Systemic racism is so embedded in systems that it often is assumed to reflect the natural, inevitable order of things. Systemic racism is the iceberg’s more dangerous part: It places people of color at a disadvantage in multiple domains affecting health in ways often more difficult to recognize than explicit interpersonal racism.
The opportunities denied include access to good jobs with benefits safe, unpolluted neighborhoods with good schools high-quality health care and fair treatment by the criminal justice system. It consists of the societal systems and structures that expose people of color to health-harming conditions and that impose and sustain barriers to opportunities that promote good health and well-being. The iceberg’s base-the much larger, usually unseen part-represents systemic and structural racism. 11 The iceberg’s visible part represents the overt racism that manifests in blatant discrimination and hate crimes-explicitly racist treatment that may be relatively easy to recognize. Gilbert Gee and Annie Ro depict systemic racism as the hidden base of an iceberg 10 (see illustration in online appendix exhibit 1). Institutional racism is sometimes used as a synonym for systemic or structural racism, as it captures the involvement of institutional systems and structures in race-based discrimination and oppression 4, 7, 8 it may also refer specifically to racism within a particular institution. 5 Because systemic racism includes structural racism, for brevity we often use systemic racism to refer to both at times we use both for emphasis. 6 Structural racism emphasizes the role of the structures (laws, policies, institutional practices, and entrenched norms) that are the systems’ scaffolding. Systemic racism emphasizes the involvement of whole systems, and often all systems-for example, political, legal, economic, health care, school, and criminal justice systems-including the structures that uphold the systems. Although systemic racism and structural racism are often used interchangeably, they have somewhat different emphases. 5 They reflect both ongoing and historical injustices. 4 Systemic and structural racism are forms of racism that are pervasively and deeply embedded in and throughout systems, laws, written or unwritten policies, entrenched practices, and established beliefs and attitudes that produce, condone, and perpetuate widespread unfair treatment of people of color. Racism is not always conscious, intentional, or explicit-often it is systemic and structural. Racism is the relegation of people of color to inferior status and treatment based on unfounded beliefs about innate inferiority, as well as unjust treatment and oppression of people of color, whether intended or not.
People of color is a term used to refer to African Americans, American Indians/Alaska Natives, Asian Americans, Latinos/Hispanics, and Native Hawaiians/other Pacific Islanders. Because systemic and structural racism permeate all sectors and areas, addressing them will require mutually reinforcing actions in multiple sectors and places acknowledging their existence is a crucial first step. This article defines systemic and structural racism, using examples explains how they damage health through many causal pathways and suggests approaches to dismantling them. Examples include residential segregation, unfair lending practices and other barriers to home ownership and accumulating wealth, schools’ dependence on local property taxes, environmental injustice, biased policing and sentencing of men and boys of color, and voter suppression policies. Systemic and structural racism are forms of racism that are pervasively and deeply embedded in systems, laws, written or unwritten policies, and entrenched practices and beliefs that produce, condone, and perpetuate widespread unfair treatment and oppression of people of color, with adverse health consequences. Racism is not always conscious, explicit, or readily visible-often it is systemic and structural.
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