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Health equity is fundamental to improving the health of populations, but in recent decades progress towards this goal has been mixed. To better support this mission, a deeper understanding of the local heterogeneity within population-level health equity is vital. This analysis presents trends in average health and health equity in the United States at the local level from 1990 to 2019 using three different health outcomes: mortality, self-reported health status, and healthy days. Furthermore, it examines the association between these measures of average health and health equity with several structural factors. Results indicate growing levels of geographic inequality disproportionately impacting less urbanized parts of the country, with rural counties experiencing the largest declines in health equity, followed by Medium and Small Metropolitan counties. Additionally, lower levels of health equity are associated with poorer local socioeconomic context, including several measures that are proxies for structural racism. Altogether, these findings strongly suggest social and economic factors play a pivotal role in explaining growing levels of geographic health inequality in the United States. Policymakers invested in improving health equity must adopt holistic and upstream approaches to improve and equalize economic opportunity as a means of fostering health equity.

IntroductionOlder adults racialized as Black experience higher rates of dementia than those racialized as White. Structural racism produces socioeconomic challenges, described by artist Marvin Gaye as "hang ups, let downs, bad breaks, setbacks" that likely contribute to dementia disparities. Robust dementia literature suggests socioeconomic factors may also be key resiliencies.MethodsWe linked state-level data reflecting the racialized landscape of economic opportunity across the 20th Century from the U.S. Census (1930-2010) with individual-level data on cognitive outcomes from the U.S. Health and Retirement Study participants racialized as Black. A purposive sample of participants born after the Brown v. Board ruling (born 1954-59) were selected who completed the modified Telephone Interview for Cognitive Status between 2010 and 2020 (N=1381). We tested associations of exposure to structural racism and resilience before birth, and during childhood, young-adulthood, and midlife with cognitive trajectories in mid-late life using mixed-effects regression models.ResultsOlder adults born in places with higher state-level structural socioeconomic racism experienced a more rapid cognitive decline in later life compared to those with lower levels of exposure. In addition, participants born in places with higher levels of state-level structural socioeconomic resilience experienced slower cognitive change over time than their counterparts.DiscussionThese findings reveal the impact of racist U.S. policies enacted in the past that influence cognitive health over time and dementia risk later in life.

We examine whether the COVID-19 pandemic was associated with changes to daily activity limitations due to poor physical or mental health and whether those changes were different within and between gendered and racialized groups. We analyze 497,302 observations across the 2019 and 2020 waves of the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System survey. Among White men and women, the COVID-19 pandemic was associated with fewer days of health-related activity limitations and decreased frequent activity limitation (≥14 days in the past month) compared to the prepandemic period. By contrast, Latina and Black women experienced increased days of activity limitation and greater likelihood of frequent activity limitation, and these changes were significantly different than for White women. These findings are robust to the inclusion of structural inequality measures and demonstrate how systemic racism and sexism likely exacerbate a myriad of pandemic-related health problems.

Achieving health equity in populations with congenital heart disease (CHD) requires recognizing existing disparities throughout the lifespan that negatively and disproportionately impact specific groups of individuals. These disparities occur at individual, institutional, or system levels and often result in increased morbidity and mortality for marginalized or racially minoritized populations (population subgroups (e.g., ethnic, racial, social, religious) with differential power compared to those deemed to hold the majority power in the population). Creating actionable strategies and solutions to address these health disparities in patients with CHD requires critically examining multilevel factors and health policies that continue to drive health inequities, including varying social determinants of health (SDOH), systemic inequities, and structural racism. In this comprehensive review article, we focus on health equity solutions and health policy considerations for minoritized and marginalized populations with CHD throughout their lifespan in the United States. We review unique challenges that these populations may face and strategies for mitigating disparities in lifelong CHD care. We assess ways to deliver culturally competent CHD care and to help lower-health-literacy populations navigate CHD care. Finally, we review system-level health policies that impact reimbursement and research funding, as well as institutional policies that impact leadership diversity and representation in the workforce.

Abstract Aims Racial disparities exist in clinical outcomes for valvular heart disease (VHD). It is unknown whether clinician segregation contributes to these disparities. Among an adequately insured population, we evaluated the relationship between clinician segregation in a hospital and receipt of care by a cardiologist according to patient race. We also evaluated the association between clinician segregation, race and care by a cardiologist on 30‐day readmission and 1‐year survival. Methods and results Using Optum's Clinformatics® Data Mart Database (CDM, US commercial and Medicare beneficiaries) from 2010 to 2018, we identified patients with a primary diagnosis of VHD. Hospitals were categorized into low, medium and high segregation groups (SG), according to clinician segregation index (SI). SI can range from 0–1 (0: the ratio of Black to White patients is the same for all clinicians; 1: each clinician treats only Black or only White patients). Outcomes were analysed using generalized linear mixed effect models. Among 8649 patients [median age 75 (67–82), 45.4% female, 16.1% Black, 83.9% White], odds of care from a cardiologist did not vary across race for all SGs [Low SG adjusted odds ratio (aOR): 0.79 (95% CI: 0.58–1.08), P = 0.14; Medium SG aOR: 0.86 (95% CI: 0.60–1.25), P = 0.43; High SG aOR: 1.07 (95% CI: 0.68–1.69), P = 0.76]. Among those that received care from a cardiologist, there was no difference in the 30‐day readmission between Black and White patients across SGs [Low SG aOR: 1.05 (95% CI: 0.83–1.31), P = 0.70; Medium SG aOR: 1.22 (95% CI: 0.92–1.61), P = 0.17; High SG aOR: 0.81 (95% CI: 0.57–1.17), P = 0.27]. Among patients that did not receive care from a cardiologist, Black patients in low SG had higher odds of 30‐day readmission compared to White patients [aOR: 2.74 (95%CI:1.38–5.43), P

Abstract Across the United Kingdom, medical schools are acknowledging the need to respond to inequalities experienced by minority groups, racism within healthcare, and the need to decolonise medical curricula. Understanding the impact of structural racism is increasingly recognised as part of health professionals’ training. In this paper we report the delivery of a new lecture and workshop on racism to first year medical students at Hull York Medical School, aimed to teach students about structural racism and the impact it has on health and healthcare services. Whereas comparable training programmes focus on personal values of inclusivity and diversity, these sessions encourage students to consider the reality of racism as part of health and healthcare experiences. The session includes conceptual content alongside applied examples of microaggression experienced by a healthcare professional. We report the results of student feedback attained through surveys using Likert scales and free text. We conclude by discussing the benefits of teaching medical students about racism, and its impact on patients and staff, rather than just inclusive practice.

