Dr Cara Booker is a Research Fellow at the Institute for Social and Economic Research. Here she tells us why systemic racism is the missing factor to understand health inequalities.

When I describe what my research expertise is, I usually say social epidemiologist. Social epidemiology has been defined as “the branch of epidemiology that studies the social distribution and social determinants of states of health”. To do this, we examine the sociostructural factors of a society to determine how they impact the distribution of health and disease. Gender, social class, social capital, social policy, discrimination and race/ethnicity are just a few examples of the sociostructural factors that have been explored in their relation to individual and population health.

While these factors are inextricably linked there is an over-riding driver of some of these factors that is often overlooked: systemic racism. When I am analysing data on adolescent mental health, I often explore inequalities by ethnicity. However, what my and many other’s research have failed to properly account for are the laws, regulations or unspoken policies that have perpetuated the oppression of people of colour and may be better predictors of the observed inequalities compared to the ethnicity of the individual. There are several reasons for why systemic racism is not accounted for, but I will focus on two: lack of discussion in lectures and poor measurement of systemic racism.

I attended the University of Southern California (USC) which is located in South Los Angeles. A couple of years before I arrived, the 1992 riots occurred following rising racial tensions and the acquittal of the police officers involved in the Rodney King beating. These riots were close to the USC campus and the effects of the riots could still be seen two years later. The riots should have opened doors for discussion in my classes about the systemic racism that allowed these events to occur. Dialogues on redlining*, racial profiling, gentrification and racism in medicine should have been imbedded in lectures. Wider discussion of how these systems directly and indirectly impact health and the inequalities we observe in population health should have been taking place in our classes.

Ignoring systemic racism does a disservice to those who wish to examine social determinants of health and, in turn, to reduce health inequalities. We are trying to address this problem with only partial information. Thus we are not equipped to develop suitable questions nor can we include information in our analyses that sufficiently captures the ongoing impact of systemic racism. We were not trained to do so.

The past 5 months have highlighted this lack of training and poor measurement of systemic racism. The COVID-19 pandemic has adversely impacted people of colour. While some of the reasons may be related to social capital, social class, or discrimination, there are also structural and systemic racist policies and laws that have driven these inequalities. Many of these laws have been repealed, but their impact lingers on. Explicit training which provides future social epidemiologist the tools and vocabulary to identify the structures within their society continue to contribute to inequalities and marginalisation based on race is necessary. Such training should not be limited to one or two classes, but should be embedded from the onset and underlie all training of social determinants of health. Graduates should not have to learn these lessons once they embark on their own career paths. We should all work to call out those structures to create meaningful change.

*Additional resources on redlining