Racism in work place

STRUCTURAL RACISM AND HEALTH INEQUITIES: Old Issues, New Directions1

Gilbert C. Gee and School of Public Health, University of California, Los Angeles

Chandra L. Ford School of Public Health, University of California, Los Angeles

Abstract

Racial minorities bear a disproportionate burden of morbidity and mortality. These inequities

might be explained by racism, given the fact that racism has restricted the lives of racial minorities

and immigrants throughout history. Recent studies have documented that individuals who report

experiencing racism have greater rates of illnesses. 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. Yet, the health of social groups is likely most strongly affected by structural,

rather than individual, phenomena. The structural forms of racism and their relationship to health

inequities remain under-studied. This article reviews several ways of conceptualizing structural

racism, with a focus on social segregation, immigration policy, and intergenerational effects.

Studies of disparities should more seriously consider the multiple dimensions of structural racism

as fundamental causes of health disparities.

Keywords

Racism; Discrimination; Health Disparity; Race; Ethnicity; Immigrant; Social Determinants; Inequity

INTRODUCTION

Health inequities among racial minorities are pronounced, persistent, and pervasive (Sondik

et al., 2010). Racism may be one cause of these inequities. Studies find that individuals who

report experiencing racism exhibit worse health than people who do not report it (Williams

and Mohammed, 2009). While this line of research has been invaluable in shifting the

discussion from innate differences in biology or culture to social exposures, it is limited by

inadequate attention to the multiple dimensions of racism, particularly structural racism. The

1The authors thank Kaori Fujishiro, the guest editors, and several anonymous reviewers for invaluable comments on an earlier draft of this manuscript. The authors acknowledge support from the California Center for Population Research at the University of California at Los Angeles.

© 2011 W. E. B. Du Bois Institute for African and African American Research

Corresponding author: Gilbert C. Gee, Department of Community Health Sciences, UCLA School of Public Health, 650 Charles E. Young Drive South, Los Angeles, CA 90095. [email protected].

NIH Public Access Author Manuscript Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

Published in final edited form as: Du Bois Rev. 2011 April ; 8(1): 115–132. doi:10.1017/S1742058X11000130.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

goal of this article is to encourage new research on forms of structural racism that may

contribute to health inequities.

RACISM AND HEALTH INEQUITIES

Health inequities are seen in many outcomes, including infant mortality, heart disease, and

cancer (Sondik et al., 2010). A century ago, W. E. B. Du Bois (2003) recognized the

connection between societal inequities and health inequities, raising several central

arguments related to racism, poverty, and other social problems. He noted, “The Negro

death rate and sickness are largely matters of [social and economic] condition and not due to

racial traits and tendencies” (p. 276). There have been many similar accounts since then, but

little attention to racism’s role. 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. 1). Despite this promising

introduction, the report failed to develop this theme further.

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. 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. 19).

The serious study of racism and health did not gain traction until the 1990s, but now this

body of work has become more commonplace. Racism may be one explanation for many of

the health disparities identified in Healthy People 2010, the compendium of the nation’s

health objectives. As James (2008) argues, “the elimination of disparities—the

magnificently democratic goal of Healthy People 2010— cannot be achieved without first

undoing racism” (p. S16). The updated Healthy People 2020 lists discrimination and

residential segregation as examples of social determinants of health.2

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).

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). Yet, self-reported measures have their limitations and they

disproportionately focus on individual experiences (Krieger 1999). The more fundamental

and broad-reaching aspects of structural racism remain under-studied.

Structural Racism

Researchers have long argued that racism operates at multiple levels, ranging from the

individual to the structural (Carmichael and Hamilton, 1967; Jones 2000). The metaphor of

2See http://healthypeople.gov/2020/about/DOHAbout.aspx.

Gee and Ford Page 2

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

an iceberg is useful for describing the levels at which racism operates (Gee et al., 2009). The

tip of the iceberg represents acts of racism, such as cross-burnings, that are easily seen and

individually mediated. The portion of the iceberg that lies below the water represents

structural racism; it is more dangerous and harder to eliminate. 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.

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). The term structural racism emphasizes the most

influential socioecologic levels at which racism may affect racial and ethnic health

inequities. Structural mechanisms do not require the actions or intent of individuals (Bonilla-

Silva 1997). As fundamental causes, they are constantly reconstituting the conditions

necessary to ensure their perpetuation (Link 1995). Even if interpersonal discrimination

were completely eliminated, racial inequities would likely remain unchanged due to the

persistence of structural racism (Jones 2000). In the next section, we describe a few

examples of structural racism and their potential connections with health inequities.

STRUCTURAL RACISM: SELECTED EXAMPLES

Social Segregation

Segregation refers to the separation of social groups. Most research on segregation and

health disparities examines racial residential segregation, the geographic separation of racial

groups’ homes. A recent review identified thirty-nine studies that tested associations

between segregation and health outcomes (Kramer and Hogue, 2009). Residential

segregation remains pervasive and may influence health by concentrating poverty,

environmental pollutants, infectious agents, and other adverse conditions (Gee and Payne-

Sturges, 2004; Williams and Collins, 2001). For instance, Morello-Frosch and Jesdale

(2006) found that segregation increased the risk of cancer related to air pollution. Studies

using multilevel modeling that simultaneously accounts for individual and structural factors

also find associations between segregation and illness (Bell et al., 2006; Subramanian et al.,

2005).

Segregation within schools, workplaces, and health care facilities may also contribute to

health disparities. For example, Walsemann and Bell (2010) found that school segregation is

related to health behaviors (e.g., alcohol use) among students. Just as importantly, they

found that segregation was associated with decreased educational aspirations among Black

males. An innovative feature of their work is the focus, not on the uneven distribution of

students across schools, but on segregation within the curriculum (i.e., racial disparities in

enrollment in advanced vs. less advanced courses). Hence, it is not only the composition of

students that may create health disparities but also the design of the curriculum.

Similarly, while de jure segregation of drinking fountains is now illegal, de facto

segregation of water coolers in offices continues because of workplace segregation.

Segregation of workplaces tracks minority workers into jobs with fewer benefits and more

dangers (Elliott and Smith, 2001). For instance, Angelon-Gaetz et al. (2010) found that not

Gee and Ford Page 3

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

only were Black workers segregated from Whites at a federal nuclear weapons site, but also

that Black workers had a greater level of radiation exposure. Racial and ethnic segregation

may also occur by immigration status. De Castro et al. (2006) reported that immigrant

employees often work in segregated environments that are dangerous (e.g., buildings with

no fire exits) and stressful (e.g., no breaks at work). They even encounter blatantly illegal

actions by their employers, including not being paid for work and systematic manipulation

of work hours to avoid compensation for overtime. Other research shows that physical

hazards and stressors are related to numerous health problems, including heart disease

(Darity 2003).

The Civil Rights Act of 1964, in combination with many grassroots efforts to enforce it,

helped reduce hospital segregation (Quadagno 2000). After the integration of Mississippi

hospitals, Black-White disparities in infant mortality were cut in half in just six years

(Almond et al., 2006). Despite these signs of progress, segregation within the health care

system continues. Clarke et al. (2007) found substantial segregation in hospitals in

Pennsylvania and Virginia; about 58% of Black and White patients admitted for acute

myocardial infarction in Pennsylvania would have to switch hospitals to achieve integration.

