This chapter explains how racial residential segregation affects the health of Black Americans. Housing is highly racially segregated in most American cities. While this occurs to some extent because people want to live with other people similar to them, it is primarily due to governmental policies and private business practices that created widespread residential segregation by severely restricting where Black people could live. The neighborhoods to which Black Americans were relegated were typically in undesirable areas, physically separated from the larger community, and containing few resources. Once these neighborhoods were created, the practices of banks (e.g., refusing loans) and real estate firms (e.g., restrictive covenants) made it difficult for Black Americans to improve these areas or to leave them. Living in these neighborhoods makes poverty more likely, which, by itself, is associated with poorer health. These neighborhoods are also more likely to have high levels of environmental toxins (e.g., polluted air and water), limited availability of healthy food, unhealthy built environments (e.g., dangerous housing, absence of green spaces), and limited access to healthcare. In sum, residential segregation, which is the product of anti-Black racism, creates living conditions that threaten Black Americans’ health.

This chapter describes the role of individuals’ race-related thoughts and feelings in racial disparities in healthcare. Racial treatment disparities exist across a wide variety of medical settings and problems. Race-related thoughts and feelings – both implicit and explicit – play an important role in Black people receiving poorer healthcare. They affect the quality of communication between non-Black physicians and Black patients. Good physician–patient communication is critical to effective treatments; however, on average, communication is poorer in racially discordant (i.e., cross-race) medical interactions than racially concordant (i.e., same race) ones. Specific race-related thoughts and feelings, such as racial bias and medical mistrust also affect the quality of healthcare. Most physicians claim to be color blind when treating their patients but, in fact, physicians’ explicit and implicit racial bias negatively affect their perceptions of Black patients and how they act toward them. The behaviors of high implicit bias physicians can often have a negative impact on their Black patients. Black patients’ experiences with racial discrimination also affect race-related thoughts and feelings relevant to their medical care. Experiences with discrimination can result in greater medical mistrust, which makes people less likely to (1) experience positive outcomes from their healthcare and (2) engage in health-promoting behaviors.

The chapter is concerned with racial health disparities in the United States. These disparities are large, significant, and persistent. Black Americans are much more likely to become ill and to die from their illnesses than are White Americans with the same illnesses. Black Americans’ poorer health reflects health disparities that have social, economic, or political causes rather than biological differences between the two groups. The root cause of these racial health disparities is anti-Black racism, which includes individual racism (negative thoughts about and feelings toward Black people) and systemic racism (societal standards, cultural values, and formal laws that systematically disadvantage Black Americans). Both kinds of racism have very long histories in the United States and continue to pose significant threats to the health of and the healthcare received by Black Americans. Specifically, individual and systemic racism cause: (1) chronic stress, which produces physiological and psychological responses that threaten a person’s health; (2) racial housing segregation, which creates poor and under-resourced Black neighborhoods, containing numerous environmental threats to the residents’ health; (3) inequities in the quality of medical care received by Black patients and White patients; and (4) disparities in socioeconomic status, the strongest single correlate of a person’s health status in the United States.

This chapter first summarizes eight threats to racial equity in health and healthcare identified in previous chapters. It then presents potential solutions to reduce their impact on Black Americans’ health. Two solutions involve lessening the impact of racial disparities in socioeconomic status on access to healthcare. The first involves broad-based efforts to improve the quality of education available to Black students, which should increase their future economic potential and thus ultimately improve their health. The second one is to establish comprehensive, single-payer insurance programs, making healthcare more available to everyone. Other proposed solutions address health threats caused by specific kinds of anti-Black racism. These solutions include programs to systematically reduce unfair and dangerous law enforcement practices and targeted investments in intentionally segregated communities to improve residents’ quality of life. A solution to the threat of inequitable healthcare is changing healthcare facilities’ focus from treating to preventing illnesses and dramatically increasing the number Black healthcare providers. Finally, a solution to the undue influence of patients’ race in healthcare outcomes is to develop interventions that reduce the impact of racial bias on healthcare professionals’ actions and equip Black Americans with the information and strategies that would make healthcare more accessible and supportive of them.