Structural racism and the ongoing modern-colonizing project in Latin America would not be the same without the contributions of Modern Western Science. Contradictorily, it is also through the sciences — especially social sciences — that colonialities have been challenged. Inspired by decolonial criticism, we tell the life story of Waxihô Karajá, an indigenous Karajá Xambioá man who entered and abandoned a Biology course. The results illustrate how Iny indigenous education contributed to the development of Waxihô Karajá's interest in Biology. Our analysis also reveals that the low quality of basic education offered in indigenous communities; the unpreparedness of higher education institutions to receive diversity; the difficulties experienced by young people with low-education backgrounds and the energy expended by cultural minorities to combat a myriad of colonial violences through student activism can compromise academic success. Results indicate that the approach and the departure from natural science courses by young indigenous people seem to have reasons that are sometimes similar and sometimes different from those listed in the research with young people from the national society. There is an urgent need to reorient university retention policies to promote the academic success of indigenous students in natural sciences courses.

Across the United Kingdom, medical schools are acknowledging the need to respond to inequalities experienced by minority groups, racism within healthcare, and the need to decolonise medical curricula. Understanding the impact of structural racism is increasingly recognised as part of health professionals' training. In this paper we report the delivery of a new lecture and workshop on racism to first year medical students at Hull York Medical School, aimed to teach students about structural racism and the impact it has on health and healthcare services. Whereas comparable training programmes focus on personal values of inclusivity and diversity, these sessions encourage students to consider the reality of racism as part of health and healthcare experiences. The session includes conceptual content alongside applied examples of microaggression experienced by a healthcare professional. We report the results of student feedback attained through surveys using Likert scales and free text. We conclude by discussing the benefits of teaching medical students about racism, and its impact on patients and staff, rather than just inclusive practice. [ABSTRACT FROM AUTHOR]

Introduction. Undocumented migrants live in a state of social, legal, and political invisibility, which affects their mental health while hindering their access to health services. It is therefore essential to understand which situations are linked to their emotional discomfort and how they cope with it. Objective. To explore the sources of emotional discomfort and the strategies used to deal with it in undocumented Mexican migrants residing in an area with a recent migratory tradition. Method. Study conducted using qualitative methodology and ethnographic strategies involving four open interviews with key informants and seven semi-structured interviews with undocumented Mexican immigrants. A thematic analysis was conducted of each of them, and the main categories constructed. Results. Immigration status was the main source of emotional discomfort, creating sadness, anger, and frustration associated with direct acts of racism and discrimination. Religiosity or spirituality, relaxation, avoidance, self-control ("gritting your teeth and bearing it"), and seeking supportive social networks were the most commonly used strategies for coping with this discomfort. Discussion and conclusions. It would be advisable to implement strategies that increased the possibilities of access to professional care, when necessary, without immigrants perceiving a threat due to their immigration status and to promote more robust social networks in the community, as well as virtual networks that could provide an alternative source of care and accompaniment from their place of origin. [ABSTRACT FROM AUTHOR]

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This article addresses structural racism and the denial of rights in the work Quarto de Despejo (1960), by Carolina Maria de Jesus. In this work, we note a striking testimony to the living conditions of the marginalized population in Brazilian urban outskirts in the 1960s, shedding light on the social injustices and racial discrimination that permeate Brazilian society. Our objective is to discuss how rights were denied in the work due to racism and how this impacted the author's life and continues to impact the lives of black men and women to this day. The theoretical contribution will be based on studies by Almeida (2018; 2021), Carneiro (2006), Gonzalez (1982), Rios (2019), among others. [ABSTRACT FROM AUTHOR]

This project uses mixed methods to examine the systemic causes and consequences of the construction of Stockton, California’s Crosstown Freeway and of urban redevelopment for Asian Americans communities. Stockton underwent spatial restructuring in the decades after the Second World War, and state and local government contributed and responded to these changes by implementing connected freeway and urban renewal programs. Historical and contemporaneous xenophobia and racism placed Chinatown, Japantown, and Little Manila in their path, with these enclaves deemed blighted and subject to “slum clearance.” The choice of freeway route was racially biased. The neighborhood surrounding an unchosen route was predominantly white, whereas that of the chosen route was predominantly home to people of color. Freeway construction during the 1960s and 1970s directly displaced hundreds of people and housing units downtown— mainly people of color, particularly Asians. The communities most harmed were the Asian American enclaves, where the housing stock declined by about three quarters between 1960 and 1970. The losses were not only physical, as the freeway and redevelopment eviscerated once vibrant ethnic commercial hubs. Because of long-standing economic and political marginalization, Asian Americans were relatively powerless to prevent the destruction; nonetheless, they fought to build affordable housing for their people, protect and in some cases relocate cultural institutions, and support surviving ethnic businesses. In the long run, Stockton failed to revitalize its downtown, while destroying its cultural diversity. The findings can help reform and improve professional practice within the transportation arena to ensure racial fairness and equity.