A similar level, 53%, is apparent for hospitals serving elderly Medicare patients nationwide

(Smith 2005). Segregation in nursing care may also remain a significant issue (Smith et al.,

2007). Relatively little work has focused on contemporary segregation in health care, and

the findings appear to be complex; segregation may increase or decrease the use of services,

depending on the types of services and communities considered (Gaskin et al., 2009).

The segregation of social networks may contribute to racialized patterns in the spread of

infectious diseases (Freeman 1978). Disparities in the spread of some diseases reflect

existing patterns of social isolation in which Blacks are more socially segregated than

members of other groups are. In groundbreaking work that redirected researchers from

hypothesizing that disparities in sexually transmitted diseases (STDs) are due to some yet

unexplained behavioral or other characteristic of Blacks, Laumann and Youm (1999) found

that segregation in social and sexual networks—not high rates of risky sexual behavior

among Blacks as had previously been assumed—explained racial disparities in STDs. This

also suggests that disparities in the spread of disease can partially reflect existing patterns of

social segregation.

Future Research Regarding Social Segregation

First, researchers should study the various types of segregation and their potential connections to health disparities—As a general phenomenon, segregation

influences health by simultaneously isolating racial groups from one another and by

concentrating exposures and resources. This rationale has been well articulated for

residential segregation (Acevedo-Garcia 2000; Gee and Payne-Sturges, 2004; Williams and

Collins, 2001) but can be extended to other forms of segregation. Studies should continue to

test the general hypothesis that segregation is related to illness and health disparities. Just as

important, studies should examine the mediating mechanisms. For instance, is workplace

segregation related to heart disease? Is this relationship due to exposure to physical hazards,

Gee and Ford Page 4

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

psychosocial stress, diminished wages, lack of insurance, or some combination of these

factors?

Second, research should consider interactions across these different forms of segregation—Little work has documented how segregation occurs across contexts and

how different types of segregation may interact with one another to influence health. For

instance, are individuals who live in residentially segregated communities and work in

segregated worksites at “double jeopardy” of illness? Creating a holistic index of

“segregated life” may be useful for summarizing multiple contexts of segregation. This

index could be constructed at specific points in time, and across the entire life course, to

evaluate how segregation can influence trajectories of social disadvantage and health

disparities.

Third, studies should attend to scale—The processes that generate segregation and

health effects likely differ by the level of analysis. This is most clearly conceptualized with

regard to residential segregation. Reardon et al. (2009) found that Black-White segregation

declined at the microlevel (local neighborhoods) from 1990–2000. Yet, this microlevel

decline was not seen at the macrolevel; metropolitan segregation remained relatively stable

(Reardon et al., 2009). These findings suggest that local level changes may yield little effect

on the broader distributions of power and resources. Thus, despite the growing interest in

neighborhood effects, it remains an important unanswered question whether local

neighborhoods are necessarily the best unit of analysis or the appropriate place to intervene

on health disparities (Kramer and Hogue, 2009). These arguments about scale can be

generalized to other settings: For instance, to what extent are disparities generated within

segregated worksites versus across segregated occupations?

Measures that allow for variations in scaling, such as the spatially modified information

theory index (Lee et al., 2008) provide a novel way of considering segregation beyond

traditional measures. These measures can allow for the decomposition of effects across

various levels and are encouraged for future research.

Immigration Policy

Immigration policy provides another form of social segregation. Since its inception, U.S.

immigration policy has defined racial groups, reinforced the social hierarchy, and influenced

the health of populations. A critical aspect of immigration policy is its connection to

citizenship and privileges, such as the ability to vote in federal elections.

The exclusion of non-Whites from citizenship has been a defining characteristic of U.S.

immigration policy. The 1790 Naturalization Act, which specified some of the earliest rules

for citizenship, only allowed free Whites to apply. As Table 1 shows, the nation’s racial and

ethnic composition and restrictions on the rights of racial minorities were heavily influenced

by immigration policy. Boswell (2003) argues, “Every group which struggled against

oppression in the United States had to, in effect, ‘become White’ because Whiteness was the

measure of full membership in the American community. As a legal matter, in order for an

immigrant to naturalize he would have to be White” (p. 319).

Gee and Ford Page 5

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

The restriction of immigration and defense of White-only citizenship came from many

sectors, including public health and medicine; these sectors have been integral in supporting

racialized immigration policy by providing “scientific evidence” in support of such policies

(Barkan et al., 2008). A major rationale for excluding non-Whites has been that immigrants

and minority races are—by nature— unclean, diseased, unintelligent, and morally

degenerate (Barkan et al., 2008; Park 2004). The development of germ theory showed that

illnesses can spread across populations. Because the origins of many health and social

problems were largely unknown, this theory was broadened to include many other issues

that we would today not consider infectious, such as “insanity” and poverty. These ideas led

to fears that immigrants and minorities would infect the “good people” and, thus, should be

controlled. As Molina (2006) noted, “By the 1870’s, public health officials had sufficient

credibility to construct what being ‘Chinese’ meant—namely, dirty, depraved and disease

ridden. These stereotypes in turn justified segregating Chinese people so that they would not

taint White city residents” (p. 26).

These fears, rationalized by social Darwinism and germ theory, were operationalized

directly into immigration control. For instance, concerns over the influx of undesirable

persons were evident when Congress established the first Bureau of Immigration in 1906

and disqualified individuals with “loathsome” or “dangerous” diseases, “moral turpitude”

and other vices, or persons who were likely to become public charges. Physicians were

enlisted to screen for these traits. The Immigration Restriction League, a group tied to the

eugenics movement, successfully lobbied Congress in 1917 to require that immigrants pass a

literacy test (Wright 2008).

Anti-immigrant actions became increasingly restrictive throughout most of the nineteenth

century (Table 1). These actions included redefining the racial category of “White,”

imposing quotas, retroactively removing citizenship, and deportation (Wright 2008). Federal

policies were not reversed until the Immigration and Naturalization Act of 1965, which

removed many (but not all) of the past barriers. Since then, however, commentators have

suggested that immigration reforms have been backsliding (Boswell 2003).

Minority groups challenged many of the restrictive policies in U.S. courts throughout the

1900s, but with little success. A lasting consequence of these challenges was the “plenary

power doctrine,” whereby the judiciary defers to Congress in matters of naturalization and

citizenship (Chae Chang Ping v. United States in 1889 provided an important precedent for

this deference). This means that immigrants must “rely on the beneficence of the legislative

branch in order to obtain relief. This leaves noncitizens with very few choices or avenues for

garnering protection … they cannot exert their power at the ballot box or in the courts”

(Boswell 2003, p. 339).

It is sobering to realize that immigration control today retains many of the actions (e.g., the

use of quotas, screening for undesirable traits, exclusion of those likely to be public charges)

developed during one of America’s most xenophobic and racist periods. Today, the

emphasis has shifted, but in many ways, the effect is the same. The tenor of discussions

around securing our borders continues to have racial overtones. The term “illegal aliens”

Gee and Ford Page 6

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

often implies persons from Mexico and Central America, while “terrorist” often connotes

persons from the Middle East (Nacos and Torres-Reyna, 2006; Nevins 2002).

