{"subscriber":false,"subscribedOffers":{}} Systemic And Structural Racism: Definitions, Examples, Health Damages, And Approaches To Dismantling | Health Affairs

Research Article

Health Equity

Systemic And Structural Racism: Definitions, Examples, Health Damages, And Approaches To Dismantling

  1. Paula A. Braveman ([email protected]), University of California San Francisco, San Francisco, California.
  2. Elaine Arkin, independent consultant, Arlington, Virginia.
  3. Dwayne Proctor, Missouri Foundation for Health, Princeton, New Jersey.
  4. Tina Kauh, Robert Wood Johnson Foundation, Princeton, New Jersey.
  5. Nicole Holm, University of California San Francisco.
PUBLISHED:Open Accesshttps://doi.org/10.1377/hlthaff.2021.01394


Racism is not always conscious, explicit, or readily visible—often it is systemic and structural. Systemic and structural racism are forms of racism that are pervasively and deeply embedded in systems, laws, written or unwritten policies, and entrenched practices and beliefs that produce, condone, and perpetuate widespread unfair treatment and oppression of people of color, with adverse health consequences. Examples include residential segregation, unfair lending practices and other barriers to home ownership and accumulating wealth, schools’ dependence on local property taxes, environmental injustice, biased policing and sentencing of men and boys of color, and voter suppression policies. This article defines systemic and structural racism, using examples; explains how they damage health through many causal pathways; and suggests approaches to dismantling them. Because systemic and structural racism permeate all sectors and areas, addressing them will require mutually reinforcing actions in multiple sectors and places; acknowledging their existence is a crucial first step.


When most people think about racism, they probably think of racial slurs, hate crimes, or other overtly racist actions. There are, however, other less obvious yet ultimately even more destructive forms of racism. Structural and systemic racism are often invisible—at least to those who are not its victims. This article defines structural and systemic racism, explains how they damage health, and provides illustrative examples. Although we focus on how structural and systemic racism can harm the health of people of color, they also may damage the health and well-being of a society overall1,2—including the health and well-being of White people.3


People of color is a term used to refer to African Americans, American Indians/Alaska Natives, Asian Americans, Latinos/Hispanics, and Native Hawaiians/other Pacific Islanders. Racism is the relegation of people of color to inferior status and treatment based on unfounded beliefs about innate inferiority, as well as unjust treatment and oppression of people of color, whether intended or not. Racism is not always conscious, intentional, or explicit—often it is systemic and structural.4 Systemic and structural racism are forms of racism that are pervasively and deeply embedded in and throughout systems, laws, written or unwritten policies, entrenched practices, and established beliefs and attitudes that produce, condone, and perpetuate widespread unfair treatment of people of color.5 They reflect both ongoing and historical injustices. Although systemic racism and structural racism are often used interchangeably, they have somewhat different emphases. Systemicracism emphasizes the involvement of whole systems, and often all systems—for example, political, legal, economic, health care, school, and criminal justice systems—including the structures that uphold the systems.6Structuralracism emphasizes the role of the structures (laws, policies, institutional practices, and entrenched norms) that are the systems’ scaffolding.5 Because systemic racism includes structural racism, for brevity we often use systemic racism to refer to both; at times we use both for emphasis. Institutional racism is sometimes used as a synonym for systemic or structural racism, as it captures the involvement of institutional systems and structures in race-based discrimination and oppression;4,7,8 it may also refer specifically to racism within a particular institution.9

Gilbert Gee and Annie Ro depict systemic racism as the hidden base of an iceberg10 (see illustration in online appendix exhibit 1).11 The iceberg’s visible part represents the overt racism that manifests in blatant discrimination and hate crimes—explicitly racist treatment that may be relatively easy to recognize. The iceberg’s base—the much larger, usually unseen part—represents systemic and structural racism. It consists of the societal systems and structures that expose people of color to health-harming conditions and that impose and sustain barriers to opportunities that promote good health and well-being. The opportunities denied include access to good jobs with benefits; safe, unpolluted neighborhoods with good schools; high-quality health care; and fair treatment by the criminal justice system. Systemic racism is the iceberg’s more dangerous part: It places people of color at a disadvantage in multiple domains affecting health in ways often more difficult to recognize than explicit interpersonal racism.

Systemic racism is so embedded in systems that it often is assumed to reflect the natural, inevitable order of things.

