Editor’s note: Health Affairs’ ongoing series of Health Policy Briefs, sponsored by the Robert Wood Johnson Foundation, focuses on the social determinants of health. Last week, we released the first brief of 2020, “Precarious Work Schedules And Population Health” by Kristen Harknett and Daniel Schneider. Previous briefs have explored health-related issues associated with housing, income, and early childhood interventions. Forthcoming briefs will address other social determinants, including social isolation, childcare subsidies, and multisector approaches to suicide prevention. In most, if not all, of these areas, stress makes a crucial contribution to many of the health outcomes—and health disparities—discussed in the research. We asked Brigette A. Davis, a PhD candidate at Harvard T.H. Chan School of Public Health and a Robert Wood Johnson Foundation Health Policy Research Scholar, to write the following post, which examines the unique role that discrimination plays in creating health inequities. A companion post by Aric A. Prather was published yesterday.
It is well understood that stress is a significant predictor of poor mental and physical health and health-harming behaviors, such as alcohol and substance use, poor sleep, and so forth. The unequal distribution of stressors is believed to be a key mechanism that explains health disparities among socially disadvantaged communities. However, researchers and communities alike know that groups such as sexual and gender minorities, women, lower-income people, and communities of color, also face another important stressor more frequently than other groups: discrimination.
The link between health and social factors—such as housing, employment, and education—is well explored in research. Epidemiologists and other researchers continue to reveal the complex, interconnected influence of non-health factors, or “social determinants of health,” on the well-being of communities. As a stressor, discrimination is a social determinant of health in its own right, getting “under the skin,” or embodied, through the direct physiologic impact of stress. Discrimination also exists within the larger social environment, impacting individuals’ health by denying them access to resources, dignity, and a high quality of life. As a follow-on to a recent Health Affairs blog post by Aric Prather exploring stress as a pathway between social factors and health, this post examines the unique role of discrimination as a stressor and the part it plays in creating health inequities.
What Is Discrimination?
Discrimination is unequal treatment based on physical characteristics or social group assignment. While “to discriminate” simply means to divide, or make distinct, to “discriminate against” connotes adverse and unfair treatment of the groups being distinguished based on underlying prejudicial beliefs, stereotypes, or general antagonism toward that target. Discrimination is most often attributed to race, sexual orientation, gender, and gender identity, but can be directed toward individuals or communities with a variety of physical and social attributes such as age, body size, ability, social class, or religion—as well as the multiple intersections thereof.
Distinct from beliefs and stereotypes, discrimination refers to an action or inaction that would not have occurred had the target been perceived as part of another group. Notably, discriminatory actions may be intentional or unintentional. Nevertheless, for the target of discrimination, research suggests that the experience itself is detrimental to health, regardless of the intent.
According to the “Discrimination in America” series—a national poll of racially diverse adults in the United States by Harvard, National Public Radio, and the Robert Wood Johnson Foundation—the majority of individuals of all races polled believed that discrimination against their own racial group exists in America today. Ninety-two percent of black Americans believed that discrimination against black people exists in America, followed by 78 percent of Latinx respondents, 75 percent of Native American respondents, 61 percent of Asian respondents, and 55 percent of whites indicating that their own racial group experiences racial discrimination. Additionally, 90 percent of individuals identifying as lesbian, gay, bisexual, transgender, or queer (LGBTQ), and 68 percent of women indicated a belief in the presence of discrimination toward their respective groups, as well as 44 percent of men indicating discrimination toward men.
Pathways Between Discrimination And Health
The study of discrimination and health in epidemiologic research is still in a nascent stage, with the majority of the studies published within the past 10 years. Discrimination attributed to racism and sexism are the most frequently studied; however there is a growing body of work measuring the impact of discrimination due to sexual and gender minority status. There has also been burgeoning research about weight discrimination particularly examining its role in health care access and treatment.
Discrimination occurs on two levels: individual and institutional. The first refers to the interpersonal experiences between an individual actor and target and may include insensitive comments, slurs, microaggressions, violence, and threats of harm. These types of life experiences are likely to impact health similarly to other stressful or traumatic life experiences.
Additionally, there are institutionally mediated experiences of discrimination, wherein resources such as housing, quality schooling, jobs, criminal justice, and other social determinants of health are differentially allocated among groups, even when following the explicitly stated “rules of the game.” When this type of discrimination is perceived by the target, it is seen as a major stressful life experience. Whether or not it is perceived by the target, institutional discrimination may trigger additional stressful life experiences, such as unemployment, exposure to poor-quality housing and environments, incarceration, or stagnated social mobility.
Accordingly, research suggests that discrimination impacts health primarily through three major pathways: psychosocial stress, access to health and social resources, and violence and bodily harm. These pathways interact with one another. For instance, denied access to jobs and housing is a cause of psychosocial stress. Discrimination acts as both a stressor and a cause of other stressors, and can directly and indirectly lead to harm for those who experience it.
Discrimination As A Psychosocial Stressor
The most studied pathway between discrimination and health is the psychosocial pathway. The impact of psychosocial stress on human health is summarized in Aric Prather’s recent Health Affairs blog post. Briefly, an external event exerts a demand on the individual, which that individual instantaneously appraises based on his or her personal resources and capacities. When the requirements of the demand exceed personal resources to address it, the result is perceived stress.
The experience of discrimination—when perceived as such—leads to a cascade of stress-related emotional, physiologic, and behavioral changes. Stress evokes negative emotional responses, such as distress, sadness, and anger; physiologic changes meant to maintain homeostasis through the stressful event; and often an increase in behaviors that harm health (such as alcohol, tobacco, and other substance use) and a decrease in healthy activities (such as sleep and physical activity).
