Structural Racism Creates Ripple Effects On Health

The continuous stress of experiencing racism makes people more vulnerable to disease.

By Kimberly Yang

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In the early months of the COVID-19 pandemic, as cases skyrocketed and overwhelmed hospitals, another disturbing trend became apparent. “COVID-19: The Great Equalizer” was splashed across headlines as everyone from celebrities to the unhoused contracted it, but it was far from an equalizer. COVID-19 was killing Black Americans at much higher rates than white Americans, according to the Brookings Institution.

Public health officials and efforts rushed to explain the disparities—they cited comorbidities, exposure of essential workers, and unequal access to health care. But the real driving force behind it was already recognizable to researchers studying structural racism and inequities.

COVID-19 was revealing and exacerbating old, existing inequities. Many of these were embedded and built up in the biological experiences of people forced to navigate life under chronic stress. This process is known as “weathering,” a term developed in 1992 by Dr. Arline Geronimus, a professor of Health Behavior and Health Equity at the University of Michigan. Weathering describes how the continuous stress of experiencing racism and maintaining vigilance degrades the body’s systems over time. It results in faster biological aging, leaving those who experience it more vulnerable to disease and earlier death.

The pandemic illustrated the harmful effects of weathering in real time.

“The oldest group of people were the most affected in the general population, but for Black people, it was people who were 10 years younger who started getting really affected,” says Linda Villarosa, author of the 2022 book Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation. “If your body is prematurely aged, then you read older, and then COVID can take hold worse.”

Today, weathering has become an accepted framework for researchers studying racial health disparities. But when Geronimus first proposed the theory in a 1992 journal article published in Ethnicity & Disease, it was highly controversial. The theory contradicted widely accepted existing explanations for racial health disparities at the time, which were most often based on either genetics or individual behavior. The personal responsibility narrative pointed to diet, exercise, and prenatal care, among other factors. Weathering argued that racist environments, rather than poor individual choices or biological differences, were the cause of chronic strain on the body and disparities in health outcomes.

For years, Geronimus’s theory struggled for acceptance. Some opponents argued that socioeconomic status was the sole reason for disparities, while others simply did not believe that the chronic everydaystress could inflict biological damage. Other critics argued that Geronimus’ research was insufficient to demonstrate the link between weathering and racial disparities.

However, the scientific evidence piled up over time. By the early 2000s, it was clear that existing narratives could not fully explain the patterns of disparity in maternal mortality, cardiovascular disease, diabetes, and shortened life expectancy among marginalized populations.

Researchers began identifying signs of accelerated aging in marginalized populations. This biological wear and tear can be tracked through three key biomarkers: protective DNA caps called telomeres, high inflammation and cortisol levels, and allostatic load.

Although telomeres naturally shorten with age, research has found that people who report experiencing high levels of discrimination or chronic stress have shown shorter telomeres than others of similar ages. A 2024 study by University of Michigan researchers found that Black women with high exposure to racial discrimination exhibited signs of biological aging approximately seven years beyond their actual chronological age.

Constant vigilance can lead to high cortisol levels, which contributes to hypertension and metabolic and immune dysfunction. This can result in the development of chronic diseases and conditions. According to a 2018 study, elevated cortisol and inflammation was found among young African American adults who were exposed to chronic stress caused by racial discrimination, even among those with higher socioeconomic status.

A 2012 study by researchers from the University of California, Santa Barbara found that even anticipating prejudice can lead to psychological and cardiovascular stress responses, suggesting that constant vigilance for discrimination contributes to racial and ethnic health disparities in the U.S. In 2021, a study by the University of Wisconsin also found that code-switching can be extremely stressful for people of color.

Allostatic load is a measurement that captures the cumulative biological wear and tear on multiple body systems. Researchers found that Black Americans consistently have higher allostatic load at earlier chronological ages compared to white Americans, a finding that remains true even after factoring in income, education, and individual health behaviors. Over the last decade, the concept of weathering has entered mainstream discourse and now holds a prominent spot in research, policy, and public conversation. Additionally, a growing body of research across various fields—genetics, epidemiology, endocrinology, social science, and more—has further strengthened the evidence that the effects of structural racism can manifest biologically.