Systemic racism is so embedded in systems that it often is assumed to reflect the natural, inevitable order of things. Slavery—explicitly supported by laws—endured for 250 years in the United States and was followed by almost 100 years of Jim Crow laws—often enforced by terror—that were deliberately designed to restrict the rights of African Americans, including the rights to vote, work, and get an education. Although civil rights legislation in the 1960s made it illegal to discriminate, enforcement of these antidiscrimination laws has been inadequate.12 Racial inequities, and their ensuing socioeconomic and health consequences, persist because of deeply rooted, unfair systems that sustain the legacy of former overtly discriminatory practices, policies, laws, and beliefs. At times, these systems and structures, which are rooted in beliefs in White supremacy, operate unconsciously or unintentionally, but nevertheless effectively, to produce and sustain racial discrimination. Systemic racism systematically and pervasively puts Black people, Indigenous people, and other people of color at compounded disadvantage within society. It often can be traced to deliberate acts of discrimination in the past, such as laws mandating residential segregation by race. Once in place, however, systemic racism is often self-perpetuating, with persistently damaging effects on health even after the explicitly discriminatory measures are no longer in effect.

The terms systemic, structural, and institutional racism, or closely related concepts, were first used by social scientists. Sociologist David Williams13 and others6,14 have traced the key concepts back to the distinguished social scientist W. E. B. Du Bois, who wrote (around 1900) about how racial discrimination was institutionalized within multiple sectors of society and was self-perpetuating.8 Douglas Massey and Nancy Denton noted the institutionalization of racial discrimination “within large sectors of the American society, including the labor market, the educational system, and the welfare bureaucracy…and racial segregation.”7(p8)

Joe Feagin and Kimberley Ducey wrote: “Systemic racism includes the complex array of antiblack practices, the unjustly-gained political-economic power of whites, the continuing economic and other resource inequalities along racial lines, and the white racist attitudes created to maintain and rationalize white privilege and power. Systemic here means that the core racist realities are manifested in each of society’s major parts…—the economy, politics, education, religion, the family—[reflecting] the fundamental reality of systemic racism.”6(p6)

Eduardo Bonilla-Silva discussed how persistent racial inequality reflects the “continued existence of a racial structure” in society.5(p476) He noted that, in contrast with the Jim Crow period, the structures maintaining contemporary racial oppression “are increasingly covert, are embedded in normal operations of institutions, avoid direct racial terminology, and are invisible to most Whites.”

Examples Of Structural And Systemic Racism

Several examples of systemic racism are presented here. They have been selected on the basis of their importance in perpetuating racial injustice with health implications and for diversity of the sectors and systems involved. Health implications are generally discussed later.

Political Disempowerment

Political disenfranchisement and disempowerment through voter suppression and gerrymandering are an important historical and contemporary manifestation of systemic racism. The legal right for all men to vote was secured in 1870. During the nearly 100-year era of Jim Crow laws, however, voter suppression of Black people was maintained in many states through violent intimidation and selectively applied laws. The Civil Rights Act of 1964 did not eliminate requirements that continue to differentially affect people of color. Even in 2021 many states recently passed or were considering legislation disproportionately restricting the voting rights of people of color,15 including by gerrymandering, the deliberate redrawing of electoral district boundaries to favor the political party in power. Gerrymandering makes some people’s votes count less than others’ do, depriving them of full representation.16


Another historical and current example of systemic racism is racial residential segregation, initially created by the deliberate and explicit racism codified in Jim Crow laws. Although segregation has declined since the Fair Housing Act of 1968 outlawed racial discrimination in housing, the United States remains highly segregated. Racial segregation is almost always accompanied by concentrated economic disadvantage and limited opportunities for upward mobility, such as good employment options and good schools.17 Because of segregation, African American and Latino people are more likely than White people with similar household incomes to live in neighborhoods with concentrated disadvantage, whose adverse health effects have repeatedly been demonstrated, yet most health and medical studies do not include variables representing neighborhood conditions.

Financial Practices

Widespread discriminatory public and private lending policies and practices are another salient instance of systemic racism and have created major obstacles to home ownership and wealth for people of color. Home ownership is the principal form of wealth for most Americans of modest means. Beginning in the 1930s bank lending guidelines from the federal Home Owners’ Loan Corporation were later adopted by private banks. The guidelines explicitly used neighborhood racial and ethnic composition and income data in assessing mortgage lending risks.18 During decades when federal loan programs greatly expanded Whites’ homeownership (and thus, wealth), non-White and low-income areas were disproportionately “redlined”—a practice whose name refers to the red shading on Home Owners’ Loan Corporation maps of neighborhoods that were deemed hazardous for lending. Racial and ethnic differences in homeownership, home values, and credit scores in formerly redlined areas persist.19 Predatory financial services disproportionately target communities of color, adding to the obstacles to their accumulating wealth.20 These include payday lenders and check cashing services, which typically charge excessive fees and usurious interest rates.20 Even when mainstream banking services are available in a segregated community, people of color are often subjected to higher service costs.20 Similar to redlining, these practices create obstacles to home ownership, starting or expanding businesses, accumulating wealth, financing college education, and generating property tax revenues to fund schools.

