.

A recent review identified thirty-nine studies that tested associations between segregation and health outcomes Kramer and Hogue, Residential segregation remains pervasive and may influence health by concentrating poverty, environmental pollutants, infectious agents, and other adverse conditions Gee and Payne-Sturges, ; Williams and Collins, For instance, Morello-Frosch and Jesdale found that segregation increased the risk of cancer related to air pollution. Racism may be one cause of these inequities.

The processes that generate segregation and health effects likely differ by the level of analysis. Segregation refers to the separation of social groups.

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In groundbreaking work that redirected researchers from hypothesizing that disparities in sexually transmitted diseases STDs are due to some yet unexplained behavioral or other characteristic of Blacks, Laumann and Youm found that segregation in social and sexual networks—not high rates of risky sexual behavior among Blacks as had ly been assumed—explained racial disparities in STDs.

These findings suggest that local level changes may yield little effect on the broader distributions of power and resources. Reardon et al. Recent studies have documented that individuals who report experiencing racism have greater rates of illnesses.

For instance, is workplace segregation related to heart disease? Yet, the health of social groups is likely most strongly affected by structural, rather than individual, phenomena. Studies find that individuals who report experiencing racism exhibit worse health than people who do not report it Williams and Mohammed, While this line of research has been invaluable in shifting the discussion from innate differences in biology or culture to social exposures, it is limited by inadequate attention to the multiple dimensions of racism, particularly structural racism.

Reviews consistently find that persons who self-report exposures to racism have greater risk for mental and physical ailments Brondolo et al.

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An innovative feature of their work is the focus, not on the uneven distribution of students across schools, but on segregation within the curriculum i. Racial and ethnic segregation may also occur by immigration status. The tip of the iceberg represents acts of racism, such as cross-burnings, that are easily seen and individually mediated. Despite this promising introduction, the report failed to develop this theme further.

Other research shows that physical hazards and stressors are related to numerous health problems, including heart disease Darity The Civil Rights Act ofin combination with many grassroots efforts to enforce it, helped reduce hospital segregation Quadagno After the integration of Mississippi hospitals, Black-White disparities in infant mortality were cut in half in just six years Almond et al.

The segregation of social networks may contribute to racialized patterns in the spread of infectious diseases Freeman Disparities in the spread of some diseases reflect existing patterns of social isolation in which Blacks are more socially segregated than members of other groups are. Relatively little work has focused on contemporary segregation in health care, and the findings appear to be complex; segregation may increase or decrease the use of services, depending on the types of services and communities considered Gaskin et al.

Introduction

Structural racism is defined as the macrolevel systems, social forces, institutions, ideologies, and processes that interact with one another to generate and reinforce inequities among racial and ethnic groups Powell The term structural racism emphasizes the most influential socioecologic levels at which racism may affect racial and ethnic health inequities. A century ago, W. Du Bois recognized the connection between societal inequities and health inequities, raising several central arguments related to racism, poverty, and other social problems.

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The portion of the iceberg that lies below the water represents structural racism; it is more dangerous and harder to eliminate. Just as important, studies should examine the mediating mechanisms. The updated Healthy People lists discrimination and residential segregation as examples of social determinants of health.

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This rationale has been well articulated for residential segregation Acevedo-Garcia ; Gee and Payne-Sturges, ; Williams and Collins, but can be extended to other forms of segregation. Studies of disparities should more seriously consider the multiple dimensions of structural racism as fundamental causes of health disparities.

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These measures can allow for the decomposition of effects across various levels and are encouraged for future research. Given that racism shapes the lives of people of color, it seems not only reasonable but necessary to study the hypothesis that racism influences health inequities. Clarke et al.

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Segregation within schools, workplaces, and health care facilities may also contribute to health disparities. This is most clearly conceptualized with regard to residential segregation. Thus, despite the growing interest in neighborhood effects, it remains an important unanswered question whether local neighborhoods are necessarily the best unit of analysis or the appropriate place to intervene on health disparities Kramer and Hogue, These arguments about scale can be generalized to other settings: For instance, to what extent are disparities generated within segregated worksites versus across segregated occupations?

Health inequities are seen in many outcomes, including infant mortality, heart disease, and cancer Sondik et al.

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Racial minorities bear a disproportionate burden of morbidity and mortality. Similarly, while de jure segregation of drinking fountains is now illegal, de facto segregation of water coolers in offices continues because of workplace segregation.

These inequities might be explained by racism, given the fact that racism has restricted the lives of racial minorities and immigrants throughout history. Yet, self-reported measures have their limitations and they disproportionately focus on individual experiences Krieger The more fundamental and broad-reaching aspects of structural racism remain under-studied.

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This also suggests that disparities in the spread of disease can partially reflect existing patterns of social segregation. Yet, this microlevel decline was not seen at the macrolevel; metropolitan segregation remained relatively stable Reardon et al. Researchers have long argued that racism operates at multiple levels, ranging from the individual to the structural Carmichael and Hamilton, ; Jones The metaphor of an iceberg is useful for describing the levels at which racism operates Gee et al.

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Studies using multilevel modeling that simultaneously s for individual and structural factors also find associations between segregation and illness Bell et al. Measures that allow for variations in scaling, such as the spatially modified information theory index Lee et al.

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Studies should continue to test the general hypothesis that segregation is related to illness and health disparities. Learn More.

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For example, Walsemann and Bell found that school segregation is related to health behaviors e. This index could be constructed at specific points in time, and across the entire life course, to evaluate how segregation can influence trajectories of social disadvantage and health disparities. Immigration policy provides another form of social segregation. Try out PMC Labs and tell us what you think.

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Despite these s of progress, segregation within the health care system continues. The goal of this article is to encourage new research on forms of structural racism that may contribute to health inequities. Segregation of workplaces tracks minority workers into jobs with fewer benefits and more dangers Elliott and Smith, For instance, Angelon-Gaetz et al. Little work has documented how segregation occurs across contexts and how different types of segregation may interact with one another to influence health.

Just as importantly, they found that segregation was associated with decreased educational aspirations among Black males.