Hence, immigration policy is a form of structural racism: exclusionary policies provide the

most permanent and broad-scale type of segregation by prohibiting groups from entering the

country, deporting those already here, and limiting the rights of those deemed to be threats.

Immigration policy influences health disparities in several ways. First, these policies can

contribute directly to our understanding about population health. For instance, foreigners

applying for entry into the United States are required to pass a medical exam that screens for

certain infectious diseases, substance use, and mental disorders. This screening not only

denies entry for those who are less healthy but also may serve as a deterrent for some

contemplating migration. Thus, these policies can contribute to the “healthy immigrant

effect,” the finding that immigrants generally have lower morbidity than non-immigrants.

These screening policies would also distinguish documented from undocumented

immigrants. By definition, undocumented immigrants do not undergo the medical screening,

and hence, should show less healthy selection than documented immigrants. The literature

generally suggests that undocumented immigrants fare worse than documented immigrants

because of socioeconomic factors, but the screening practices may play an independent and

complementary role. Consistent with this argument, Kelaher and Jessop (2002) found that

undocumented Latinas were more likely to have a low-birth-weight infant than documented

Latinas, even after accounting for education, country of origin, and other risk factors. Future

studies using a similar approach could quantify the contribution of these screening practices

on health estimates.

Historic policy can influence some key “facts” about several racial or ethnic groups. For

instance, historic restrictions on Asian immigration affect our inferences about Asian

Americans today. Had these policies not been established, the current-day Asian American

population would likely be numerically larger. This implies that part of the current-day data

gaps for Asian Americans is due to historically racist policies. Furthermore, there would be

presently a greater proportion of nonimmigrant Asians (currently, 76% of Asian Americans

are immigrants). Because non-immigrants generally have higher morbidity than immigrants,

it is possible that current health estimates for Asian Americans would show greater

morbidity.

Current policies that place greater scrutiny on persons from Middle-Eastern countries and

other “undesired” places may have similar effects. That is, structural racism in the form of

restrictive policies directly influences population size, our inferences about health, and the

resources available for the study of a given population. Hence, health statistics that show an

immigrant advantage and/or an economic paradox should consider that these estimates are

not simply a neutral or natural phenomenon, but they also partially reflect the legacy of

racially discriminatory policies. For the sake of completeness, researchers studying the

healthy immigrant effect and similar phenomena should use a broad historical lens that

incorporates the legacy of immigration policy.

Gee and Ford Page 7

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

Second, some policies impact immigrants’ access to health and other social services, both directly and indirectly—For instance, the Deficit Reduction Act of

2005 required that Medicaid applicants provide documentation of citizenship; this

requirement appears to have contributed to a decrease in insurance coverage among

noncitizens (Sommers 2010). The 2010 Affordable Care Act continues this trend of

excluding undocumented immigrants and imposing restrictions on documented immigrants.

Research on the 1996 Personal Responsibility and Work Opportunity Act (PRWORA)

suggests that these policies exert not only direct effects via means testing but also indirect

effects through discouragement. PRWORA’s restriction of the eligibility of immigrants for

Medicaid and Temporary Aid to Needy Families (TANF) was associated with a 10%

increase in the uninsured among low-educated, foreign-born single women (Kaushal and

Kaestner, 2005). Moreover, PRWORA’s effect on immigrant uninsurance was seen even in

states that provided alternative sources of coverage. This suggests that legislation can harm

immigrants, not only directly via eligibility standards but also indirectly via a climate of

fear, even among those legally eligible to receive services.

Third, the broader anti-immigrant climate can contribute to experiences with discrimination, stress, and illness—For instance, Lauderdale (2006) documented an

increased risk of preterm birth and low birth weight among Arab-named women following

the September 11 attack. No increase was seen among other women, and this disparity was

attributed to a climate of anti-Arab sentiment. This study raises numerous questions about

how the current immigration legislation arising from Arizona (Senate Bill 1070) and other

states may contribute to health outcomes among Latinos. Arizona SB 1070 requires that

immigrants have registration documents in their possession at all times and encourages

police to check for a person’s immigration status if there is “reasonable suspicion” that the

person is an illegal alien during a “lawful stop, detention, or arrest.” Criticism maintains that

the legislation leads to racial profiling, particularly among Latino populations. The bill is

currently being challenged in court. Regardless of whether the bill is ultimately upheld, it

would be of interest to see if the climate that the bill generated contributes to poor health

outcomes among Latino populations.

More generally, racism may manifest as xenophobia. Experiences of racism based on

language and nativity can be just as important as experiences based on race (Viruell-Fuentes

2007; Yoo et al., 2009). Latino and Asian immigrants were more likely than non-immigrants

to report discrimination in health care (Lauderdale et al., 2006). Yet, few existing

instruments of racism explicitly account for anti-immigrant sentiment, potentially

understating the level of concern for immigrant communities (Gee et al., 2009). The

literature is replete with research on acculturation and health, but these studies may fail to

account for discriminatory experiences faced by immigrants (Finch et al., 2004; Viruell-

Fuentes 2007). Proxies for acculturation, such as years in the United States, can indicate not

only cultural adaptation but also exposure to racial bias (Gee et al., 2009). Hence, studies of

immigrants should do a better job of accounting for racism, and vice versa.

Fourth, research should investigate disparities not only by race and ethnicity but also by citizenship—Noncitizens were more likely to report discrimination in health

Gee and Ford Page 8

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

care and less likely to have health insurance and a usual place for care than citizens (Yu et

al., 2006). Noncitizens often work in occupations without insurance benefits (Goldman et

al., 2005). The literature on citizenship and health has focused on access to health care. Yet,

it is important to acknowledge that citizenship extends far more deeply into fundamental

rights, such as the ability to vote. Scholars have recognized that studies of race and health

must also consider socioeconomic position (Krieger et al., 1997). We believe this argument

should be extended to nativity and citizenship.

We should also develop a more granular analysis between immigrant types. This can take

several forms, including between documented versus undocumented migrants, between

citizens and noncitizens, and even within classes of legal noncitizen immigrants. For

instance, it is unknown whether there are disparities across different classes of visa holders,

such as between those who hold an H-1B visa (professionals, such as accountants) versus

those with an H-2B visa (non-agricultural seasonal/ temporary workers). While it is a

concern that individuals may be reluctant to provide such information, the California Health

Interview Survey has shown that undocumented persons from Mexico are willing to provide

this information under the right circumstances (Ortega et al., 2007).

Regardless of identity or social status in their countries of origins, immigrants are often

viewed on the basis of their fit within the United States’ existing racial hierarchies. Ford and

Harawa (2010), therefore, proposed that ethnicity be conceptualized as a two-dimensional

construct in research on health disparities: an attributional dimension that describes

characteristics (e.g., culture) of the group to which one is socially tied, and a relational

dimension that indexes a group’s location (e.g., minority vs. majority status) within the

social hierarchy. According to this model, immigrants racialized as Black (e.g., Haitians)

may have different experiences and trajectories than those considered non-Black (e.g.,

Cuban). This pattern may hold within groups: for example, among darker-skinned Latinos

(e.g., Puerto Ricans) and lighter-skinned Latinos (e.g., Spaniards) (Borrell 2005).