In addition, the dependence of public schools on local property taxes results in schools in segregated areas often being poorly resourced,21 making it difficult for children to escape from poverty and, as a consequence, ill health as adults. Property tax revenue is lower in segregated areas because of the obstacles to home ownership and wealth mentioned above. Although this example of systemic racism also affects poor White people, it disproportionately affects Black people because systemic racism has produced higher rates of household poverty, lack of wealth, and concentrated community poverty among them.

Environmental Injustice

Environmental injustice is systemic racism with direct health consequences. Racially segregated communities have often experienced the damaging health effects of environmental injustice. Examples include well-documented patterns of selectively locating coal-fired power plants and hazardous waste disposal in or near communities of color, with adverse effects on the population’s health.22 In largely Black Flint, Michigan, in 2014, officials changed the city’s water source to cut costs, inducing the erosion of old lead pipes—with resulting widespread lead poisoning among children. City officials then repeatedly ignored residents’ concerns. The Flint water crisis reflects a long history of segregation, disinvestment in infrastructure, and officials’ ignoring Black residents’ concerns, with devastating long-term health impacts.

Criminal Justice System

The stark racial patterning of incarceration also reflects pervasive discriminatory policing and sentencing practices. Although people of color represent 39 percent of the US population,23 they make up over 60 percent of incarcerated people.24 A 2017 review noted that “nearly one in three black men will ever be imprisoned, and nearly half of black women currently have a family member or extended family member who is in prison.”25 It also described studies linking incarceration to adverse health consequences for both ex-prisoners and their families.25 Mass incarceration permanently stigmatizes people postrelease, blocking employment opportunities. This stigmatization restricts economic opportunities for ex-prisoners and their families and communities throughout their lives, and in some states it also denies them the right to vote.

In addition, police violence is a leading cause of death for young Black men in the United States. Approximately 1 in every 1,000 Black men is killed by police.26,27 Also, Black victims killed by police are more likely than White victims to have been unarmed, suggesting disparate treatment.27 Police killings of Black men have been associated with worse health of entire statewide Black populations.28 Systemic racism includes not only laws and written policies but also unwritten policies and prevailing norms that guide entrenched routine practices. These norms and policies reflect the lives of people of color, particularly Black men, being valued less than the lives of others.

The “school-to-prison pipeline” refers to the phenomenon in which children—mainly, but not exclusively, boys—of color are systematically disciplined more harshly (including suspension and expulsion from school) than other children for behavioral problems warranting counseling and support rather than punishment. Police are more likely to be called into schools to deal with misbehavior by students of color, and suspensions, expulsions, and police involvement greatly raise the risk for incarceration.29,30 This practice is not based on written policies but on pervasive, entrenched discriminatory beliefs and attitudes in the educational system that reflect systemic racism.

Historical Examples

Important historical examples of structural racism include the forcible internment of Japanese Americans in concentration camps that took place during World War II31 and the removal of American Indian children to boarding schools far from their families from throughout the nineteenth century until 1978.32 Serious adverse health consequences of both have been documented.31,32

Data Aggregation

A final example: the Office of Management and Budget mandates the collection and reporting, at a minimum, of five “racial” groups and one “ethnic” group for all federal data: Black or African American, American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, and White (for race), and Hispanic or Latino (for ethnicity).33 Failure to disaggregate race or ethnicity data at least at those federally mandated levels, or failure to reflect substantial diversity within various groupings, can mask critical between- and within-group differences that policies and programs should address.34 Lack of adequately disaggregated data can contribute to the unmet needs of underrepresented populations by rendering them invisible when policies are made, resources are allocated, and programs are designed and implemented; it reflects systemic inequities and, when oppressed or excluded racial or ethnic groups are involved, systemic racism.

Causal Pathways For Health Damages

Decades, even generations, may pass between exposure to systemic racism and evidence of its health damages, obscuring the connection. Research indicates how diverse experiences of racism contribute to racial or ethnic disparities in health by setting in motion various sequential causal pathways. The pathways’ complexity and length often makes it difficult to detect their origins—the underlying but unseen causes.

