The community health center movement began in the 1960’s to create affordable and accessible healthcare for all. This vision persists today, and it’s exciting that so many community healthcare organizations are now prioritizing health equity in their strategies. I often hear the term “health equity” used to mean racial health equity, and in order to talk about racial health equity, it’s essential to talk about racism. So, let’s dig into some frameworks and reflections to help us consider how to challenge structural racism as a foundation for improving racial health equity.
The Robert Wood Johnson Foundation says that “health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”
You’ll notice that the obstacles to health equity that the Robert Wood Johnson Foundation describes are structural, systemic issues that span across and between domains beyond health care. In other words, health equity requires that we dismantle structural racism throughout our communities, not just within ourselves and our unique institutions (although this is important too, of course).
Structural racism can be a tricky concept to understand, so it is helpful to see it in contrast to other forms of racism.
Interpersonal Racism is the “prejudiced belief that motivates a particular bad actor to discriminate against a particular victim. It is the intentional behavior of the racist actor, motivated, at least in part, by racist beliefs, that causes the racial harm.”1
Institutional Racism refers to how “institutional practices and cultural patterns can perpetuate racial inequity without relying on racist actors… [it] reflects a broader recognition of the forms through which racialized power is deployed, dispersed, and entrenched.” 1
Structural Racism involves “interconnected institutions, whose linkages are historically rooted and culturally reinforced. It refers to the totality of ways in which societies foster racial discrimination, through mutually reinforcing inequitable systems (in housing, education, employment, earnings, benefits, credit, media, health care, criminal justice, and so on) that in turn reinforce discriminatory beliefs, values, and distribution of resources, which together affect the risk of adverse health outcomes.”2
The key here is that structural racism works between and within different systems and domains. For example, in St. Louis City, discrimination and segregation in housing policy leads to segregated neighborhoods where children in predominantly Black neighborhoods face greater exposure to environmental toxins that impact health outcomes like asthma.3,4 These same neighborhoods have a limited number of nearby medical facilities and less opportunity for upward economic mobility, meaning that access to health insurance and healthcare is limited.3,4 Just like a soccer ball that deforms in one spot when you kick it, but then pops back into place because of the overall strength of all its connections, structural racism is remarkably resilient even when pressure for change is applied in one particular institution or sector. 5 For example, a local community health center may provide asthma treatment and education to Black families in St. Louis City, but the structural (housing, environmental, and economic) conditions continue to create the very health disparities that the community health center is working so hard to fix. Therefore, we have to work across domains if we really want to make change.
Reflection Questions for Community Health Centers and Organizations that Support Them:
Many community health centers and related organizations have already made great strides in rooting out structural racism in their communities. The following questions provide some further reflection points for those who want to deepen their engagement in creating racial health equity. They are meant to inspire conversations that may illuminate strengths and opportunities for growth. They could also be used as check-in questions for meetings or when embarking on a new initiative.
• Partnerships: With which sectors outside of healthcare do we (or could we) form partnerships (education, housing, employment, transportation, criminal justice, media, finance, etc.)? In what ways do we (or could we) specifically and explicitly work toward racial equity through these partnerships?
• Patient-Centered Structural Change: What are the experiences of our patients as they navigate multiple systems to access our services? How can we smooth these pathways on a systemic level so each individual person doesn’t have to figure it out?
• Data and Programs: What health data do we (or could we) disaggregate by race and ethnicity to look for racial disparities? Beyond this, are we implementing targeted programs that recognize and address the structural roots of these disparities?
• Advocacy: To what degree are we empowering our patients and staff to advocate for racial justice and systems-level change? Are we providing them with the time, education, financial resources, and support that they need to do this successfully?
• Community Connection: Are we consistently plugged into the grassroots racial justice community organizing happening in our local community? Do we use these calls to action to inform our work, and do we support these movements when we can?
 powell, j. a. (2008). Structural racism: Building upon the insights of John Calmore. North Carolina Law Rev., 86, 791.
 Bailey, Z. D., Krieger, N., Agénor, M., Graves, J., Linos, N., & Bassett, M. T. (2017). Structural racism and health inequities in the USA: evidence and interventions. The Lancet, 389(10077), 1453-1463.
 Purnell, J. (2014). For the Sake of All: A Report on the Health and Well-Being of African Americans in St. Louis and Why It Matters for Everyone. Washington University in St. Louis.
 Cambria, N., Fehler, P., Purnell, J. Q., & Schmidt, B. (2018). Segregation in St. Louis: Dismantling the Divide.
 Gee, G. C., & Hicken, M. T. (2021). Structural Racism: The Rules and Relations of Inequity. Ethnicity & Disease, 31(Suppl), 293-300.