The Impact of on Health Outcomes
This paper, and the research behind it, is an evolving work-in-progress. We invite others who are interested to join us in our research on the health and safety impacts of racism.
In the fall of 2017, a series of high-profile racist incidents at the University of Toronto (UofT) made local, national and international headlines. These acts targeted racialized students and academic workers on campus, some of whom are also members of CUPE Local 3902. These incidents ignited long-standing concerns about racism – especially anti-Black, anti-Indigenous and Islamophobic racism – at UofT and other post-secondary institutions across the country more broadly. Various groups and collectives working to create awareness about the ubiquity of racism in academia and advance race-equity at UofT sprang into action, calling for an immediate response coupled with meaningful actions from the university’s administration.
One positive outcome of these pernicious events was the attention they drew. They revealed that academia is not exempt from racist attitudes and behaviours; on the contrary, racism continues to be widespread, and it plays a significant role in the lives of the students, faculty, and staff who study, work, and sometimes even live at UofT . While the racist nature of these incidents received condemnation from some, limited steps were taken by the administration to deal with the problem. Moreover, few people stopped to reflect on the consequent emotional and psychological harm inflicted on the community, especially on those who were affected directly by racism or put themselves on the line to combat it.
At the same time this was happening, CUPE 3902’s two largest units – one and three – were in bargaining with UofT. Part of the bargaining process included surveying members to identify their bargaining priorities. As expected, most priorities fell under the category of so-called ‘bread-and-butter’ issues, especially the ones members would be willing to strike for: compensation, healthcare benefits, job security, professional development and working conditions. Attempts were also made to advance an equity agenda: the Unit 1 bargaining team scheduled times to meet with equity-seeking groups to identify the issues that affected them. In many ways, the Local was successful in making important gains in favour of equity-seeking members.¹
Nevertheless, racialized leaders and their allies in CUPE 3902 repeatedly pointed out that the Local, like much of the labour movement too often ignores or fails to adequately address, members’ experience of racism.
 The gains achieved for equity-seeking members include improved parental leave, sexual and domestic violence funds, a trans fund, recognition of lived experience where relevant to hiring decisions, among others.
We will upload new research and information as it becomes available to us. This working paper provides a review of the existing literature that addresses the health implications of the experience of racism. We examine racism not only as an intervening variable resulting in negative effects on health, but also as a psychosocial stressor that has a direct negative impact on one’s well-being. Race-related stress is understood as distinct from the more generalized form of stress we attribute to daily living (Harrell 2000).
 One line of argumentation that may be leveled against our proposition is the inherent methodological limitation of establishing a causal relationship between racism and health outcomes due to the time lag between the experience of racism and the health outcomes. However, we argue that one cannot associate a specific time frame to racism given the recurrent experience of racism and its long-lasting impact. Similarly, a recent change within Ontario’s Workplace Safety and Insurance Board’s policies demonstrates a recognition of the health impact of chronic stress. For more information please see WSIB’s Chronic Mental Stress FAQ at http://www.wsib.on.ca
Racism: How Does it Express Itself?
According to the Merriam-Webster dictionary, racism is defined as “a belief that race is the primary determinant of human traits and capacities and that racial differences produce the inherent superiority of a particular race.” Put simply, it is an ideology premised on the notion that one racial group is superior to another.
Racism is manifested through beliefs (e.g. negative stereotypes), emotions (e.g. fear and hatred), behaviours, practices and interactions including but not limited to unfair treatment, threats, verbal and nonverbal insults (Priest et. al. 2013). It may present in a covert or overt manner, intentionally or not.
Racism operates on multiple levels: internalized, interpersonal, institutional, and cultural (Paradies et. al 2015; Williams and Mohammed 2013; Jones 1972).
Internalized racism refers to the psychological acceptance of racially-oppressive ideologies, negative attitudes and beliefs about one’s racial group and oneself (Speight 2007). For example, various racialized groups privilege individuals with lighter skin over those with darker skin, thereby reproducing beliefs about a racial hierarchy.
Interpersonal racism expresses itself in various direct and indirect forms of racial discrimination and prejudice. It is observable through the actions, interactions, and verbal statements of others (Harrell 2000, 42; Priest et al. 2013). Being treated with suspicion at a retail space or undervalued in the workplace based on racist representations of the intellectual capacity of one’s racial group is an example.
