Elsevier

The Lancet

Volume 400, Issue 10368, 10–16 December 2022, Pages 2109-2124
The Lancet

Series
Racism, xenophobia, and discrimination: mapping pathways to health outcomes

https://doi.org/10.1016/S0140-6736(22)02484-9Get rights and content

Summary

Despite being globally pervasive, racism, xenophobia, and discrimination are not universally recognised determinants of health. We challenge widespread beliefs related to the inevitability of increased mortality and morbidity associated with particular ethnicities and minoritised groups. In refuting that racial categories have a genetic basis and acknowledging that socioeconomic factors offer incomplete explanations in understanding these health disparities, we examine the pathways by which discrimination based on caste, ethnicity, Indigeneity, migratory status, race, religion, and skin colour affect health. Discrimination based on these categories, although having many unique historical and cultural contexts, operates in the same way, with overlapping pathways and health effects. We synthesise how such discrimination affects health systems, spatial determination, and communities, and how these processes manifest at the individual level, across the life course, and intergenerationally. We explore how individuals respond to and internalise these complex mechanisms psychologically, behaviourally, and physiologically. The evidence shows that racism, xenophobia, and discrimination affect a range of health outcomes across all ages around the world, and remain embedded within the universal challenges we face, from COVID-19 to the climate emergency.

Introduction

Given the pervasive nature of racism, xenophobia, and other forms of discrimination, it should be no surprise that they are fundamental determinants of health.1 However, viewing discrimination as a central health concern is not commonplace. Across health conditions, from cancers and cardiovascular disease to COVID-19, caste, ethnicity, and race are often listed as risk factors.2, 3 In this Series paper, we capture the extensive nature of these health risks, and we challenge the so-called non-modifiable nature of these associations.

We reject the inevitability associated with the health risks of belonging to a minoritised group (and question the label minority itself). We reject that genetic differences are primarily responsible for health disparities among racialised groups.4, 5, 6 We reject simplistic models that explain differences by adjusting for socioeconomic status without questioning why some groups are systematically less wealthy than others.7 Our drive to modify this relationship between minoritised groups and inequitable health outcomes underpins this Series. We propose that differential health outcomes among minoritised groups are not prewritten in genetics ascribed to race or other categorisations such as ethnicity and Indigeneity, but instead are largely physiological responses to a complex range of mechanisms underpinned by past and present discrimination; including epigenetic responses to allostatic load and intergenerational exposures, with the life course stage mediating the health effects.

As health-care professionals, if we accept that people of minoritised castes, ethnicities, and races are innately more likely to be unhealthy and die early than privileged populations, we are complicit in upholding these inequities. By revealing the active role of discrimination in these associations of higher morbidity and mortality with minoritised categories of caste, ethnicity, Indigeneity, migratory status, race, religion, and skin colour, we identify areas for action.

The evidence is both overwhelming and a gross underestimate. In only identifying studies where discrimination was overtly examined, the health effects of discrimination are under-recognised. For example, Black women in the UK are 4 times more likely to die in childbirth than White women,8 whereas in some districts in Odisha, India, children belonging to a minoritised caste are more likely to be anaemic after adjusting for socioeconomic status.9 Discrimination was not directly measured in these studies, but it does not mean discrimination was not a contributing factor.

We acknowledge that assessing discrimination scientifically can be complex and limited.10 Academia and science themselves are not free from discrimination.10 We also acknowledge other forms of discrimination (eg, based on class, gender, sexuality, age, or ableness): the third paper in this Series examines these in more detail.11 Even categorisations used in gathering data across populations can be problematic and further discriminate, sometimes conflating skin colour with country or continent.12 We show how proximal pathways unravel and interconnect to cause differential health outcomes, from the climate emergency to COVID-19, with the first paper in this Series focusing on structural pathways such as historical context and racial capitalism (see the Race and Health platform).10 We identify discrimination as a standalone mechanism, and as a key factor influencing the severity of social, economic, and environmental inequalities.1 The first paper in this Series addresses the fraught relationship between science and racism, highlighting how science and medicine are not always objective truths, and can perpetuate racist and discriminatory ideology.13 We embrace uncertainty, indeterminacy, and complexity in our work, underpinned by an unwavering anti-racist, anti-caste, and decolonial perspective that is continually evolving.14

Key messages

  • Discrimination based on ethnicity, caste, Indigeneity, migratory status, race, religion, and skin colour occurs everywhere, adversely affecting mental and physical health across all ages, contributing to health inequities.

