Editorials

Racism and health

Antiracism is an important health issue

Discussion of racial discrimination in medicine has concerned mainly recruitment and career development. ^{1 2} This has overshadowed a growing literature showing an association between racism, morbidity and mortality.^3-7 Racism may be aetiologically important in the development of illness.

Racism stems from the belief that people should be treated differently because of a few phenotypic features. Racism can manifest as individual or group acts and attitudes or institutionalised processes that lead to disparities. Racism is common: in one national survey in the United Kingdom, 25-40% of participants said they would discriminate against ethnic minorities; an estimated 282 000 UK crimes were racially motivated in 1999; and a third of people from ethnic minorities constrain their lives through fear of racism. ^{8 9} Disparities between ethnic minority and majority groups in housing, education, arrests, and court sentencing are believed to be due to racism, not simply to economic fources. ^{8 9}

Cross sectional studies in the United States report associations between perceived racial discrimination and hypertension, birth weight, self related health, and days off sick. ^{3 4} In a recent study from the United Kingdom victims of discrimination were more likely to have respiratory illness, hypertension, a long term limiting illness, anxiety, depression, and psychosis. People who believed that most companies were discriminatory were also at increased risk of mental illness.⁵

Racism may be associated with illness at an ecological level.⁶ Kennedy et al found that a 1% increase in racial disrespect in a US state was associated with an increase of 350.8 per 100 000 in "black" all cause mortality.⁷ Most of the studies have, however, been secondary analyses, and racism has often been poorly measured and the ability to allow for confounders limited.

One prospective study in the literature adds support to the hypothesis that discrimination affects psychological health. In a study of over 4800 residents of Maastricht who screened negative for mental illness and paranoid traits at baseline, those who said that they had suffered from discrimination were twice as likely to develop psychotic symptoms in the following three years.¹⁰

Stress mediated responses in the neuroendocrine and immune systems have been considered possible mechanisms for the effects of racism on health.¹¹ Racist acts may be acute stressors and the perception of society as racist and the effects of racism on self perception chronic stressors.¹¹ But the literature is sparse. To date the effects of racism at a community levelsuch as the production of alternative economies (for example, gang culture) or the creation and maintenance of socioeconomic disparitieshave rarely been modelled as part of its effects. The effects of racism on future generationsfor example, on the long term impact of having a parent with an illnesshave not been addressed either.¹¹ The effects of racism are modified by individual coping styles and expectations,⁴ community structure and response to racism, historical and macropolitical factors.¹¹

Considering racism as causative is an important step in developing the research agenda and response from health services. It moves the discussion away from recruitment and access and towards prevention and the impact of societal structures on rates of illness. The investigation of specific risk factors for illness in ethnic minority groups may be vital if we are to develop equity in efficacy of treatment. For example, is the poorer response to antihypertensive treatment in African-Caribbeans due to biology or is it a reflection of the role of perceived racism in its development and persistence? Investigation of racism's pathophysiological, cognitive, or psychophysiological correlates may offer new avenues for treatment and more efficacious management. Developing a deeper understanding of possible links between racism and health is a prerequisite for initiatives to decrease impact at a community and individual level.

Despite general agreement that racism is wrong, no concerted political effort has tried to decrease its prevalence. Granted, if the Race Relations Amendment Act were enforced it could decrease institutional racism in public bodies, but it is an isolated act that should be seen in the context of other acts and government rhetoric considered to harm race relations (for example, the current discourse on asylum) and the widespread nature of racism.¹²

Public health is the art and science of preventing disease, prolonging life, and promoting health through the organised efforts of society. One of the chief responsibilities of public health medicine is fostering policies that promote health. I argue that countering racism should be considered a public health issue. The lack of a concerted research and public health effort means that in the United Kingdom the science of investigating the effects of racism on health and the development of preventive strategies are in their infancy. It is tempting to argue that it is not for doctors to be involved in areas that are so political. The real question, however, is best laid at the doors of those who would prefer not to take on this challenge. How can we have equity in health if one of the major possible causes of illness in minority ethnic groups in the United Kingdom does not have a dedicated research effort or prevention strategy?

Kwame McKenzie, senior lecturer in transcultural psychiatry. 

Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, London NW3 2PF (k.mckenzie{at}rfc.ucl.ac.uk)

Footnotes

Competing interests: None declared.