Structural racism and health in the age of COVID-19: A selective review with policy implications

Structural racism encompasses the effects of racial bias across all systems of society. A growing body of data indicates that structural racism contributes to racial inequities in health across the lifespan. Investigators have documented associations of different dimensions of structural racism, including cultural and institutional discrimination, to health. To clarify and integrate the scope of these data, we examine a broad array of manifestations of both cultural and institutional racism and review their associations to specific health effects outcomes. We examine effects on COVID-19 prevalence and mortality, but also investigate data on birth outcomes and premature mortality to gain insight into health effects at each end of the lifespan. Given the pervasive and well-documented history of racism facing Black Americans, we focus this review on the effects of structural racism on the health of Black populations in the United States.To examine the association of cultural discrimination to health, we review studies of prejudicial communications assessed with measures of area-level prejudice, leader communications of prejudice, and reactions to race-related cultural events. To examine the association of institutional discrimination to health, we examine laws and institutional policies that discriminated against Black Americans and shaped social and physical environments characterized by residential racial segregation and disadvantage, occupational segregation, and restricted voting rights, among other manifestations of inequity. As we document, research has demonstrated associations of cultural racism to birth outcomes and mortality, data are lacking on direct relations to COVID-19 mortality. Institutional discrimination has been consistently linked to the increased prevalence of and mortality from COVID-19, and some aspects are associated with birth outcomes and mortality. Understanding the interrelations among cultural and institutional aspects of discrimination and their historical roots have important implications for the development of policies and interventions to reduce structural racism and mitigate its effects on health.