Despite growing interest in the health-related consequences of racially discriminatory institutional policies and practices, public health scholars have yet to reach a consensus on how to measure and analyze exposure to institutional racism. The purpose of this paper is to provide an overview of the conceptualization, measurement, and analysis of institutional racism in the context of quantitative research on minority health and health disparities in the United States. We begin by providing definitions of key concepts (e.g., racialization, racism, racial inequity) and describing linkages between these ideas. Next, we discuss the hypothesized mechanisms that link exposure to institutional racism with health. We then provide a framework to advance empirical research on institutional racism and health, informed by a literature review that summarizes measures and analytic approaches used in previous studies. The framework addresses six considerations: (1) policy identification, (2) population of interest, (3) exposure measurement, (4) outcome measurement, (5) study design, and (6) analytic approach. Research utilizing the proposed framework will help inform structural interventions to promote minority health and reduce racial and ethnic health disparities.

IntroductionPublic policies and legislative approaches are used to address racial health inequities. While most recent studies examine federal and state-level legislative activity, a paucity of analyses characterize policies enacted in a single state and across local jurisdictions. To address this gap, we identify racial health equity policies in the state of Maryland and describe key features and themes.MethodsA legal mapping study and content analysis was conducted. Maryland policies and legislative activity adopted at the state or county level (2012–2021) were identified by systematically searching Westlaw and state and county government legislative databases. Information for each policy was ascertained and analyzed to identify content domains.ResultsWe identified 22 state-level policies and 10 county-level policies and actions that explicitly addressed racial health inequities. Six domains were identified: healthcare and public health cultural competence; disease-specific care and outcomes; access to healthcare services; social determinants of health; collection action and research infrastructure; and structural racism. At the state- and county- level, most policies pertained to the healthcare and public health cultural competence domain. Of Maryland’s 24 counties, only 8 (33%) passed health equity policies and implemented equity-specific policy priorities.ConclusionThis study provides a snapshot of the Maryland policy landscape and suggests an increasing prioritization of equity policy at the state and county levels. While policies address issues ranging from cultural competence to structural racism, policy content differed by level of jurisdiction. Future efforts to critically evaluate the impact of specific policies on health inequities are needed.

The COVID-19 pandemic profoundly impacted population health, including mental health, in ways that were patterned unevenly by pre-existing systemic inequalities such as structural gendered racism and xenophobia. However, it remains unclear whether pandemic-related mental health deterioration has persisted over time. Drawing on theories of disruptive events and structural racism, we conceptualize the pandemic as a prolonged macro-level disruptive event with unequal ramifications for different racialized groups and by immigration status. We use six waves (2017–2022) of repeated cross-sectional data from the California Health Interview Survey (CHIS; N = 121,063) from men and women from nine racialized and immigration status groups (US-born citizens, naturalized citizens, and noncitizens of White, Latina/o, and Asian racialized groups, respectively). We use multivariable regression to examine changes in psychological distress within each group, and then assess patterns of racialized health disparities between Latina/o and Asian groups, respectively, compared to White US-born citizens, who occupy the most structurally privileged social status. Our analyses reveal several key findings. First, we observed persistent increases in psychological distress from 2020 through 2022, relative to the pre-pandemic period (2017–2019), for all racialized and immigration status groups, among men and women. Second, few groups had returned to pre-pandemic distress levels as of 2022. Third, there was a consistent health advantage for White US-born citizens across the pre-pandemic and pandemic years, whose highest post-pandemic distress measure was lower or equivalent to the pre-pandemic distress of US-born Latina/o and Asian groups. Fourth, the psychological distress gap between the White US-born population and US-born Latina/o and Asian groups, respectively, grew or held steady through 2022. Finally, the 2020–2022 period was associated with a reduction in pre-pandemic health advantages among Asian immigrant groups, relative to US-born White citizens, especially among men. Our findings provide strong evidence that population mental health has not recovered from the pandemic period.

Introduction: Climate change and structural racism are significant threats to public health and health equity. The impacts of each individual problem on human health and well-being have been documented; what is less known is the impact of the intersection of climate change and structural racism on health. Purpose: To conduct a scoping review to examine the emerging knowledge related to the impact of climate change and structural racism on the health and well-being of racialized minority groups in the United States. Methods: A scoping review was conducted using the Joanna Briggs Institute methodology and PubMed, CINAHL, and PsychInfo databases. Two searches were conducted between 11/2021 and 7/2023. Data were extracted and analyzed; and themes were identified. Results: Of 148 full-text reviews, 28 were included in the final synthesis. Texas was the US state most represented in research studies. Black/African American and Hispanic/Latino populations were the most discussed and studied populations. The overarching theme identified was the enduring legacy of historical redlining on inequitable climate and environmental exposures. Four subthemes included environmental justice impacts, climate justice impacts, ecopandemic injustice, and the emergence of syndemics. Conclusion: Climate justice, environmental justice and structural racism have individual impacts on health; however, they are inextricably linked and have wide-ranging impacts on health and well-being. Implications for education, clinical practice, policy and advocacy, and research are outlined. Health providers have an opportunity to partner with disinvested communities to develop realistic strategies to create more resilient, vibrant communities that will lead to improved health outcomes.

BackgroundRacial and ethnic disparities in COVID-19 risk are well-documented; however, few studies in older adults have examined multiple factors related to COVID-19 exposure, concerns, and behaviors or conducted race- and ethnicity- stratified analyses. The Women's Health Initiative (WHI) provides a unique opportunity to address those gaps.MethodsWe conducted a secondary analysis of WHI data from a supplemental survey of 48,492 older adults (mean age 84 years). In multivariable-adjusted modified Poisson regression analyses, we examined predisposing factors and COVID-19 exposure risk, concerns, and behaviors. We hypothesized that women from minoritized racial or ethnic groups, compared to Non-Hispanic White women, would be more likely to report: exposure to COVID-19, a family or friend dying from COVID-19, difficulty getting routine medical care or deciding to forego care to avoid COVID-19 exposure, and having concerns about the COVID-19 pandemic.ResultsAsian women and Non-Hispanic Black/African American women had a higher risk of being somewhat/very concerned about risk of getting COVID 19 compared to Non-Hispanic White women and each were significantly more likely than Non-Hispanic White women to report forgoing medical care to avoid COVID-19 exposure. However, Asian women were 35% less likely than Non-Hispanic White women to report difficulty getting routine medical care since March 2020 (aRR 0.65; 95% CI 0.57, 0.75).ConclusionsWe documented COVID-related racial and ethnic disparities in COVID-19 exposure risk, concerns, and care-related behaviors that disfavored minoritized racial and ethnic groups, particularly Non-Hispanic Black/African American women.