This chapter is about the origins of anti-Black racism in the United States. It describes two separate but related processes. The first process involves historical events, of which slavery is the most important. In addition to systemic exploitation and degradation of enslaved people, slavery produced beliefs that enslaved people were inferior human beings. Reinforcing these beliefs was scientific racism – supposedly scientific theories that purported to prove the innate inferiority of Black people. Even after slavery ended, economic competition, racist laws, and social norms created social and economic disadvantages for Black people. The second process involves the ways humans think about the people they encounter. Humans place themselves and other people in social groups largely based on physical characteristics, particularly those that society considers to be important. Perceived race is a major determinant of how people socially categorize others, which forms the psychological foundation for racial biases at both the conscious and nonconscious levels. Thus, even in the absence of malevolent intent, it is likely that people will develop negative racial beliefs and feelings. These biases lead to the tendency of White Americans to justify the disadvantages experienced by Black Americans by attributing them to inherent defects in Black people.

This chapter considers disparities in the quality of healthcare Black patients and White patients receive. One major cause of these disparities is that healthcare in the United States is basically a privately financed system. This makes access to necessary healthcare more difficult for Black Americans, because they are, on average, economically disadvantaged. Another factor is that American healthcare is still largely separate and unequal. Black patients are often treated at lower-quality medical facilities. Even within the same facilities, they frequently receive poorer care. Systemic racism within medicine also creates practice that contributes to racial healthcare disparities. One example of this is the widespread use of flawed diagnostic algorithms that reflect racist myths about the bodies of Black people; another is algorithms that systematically underestimate the health needs of Black patients. In addition, unique educational and financial challenges to entering medical professions faced by Black people and hostile institutional and professional climates that discourage Black trainees and practitioners have created serious shortages of Black healthcare professionals. This has numerous negative consequences for Black patients. Thus, racial healthcare inequities reflect both the nature of contemporary political, economic, and social structures in the United States and practices within medicine that seriously disadvantage Black patients.

This chapter concerns the history of anti-Black racism in American medicine. For a very long time, medical professionals either refused to treat Black patients or required they be treated in segregated, dramatically under-resourced settings. This was due to both racist laws and social customs that produced systemic racism within the medical establishment. Major medical professional organizations both actively and passively supported segregated healthcare. Black people were also largely excluded from professional schools and greatly restricted in their ability to practice medicine. Further, Black people were often abused and exploited by unethical medical practices, which included robbing their graves to provide cadavers and forcing them to participate in dangerous and unethical medical experiments. Black Americans were further harmed by physicians’ involvement in the eugenics movement. Based on gross misunderstandings of genetics and heredity, eugenics proposed that society could be improved by limiting reproduction among socially disadvantaged groups. This resulted in involuntary sterilizations that disproportionally targeted Black Americans. Most racist medical policies and practices were eliminated by legislation and changes in professional and societal norms. However, the legacy of racism in American medicine can still be seen in current healthcare practices that harm Black patients and greater medical mistrust among Black Americans.

This chapter discusses the direct effects of racial discrimination on Black Americans’ health. It begins by documenting that daily exposure to the various forms of racial discrimination is a common experience for Black people living in the United States. Encountering racial discrimination creates stress, which activates physiological stress responses – bodily systems that normally provide person with the energy needed to rapidly reduce the stress. However, the stress created by racial discrimination is usually chronic because many Black Americans repeatedly experience racial discrimination over a prolonged period of time. When the bodily systems activated by stress response remain active, it creates a harmful physical condition – allostatic overload. Allostatic overload is responsible for a host of physical illnesses, including heart diseases, diabetes, and immune disorders. It is also associated with poorer mental health, as well as alterations in epigenetics, such as premature aging. Chronic stress can also cause people to engage in behaviors that may provide short-term emotional relief from discrimination-related stress but are unhealthy, such as drug use or eating certain unhealthy “comfort” foods. In sum, prolonged exposure to racial discrimination is a chronic stressor that threatens the health of Black Americans.