Appendix exhibit 2 depicts in simplified form a series of sequential general steps (represented by boxes) through which systemic racism is thought to produce racial disparities in health, listing examples of factors often involved at each step.11 Although some factors could be listed in more than one step, we have avoided that for the sake of readability; also not displayed are the many potential interactions among the listed factors (or between listed and unlisted factors) that can aggravate the health damages. Most people of color are affected by multiple factors and pathways. Below we highlight four causal pathways that are examples of how systemic racism can damage health. A more extensive exploration of causal pathways can be found in a Robert Wood Johnson Foundation report on systemic racism.35

Systemic racism can harm health, for example, by disenfranchising people—depriving them of the right to vote or decreasing the weight of their votes. Despite legal emancipation, gerrymandering and voter suppression continue to deprive people of political power, which can lead to or exacerbate all the other health-damaging pathways. Lack of political power produces lack of access to key resources and opportunities needed to be healthy, such as clean water, pollution-free neighborhoods, well-resourced schools, affordable housing, and access to medical care. When people are prevented from voting or when their votes count less, they cannot get elected representatives to act on their behalf.

Systemic racism also can harm health by placing people of color at economic disadvantage. Given the strong and well-documented influence of economic advantage and disadvantage on health,36 racially discriminatory obstacles to economic resources and opportunities are a major pathway through which systemic racism can harm health.37,38 People of color face numerous racism-based obstacles to economic opportunity. As noted earlier, segregation systematically limits their incomes and wealth—for example, through lack of access to good jobs and by facilitating unfair lending practices such as redlining, which have been major obstacles to home ownership and accumulating wealth. Segregation also constrains the next generation’s employment, and hence their economic opportunities—for example, through poorly resourced schools. Lower levels of income, wealth, and education among people of color have repeatedly been shown to be major contributors to racial or ethnic disparities in health.3942

Systemic racism can also lead to poorer health by increasing exposure to health-harming conditions and limiting access to health-promoting resources and opportunities. Economic disadvantage and racial segregation lead to poorer health in part by increasing exposures to health-harming conditions (for example, air pollution, toxic waste, mold in substandard housing, or other environmental hazards). Access to healthy residential conditions can be blocked for economic reasons or by discrimination in housing. Health is also damaged by limited access to health-promoting resources and opportunities (for example, access to educational opportunities and medical care) and by chronic financial strain—the health-damaging chronic stress associated with having to face daily challenges with inadequate financial resources.43 Biased policing and sentencing produce mass incarceration of men of color, resulting both in harmful exposures (for example, violence) while incarcerated and, because of stigmatization, lifelong lack of access to key resources and opportunities needed for health after incarceration.

Finally, systemic racism can lead to poorer health among people of color at all economic levels by exposing them chronically to race-based unfair interpersonal treatment (or the threat thereof); this can produce chronic stress, which has been shown to lead to increased risks for chronic disease.44 Awareness of race-based unfair treatment of others in one’s group could be stressful even if a given individual has not personally experienced an overtly discriminatory incident. It could lead to chronic anxiety and worry about whether personal incidents will occur45 and, potentially, because it reflects social exclusion, hatred or lack of respect for one’s racial or ethnic group. Interpersonal racism could undermine one’s self-esteem—an important indirect influence on health.46

Dismantling Systemic Racism: Examples Of Approaches

Strategies to dismantle systemic racism must give high priority to addressing inequities in the key determinants of health.

Systems, laws, and policies have created racial inequities in health and its determinants; systems, laws, and policies can eliminate those inequities. Strategies to dismantle systemic racism must give high priority to addressing inequities in the key determinants of health—for example, economic security, housing security, educational opportunity, and treatment by the criminal justice system. Appendix exhibit 3 lists a few powerful historical examples of addressing systemic racism.11 Below we present several other examples of approaches to addressing systemic racism, selected on the basis of the literature and judgments about the general kinds of actions that appear to hold promise for reducing racial injustice and thereby advancing health equity.


Enforcing existing antidiscrimination laws is crucial for addressing systemic racism. Although enacting more just new laws and policies and eliminating unjust laws and policies are essential, history has shown that such actions are inadequate without enforcement. This is because widespread and deeply rooted unwritten policies, practices, beliefs, and attitudes allow discriminatory practices to continue even after written laws and policies have changed.5

New Legislation

New legislation is also needed to address systemic racism on multiple fronts. One of the most crucial areas for new legislation, as well as enforcing prior laws, is preventing voter suppression. Preventing voter suppression may require litigation, placing trained personnel at poll sites to witness or deter acts of suppression, assisting people with transportation to polling sites, and providing water and food to prospective voters enduring long lines to cast their ballots.