Calls-to-action in health research have described a need to improve research on race, ethnicity, and structural racism. Well-established cohort studies typically lack access to novel structural and social determinants of health (SSDOH) or precise race and ethnicity categorization, contributing to a loss of rigor to conduct informative analyses and a gap in prospective evidence on the role of structural racism in health outcomes. We propose and implement methods that prospective cohort studies can use to begin to rectify this, using the Women's Health Initiative (WHI) cohort as a case study. To do so, we evaluated the quality, precision, and representativeness of race, ethnicity, and SSDOH data compared with the target US population and operationalized methods to quantify structural determinants in cohort studies. Harmonizing racial and ethnic categorization to the current standards set by the Office of Management and Budget improved measurement precision, aligned with published recommendations, disaggregated groups, decreased missing data, and decreased participants reporting "some other race". Disaggregation revealed sub-group disparities in SSDOH, including a greater proportion of Black-Latina (35.2%) and AIAN-Latina (33.3%) WHI participants with income below the US median compared with White-Latina (42.5%) participants. We found similarities in the racial and ethnic patterning of SSDOH disparities between WHI and US women but less disparity overall in WHI. Despite higher individual-level advantage in WHI, racial disparities in neighborhood resources were similar to the US, reflecting structural racism. Median neighborhood income was comparable between Black WHI ($39,000) and US ($34,700) women. WHI SSDOH-associated outcomes may be generalizable on the basis of comparing across race and ethnicity but may quantitatively (but not qualitatively) underestimate US effect sizes. This paper takes steps towards data justice by implementing methods to make visible hidden health disparity groups and operationalizing structural-level determinants in prospective cohort studies, a first step to establishing causality in health disparities research.

Introduction: Past research shows that structural racism contributes to disparities in cardiometabolic health among racially/ethnically minoritized populations. Methods: This cross-sectional study examined the correlation between census tract-level racialized economic segregation and child health metrics among a racially and ethnically diverse cohort of 350 children (ages 6.5?13.8) from Minneapolis?St. Paul, MN. Results: A consistent cardiometabolic and cortisol outcome gradient was observed across the index of concentration at the extremes tertiles, such that health risk factors increased as tract privilege decreased. Conclusion: Racialized economic segregation was associated with less favorable child health outcomes, underscoring the potential importance of place-based interventions for promoting children?s health.

ObjectiveTo describe the perception of professional climate in health services and policy research (HSPR) and efforts to advance diversity, equity, and inclusion (DEI) in the HSPR workforce and workplaces.Data sourceWe administered the HSPR Workplace Culture Survey online to health services and policy researchers.Study designOur survey examined participants' sociodemographic, educational, and professional backgrounds, their perception on DEI in HSPR, experience with DEI initiatives, feeling of inclusion, and direct and witnessed experiences of discrimination at their institutions/organizations. We calculated sample proportions of responses by gender identity, sexual orientation, race/ethnicity, and disability status and compared them with Fisher's exact test.Data collectionWe administered the survey online from July 28 to September 4, 2020. HSPR professionals and trainees aged 18 and older were eligible to participate. Analyses used complete cases only (n = 906; 70.6% completion rate).Principal findings53.4% of the participants did not believe that the current workforce reflects the diversity of communities impacted by HSPR. Although most participants have witnessed various DEI initiatives at their institutions/organizations, nearly 40% characterized these initiatives as "tokenistic." Larger proportions of participants who identified as female, LGBQI+, underrepresented racial/ethnic groups, and those with a disability held this perception than their male, heterosexual, White, and non-disabled counterparts. Current DEI initiatives focused on "planning" activities (e.g., convening task forces) rather than "implementation" activities (e.g., establishing mentoring or network programs). 43.7% of the participants felt supported on their career development, while female, Black, Hispanic/Latino, LGBQI+ participants and those with a disability experienced discrimination at their workplace.ConclusionsDespite an increasing commitment to increasing the diversity of the HSPR workforce and improving equity and inclusion in the HSPR workplace, our results suggest that there is more work to be done to achieve such goals.

Communities of color and poor neighborhoods are disproportionately exposed to more air pollution-a pattern known as environmental injustices. Environmental injustices increase susceptibility to negative health outcomes among residents in affected communities. The structural mechanisms distributing environmental injustices in the USA are understudied. Bridging the literatures on the social determinants of health and environmental justice highlights the importance of the environmental conditions for health inequalities and sheds light on the institutional mechanisms driving environmental health inequalities. Employing a critical quantitative methods approach, we use data from an innovative state racism index to argue that systematic racialized inequalities in areas from housing to employment increase outdoor airborne environmental health risks in neighborhoods. Results of a multilevel analysis in over 65,000 census tracts demonstrate that tracts in states with higher levels of state-level Black-white gaps report greater environmental health risk exposure to outdoor air pollution. The state racism index explains four-to-ten percent of county- and state-level variation in carcinogenic risk and noncarcinogenic respiratory system risks from outdoor air toxics. The findings suggest that the disproportional exposure across communities is tied to systematic inequalities in environmental regulation and other structural elements such as housing and incarceration. Structural racism is an environmental justice issue.

