Opportunity for Health

Structural Racism and Health Disparities

We know that access to the American Dream depends greatly on race, ethnicity, and gender. We also know that underrepresented minority populations tend to have worse health outcomes on a variety of measures. Are barriers to upward mobility faced by these populations a potential driver of their poorer health outcomes?

We have explored this question in three studies thus far. In the first, “Structural racism, economic opportunity, and racial health disparities: Evidence from U.S. counties” (2020), we used newly released county-level race- and gender-specific data on economic opportunity (measured as the income a child in a poor household could expect to make as an adult) to assess correlations between racial gaps in economic opportunity and adult mortality. Focusing on Black Americans and Whites, we found a correlation between the racial opportunity gap and the racial mortality gap across U.S. counties.[1] These results suggest that the racial opportunity gap may serve as a useful marker of structural racism, defined by Dr. Rachel Hardeman and colleagues as the “confluence of institutions, culture, ideology, and codified practices that generate and perpetuate inequity among racial and ethnic groups.” We intend to use this measure in future work.

Figure 1. Racial mortality gap and racial opportunity gap across U.S. Counties

Racial mortality gap and racial opportunity gap across U.S. Counties total populations weights (A) and black only population weights (B)

In a second study, “College Affirmative Action Bans and Smoking and Alcohol Use Among Underrepresented Minority Adolescents: A Difference-in-Differences Study” (2019), we assessed how public programs that ostensibly shift real or perceived economic opportunities for racial and ethnic minorities affected health behaviors. We focused on college affirmative action programs, which have long sought to alleviate some of the inequalities present in today’s society that hurt underrepresented minorities. However, between 1996 and 2013, nine U.S. states banned race-based affirmative action in college admissions. These bans reduced the likelihood of minority students attending top colleges and thus may have curtailed their future expectations and economic opportunities. We examined whether banning affirmative action policies, by worsening economic opportunity, led to health behaviors among underrepresented minority adolescents.

Using data from the 1991-2015 US national Youth Risk Behavior Survey (YRBS), we conducted a natural experiment comparing smoking and alcohol use among minority 11th and 12th graders before and after ban implementation, using states that did not implement bans as controls. We found that in states with an affirmative action ban, underrepresented minority 11th and 12th graders reported increased rates of risky behaviors compared to peers in states without a ban, including a 3.8% increase in smoking.[2] The impacts on high-school student health behaviors is consistent with other research showing how affirmative action policies affect educational performance, college attendance, and earnings in adulthood.

Figure 2. Affirmative action bans and health risk behaviors

College affirmative action programs give preferential admissions consideration to underrepresented minorities (Blacks, Hispanics, Native Americans) to address historical discrimination. While these policies are intended to expand educational and economic opportunities, they remain controversial. Between 1996 and 2013, nine states banned affirmative action in higher education. This study builds on previous research on the impact of economic opportunity on health behaviors by analyzing whether banning affirmative action is associated with risky behaviors in underrepresented minority teens.

College affirmative action bans were associated with higher rates of smoking and drinking in underrepresented minority 11th and 12th graders, and these students continued to smoke at higher rates into young adulthood. Policymakers should consider unintended public health consequences of proposals, such affirmative action bans, that may limit socioeconomic opportunities.

Figure 3. Changes in poor mental health days associated with exposure to police killings by race of police killing victim, whether the victim was armed, and race of the BRFSS respondent

Each estimate in this figure is derived from a separate regression. See appendix for full estimates. BRFSS=Behavioral Risk Factor Surveillance System. *Primary analysis.

In a third study, “Police killings and their spillover effects on the mental health of black Americans: a population-based, quasi-experimental study” (2018), we further examined how opportunity-limiting structural racism may causally impact health. Specifically, we examined the broader mental health consequences of police killings of unarmed black Americans—events which are thought to arise as a result of systemic racism. By connecting self-reported mental health data from the 2013-2015 US Behavioral Risk Factor Surveillance System (BRFSS) with data on police killings from the crowdsourced Mapping Police Violence (MPV) database, we found that police killings of unarmed Black Americans had substantial negative effects for individuals living in the same state[3]—the majority of whom would have had no direct relationship to the victim of the police killing. The negative mental health consequences of police killings were borne only by Black Americans and specific to instances where the victim was Black American and deemed unarmed. The size of the estimates suggest that the total population burden of mental illness accruing from police killings of unarmed Black Americans is similar in magnitude from the burden of mental illness that accrues from a widely prevalent disease like diabetes. This study, whose findings have been confirmed by other scholars, highlights the role that structural racism plays in generating racial disparities in health.

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