Maternal and Infant Health Disparities

Nowhere is weathering more evident and alarming than in maternal and infant health. According to the Centers for Disease Control and Prevention (CDC), the U.S. maternal mortality rate is already the highest among comparable wealthy countries, but researchers have found that Black women are almost three times more likely to die from a pregnancy-related cause than white women.

Even across education levels, this disparity persists to a shocking extent. According to a CDC study, a Black woman with a graduate degree still faces a higher risk of severe maternal morbidity than a white woman with a high school diploma.

Villarosa offers her own experience as an example. While she was the health editor for the magazine Essence, she experienced having a low birth weight baby who was nearly premature despite her having no underlying health concerns.

“I was trying to do every single thing right,” Villarosa says, in terms of education, career, and prenatal and other health care. She questioned why someone like herself would have this outcome, eventually arriving at the conclusion that race played a significant role in health outcomes. “This isn’t just about [socioeconomic factors] like poverty,” she says. “This is about race”.

Patients with no obvious risk factors on paper can still be victim to the physiological damage inflicted by chronic stress. Weathering offers a framework for understanding and explaining this disturbing pattern.

Research has found that repeated exposure to discrimination or microaggressions can lead to inflammation, weaker immune system function, and blood pressure issues. This can increase risk of pregnancy-related complications, including a blood pressure disorder called preeclampsia, preterm birth, and other cardiovascular problems during delivery.

Poor health at birth also plays a significant role in perpetuating health disparities. According to a 2020 study by Brown University, infants born with poor health, such as being preterm or low birth weight, can be negatively affected throughout their lives, thus creating a vicious intergenerational cycle of poor health.

Declaring Racism a Public Health Crisis

According to the American Public Health Association (APHA), declaring racism a public health crisis means to define and acknowledge the harm that racism causes to the health and wellbeing of people of color. Since 2020, more than 260 cities, counties, public health agencies, and academic institutions have declared racism a public health crisis. These declarations have been seen as a turning point—an acknowledgement that racism is a key driver of poor health outcomes rather than only a social issue.

However, although these declarations have signaled progress in intention and language used in related discourse, their impact on people’s actual lived experiences has been much less clear.

Dr. Claire Decoteau, a professor of Sociology at the University of Illinois at Chicago, has studied how these declarations have reshaped the local governmental organization of public health departments in cities such as Milwaukee, Wisconsin and Chicago, Illinois. Her research has found that declarations often help change the internal language and culture of these departments, but do not necessarily translate into meaningful improvements in health outcomes.

“In some ways, both cities were successful [in implementing change],” Decoteau says. “The city of Milwaukee was able to really transform the way that racism is talked about, the training around racism within public health spheres, and who actually is doing the public health work”.

The declaration helped bring more people of color, particularly Black people, into the public health workforce and created a shift for open discussion of racism within public health. Similarly, in Chicago, the declaration helped bring more community groups into the public health infrastructure and decision making.

“It’s a really important transformation. But that’s a transformation within the public health department that doesn’t trickle down to people on the ground,” Decoteau says.

In Milwaukee, the declaration had little impact on access to care, funding for community services, or the structural conditions that lead to poor health outcomes. In Chicago, community groups had very little say in the public health department’s programming. The department often focused on narrow metrics rather than the broader issue of the racism-induced stress in daily lived experience. Many community groups were unable to provide input due to the group size and funding required to navigate the process.

The Importance of Upstream Intervention

Dr. Noble Maseru, a professor of Public Health Practice at the University of Pittsburgh and former Health Commissioner of Cincinnati, Ohio, emphasized the importance of concrete and effective action that must follow declarations. “The status quo is unacceptable,” Maseru says. “If the data show injustice, the system has to change.”