Cities worldwide are grappling with complex urban environmental injustices. While environmental justice as a concept has gained prominence in both academia and policy, operationalizing and implementing environmental justice principles and norms remains underexplored. Notably, less attention has been given to centering the perspectives and experiences of community-based actors operating at the grassroots level, who can inform and strengthen urban environmental justice practice. Through ethnographic, participant-as-observer methods, interviews, and geovisualizations, this study explores the perspectives, experiences, knowledge, and practices of community-based urban forest stewards in Philadelphia, Pennsylvania (United States) who are invested in addressing environmental injustices through urban tree-planting and stewardship. Interviewees were asked how they were addressing issues of distribution, procedure, and recognition in urban forest planning and practice, as well as the socio-political and institutional factors that have influenced their perspectives and practices. Particular attention is given to how urban forest stewards implement recognitional justice principles. Findings from this study exposed several complex socio-political challenges affecting steward engagement in community-led tree initiatives and the broader pursuit of environmental justice, including discriminatory urban planning practices, gentrification concerns, underrepresentation of Black and Latinx voices in decision-making, volunteer-based tree-planting models, and tree life cycle costs. Nevertheless, urban forest stewards remain dedicated to collective community-building to address environmental injustices and stress the importance of recognizing, listening to, dialoguing with, and validating the perspectives and experiences of their neighbors as essential to their process. [ABSTRACT FROM AUTHOR]

Background: Timely and reliable dispensing of buprenorphine is critical to accessing treatment for opioid use disorder (OUD). Racial and ethnic inequities in OUD treatment access are well described, but it remains unclear if inequities persist at the point of dispensing. Methods: We analyzed data from a U.S. telephone audit that measured restricted buprenorphine dispensing in community pharmacies, defined as inability to fill a buprenorphine prescription requested by a “secret shopper.” Using the Index of Concentration at the Extremes (ICE), we constructed county-level measures of racial, ethnic, economic, and racialized economic (joint racial and economic segregation) segregation. Logistic regression models evaluated the association of ICE measures and restricted buprenorphine dispensing, adjusting for county type (urban vs. rural) and pharmacy type (chain vs. independent). Results: Among 858 pharmacies surveyed in 473 counties, pharmacies in the most ethnically segregated and economically deprived counties had 2.66 times the odds (95 % CI: 1.41, 5.17) of restricting buprenorphine dispensing, compared to pharmacies in the most privileged counties after adjustment. Pharmacies in counties with high racialized economic segregation (quintile 2 and 3) also had higher odds of restricting buprenorphine dispensing (aOR 3.09 [95 % CI 1.7, 5.59]; aOR 2.11 [95 % CI 1.17, 3.98]). Similar associations were observed for economic segregation (aOR: 2.18 [95 % CI: 1.21, 3.99]), but not ethnic (0.59 [0.34, 1.05]) or racial (0.61 [0.35, 1.07]) segregation alone. Conclusions: Restricted buprenorphine dispensing was most pronounced in socially and economically disadvantaged communities, potentially exacerbating gaps in OUD treatment access. Policy interventions should target both prescribing and dispensing capacity to advance pharmacoequity.

Structurally racist policies and practices of the past are likely to be a driving factor in current day differences in exposure to air pollution and may contribute to observed racial and ethnic disparities in adverse birth outcomes in the United States (U.S.). Non-Hispanic Black women in the U.S. experience poorer health outcomes during pregnancy and throughout the life course compared to non-Hispanic White women. This disparity holds even among non-Hispanic Black women with higher socioeconomic status. Reasons for this finding remain unclear, but long-term environmental exposure, either historical exposure or both historical and ongoing exposure, may contribute. Structural racism likely contributes to differences in social and environmental exposures by race in the U.S. context, and these differences can affect health and wellbeing across multiple generations. In this paper, we briefly review current knowledge and recommendations on the study of race and structural racism in environmental epidemiology, specifically focused on air pollution. We describe a conceptual framework and opportunities to use existing historical data from multiple sources to evaluate multi-generational influences of air pollution and structurally racist policies on birth and other relevant health outcomes. Increased analysis of this kind of data is critical for our understanding of structural racism's impact on multiple factors, including environmental exposures and adverse health outcomes, and identifying how past policies can have enduring legacies in shaping health and well-being in the present day. The intended purpose of this manuscript is to provide an overview of the widespread reach of structural racism, its potential association with health disparities and a comprehensive approach in environmental health research that may be required to study and address these problems in the U.S. The collaborative and methodological approaches we highlight have the potential to identify modifiable factors that can lead to effective interventions for health equity.

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities.As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments—communicable diseases, non-communicable conditions, and injuries—and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.

BackgroundEating disorders are associated with substantial morbidity and mortality that can be minimized by timely access to evidence-based treatment. However, disparate access to eating disorders treatment may contribute to significant health disparities amongst marginalized groups. This study examined the association between insurance type (public vs. private) and receipt of recommended mental health treatment in a sample of racially/ethnically diverse youth who presented to an adolescent medicine clinic with malnutrition secondary to disordered eating.MethodsA retrospective chart review was conducted for youth ages 11-25 years (N = 1060) who presented to an urban adolescent medicine specialty program between June 1, 2012 and December 31, 2019 for malnutrition secondary to disordered eating. Bivariate and logistic regression analyses examined the association between insurance type (public vs. private) and other demographic/clinical factors on receipt of recommended treatment within six months of the initial evaluation.ResultsPatients with public insurance were one third as likely to receive recommended treatment as patients with private insurance (AOR = 3.23; 95% CI = 1.99, 4.52), after adjusting for demographic and clinical factors. Latinx (AOR = 0.49; 95% CI = 0.31, 0.77) and Asian (AOR = 0.55; 95% CI = 0.32, 0.94) patients were half as likely to receive recommended treatment as White patients.ConclusionsAccess to evidence-based mental health treatment is a necessary first step towards health equity for individuals with eating disorders. Additional work is needed to dismantle systemic inequities that contribute to disparities in care for youth of color and those with public insurance.