Therefore, we suggest that studies should: (1) take a historical lens that incorporates

structural racism when interpreting contemporary health statistics; (2) continue to document

how immigration legislation directly influences one’s access to social resources (e.g., health

insurance) and indirectly contributes to a climate of uncertainty and fear that could influence

health disparities; and (3) focus more directly on citizenship and examine heterogeneity

across and within immigrants.

Intergenerational Drag

A comprehensive research program on racism and health must account for key ways that

historical factors influence present outcomes. The racist actions and inequities experienced

by one generation may be felt across subsequent generations. Indeed, key characteristics of

structural forms of racism (e.g., policies) include that they (1) persist over time, (2) adapt to

new sociopolitical contexts as they unfold, and (3) impact population level patterns of

disease more fundamentally than do proximal factors (Bonilla-Silva 1997). Seemingly

inexplicable disadvantages that persist across conditions, subpopulations, and time may be

attributable to historical traumas (Brave Heart and DeBruyn, 1998), or to what some have

called intergenerational drag.

Gee and Ford Page 9

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

The intergenerational drag hypothesis posits that “Ethnic or racial groups pass social assets

and liabilities on to their descendants” (Darity et al., 2003, p. 439). Intergenerational drag

views contemporary disparities as the cumulative effects of macrolevel systems interacting

with one another in ways that generate and sustain racial inequalities. Intergenerational drag

research attempts to determine what fraction of a contemporary disparity is attributable to an

historical event. It examines not only the losses of one group but also the corresponding

gains by another group.

Prior research on intergenerational drag has focused on how factors such as educational

attainment or wealth of one generation contribute to population level socioeconomic

disparities in a subsequent generation (Heckman and Payner, 1989; Margo 1990). Studies

have also examined whether racially differential allocations of resources during the U.S.

antebellum period have had lasting impacts on Black-White differences in socioeconomic

status (Sacerdote 2005; White 2007). This type of research helps in assessing the long-term

effects of policies and other societal characteristics on disparities. Margo’s (1990) seminal

study demonstrated that structural racism played an important role in the intergenerational

transmission of educational disparities in the South. Census data reveal an initial and

dramatic reduction in states’ investments in schools for Black children in the late nineteenth

century. Following this initial reduction, literacy rates steadily increased for Black children

through the mid-twentieth century. Disparities in the quality of the educational opportunities

available to Black relative to White children persisted, however. Margo concludes that

Black-White educational disparities of the mid-twentieth century were attributable to the

cumulative effects of four intersecting factors: poorer quality schools for Blacks; demands

for Black labor; activism by Whites in the early 1900s against Blacks’ education; and

activism by educated Blacks after the 1940s for more investment in Blacks’ education

(Margo 1990).

While this literature generally suggests that past events can have material consequences for

subsequent generations (Collins and Margo, 2001; Heckman and Payner, 1989), few studies

target health outcomes or health disparities. Applying intergenerational drag approaches to

the study of health disparities could help to clarify how contemporary mechanisms, baseline

differentials between groups, and the cumulative accrual of advantages and disadvantages

from one generation to the next influence various health disparities.

The idea of intergenerational drag provides an empirical foundation for the study of

historical trauma, the “soul wounds” against an entire community that occur from events

such as theWounded Knee Massacre or the Holocaust (Brave Heart and DeBruyn, 1998).

This idea is also consistent with a growing body of theoretical and empirical work on life

course and health. This evidence indicates that health outcomes vary depending on the

developmental stage(s) at which exposures occur, and that biological or social factors

inherited from parents or grandparents can influence an individual’s health. For instance,

research indicates that stressors encountered by parents while an infant is in utero may

increase the risk of heart disease and other illnesses when the child becomes an adult

(Barker 2002; Seckl and Holmes, 2007). Other studies suggest that environmental traumas,

such as famine, may alter gene expression in subsequent generations (Pembrey et al., 2005).

Gee and Ford Page 10

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

Diverse theory-based strategies may be used to model intergenerational trends. The simplest

models specify a standard rate of change across multiple generations. To improve the

precision and accuracy of overall estimates, however, one may specify a different rate of

transfer for each generation. Consider the post-World War II period when the government

assisted veterans in purchasing homes. The amount needed to purchase a home and the

resultant net wealth transferable to the next generation differed substantially during this

period from either the period preceding or following it. These ideas could be extended to

health disparities. For instance, studies could examine how racial disparities in the transfer

of wealth across generations contribute to inequities in morbidity.

In addition, the rates should be calculated with baselines that carefully consider potentially

important racialized events. Some of these baselines may refer to specific historic events.

For example, using a baseline of 1865 (i.e., the formal end of U.S. enslavement of Blacks),

researchers have estimated the proportion of current Black-White wealth inequalities that are

attributable to differences in wealth at emancipation (White 2007). Other baselines may

represent specific traumatic events (e.g., the Wounded Knee Massacre). At the same time,

these events may serve as the focus for the investigation of period-specific events (see, for

instance, Lauderdale 2006).

The comprehensive study of racism and health should account for the impact of historical

factors on present outcomes. Both baseline traumas and intergenerational effects encourage

the persistence of racial disparities through time. The structural nature of these mechanisms

means they may affect multiple outcomes. For instance, passage of the 1964 Civil Rights

Act, which prohibited employment discrimination, helped to change the complexion of the

health care workforce, by increasing the number of people of color pursuing medical and

other degrees. It also increased the numbers who were hired upon completion of their

training, and many of these persons serve underserved communities. The Civil Rights Act

and subsequent efforts, therefore, directly and indirectly influenced the health of African

Americans (Williams et al., 2008).

Intergenerational drag may be a useful tool for investigating structural racism’s contribution

to health disparities across time. This approach can guide research on the long-term

implications of policies and other social forces. Examples of timely applications to the study

of health disparities include mapping the effects of current anti-immigrant policies on future

health disparities among racially and ethnically diverse recent immigrants. Large segments

of the Caribbean, African, Asian, and Latin American populations arrived after immigration

reform in 1965. Thus, that year marks one of several appropriate baselines to track the extent

to which racially and ethnically diverse groups differentially advance in U.S. society, and to

note their experiences with racism.

We offer the following recommendations for incorporating intergenerational drag into a

comprehensive research agenda on racism and population health: (1) conceptualize and

measure structural racism in period-specific ways; (2) develop standardized approaches and

statistical models for estimating trends over time; and (3) expand institutional support for

intergenerational research.

Gee and Ford Page 11

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

First, conceptualize and measure structural racism in period-specific ways— Racism may manifest in ways that are time- and context-specific; researchers should be

careful to not assume that structural racism functions the same way and has similar impacts

regardless of when and where it occurs. When estimating cumulative racism effects, each

measure should be historically relevant because a concept’s meaning could change over

time. Prejudicial attitudes, for example, are expressed less overtly today than in decades past

(Bobo 2000). Similarly, tools used to perpetuate residential segregation in some respect have

softened (e.g., arson and lynchings are no longer commonplace); nonetheless, the existing

tools (e.g., racial steering) help maintain a high level of segregation (Ross and Turner, 2005;

Turner et al., 2002). Prior to the Voting Rights Act of 1965, disfranchisement of Blacks

directly reflected de jure and de facto policies of racial discrimination. Presently, this

disfranchisement largely reflects high rates of Black felonization, which has implications for

both voting power and disease distributions (Wakefield and Uggen, 2010). Expanding the

vocabulary for discussing subtle differences among racism concepts is essential for

advancing this knowledge base (Ford and Airhihenbuwa, 2010).

