The term structural racism emphasizes the most influential socioecologic levels at which racism may affect racial and ethnic health inequities. Structural racism is defined as the macrolevel systems, social forces, institutions, ideologies, and processes that interact with one another to generate and reinforce inequities among racial and ethnic groups ( Powell 2008).

Policies and interventions that change the iceberg’s tip may do little to change its base, resulting in structural inequalities that remain intact, though less detectable. The portion of the iceberg that lies below the water represents structural racism it is more dangerous and harder to eliminate. The tip of the iceberg represents acts of racism, such as cross-burnings, that are easily seen and individually mediated. The metaphor of an iceberg is useful for describing the levels at which racism operates ( Gee et al., 2009). Researchers have long argued that racism operates at multiple levels, ranging from the individual to the structural ( Carmichael and Hamilton, 1967 Jones 2000). The more fundamental and broad-reaching aspects of structural racism remain under-studied.

Yet, self-reported measures have their limitations and they disproportionately focus on individual experiences ( Krieger 1999). These associations are seen among many racial/ethnic minority populations, including African Americans ( Mays et al., 2006) American Indians ( Chae and Walters, 2009), Arab Americans ( Padela and Heisler, 2010), Asian Americans ( Gee et al., 2009), and Latinos ( Araujo and Borrell, 2006). Reviews consistently find that persons who self-report exposures to racism have greater risk for mental and physical ailments ( Brondolo et al., 2009 Williams and Mohammed, 2009). The updated Healthy People 2020 lists discrimination and residential segregation as examples of social determinants of health. As James (2008) argues, “the elimination of disparities-the magnificently democratic goal of Healthy People 2010- cannot be achieved without first undoing racism” (p. Racism may be one explanation for many of the health disparities identified in Healthy People 2010, the compendium of the nation’s health objectives. The serious study of racism and health did not gain traction until the 1990s, but now this body of work has become more commonplace. Two decades ago, Becker (1986) noted the reluctance to address structural factors: “Doing something about poverty, racism … involves notions of planned social and economic change, alternations not likely to be achieved by lowering the public’s cholesterol level” (p. Given that racism shapes the lives of people of color, it seems not only reasonable but necessary to study the hypothesis that racism influences health inequities. Despite this promising introduction, the report failed to develop this theme further. For instance, in 1985, the influential Report of the Secretary’s Task Force on Black and Minority Health alluded to racism in stating, “Blacks, Hispanics, Native Americans and those of Asian/Pacific Islander heritage have not benefited fully or equitably from the fruits of science or from those systems responsible for translating and using health sciences technology” ( Heckler 1985, p. There have been many similar accounts since then, but little attention to racism’s role. He noted, “The Negro death rate and sickness are largely matters of condition and not due to racial traits and tendencies” (p. Du Bois (2003) recognized the connection between societal inequities and health inequities, raising several central arguments related to racism, poverty, and other social problems. Health inequities are seen in many outcomes, including infant mortality, heart disease, and cancer ( Sondik et al., 2010). Studies of disparities should more seriously consider the multiple dimensions of structural racism as fundamental causes of health disparities. This article reviews several ways of conceptualizing structural racism, with a focus on social segregation, immigration policy, and intergenerational effects. The structural forms of racism and their relationship to health inequities remain under-studied.

Yet, the health of social groups is likely most strongly affected by structural, rather than individual, phenomena. While this body of research has been invaluable in advancing knowledge on health inequities, it still locates the experiences of racism at the individual level. Recent studies have documented that individuals who report experiencing racism have greater rates of illnesses. These inequities might be explained by racism, given the fact that racism has restricted the lives of racial minorities and immigrants throughout history. Racial minorities bear a disproportionate burden of morbidity and mortality.

Legacy racial tyranny