BackgroundRecent studies have reignited the tinderbox of debate surrounding the use of race and ancestry in medicine. These controversial studies have argued for a strong correlation between genetic ancestry and race, justifying continued use of genetic ancestry measures in studies of disease. These studies contend that increased use of continental ancestry estimates can inform clinical risk assessments and management. Further, recent studies of racial corrections used in clinical algorithms, such as those used to estimate 'normal' lung function, also advocate for use of genetic ancestry in place of race for refining risk algorithms.Main bodyThese positions are misleading, harmful, and reflect superficial interpretations of population genetics. In this Perspective, we argue that continental genetic ancestry, often proxied by race, serves as a poor indicator of disease risk, and reinforces racialized inequities.ConclusionInstead, we endorse that racial disparities in disease should be investigated by rigorous measures of structural racism alongside careful measures of genetic factors in relevant disease pathways, rather than relying on genetic ancestry or race as a crude proxy for disease-causing alleles.

Following the Great Depression and related home foreclosures, the federal government established new agencies to facilitate access to affordable home mortgages, including the Home Owners' Loan Corporation (HOLC) and Federal Housing Administration (FHA). HOLC and FHA directed widespread neighborhood appraisals to determine investment risk, referred to as "redlining," which took into account residents' race. Redlining thereby contributed to segregation, disinvestment, and racial inequities in opportunities for homeownership and wealth accumulation. Recent research examines associations between historical redlining and subsequent environmental determinants of health and health-related outcomes. In this scoping review, we assess the extent of the current body of evidence, the range of outcomes studied, and key study characteristics, examining the direction and strength of the relationship between redlining, neighborhood environments, and health as well as different methodological approaches. Overall, studies nearly universally report evidence of an association between redlining and health-relevant outcomes, although heterogeneity in study design precludes direct comparison of results. We critically consider evidence regarding HOLC's causality and offer a conceptual framework for the relationship between redlining and present-day health. Finally, we point to key directions for future research to improve and broaden understanding of redlining's enduring impact and translate findings into public health and planning practice.

In the United States, racial disparities in adverse maternal health outcomes remain a pressing issue, with Black women experiencing a 3-4 times higher risk of maternal mortality and a 2-3 times higher risk of severe maternal morbidity. Despite recent encouraging efforts, fundamental determinants of these alarming inequities (e.g. structural racism) remain understudied. Approaches that address these structural drivers are needed to then intervene upon root causes of adverse maternal outcomes and their disparities and to ultimately improve maternal health across the U.S. In this paper, we offer a conceptual framework for studies of structural racism and maternal health disparities and systematically synthesize the current empirical epidemiologic literature on the links between structural racism measures and adverse maternal health outcomes. For the systematic review, we searched electronic databases (Pubmed, Web of Science, and EMBASE) to identify peer-reviewed U.S. based quantitative articles published between 1990 and 2021 that assessed the link between measures of structural racism and indicators of maternal morbidity/mortality. Our search yielded 2394 studies and after removing duplicates, 1408 were included in the title and abstract screening, of which 18 were included in the full text screening. Only 6 studies met all the specified inclusion criteria for this review. Results revealed that depending on population sub-group analyzed, measures used, and covariates considered, there was evidence that structural racism may increase the risk of adverse maternal health outcomes. This review also highlighted several areas for methodological and theoretical development in this body of work. Future work should more comprehensively assess structural racism in a way that informs policy and interventions, which can ameliorate its negative consequences on racial/ethnic disparities in maternal morbidity/mortality.

Introduction: Older adults racialized as Black experience higher rates of dementia than those racialized as White. Structural racism produces socioeconomic challenges, described by artist Marvin Gaye as ?hang ups, let downs, bad breaks, setbacks? that likely contribute to dementia disparities. Robust dementia literature suggests socioeconomic factors may also be key resiliencies. Methods: We linked state-level data reflecting the racialized landscape of economic opportunity across the 20th Century from the U.S. Census (1930?2010) with individual-level data on cognitive outcomes from the U.S. Health and Retirement Study participants racialized as Black. A purposive sample of participants born after the Brown v. Board ruling (born 1954?59) were selected who completed the modified Telephone Interview for Cognitive Status between 2010 and 2020 (N=1381). We tested associations of exposure to structural racism and resilience before birth, and during childhood, young-adulthood, and midlife with cognitive trajectories in mid-late life using mixed-effects regression models. Results: Older adults born in places with higher state-level structural socioeconomic racism experienced a more rapid cognitive decline in later life compared to those with lower levels of exposure. In addition, participants born in places with higher levels of state-level structural socioeconomic resilience experienced slower cognitive change over time than their counterparts. Discussion: These findings reveal the impact of racist U.S. policies enacted in the past that influence cognitive health over time and dementia risk later in life.

Power inequalities and structural racism are long-standing problems within the humanitarian aid sector. Staff from high income countries typically work as “international staff,” receiving better treatment than “national staff” from low- and middle-income countries. This can result in harm not only to those disadvantaged by the system but also to those who appear to be benefiting from but are morally conflicted by systemic disparities. Ten current and former international humanitarians, with careers spanning from 3 to 15 years, were interviewed for this qualitative exploratory research. Participants were asked to share occupational experiences that they perceived to be morally troubling and to describe any mental health or other implications. Using Thematic Analysis, responses were coded and grouped into key themes highlighting inequities between international and national staff in − (1) decision-making authority and roles, (2) salary, contract status, leave and access to medical services, (3) access to equipment and other resources and (4) security risks. Participants described morally conflicting events vis-à-vis structural inequities and corresponding psychological, social, and behavioural outcomes that suggest the presence of moral distress in international aid workers. Reform of the humanitarian system is necessary for both individuals and operations to thrive, as we work collectively to decolonise aid.