Second, develop standardized approaches and new statistical models for estimating intergenerational effects—Few, if any, U.S. data sources provide optimal

data for directly calculating the intergenerational effects of such historical traumas as

slavery, genocidal treatment of American Indians, or the internment of Japanese Americans.

Much research uses census data, yet, a major challenge is that the racial categories and

methods for assessing these categories change over time (LaVeist 1994). The scientific

literature has provided a rich discussion on the effects of these changes for assessing trends

over time (Institute of Medicine, 2009). There is yet no clear guidance on how changing

racial categories can impact research across generations.

Third, expand support for intergenerational research—Currently, funding for

public health research and practice is primarily organized by disease or condition. This

approach limits possibilities for studying intergenerational effects across multiple health

outcomes. Structural racism impacts numerous outcomes that may interact with one another,

and it occurs through time; therefore, support must expand to increase the study of multiple

outcomes, and not merely specific diseases. Funding entities could permit studies to be

carried out over longer periods of time and examine multiple outcomes. Although some of

this work can be completed retrospectively, to incorporate the current knowledge requires

the prospective collection of data.

FUTURE SETTINGS: STRUCTURAL RACISM IN CYBERSPACE

The legacy of structural racism continues to evolve into new arenas, including computer

access and cyberspace. The ability to access and manipulate information provides new

avenues to gain power, as illustrated by President Obama’s successful Internet-based

presidential campaign.

As with many other social settings, parts of cyberspace serve as a medium for the

reproduction of extant race relations. Some have noted the rise of “cyber racism” (Daniels

2010) and “White flight” from online social networking sites like MySpace (Boyd 2009).

Gee and Ford Page 12

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

Many video games are racialized; Leonard (2009) argues that “the dominant discourse

concerning youth and video games rationalizes the fear and policing of Black and Brown

communities” (p. 248). Some games, like the popular World of Warcraft, allow individuals

to play characters of various “races” (e.g., Trolls, Elves), which differ in innate attributes,

such as resistance to disease. Some attributes have racial overtones: trolls are known for

their rage and possess an ability called “da voodoo shuffle.” These games reinforce the

notion that traits are racialized, essentialized, and related to health. In short, cyberspace and

video games can contribute to the perpetuation of status quo conceptualizations of racial

hierarchy (Daniels 2010; Leonard 2009).

Further, the “digital divide”—the inequities in access to computers and the Internet—

represents a contemporary form of social stratification. Currently, 51% of African

Americans, compared to 65% of Whites, own a computer (Smith 2010). Certainly, computer

use and Internet access are important because of their utility as educational and

informational resources. In this sense, the digital divide might be viewed as a contemporary

marker of socioeconomic position (SEP).

Thus, future research on health disparities should consider cyberspace among the “places”

that contribute to health disparities. It should examine how cyberinteractions can directly

influence behavior, as with cyberbullying (Vanderbilt and Augustyn, 2010). Victims of

cyberbullying appear to have greater risk of depression than victims of physical bullying

(Wang et al., 2009). Further research should also include markers of digital access along

with standard measures of SEP. And most fundamentally, future work should consider how

cyberspace reinforces our ideologies of race relations.

CONCLUSION

To investigate racism seriously as a fundamental determinant of health disparities requires

attending to the multiple manifestations of racism. Structural racism operates on the

macrolevel of the socioecologic framework; therefore, it more fundamentally influences

outcomes than do proximal factors. To date, research has focused on the relatively narrow

band that emphasizes self-reported racism and residential segregation. We encourage

research on additional forms of racism, including other dimensions of social segregation,

immigration policy, and the intergenerational transfer of assets and liabilities. There are

many other forms of racism that we did not have space to discuss, including the prison

industrial complex, historical trauma, emotional rules, and media portrayals. Some of these

ideas are developed more fully elsewhere in this issue of the journal.

Research on structural racism should not only focus on independent effects but also should

address interactions among multiple forms of racism. Further, it is likely that forms of

racism may reinforce one another, and efforts to dismantle one system may yield little effect

without simultaneous efforts on another system. For example, part of the segregation that

occurs across and within occupations is related to immigration policy (Catanzarite 2000).

The study of single forms of racism would lead to an incomplete understanding and,

potentially worse, biased estimates. For instance, assume that five forms of racism fully

account for health disparities, but an intervention only targets one form. That intervention

Gee and Ford Page 13

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

may show no effect simply because it is incomplete, and potentially lead to the erroneous

conclusion that anti-racism efforts fail. Hence, it is absolutely critical to consider the

multiple forms of racism. Further, our analysis highlights the importance of time and its

dimensions—historical period, age, cohort, and placement in the life course. Given this

complexity, conventional tools of regression analyses, and even their extensions such as

multilevel analysis, would likely be inadequate. Such study may benefit from simulation

models, such as agent-based modeling (Bruch and Mare, 2006).

Accomplishing these goals requires adequate tools and data. This should be assisted via

ongoing surveillance, using both qualitative and quantitative methods, to monitor the

endemics of racial bias. We should integrate assessment of racial bias into core data systems,

such as in the National Health Interview Survey (NHIS) and the American Community

Survey. Agencies should cross link their data systems, for instance, by merging data from

the Home Mortgage Disclosure Act (HMDA) (which monitors racial bias by lending

institutions) to NHIS (see Gee (2002) for an example). Further, a major limitation is that

federal agencies have historically varied in their collection of data related to racial and

ethnic groups, making it very difficult to conduct the types of historical and

intergenerational research we have described. The collection of race and ethnicity

information is regulated by Directive 15 of the Office of Management and Budget (OMB)

(OMB, 1997). While this directive specifies how federal agencies should collect racial and

ethnic data and indicates that “programs should adopt the standards as soon as possible”, it

does not mandate that federal agencies actually collect these data. Yet, without this

information, one would not be able to inquire about the basic question of disparity, much

less racism. Accordingly, researchers should call upon the OMB to require that all federal

agencies collect racial data and, further, to create new data systems analogous to the HMDA

to monitor racial bias (e.g., monitoring of civil rights abuses within hospitals).

In short, the study of racism as a potential cause of health disparities should be significantly

expanded. This expansion should include under-studied forms of racism, their intersections,

and integration of data systems. Only through such an expansion might we see below the tip

of the iceberg and effectively change the course of health disparities.

REFERENCES

Acevedo-Garcia D. Residential Segregation and the Epidemiology of Infectious Diseases. Social Science & Medicine. 2000; 51(8):1143–1161. [PubMed: 11037206]

Almond, DV.; Chay, KY.; Greenstone, M. Civil Rights, the War on Poverty, and Black-White Convergence in Infant Mortality in the Rural South and Mississippi; Working Paper No. 07-04, Department of Economics, Massachusetts Institute of Technology; 2006.