“Health inequities mean that there is a root cause for systemic unfairness [in outcomes],” Maseru says. “We want to go upstream and actually identify what are the resource allocations of those affected populations”. He explains that political determinants of health—decisions about housing, transportation, environmental regulation, employment, and resource distribution—play a large role in health outcomes.

“Health is shaped long before someone enters a hospital,” Maseru says.

Political determinants are an example of the upstream factors that can influence health outcomes beyond the individual level. These include income, discrimination, housing, education, and environment. Downstream determinants are the individual behavioral factors that directly affect health, such as diet, exercise, smoking, and access to medical care.

Environmental exposure is another example of upstream harm. Villarosa has reported on people who spent decades living near highways or industrial sites, where asthma, cancer, and poor health outcomes were prevalent.

“People continue to be blamed for their own health issues,” Villarosa says, “But [they are] affected by the environment—the air, the water, the land, the lack of food, the lack of healthy green space to exercise in, and it keeps going.”

Even when individuals later move away, she notes, the physiological damage often remains throughout their lives.

According to a study published in Social Science & Medicine, policy changes and public health interventions following declarations often redirect focus away from addressing racism as an upstream cause and instead concentrate on downstream factors.

Many downstream interventions use a particular metric to determine which groups are “most vulnerable”. Individualizing and isolating program impact to these specific groups leads these interventions to ignore the broader upstream causes of health disparities. As a result, they end up contributing to health disparities through inequitable access to the care that the interventions are meant to provide to the community.

Public health departments have emphasized measurement over concrete change, investing heavily in tracking disparities, such as life expectancy gaps, without making corresponding investments in services that could reduce chronic stress. In Milwaukee, for example, a state-sponsored doula program was launched to support Black mothers during pregnancy and childbirth, but the program was so underfunded that it reached only a small fraction of people.

“If they actually funded those initiatives [chosen by the community], that would go further than restructuring public health departments or focusing on epidemiological number-crunching,” Decoteau says, emphasizing the importance of community input to effectively address these issues.

While the declarations mark an important shift in how racism is discussed within public health, they have not produced sufficient upstream changes to mitigate the biological toll that weathering takes.

What Does Real Change Look Like?

Although real change in health outcomes from governmental intervention is still unclear, there are examples of effective change emerging outside traditional hospital systems.

In Hamden, Connecticut, two obstetricians opened and began operating Enrich Health, a community-based maternity care center designed explicitly to address racial disparities in maternal outcomes. The clinic prioritizes respectful care, longer appointment times, and strong relationships between providers and patients. Community members were also involved in shaping the center’s design and services.

Villarosa points to Enrich Health as a model for what effective future changes could look like. “It’s thoughtful, it’s community-based, and it’s created and run by people who are on the ground and actually practice there,” she says. “That kind of co-created care is the future.”

While not every community has access to the funding that made Enrich Health possible, its approach highlights how trust and dignity can be built into care systems by reducing stress rather than compounding it.

Other models have demonstrated the same success. In Chicago, HIV care has long been organized around the recognition that medical treatment alone is not enough. With this program, patients living with HIV have historically been eligible for housing support, food assistance, addiction services, and transportation—resources that stabilize daily life so treatment can succeed.

“That’s a model that says we recognize vulnerability,” Decoteau says. “We recognize that it isn’t just linked to one illness”. Similar approaches, she says, could be applied to maternal health and chronic disease if sustained funding and sufficient political support follow.

Governmental interventions have not yet reached the level needed for real change, but this kind of community-driven local work can still reshape lives in tangible ways in the meantime. “People can also make change without being tied to a giant institution,” Villarosa says.

The systemic roots of health disparities must be recognized and effectively addressed in order to truly mitigate health inequity. Declaring racism as a public health crisis is a first step, but addressing its upstream causes through policy and community-driven care is what will determine whether or not real change in closing these gaps occurs.