Elsevier

The Lancet

Volume 400, Issue 10368, 10–16 December 2022, Pages 2097-2108
The Lancet

Series
Racism, xenophobia, discrimination, and the determination of health

https://doi.org/10.1016/S0140-6736(22)01972-9Get rights and content

Summary

This Series shows how racism, xenophobia, discrimination, and the structures that support them are detrimental to health. In this first Series paper, we describe the conceptual model used throughout the Series and the underlying principles and definitions. We explore concepts of epistemic injustice, biological experimentation, and misconceptions about race using a historical lens. We focus on the core structural factors of separation and hierarchical power that permeate society and result in the negative health consequences we see. We are at a crucial moment in history, as populist leaders pushing the politics of hate have become more powerful in several countries. These leaders exploit racism, xenophobia, and other forms of discrimination to divide and control populations, with immediate and long-term consequences for both individual and population health. The COVID-19 pandemic and transnational racial justice movements have brought renewed attention to persisting structural racial injustice.

Introduction

Racism, xenophobia, and discrimination exist in every society, causing avoidable disease and premature death among groups that are already disadvantaged.1 Such discrimination underpins assaults on people seen as others, whether through institutionalised discriminatory policies, in communities where inequalities are entrenched, or through individuals playing a role in systemic oppressions and interpersonal aggressions. Although the types of discrimination take different forms across time and space, the root causes are situated in efforts to maintain historic power structures. Understanding and challenging discrimination and its underlying ideologies is central to public health and the promotion of social equity. Equally, by ignoring these realities, health professionals are complicit in the structural violence that leads to ill health.2, 3

Racism, xenophobia, and discrimination can present in many forms, from microaggressions to interpersonal and state violence. As described in detail in the second paper of the Series, health outcomes are usually worse among minoritised groups, with strong evidence that racism plays a role.4 For example, when managing a child with asthma, we know that it is important to consider the environment that they live in and their ability to access good-quality health care. However, the importance of structural racism as a determinant of health remains under-considered. The tragic death of Ella Kissi-Debrah in the UK, on whose death certificate air pollution was included, is a recent example of environmental racism, whereby minoritised communities are more likely than non-minoritised groups to be exposed to environmental hazards as a result of where they end up having to live.5, 6 A systematic review of the literature found that racism was associated with worse mental health (mean weighted effect size r –0·23, 95% CI –0·24 to –0·21) and physical health (–0·09, –0·12 to –0·06).7 The situation worsened during the COVID-19 pandemic,8 in which minoritised ethnic groups were more severely affected by the disease and the consequences of the responses. For example, in the second wave of the pandemic in the UK (Sept 12, 2020 and onwards), Bangladeshi women were 4·11 (hazard ratio adjusted for age, 95% CI 3·62 to 4·66) times more likely and Bangladeshi men 4·96 (4·49 to 5·48) times more likely to die from COVID-19 than the White British population. Higher mortality rates were also seen among Black African, Black Caribbean, Pakistani, and Indian ethnic groups.9 Global inequity in vaccine access along racial lines has highlighted persistent racism in global power dynamics, rooted in legacies of colonialism and exploitation.10 Migrant groups and other groups, such as the scheduled castes in India, are often particularly disadvantaged by barriers to care imposed by governments.11, 12 Similarly, Indigenous populations across the world have had poorer health outcomes than non-Indigenous populations, including lower life expectancy, higher infant and maternal mortality, and malnutrition.13 These health consequences do not only affect minoritised people—as with social inequality, a society with widespread discrimination threatens the health of everyone.14, 15

Key messages

  • Racism, xenophobia, and discrimination are fundamental determinants of health and must be considered as such when considering approaches to public health

  • The health consequences of racism, xenophobia, and discrimination occur in every context that has been studied and can be similar for the related categories of caste, ethnicity, Indigeneity, migratory status, race, religion, and skin colour

  • History and current practice prove that discriminatory ideology has shaped science and research, and how they are interpreted

  • The precursors to discrimination are the two core structural processes of separation, whereby individuals see themselves as different from others, and hierarchical power

  • Ill health and health inequities are affected by racism, xenophobia, and discrimination through a host of structural factors and their historical and political roots; interpersonal discrimination cannot be tackled without addressing these complex processes

  • Populist leaders and policies can exploit populations using racist, xenophobic, and discriminatory ideologies that minoritise people and lead to poor health

Although the importance of social and political factors and their effects on health are widely accepted,16, 17 racism and xenophobia are under-developed and under-recognised concepts in medicine and health around the world (with the possible exception of the USA7). In this Series, we provide a global overview of the nature of racism, xenophobia, and other discriminatory ideologies and summarise potential interventions to tackle their effects on health and wellbeing. In doing so, we attempt to provide theories, data, and examples from across the world, and at times have chosen not to cite the most commonly known ones to avoid their over-representation. We cannot be comprehensive and cover all minoritised or persecuted groups. We do not wish to diminish the suffering or importance of groups not included, but we are limited in what we can include and believe that the concepts and health mechanisms are transferable.