Angelon-Gaetz KA, Richardson DB, Wing S. Inequalities in the Nuclear Age: Impact of Race and Gender on Radiation Exposure at the Savannah River Site (1951–1999). New Solutions. 2010; 20(2):195–210. [PubMed: 20621884]

Araujo BY, Borrell LN. Understanding the Link between Discrimination, Mental Health Outcomes, and Life Chances Among Latinos. Hispanic Journal of Behavioral Sciences. 2006; 28(2):245–266.

Barkan, ER.; Diner, H.; Kraut, AM. From Arrival to Incorporation: Migrants to the US in a Global Era. New York: New York University Press; 2008.

Barker DJP. Fetal Programming of Coronary Heart Disease. Trends in Endocrinology and Metabolism. 2002; 13(9):364–368. [PubMed: 12367816]

Gee and Ford Page 14

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

Becker MH. The Tyranny of Health Promotion. Public Health Review. 1986; 14(1):15–23.

Bell JF, Zimmerman FJ, Almgren GR, Mayer JD, Huebner CE. Birth Outcomes among Urban African American Women: A Multilevel Analysis of the Role of Racial Residential Segregation. Social Science & Medicine. 2006; 63(12):3030–3045. [PubMed: 16997438]

Bobo, L. Racial Attitudes and Relations at the Close of the Twentieth Century. In: Smelser, N.; Wilson, WJ.; Mitchell, F., editors. America Becoming: Racial Trends and Their Implications. Washington, DC: National Academy Press; 2000. p. 262-299.

Bonilla-Silva E. Rethinking Racism: Toward a Structural Interpretation. American Sociological Review. 1997; 62(3):465–480.

Borrell LN. Racial Identity among Hispanics: Implications for Health and Well-Being. American Journal of Public Health. 2005; 95(3):379–381. [PubMed: 15727961]

Boswell RA. Racism and U.S. Immigration Law: Prospects for Reform after “9/11”? Immigration and Nationality Law Review. 2003; 7:315–356.

Boyd, D. White Flight in Networked Public Places? How Race and Class Shaped American Teen Engagement with MySpace and Facebook. In: Nakamura, L.; Chow-White, P., editors. Digital Race Anthology. New York: Routledge Press; 2009.

Brave Heart M, DeBruyn LM. The American Indian Holocaust: Healing Historical Unresolved Grief. American Indian and Alaska Native Mental Health Research. 1998; 8(2):60–82.

Brondolo E, Brady ver Halen N, Pencille M, Beatty D, Contrada R. Coping with Racism: A Selective Review of the Literature and a Theoretical and Methodological Critique. Journal of Behavioral Medicine. 2009; 32(1):64–88. [PubMed: 19127420]

Bruch E, Mare R. Neighborhood Choice and Neighborhood Change. American Journal of Sociology. 2006; 112:667–709.

Carmichael, S.; Hamilton, CV. Black Power: The Politics of Liberation in America. New York: Vintage Books; 1967.

Catanzarite L. Brown-Collar Jobs: Occupational Segregation and Earnings of Recent-Immigrant Latinos. Sociological Perspectives. 2000; 43(1):45–75.

Chae Chang Ping v. United States. 1889 130 U.S. 581.

Chae DH, Walters KL. Racial Discrimination and Racial Identity Attitudes in Relation to Self-Rated Health and Physical Pain and Impairment among Two-Spirit American Indians/Alaska Natives. American Journal of Public Health. 2009; 99(S1):S144–S151. [PubMed: 19218182]

Clarke SP, Davis BL, Nailon RE. Racial Segregation and Differential Outcomes in Hospital Care. Western Journal of Nursing Research. 2007; 29(6):739–757. [PubMed: 17630385]

Collins WJ, Margo RA. Race and Home Ownership: A Century-Long View. Explorations in Economic History. 2001; 38(1):68–92.

Daniels, J. Race, Civil Rights, and Hate Speech in the Digital Era. In: Everett, A., editor. Learning Race and Ethnicity: Youth and Digital Media. Cambridge, MA: MIT Press; 2010. p. 129-154.

Darity WA Jr. Employment Discrimination, Segregation, and Health. American Journal of Public Health. 2003; 93(2):226–231. [PubMed: 12554574]

Darity W, Dietrich J, Guilkey DK. Persistent Advantage or disadvantage?: Evidence in Support of the Intergenerational Drag Hypothesis. American Journal of Economics and Sociology. 2003; 60(2): 435–470.

de Castro AB, Fujishiro K, Schweitzer E, Olivia J. How Immigrant Workers Experience Workplace Problems: A Qualitative Study. Archives of Environmental and Occupational Health: An International Journal. 2006; 61(6):249–258.

Du Bois WEB. The Health and Physique of the Negro American. American Journal of Public Health. 2003; 93:272–276. [PubMed: 12554583]

Elliott JR, Smith RA. Ethnic Matching of Supervisors to Subordinate Work Groups: Findings on “Bottom-Up” Ascription and Social Closure. Social Problems. 2001; 48:258–276.

Finch BK, Frank R, Vega WA. Acculturation and Acculturation Stress: A Social-Epidemiological Approach to Mexican Migrant Farmworkers’ Health. International Migration Review. 2004; 38(1): 236–262.

Gee and Ford Page 15

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

Ford CL, Airhihenbuwa CO. The Public Health Critical Race Methodology: Praxis for Antiracism Research. Social Science & Medicine. 2010; 71(8):1390–1398. [PubMed: 20822840]

Ford CL, Harawa NT. A New Conceptualization of Ethnicity for Social Epidemiologic and Health Equity Research. Social Science & Medicine. 2010; 71(2):251–258. [PubMed: 20488602]

Freeman LC. Segregation in Social Networks. Sociological Methods and Research. 1978; 6(4):411– 429.

Gaskin DJ, Price A, Brandon DT, LaVeist TA. Segregation and Disparities in Health Services Use. Medical Care Research and Review. 2009; 66(5):578–589. [PubMed: 19460811]

Gee GC. A Multilevel Analysis of the Relationship between Institutional and Individual Racial Discrimination and Health Status. American Journal of Public Health. 2002; 92(4):615–623. [PubMed: 11919062]

Gee GC, Payne-Sturges DC. Environmental Health Disparities: A Framework Integrating Psychosocial and Environmental Concepts. Environmental Health Perspectives. 2004; 112(17):1645–1653. [PubMed: 15579407]

Gee GC, Ro A, Shariff-Marco S, Chae DH. Racial Discrimination and Health among Asian Americans: Evidence, Assessment, and Directions for Future Research. Epidemiologic Reviews. 2009; 31(1):130–151. [PubMed: 19805401]

Goldman DP, Smith JP, Sood N. Legal Status and Health Insurance among Immigrants. Health Affairs. 2005; 24(6):1640–1653. [PubMed: 16284039]

Heckler, MM. Report of the Secretary’s Task Force on Black and Minority Health. Washington, DC: U.S. Department of Health and Human Services; 1985.

Heckman JJ, Payner BS. Determining the Impact of Federal Antidiscrimination Policy on the Economic Status of Blacks: A Study of South Carolina. The American Economic Review. 1989; 79(1):138–177.

Institute of Medicine. Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement. Washington, DC: The National Academies Press; 2009.