  • Discrimination directly affects the body through activation of the stress response, resulting in short-term and long-term biological changes. Through mechanisms such as epigenetic changes, exposure to discrimination in one generation might propagate adverse health effects to the subsequent generation. The importance for health of biological responses to discrimination has been severely under-recognised, due to a tendency to assume that population differences in disease risk have a genetic basis.

  • Discrimination profoundly shapes people's environments and opportunities, driving diverse processes for ill-health. Discrimination affects formal education, informal networks, recreation, jobs and careers, and access to health care. Discrimination also increases the likelihood of facing poor quality housing, neighbourhood deprivation and violence, air pollution, limited access to green space, and unhealthy food retail environments.

  • The COVID-19 pandemic highlights the cumulative imprint of discrimination on health outcomes, reflecting differences in susceptibility to disease, occupational exposure, access to appropriate care, clinical prognosis, and outcomes.

  • The intersection between racism, discrimination, and the climate emergency is often overlooked within public health but, at each level of society, minoritised populations are worst affected by the health effects, while often not being the main contributors.

  • At a societal level, discrimination is costly and inflicts collective trauma. There is evidence that discrimination affects all groups, and it would benefit us all to tackle it. Although tackling discrimination will improve health outcomes, a key motivator to addressing racism, xenophobia, and discrimination is to address our collective trauma through motivations rooted in justice and healing.

Section snippets

Conceptual framework: mapping pathways of discrimination to health outcomes

Anchored in figure 1 and throughout our Series is our conceptual framework, drawing out how discrimination affects health. Figure 1 illustrates a range of health outcomes affected by discrimination, mapped onto their respective life course stages, while centring the pathways of discrimination. At the core of how racism, xenophobia, and discrimination affect health are the concepts of hierarchical power and separation.13 Our first paper in the Series explores how these central themes manifest at

Individual responses

To illustrate the health consequences of discrimination, we focus on three responses evident in individuals: behavioural, psychological, and physiological (panel 1).

First, there is substantial evidence that many behaviours considered unhealthy, from physical inactivity to poor nutrition, are associated with experiences of discrimination.15, 16 The spatial determination of these behaviours is explored in panel 2. Risk factors must be viewed not only as causative to ill-health but also as

Communities

Health and wellbeing are structured by the relationships between people and their environments, including other people and broader ecosystems. In other words, individual health is co-constituted by the various aspects of communities in which we live, due to our manifold forms of connected interdependence. Discrimination plays a key role in structuring communities, by corralling minoritised people into places that create or perpetuate unhealthy environments, simultaneously increasing their

The effect of racism, xenophobia, and discrimination on health systems

Discrimination, past and present, substantially affects the experience and usage of health-care systems.40, 41 WHO's quality of care framework emphasises that services must be available, accessible, acceptable, and of the highest quality.42 Figure 3 shows how discrimination undermines this criteria. Discrimination diminishes systemic quality of care and quality of life for minoritised patients and health-care professionals.

A life course perspective on discrimination

Timing of discrimination exposure influences the health effects. For example, the effects of discrimination encountered in utero can manifest as chronic disease during adulthood.48, 49 Furthermore, some periods indicate increased sensitivity to the harmful effects of discrimin-ation, such as the key stage of transitioning from adolescence into adulthood: experience of events affected by discrimination such as incarceration, unemployment, or poor education in young people can have profound

Who does racism, xenophobia, and discrimination harm?

In addition to the profound damage to oppressed and minoritised groups globally, racism and discrimination financially strain health systems. For example, an estimate of health-care-related costs from racial inequalities in the USA over a 4-year period (2003–08) was US$229 billion, along with a loss of $1 trillion due to lost productivity from illness and premature deaths.126 Similar work estimated that, from 2001 to 2011, racism cost the Australian economy 3% of annual gross domestic product.

Limitations

The study of racism, xenophobia, and discrimination as a determinant of health is still relatively nascent, despite consistent growth in studies with an explicit focus on these concerns. The literature we reviewed represents a subset of the more established scholarship on the health effects of discrimination, which is itself a topic that is grossly underexamined due to the skewing of global research efforts towards the health needs of privileged groups and high-income countries.135, 136 Most of

Conclusion

Despite the overwhelming evidence regarding these health inequities, racism, xenophobia, and discrimination are potentially modifiable risk factors; they are contingent on geopolitical economic power relations rather than anything intrinsic to the categorisations of caste, ethnicity, migration status, Indigeneity, race, religion, or skin colour. Racism, xenophobia, and discrimination constitute a social, political, and cultural crisis in themselves, fracturing and undermining social cohesion

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, DD, TAD, and PdMS are recipients of the Wellcome Trust grant on climate and racial justice (grant number 24687/Z/21/Z). TAD is an

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