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
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Racism, xenophobia, and discrimination are fundamental determinants of health and must be considered as such when considering approaches to public health
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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
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History and current practice prove that discriminatory ideology has shaped science and research, and how they are interpreted
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The precursors to discrimination are the two core structural processes of separation, whereby individuals see themselves as different from others, and hierarchical power
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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
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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.