Abstract Background While several medical societies endorse race as a social construct, it is still often used as a biological trait in medical education. How medical educators employ race while teaching is likely impacted by their beliefs as to what race represents and its relevance in clinical care. Understanding these beliefs is necessary to guide medical education curriculum reform. Methods This was a qualitative survey study, conducted in June 2020, of Georgetown University Medical Center faculty. As part of the survey, faculty were asked to rate, on a 5-point Likert scale, the extent to which they perceived race as a biological trait and its importance in clinical care. Self-identified clinical or preclinical faculty (N = 147) who believed that race had any importance were asked to provide an example illustrating its significance. Free-text responses were coded using content analysis with an inductive approach and contextualized by faculty’s perspectives on the biological significance of race. Results There were 130 (88%) responses categorized into two major themes: race is important for (1) screening, diagnosing, and treating diseases and (2) contextualizing patients’ experiences and health behaviors. Compared to faculty who perceived race as biological, those who viewed race as strictly social were more likely to report using race to understand or acknowledge patients’ exposure to racism. However, even among these faculty, explanations that suggested biological differences between racial groups were prevalent. Conclusions Medical educators use race primarily to understand diseases and frequently described biological differences between racial groups. Efforts to reframe race as sociopolitical may require education that examines race through a global lens, accounting for the genetic and cultural variability that occurs within racial groups; greater awareness of the association between structural racism and health inequities; movement away from identity-based risk stratification; and incorporation of tools that appraise race-based medical literature.

This article discusses the concept of environmental racism and its impact on environmental epidemiology. It highlights the disparities in exposure to pollution and access to environmental amenities that disproportionately affect communities of color. The article emphasizes the need to incorporate structural racism into epidemiologic studies and suggests using historical and theoretical approaches to assess its influence. It also discusses the limitations of measured and modeled data in assessing environmental exposures and recommends engaging affected communities in surveillance efforts. The article concludes by calling for a greater focus on modifiable policies and interventions to address environmental injustice. [Extracted from the article]

Racial/ethnic minorities have experienced higher COVID-19 infection rates than whites, but it is unclear how individual-level housing, occupational, behavioral, and socioeconomic conditions contribute to these disparities in a nationally representative sample. In this study, we assess the extent to which social determinants of health contribute to racial/ethnic differences in COVID-19 infection. Data are from the Understanding America Study's Understanding Coronavirus in America survey (UAS COVID-19 waves 7-29). UAS COVID-19 is one of the only nationally representative longitudinal data sources that collects information on household, work, and social behavioral context during the pandemic. We analyze onset of COVID-19 cases, defined as a positive test or a diagnosis of COVID-19 from a healthcare provider since the previous survey wave, over a year of follow-up (June 2020-July 2021). We consider educational attainment, economic resources, work arrangements, household size, and social distancing as key social factors that may be structured by racism. Cox hazard models indicate that Hispanic people have 48% higher risk of experiencing a COVID-19 infection than whites after adjustment for age, sex, local infection rate, and comorbidities, but we do not observe a higher risk of COVID-19 among Black respondents. Controlling for engagement in any large or small social gathering increases the hazard ratio for Hispanics by 9%, suggesting that had Hispanics had the same social engagement patterns as whites, they may have had even higher risk of COVID-19. Other social determinants-lower educational attainment, working away from home, and number of coresidents-all independently predict higher risk of COVID-19, but do not explain why Hispanic Americans have higher COVID-19 infection risk than whites.

Social inequality is a pervasive and complex phenomenon that transcends geographical, cultural, and historical boundaries. It manifests in various forms, including economic disparities, unequal access to resources and opportunities, discrimination based on race, gender, and other identities, and disparities in power and privilege. This research article aims to delve into the multifaceted nature of social inequality, examining its underlying causes, consequences, and potential avenues for addressing it. Drawing upon interdisciplinary perspectives from sociology, economics, psychology, and political science, this article provides a comprehensive analysis of social inequality, highlighting its impact on individuals, communities, and societies at large. By exploring the interconnectedness of various dimensions of inequality, this research seeks to contribute to a deeper understanding of the mechanisms perpetuating social disparities and inform strategies for promoting greater equity and justice. [ABSTRACT FROM AUTHOR]

Despite routine law enforcement use of chemical agents for crowd control, the reproductive health safety profiles of these products are unknown. Moreover, limited evidence has documented a link between such exposures and adverse reproductive health outcomes including abnormal uterine bleeding and potential pregnancy disruption. This cross-sectional study examined reproductive outcomes in adults with uteri exposed to chemical agents used by law enforcement, more commonly known as "tear gas". Participants were recruited through social media in the wake of police violence protests. Of the 1,276 participants included in analysis, 83% reported experiencing at least one of the outcomes of interest, included uterine cramping (69%), early menstrual bleeding (55%), breast tenderness (30%), and delayed menstrual bleeding (19%). Chemical agent exposure was significantly associated with higher odds of an adverse reproductive health outcome, those with 5 days or more of exposure have 2.6 times the odds (CI: 1.61, 4.22) of adverse outcomes and having a perception that one's menstruation may fluctuate according to psychosocial stressors was associated (OR = 1.94, CI: 1.36, 2.79) with a higher odds of an adverse reproductive health experience. These findings suggest a potential relationship between exposure to chemical agents and adverse reproductive health outcomes. Given the pervasive use of these chemical agents and their potential for reproductive health harm, further investigation into the safety of these products and their impacts on individual and community health is warranted urgently. [ABSTRACT FROM AUTHOR]

