Research Topics

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 several ways. In one of our first studies, “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

In another 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

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

In the 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.

We’ve also examined the relationship between long-standing racial disparities in wealth and racial disparities in health. In our study, “Association between racial wealth inequities and racial disparities in longevity among U.S. adults and role of reparations payments, 1992-2018,” we found that differences in wealth between Black and White adults surveyed in the U.S. Health and Retirement Survey can entirely explain Black-White gaps in life expectancy (conditional on making it to age 50). We use these findings to model the potential effects of reparations payments, one policy that has been suggested as a means to address racial wealth gaps. Our back-of-the-envelope calculations suggests that reparations payments could close anywhere between 62-100% of the existing racial longevity gap.

Figure 4. Impact of Reparations Policies on Racial Longevity Gaps

We are currently building on this work on several fronts. In an National Institutes of Health-funded project led by our lab’s Alexander Tsai and Atheendar Venkataramani, we are examining how police use of deadly force contributes to racial disparities in sleep health. In a Robert Wood Johnson Foundation Policies for Action (P4A)-funded project, led by Atheendar Venkataramani, Courtney Boen, and Hedwig Lee, we are investigating the effects of state-level sentencing and incarceration policies on racial disparities in physical and mental health from birth to young adulthood.

In addition to identifying drivers of racial disparities in health, we are also hard to identify scalable solutions. We are collaborating with Eugenia South and the Penn Urban Health Lab to design, implement, and test a multi-component, “big-push” intervention to improve health in Black communities in Philadelphia. This intervention, funded as part of the National Institutes of Health’s historic Transformative Research to Address Health Disparities and Advance Health Equity initiative, aims to achieve a larger and more durable narrowing of the racial health gap by addressing both environmental and economic factors contributing to poor health in Black neighborhoods.