In a recent paper highlighting 29 reviews of empirical studies of discrimination based on race/ethnicity, my coauthors and I found that experiences of everyday discrimination were associated with depression, anxiety symptomology, general psychological distress, and diagnosed psychiatric mental illness. These reviews suggest that the effects can be cumulative with a clear dose-response relationship, such that greater exposures over time produces worse mental health outcomes.
Trauma-related symptomology such as hypervigilance is also associated with discrimination related to race, transgender status, and sexual orientation. Hypervigilance, or a heightened awareness and anticipation of protecting oneself against additional trauma, is a key feature of post-traumatic stress disorders and is one of the proposed pathways through which trauma leads to poor cardiovascular and metabolic health, substance abuse, and sleep disturbances. Anticipatory stress and vigilance—or the impact of anticipating a discriminatory experience—are also examined in discrimination research. In a review of racial discrimination, vigilance was also positively associated with sleep disturbances, high blood pressure, waist circumference, and depression.
The brief physiologic responses to psychologic stress are adaptive. However, when stress is chronic, these responses can be harmful. The role of discrimination in cardiovascular disease (CVD) has been extensively studied, particularly in regard to unexplained hypertension-related disparities among black people, women, and in particular black women, in the United States. In one study, the risk of cardiovascular events in otherwise healthy middle-age and older adults was significantly greater among those reporting discrimination in two or more life domains (such as jobs, education, police), even when controlling for chronic stress and CVD risk behaviors. This remained true for all reports of discrimination, without regard to race, sexual orientation, or class. Discrimination has also been associated with reclinical indicators of cardiovascular events, including higher blood pressure, intima-media thickness, and heart rate variability.
The hypothalamic-pituitary-adrenal (HPA) axis is specifically tied to the stress response and has multiple implications for metabolism and inflammation. Heightening HPA axis activity is also related to discrimination in multiple domains, including racial, sexist, and weight-related discrimination.
The multitude of cardiovascular, metabolic, and inflammation responses to stress—when prolonged—are known as allostatic load, which leads to general wear and tear on the body. Arline T. Geronimus’ landmark “weathering” hypothesis posits allostatic load due to multiple disadvantages—including discrimination—contributes to worse health and the apparent signs of early physiologic aging among African Americans. Among older adults, experiences with discrimination have even been associated with risk of death. While discrimination has also been associated with health-harming behaviors such as alcohol and tobacco consumption, and worse sleep quality, these behaviors do not fully explain the relationship between discrimination and worse health.
Access To Health And Social Resources
Discrimination can also influence individuals’ health indirectly, even when they are unaware that it has happened. Discrimination due to race, gender, gender identity, and sexual orientation determine access to health care and the social determinants of health, including contact with the criminal justice system. While loss of jobs, financial stress, and loss of a loved one to death or incarceration are all stressors any individual may face, they are experienced earlier and at higher rate for populations experiencing discrimination. Reduced access to health and social resources also affects the families of individuals being discriminated against. For instance, quality housing, safe neighborhoods, and having employed parents are all important factors for healthy child development. However parental discrimination restricts access to these opportunities for children, and in some cases—such as when it leads to extreme poverty and parental incarceration—can be considered an adverse childhood experience. This means the inequities in access to resources caused by discrimination can ricochet though familial networks—worsening disparities in already impacted communities.
Discriminatory Violence
The most direct pathway between discrimination and health is violence. The discriminatory violence that permeates our nation’s history (for example, genocide, lynching) has lessened but has taken new forms, with a striking resurgence in violent hate crimes in the past five years. In fact, following the 2017 violent attack in Charlottesville, Virginia, the American College of Physicians issued an official statement calling hate crimes a public health issue. These crimes cause direct harm to victims and are additional stressors for families and individuals who perceive they are at risk.
Transgender youth report being threatened or injured at school by a weapon at a rate 3.4 times that of cisgender male and female youth. And despite the fact that the deaths of transgender individuals are likely undercounted and misgendered in crime statistics, black transwomen between the ages of 15 and 34 are estimated to die by homicide at a rate two times that of black cisgender males—a group facing the greatest homicide rates in the nation.
Extrajudicial police killings are another form of discriminatory violence. Black, Native American, and Latinx men, and black and Native women, are all significantly more likely to die by police violence than their white counterparts. Racial profiling in policing, as well as implicit bias in assuming innocuous objects as weapons, are two types of discrimination that prove fatal for many non-white individuals in the United States.
The threat of, or consistent exposure to, discriminatory violence is an additional stressor for individuals, particularly those who may perceive themselves at risk for such violence. For instance, Stop, Question, and Frisk (SQF)—a form of racially discriminatory policing that can lead to violence—is associated with worse mental health symptomology and distress among people in neighborhoods where it occurs—even if they themselves have not experienced SQF. The depressive and anxiety-related symptomology is greatest for young men of color, and health effects are worse in neighborhoods where SQF is associated with force. Similarly, a recent study has found worse mental health among black Americans following the killing of unarmed black men by the police in their state.
Conclusion
Discrimination is itself a social determinant of health, as a type of stressor experienced by communities of color, sexual and gender minorities, women, and many others in the United States. It is also a determinant of access to other important social determinants of health. The direct and indirect health impacts of discrimination are harmful not just to the targets but to their families, loved ones, and communities. Thus, the impact of discrimination on health is far-reaching, contributing to the multitude of health inequities many marginalized communities face.