Background: While several medical societies endorse race as a social construct, it is still often used as a biological trait in medical education. How medical educators employ race while teaching is likely impacted by their beliefs as to what race represents and its relevance in clinical care. Understanding these beliefs is necessary to guide medical education curriculum reform. Methods: This was a qualitative survey study, conducted in June 2020, of Georgetown University Medical Center faculty. As part of the survey, faculty were asked to rate, on a 5-point Likert scale, the extent to which they perceived race as a biological trait and its importance in clinical care. Self-identified clinical or preclinical faculty (N = 147) who believed that race had any importance were asked to provide an example illustrating its significance. Free-text responses were coded using content analysis with an inductive approach and contextualized by faculty's perspectives on the biological significance of race. Results: There were 130 (88%) responses categorized into two major themes: race is important for [1] screening, diagnosing, and treating diseases and [2] contextualizing patients' experiences and health behaviors. Compared to faculty who perceived race as biological, those who viewed race as strictly social were more likely to report using race to understand or acknowledge patients' exposure to racism. However, even among these faculty, explanations that suggested biological differences between racial groups were prevalent. Conclusions: Medical educators use race primarily to understand diseases and frequently described biological differences between racial groups. Efforts to reframe race as sociopolitical may require education that examines race through a global lens, accounting for the genetic and cultural variability that occurs within racial groups; greater awareness of the association between structural racism and health inequities; movement away from identity-based risk stratification; and incorporation of tools that appraise race-based medical literature. [ABSTRACT FROM AUTHOR]

The privilege walk is a pedagogical tool used to teach students about often-ignored aspects of privilege. Despite their popularity, privilege walks are under-examined in the scholarship of teaching and learning. This leaves open questions about the efficacy of the walk, and whether, and to what extent, the walk yields different results among students from different backgrounds. This paper critically examines the privilege walk by reflecting on our experience of teaching the walk and analyzing student learning reflections about the exercise. We draw on critical race theory to interpret our data and also to help introduce the concept of slippage. We use slippage as shorthand for systematic issues long described by critical race theorists, such as meritocracy, that are reframed as individual responsibilities. We conclude by discussing how educators might prioritize teaching about structural power by integrating ideas from critical race theory, and abandon intellectual traditions that center Whiteness or the individual. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Community disadvantage is associated with late‐life cognition. Few studies examine its contribution to racial disparities in cognition/cognitive change. METHODS: Inverse probability weighted models estimated expected mean differences in cognition/cognitive change attributed to residing in less advantaged communities, defined as cohort top quintile of Area Deprivation Indices (ADI): childhood 66–100; adulthood ADI 5‐99). Interactions by race tested. RESULTS: More Black participants resided in less advantaged communities. Semantic memory would be lower if all participants had resided in less advantaged childhood (b = ‐0.16, 95% confidence interval [CI] = ‐0.30, ‐0.03) or adulthood (b = ‐0.14, 95% CI = ‐0.22, ‐0.04) communities. Race interactions indicated that, among Black participants, less advantaged childhood communities were associated with higher verbal episodic memory (interaction p‐value = 0.007) and less advantaged adulthood communities were associated with lower semantic memory (interaction p‐value = 0.002). DISCUSSION: Examining racial differences in levels of community advantage and late‐life cognitive decline is a critical step toward unpacking community effects on cognitive disparities. [ABSTRACT FROM AUTHOR]

Examining coping strategies and resilience among immigrant communities reflects a commitment to working with immigrant communities to understand their needs while also identifying and building upon their strengths. In the United States, the physical, emotional, and economic impacts of the COVID-19 pandemic intersected with existing structural inequities to produce distinct challenges and stressors related to the pandemic, immigration, caregiving responsibilities, and structural xenophobia. Leveraging an understanding of the multilevel effects of stress, this qualitative study explores individual, interpersonal, and community-level coping strategies immigrant women used to respond to, alleviate, or reduce distress related to these compounding stressors. Using semi-structured in-depth interviews conducted in 2020 and 2021 with 44 first- and second-generation cisgender immigrant women from different national origins and 19 direct service providers serving immigrant communities in New York City, data were coded and analyzed using a constant comparative approach. Four central themes were identified: caregiving as a source of strength, leveraging resources, social connections, and community support. While women described a range of coping strategies they used to manage stressors and challenges, perspectives from direct service providers also connect these coping strategies to the harm-generating institutions, policies, and structures that produce and uphold structural oppression and inequities. Accounts from service providers point to the detrimental long-term effects of prolonged coping, underscoring a duality between resilience and vulnerability. Exploring the coping strategies cisgender immigrant women used to ease distress and promote resilience during a period of heightened structural vulnerability is critical to centering the experiences of immigrant women while simultaneously directing attention towards addressing the fundamental causes of cumulative disadvantage and the systems and structures through which it is transmitted.

BackgroundThis study examines the lasting impact of historical redlining on contemporary neurosurgical care access, highlighting the need for equitable healthcare in historically marginalized communities.ObjectiveTo investigate how redlining affects neurosurgeon distribution and reimbursement in U.S. neighborhoods, analyzing implications for healthcare access.MethodsAn observational study was conducted using data from the Center for Medicare and Medicaid Services (CMS) National File, Home Owner’s Loan Corporation (HOLC) neighborhood grades, and demographic data to evaluate neurosurgical representation across 91 U.S. cities, categorized by HOLC Grades (A, B, C, D) and gentrification status.ResultsOf the 257 neighborhoods, Grade A, B, C, and D neighborhoods comprised 5.40%, 18.80%, 45.8%, and 30.0% of the sample, respectively. Grade A, B, and C neighborhoods had more White and Asian residents and less Black residents compared to Grade D neighborhoods (p

ObjectiveTo characterize associations between living in primary care shortage areas and graft failure/death for children after liver transplantation.Study designThis was an observational study of all pediatric patients (aged

Climate change is the greatest threat to global health in human history. It has been declared a public health emergency by the World Health Organization and leading researchers from academic institutions around the globe. Structural racism disproportionately exposes communities targeted for marginalization to the harmful consequences of climate change through greater risk of exposure and sensitivity to climate hazards and less adaptive capacity to the health threats of climate change. Given its interdisciplinary approach to integrating behavioral, psychosocial, and biomedical knowledge, the discipline of behavioral medicine is uniquely qualified to address the systemic causes of climate change-related health inequities and can offer a perspective that is currently missing from many climate and health equity efforts. In this article, we summarize relevant concepts, describe how climate change and structural racism intersect to exacerbate health inequities, and recommend six strategies with the greatest potential for addressing climate-related health inequities.