James SA. Confronting the Moral Economy of US Racial/Ethnic Health Disparities. American Journal of Public Health. 2008; 98(Supplement 1):S16. [PubMed: 18687604]

Jones CP. Levels of Racism: A Theoretic Framework and a Gardener’s Tale. American Journal of Public Health. 2000; 90(8):1212–1215. [PubMed: 10936998]

Kaushal N, Kaestner R. Welfare Reform and Health Insurance of Immigrants. Health Services Research. 2005; 40(3):697–722. [PubMed: 15960687]

Kelaher M, Jessop DJ. Differences in Low-Birthweight among Documented and Undocumented Foreign-Born and US-born Latinas. Social Science and Medicine. 2002; 55:2171–2175. [PubMed: 12409130]

Kramer MR, Hogue CR. Is Segregation Bad for Your Health? Epidemiologic Reviews. 2009; 31(1): 178–194. [PubMed: 19465747]

Krieger N. Embodying Inequality: A Review of Concepts, Measures, and Methods for Studying Health Consequences of Discrimination. International Journal of Health Services. 1999; 29(2):295–352. [PubMed: 10379455]

Krieger N, Williams DR, Moss NE. Measuring Social Class in US Public Health Research: Concepts, Methodologies, and Guidelines. Annual Review of Public Health. 1997; 18:341–378.

Lauderdale DS. Birth Outcomes for Arabic-Named Women in California Before and After September 11. Demography. 2006; 43(1):185–201. [PubMed: 16579214]

Lauderdale DS, Wen M, Jacobs EA, Kandula NR. Immigrant Perceptions of Discrimination in Health Care: the California Health Interview Survey 2003. Medical Care. 2006; 44(10):914–920. [PubMed: 17001262]

Laumann EO, Youm Y. Racial/Ethnic Group Differences in the Prevalence of Sexually Transmitted Diseases in the United States: A Network Explanation. Sexually Transmitted Diseases. 1999; 26:250–261. [PubMed: 10333277]

LaVeist TA. Beyond Dummy Variables and Sample Selection: What Health Services Researchers Ought to Know about Race as a Variable. Health Services Research. 1994; 29(1):1–16. [PubMed: 8163376]

Gee and Ford Page 16

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

Lee BA, Reardon SF, Firebaugh G, Farrell CR, Matthews SA, O’Sullivan D. Beyond the Census Tract: Patterns and Determinants of Racial Residential Segregation at Multiple Scales. American Sociological Review. 2008; 73:766–791. [PubMed: 25324575]

Leonard D. Young, Black (& Brown) and Don’t Give a Fuck. Cultural Studies Gåö Critical Methodologies. 2009; 9(2):248–272.

Link BG, Phelan J. Social Conditions as Fundamental Causes of Disease. Journal of Health and Social Behavior. 1995; 35(extra issue):80–94. [PubMed: 7560851]

Margo, RA. Race and Schooling in the South, 1880–1950: An Economic History. Chicago, IL: University of Chicago Press; 1990.

Mays VM, Cochran SD, Barnes NW. Race, Race-Based Discrimination, and Health Outcomes among African Americans. Annual Review of Psychology. 2006; 58:201–225.

Molina, N. Fit to Be Citizens. Berkeley, CA: University of California Press; 2006.

Morello-Frosch R, Jesdale BM. Separate and Unequal: Residential Segregation and Estimated Cancer Risks Associated with Ambient Air Toxics in U.S. Metropolitan Areas. Environmental Health Perspectives. 2006; 114(3):386–393. [PubMed: 16507462]

Nacos, BL.; Torres-Reyna, O. Fueling Our Fears: Stereotyping, Media Coverage, and Public Opinion of Muslim Americans. Lanham, MD: Rowman and Littlefield; 2006.

Nevins, J. Operation Gatekeeper: The Rise of the “Illegal Alien” and the Making of the US-Mexico boundary. New York: Routledge; 2002.

Office of Management and Budget (OMB). Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity. Federal Register. 1997; 62:58781–58790.

Ortega AN, Fang H, Perez VH, Rizzo JA, Carter-Pokras O. Health Care Access, Use of Services, and Experiences among Undocumented Mexicans and Other Latinos. Archives of Internal Medicine. 2007; 167(21):2354–2360. [PubMed: 18039995]

Padela AI, Heisler M. The Association of Perceived Abuse and Discrimination after September 11, 2001, with Psychological Distress, Level of Happiness, and Health Status among Arab Americans. American Journal of Public Health. 2010; 100(2):284–291. [PubMed: 20019301]

Park, JSW. Elusive Citizenship: Immigration, Asian Americans, and the Paradox of Civil Rights. New York: New York University Press; 2004.

Pembrey ME, Bygren LO, Kaati G, Edvinsson S, Northstone K. Sex-specific, Male-line Transgenerational Responses in Humans. European Journal of Human Genetics. 2005; 14(2):159– 166. [PubMed: 16391557]

Powell JA. Structural Racism: Building upon the Insights of John Calmore. North Carolina Law Review. 2008; 86:791–816.

Quadagno J. Promoting Civil Rights through the Welfare State: How Medicare Integrated Southern Hospitals. Social Problems. 2000; 47(1):68–89. [PubMed: 18050538]

Reardon SF, Farrell CR, Matthews SA, O’Sullivan D, Bischoff K, Firebaugh G. Race and Space in the 1990s: Changes in the Geographic Scale of Racial Residential Segregation, 1990–2000. Social Science Research. 2009; 38(1):55–70. [PubMed: 19569292]

Ross SL, Turner MA. Housing Discrimination in Metropolitan America: Explaining Changes between 1989 and 2000. Social Problems. 2005; 52(2):152–180.

Sacerdote B. Slavery and the Intergenerational Transmission of Human Capital. Review of Economics and Statistics. 2005; 87(2):217–234.

Seckl JR, Holmes MC. Mechanisms of Disease: Glucocorticoids, their Placental Metabolism and Fetal ‘Programming’ of Adult Pathophysiology. Nature Clinical Practice Endocrinology & Metabolism. 2007; 3(6):479–488.

Smith, Aaron. Technology Trends Among People of Color. Pew Internet & American Life Project, September 17. 2010 ⟨http://www.pewinternet.org/Commentary/2010/September/ Technology- Trends-Among-People-of-Color.aspx⟩.

Smith DB. Racial and Ethnic Health Disparities and the Unfinished Civil Rights Agenda. Health Affairs. 2005; 24(2):317–324. [PubMed: 15757914]

Gee and Ford Page 17

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

Smith DB, Feng Z, Fennell ML, Zinn JS, Mor V. Separate and Unequal: Racial Segregation and Disparities in Quality across U.S. Nursing Homes. Health Affairs. 2007; 26(5):1448–1458. [PubMed: 17848457]

Sommers BD. Targeting in Medicaid: The Costs and Enrollment Effects of Medicaid’s Citizenship Documentation Experiment. Journal of Public Economics. 2010; 94(1–2):174–182.

Sondik EJ, Huang DT, Klein RJ, Satcher D. Progress toward the Healthy People: 2010 Goals and Objectives. Annual Review of Public Health. 2010; 31(1):271–281.