Advocacy is crucial in any strategy to dismantle systemic racism. Advocacy is needed to build public support for policies pursuing fairness, justice, and equal opportunities for all to achieve health and well-being. Civil society (for example, civil rights, faith-based, health and health care, academic, business, and philanthropic organizations) can play a crucial role in keeping equity on the agenda, advocating for changes in policies and laws, supporting enforcement, and helping identify what is and is not working and changes needed in strategy.

Affirmative Action

Affirmative action and “diversity, equity, inclusion” efforts aim to address centuries of exclusion of people of color from employment, job promotion, and admission to schools and universities. Affirmative action involves fairly considering qualified candidates who previously would have been rejected on the basis of their racial or ethnic group—for example, by considering the obstacles faced by candidates when assessing their strengths and potential to succeed. In response to challenges to affirmative action initiatives, which sometimes have been accused of discriminating against White or Asian people, many institutions have reframed their efforts under the banner of diversity, equity, and inclusion.

Reducing The Damage

Some interventions would repair or reduce the damage that systemic racism has caused. Sometimes called “healing-centered” approaches,47 they include “truth and reconciliation” interventions such as those pioneered in postapartheid South Africa.48 There can be no reconciliation or healing without truth. The horrifying truth about slavery, White supremacy, and historical and ongoing violations of rights must be told in public and private schools, houses of worship, and other public fora, despite the discomfort that it generates. Resistance to antiracism initiatives, including to teaching about racism, must be overcome.

Providing reparations is another approach to addressing systemic racism by reducing the damage it has caused. Reparations for African Americans are a fair and just response to the incalculable harm and suffering caused by centuries of slavery and ongoing violations of rights.49 Reparations could take many forms—for example, investments in kindergarten through college education for all African American children and improvements in communities. Although repairing and reducing the damage caused by systemic racism will not eliminate it, reparations are an important aspect of pursuing justice.

Changing White Attitudes

One widely encountered approach to addressing racism attempts to change the discriminatory attitudes of White people toward people of color, typically through workshops or organizational retreats. Because widely prevalent, entrenched beliefs and attitudes underpin systemic racism, making White people more aware of biases and the harms they inflict may be helpful; furthermore, awareness building may be important for building broad public support for antiracism initiatives. However, because this approach typically focuses on interpersonal racism (overt incidents between individuals) without directly addressing underlying systems or structures, it may most appropriately be an adjunct to rather than a substitute for efforts explicitly targeting systems and structures. Awareness should include understanding by White people of how they have benefited from systemic racism and what they have to gain from living in a more just society.

Addressing Systemic Racism: General Considerations

Addressing systemic racism will require changing systems, laws, policies, and practices in ways that will be effective, endure long-term, and affect many people, instead of implementing piecemeal, time-limited programs that fail to produce sustained or fundamental change. It is far easier to mitigate the harmful effects of systemic racism while leaving in place the unfair systems and structures that produce those effects. Structures whose effects place people of color at a disadvantage must be dismantled.

Opportunities to address systemic racism must be sought wherever public attention is focusing.

Because systemic racism permeates all sectors and geographic areas, effective strategies will require mutually reinforcing actions in multiple sectors and places, from local to national. No single strategy alone is likely to be effective. Effective approaches will activate and support people to vote; learn; speak out to their children, families, friends, and coworkers; organize in their neighborhoods, towns, states, and nation; and support, join, and lead organizations pushing for change. Opportunities to address systemic racism must be sought wherever public attention is focusing—for example, the COVID-19 pandemic and climate change. Vigilance over time will be crucial to detect and oppose actions that would exacerbate systemic racism.

Addressing systemic racism will require continuing and deepening studies of it, revealing the profound and enduring harms it has caused and continues to cause. Ongoing research is essential both to guide action and to build and maintain the political will needed to change unfair systems and structures. To build political will, research findings must be used to educate the public and policy makers about what systemic racism is, the damage it has inflicted and continues to inflict, why dismantling it must be a priority, and how living in a more equitable society can enhance everyone’s lives.


The work for this article was supported by a grant from the Robert Wood Johnson Foundation. The authors gratefully acknowledge Alonzo Plough, the Robert Wood Johnson Foundation; Gail Christopher, the National Collaborative for Health Equity; Gilbert Gee, University of California Los Angeles; and Jamie Riley, Center for Law and Social Policy, for their thoughtful comments on drafts. The Robert Wood Johnson Foundation Issue Brief cited in note 35 provided a basis for this work. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work, for commercial use, provided the original work is properly cited. See https://creativecommons.org/licenses/by/4.0/.


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