This first paper introduces our conceptual framework that underpins the Series. We propose contemporary definitions that we use throughout the Series (panel 1), then describe the theoretical basis for our model, before examining the layers of the model and the underlying reasons why discrimination exists. Finally, we focus on what happens at a structural level and include discussions of power, populism, and racialised capitalism and how they contribute to health. Throughout, we look back to history, including the role of colonisation. The health of minoritised populations is affected by the history that has led to their experiences of discrimination and their status in the social hierarchies of the states in which they live. A historically rooted approach shows the durability of racist beliefs and structures, and shows the ways in which racial logics continue to undergird social organisations and, by extension, affect health. We confront the legacy of science that has preserved the power hierarchies among different groups, and we highlight the extent to which colonial history has relied on racist ideologies, whereby an other or separate group was seen as uncivilised or inferior. The consequences play out over generations (eg, through intergenerational drag),38 requiring contemporary public health policies to confront the legacy of past policies that result in persisting disadvantage based on group identity.

Section snippets

Definitions

There are many different ways in which people are categorised. Each method responds to the population and history of a specific location, and none encompass all groups adequately.25 The terms we use can never capture the complexity of an individual. We acknowledge the extensive discourse surrounding definitions relevant to the topics we cover and we acknowledge that consensus might never be reached, but for this Series, we identify our key definitions in panel 1, with more detailed and further

Conceptual model

The Series is structured according to our conceptual model, which uses the lens of racism, xenophobia, and discrimination to consider how health is determined (figure). The model is informed by the following six principles. First, health and health inequalities are determined by active processes, not static risk factors and behaviours.40 As explored by Krieger's work on ecosocial theory,41, 42 these processes occur across complex ecosystems that exist within power structures; they affect

Individuals

The level of the individual is where we can most easily comprehend effects of racism, xenophobia, and discrimination. Most people can think of a time they have experienced or witnessed racism, but to focus only on this level would mean overlooking the structural factors that have given rise to these individual manifestations. The murder of George Floyd, for example, cannot be explained by the actions of one ‘bad’ police officer, but was instead due to the structural racism and discrimination

Communities

Communities come in various forms—physical or virtual, homogeneous or diverse—and are defined by common identities, traditions, knowledge, and worldviews.55 A community's shared conditions and constraints shape collective access to power, both material and symbolic.55 These conditions can be defined by natural barriers or be human made, such as segregation laws. Discrimination can contribute to the formation of communities based on the commonality of their experiences. This formation of

Spatial determination

Spatial determination encompasses the environmental, ecological, and geographical factors affecting health. In the context of discrimination, spatial determination can place minoritised people in unhealthy environments. This process works in two main ways. First, discrimination situates minoritised populations closer to unhealthy and harmful environmental exposures than non-minoritised groups, including through residential and racial segregation, access to green spaces, air quality, and

Institutions and systems

Racism and discrimination affect every institution and system that governs society, many upholding established power imbalances. These systems include but are not limited to health care, housing, education, and the criminal justice system. The concept of racism affecting health as an independent factor and through its effect on social determinants of health has been explored before,1, 4 but we expand upon it to apply the relationship between health and discrimination based on caste, ethnicity,

Structural discrimination: separation and hierarchical power

Having introduced separation and hierarchical power as foundational principles of the conceptual model that are at the core level of structural discrimination, we explore how these two concepts play out in processes of structural discrimination from governance, colonialism, and racial capitalism to political dynamics and exclusionary populism.

Conclusions

In this first paper of the Series, we describe some of the underlying features of racism, xenophobia, and discrimination, and the ideologies and histories that lead to health inequities. Categories such as race and caste are biologically arbitrary, but the discrimination that minoritised groups face is very real. Although health outcomes are not deterministic, some groups have the cards stacked in their favour and some do not. In this Series we explore many different forms of discrimination

Declaration of interests

DD and SS are co-founders of the Race & Health collective within UCL, an organisation committed to tackling the health effects of racism, xenophobia, and discrimination. SS is also a trainee representative of the Royal College of Obstetricians and Gynaecologists’ Race Equality Taskforce, and regularly speaks at events and advises organisations on related topics. SS and DD are recipients of the Wellcome Trust grant on climate and racial justice (grant number 24687/Z/21/Z). All other authors

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