Subramanian SV, Acevedo-Garcia D, Osypuk TL. Racial Residential Segregation and Geographic Heterogeneity in Black/White Disparity in Poor Self-Rated Health in the US: A Multilevel Statistical Analysis. Social Science & Medicine. 2005; 60(8):1667–1679. [PubMed: 15686800]

Turner, MA.; Freiberg, F.; Godfrey, E.; Herbig, C.; Levy, DK.; Smith, RR. All Other Things Being Equal: A Paired Testing Study of Mortgage Lending Institutions. Washington, DC: U.S. Department of Housing and Urban Development; 2002.

Vanderbilt D, Augustyn M. The Effects of Bullying. Paediatrics and Child Health. 2010; 20(7):315– 320.

Viruell-Fuentes EA. Beyond Acculturation: Immigration, Discrimination, and Health Research among Mexicans in the United States. Social Science &Medicine. 2007; 65(7):1524–1535. [PubMed: 17602812]

Wakefield S, Uggen C. Incarceration and Stratification. Annual Review of Sociology. 2010; 36:387– 406.

Walsemann KM, Bell BA. Integrated Schools, Segregated Curriculum: Effects of Within-School Segregation on Adolescent Health Behaviors and Educational Aspirations. American Journal of Public Health. 2010; 100(9):1687–1695. [PubMed: 20634462]

Wang J, Iannotti RJ, Nansel TR. School Bullying among Adolescents in the United States: Physical, Verbal, Relational, and Cyber. Journal of Adolescent Health. 2009; 45(4):368–375. [PubMed: 19766941]

White TK. Initial Conditions at Emancipation: The Long-Run Effect on Black-White Wealth and Earnings Inequality. Journal of Economic Dynamics and Control. 2007; 31:3370–3395.

Williams DR, Collins CA. Racial Residential Segregation: A Fundamental Cause of Racial Disparities in Health. Public Health Reports. 2001; 116:404–416. [PubMed: 12042604]

Williams DR, Costa MV, Odunlami AO, Mohammed SA. Moving Upstream: How Interventions That Address the Social Determinants of Health Can Improve Health and Reduce Disparities. Journal of Public Health Management and Practice. 2008; 14(6):S8–S17. [PubMed: 18843244]

Williams DR, Mohammed SA. Discrimination and Racial Disparities in Health: Evidence and Needed Research. Journal of Behavioral Medicine. 2009; 32:20–47. [PubMed: 19030981]

Wright, RO. Chronology of Immigration in the United States. Jefferson, NC: McFarland & Company, Inc; 2008.

Yoo HC, Gee GC, Takeuchi D. Discrimination and Health among Asian American Immigrants: Disentangling Racial from Language Discrimination. Social Science & Medicine. 2009; 68(4): 726–732. [PubMed: 19095340]

Yu SM, Huang ZJ, Schwalberg RH, Nyman RM. Parental English Proficiency and Children’s Health Services Access. American Journal of Public Health. 2006; 96(8):1449–1455. [PubMed: 16809589]

Gee and Ford Page 18

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

Gee and Ford Page 19

Table 1

Selected actions related to immigration/naturalization with bearing on race/ethnicity

Year Act or Law Results or Implications

1788 U.S. Constitution ratified Article 1 section 9 prohibits Congress from restricting the “importation” of slaves or other migrants until the year 1809.

1790 Naturalization Act Two years of residence in the country and one year of residence in a state required to apply for citizenship; “any alien, being a free White person, may be admitted to become a citizen.”

1795 Naturalization Act of 1795 Extends residency period to five years to become U.S. resident and two years to become resident of a state.

1808 U.S. slave trade banned Between 50,000 and 25,000 Blacks continued to be imported (until 1865) and were thus considered illegal immigrants.

1850 U.S. Census records nativity Establishes whether residents were born in the U.S. or outside of it.

1854 California Supreme Court People v. Hall The court rules that a White man charged with murder cannot be convicted based on the testimony of a Chinese person.

1862 Homestead Act; Land Grant Act Encouraged immigrants, most of whom were European, to move westward; provided them with land and education to establish homes there.

1862 Anti-Coolie Act Taxed California employers who hired Chinese workers.

1868 14th Amendment Anyone born in the U.S. is a citizen; intended for former slaves.

1870 15th Amendment Voting rights granted regardless of “race, color, or previous condition of servitude.”

1875 Page Act passed Required processing of Asian immigrants to assess “moral” character.

1882 Chinese Exclusion Act Barred immigration from China, but did issue certificates allowing Chinese persons who had already established a presence in the U.S. to re-enter.

1888 Amendment to the 1882 Exclusion Act Congress repealed the provision of re-entry and voided all outstanding certificates.

1889 Chae Chan Ping v. U.S. Case challenged the 1888 amendment; Court rules that Congress has the constitutional authority to modify immigration legislation at its discretion.

1896 U.S. Supreme Court Plessey v. Ferguson Establishes that “separate but equal” is constitutional.

1907 Expatriation Act American women who marry foreign nationals lose their citizenship.

1911 Dillingham report published Argued to limit migration from Southern/Eastern Europe due to these people’s inferior genes and potential to subvert American society.

1913 California implements Alien Land Law Primarily targeted Asians; barred them from owning property.

1917 Asiatic Barred Act (Immigration Act of 1917)

Established regions of Asia and the Pacific Islands whose emigrants could not become U.S. citizens; contained literacy test for immigrants.

1921 Emergency Quota Act (Johnson Quota Act) Limits immigrants to no more than 3% of the number already residing in the U.S.; dispropor tionately limited non-Europeans.

1923 Supreme Court U.S. v. Bhaghat Singh Thind The U.S. Supreme Court ruled that immigrants from the Indian sub-continent cannot become U.S. citizens because they were not “White.”

1934 Tydings-McDuffie Act (Philippine Independence Act)

Effectively reversed the status of Filipinos from nationals to aliens, thus subjecting them to strict immigration quotas.

1942 Japanese American internment Americans of Japanese descent were interned in U.S. camps ostensibly to prevent them from collaborating with the Japanese military during WWII.

1942 U.S.–Mexico Bracero Established a program of temporary laborers from Mexico.

1952 Harisaides vs. Shaughnessy Court upheld the right of Congress to expel noncitizens who were former Communists.

1965 Immigration and Nationality Act (Hart- Cellar Act)

Annual immigration quotas increased to 120,000 for Westerners and 20,000 for non- Westerners; eliminated the national origins quota and established preference for skilled workers and family unification.

1978 Immigration and Nationality Act amended Abolished separate (Western vs. non-Western) quotas for immigration. It effectively increased immigration from non-European countries.

1982 Plyer v. Doe Established that children of undocumented immigrants have the right to free public education.

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.

N IH

-P A

A uthor M

anuscript N

IH -P

A A

uthor M anuscript

N IH

-P A

A uthor M

anuscript

Gee and Ford Page 20

Year Act or Law Results or Implications

2000 Legal Immigration and Family Equity Act Granted residency to 400,000 undocumented immigrants.

2005 Real ID Act of 2005 Based on Homeland Security recommendations, requires additional protections to enhance assurance of the validity of drivers’ licenses, enhances immigration restrictions.

2010 Arizona passes SB 1070 Requires immigrants to carry registration documents at all times; requires police to check immigration status of people suspected of being undocumented (e.g., based upon how one is dressed).

Du Bois Rev. Author manuscript; available in PMC 2015 January 26.