Institutional racism refers to systemic forms of racial oppression that play out in economic, social, and political institutions (Priest et al. 2013). At the institutional level, racism may operate without the deliberate and intentional discriminatory action of a single individual. Instead, it may look like policies and practices that produce racially disparate outcomes (Unzueta and Lowery 2008), such as inequalities in power or access to opportunities, resources, and services (Walton, Priest, and Paradies 2013).
As a consequence of its embeddedness in institutional policies, procedures and informal practices, this sort of racism can present itself as routine, everyday processes. This makes institutional racism easy to overlook and ignore. The following example illustrates the point: in many workplaces, the occurrence of a racist incident on the job between two employees, if documented, is described as a negative interaction between two individuals. Often, the analysis does not extend any further. When an institution does not appropriately address a racist incident or reflect on the workplace culture and norms in which the incident was performed, the institution ends up reproducing racial oppression through inaction.
At the cultural level, racism is exemplified in the negative images, depictions, characterizations, and popular perceptions of racial groups in the media (e.g. music, art, literature, etc.). It is also evident in the knowledge-producing systems of the medical and social science fields (Harrell 2000; Collins 1990; hooks 1984). Two recent and notable instances in the exercise of cultural racism are the characterization of one of the world’s most notable athletes, Serena Williams, and the former First Lady of the United States of America, Michelle Obama, as primates (Desmond-Harris 2018; Pilgrim 2018; Phillips and Bever 2016; Hutchinson 2015). This expression of racist vitriol, which characterizes Blacks as animals, is linked to Transatlantic slave trade in the Americas, where categorizing enslaved Blacks as subhuman legitimized their enslavement and dehumanizing treatment (Pilgrim 2018; Hobson 2003).
The four forms of racism outlined here are embedded in the sociopolitical fabric of society. Psychologist Shelly Harrell (2000) captures the interactive and persistent nature of racism when she states that the “ total experience of racism for any individual involves the simultaneous exposure of racism in interpersonal, collective, cultural-symbolic and socio-political contexts” (44). Harrell’s description illustrates the pervasive reach and scope of racism.
 This discriminatory practice is referred to as ‘colorism’
Racism as a Stressor
Scholars have identified six types of racism-related stress: racism-related life events, experiences of vicarious racism, daily racism micro-stressors, chronic contextual stress, collective experiences of racism, and transgenerational transmission of group traumas (Harrell 2000).
1. Racism-related life events refer to relatively time-limited, infrequent events of racism. They are unlikely to occur on a regular basis. The experience has a relatively clear beginning and end. However, it can lead to other events that may have more long-lasting effects. As an example, one might be passed over a work promotion, losing out on improved wages.
2. Vicarious racism is the experiential effect of observing or hearing about someone else’s experience of racism. For example, the feelings of distress that accompany hearing about the experience of friends, family, or other racial group members’ experience of racial discrimination. Vicarious racism can create feelings of anxiety, sadness, hopelessness, and helplessness.
3. Daily racism microstressors, better known as microaggressions, are the most common daily experience of racism. This micro expression of racism often occurs during interpersonal interactions. Microaggressions are characterized as “subtle, innocuous, preconscious or unconscious degradations and putdowns” (Pierce 1995, 281, as cited by Harrell 2000). This may look like off-hand mocking comments, slights, or exclusionary behaviours based on the belief that a racial or ethnic group is inferior in some way or another. Examples of racial microaggressions include, but are not limited to, being surveilled while shopping in a store, being mistaken for hired help in an academic setting, or colleagues repeatedly mispronouncing one’s name or calling one by the name of another colleague who shares the same ethnic/racial background. These experiences may lead to feeling criminalized, objectified, dismissed, or reduced to a negative stereotype. Because of the ubiquitous nature of racism, a racialized person will experience countless racial microaggressions over the course of their lifetime; the accumulation of racial microaggressions contribute to the overload of stress in an individual’s life (Derald et al. 2007; Harrell 2000).
4. Chronic contextual stress refers to the structural processes in our society that produce social and environmental racism. The structural manifestation of racism is reflected in the differential quality of one’s living conditions and overall quality of life due to unequal distribution of resources and limited opportunities. The growing concern about how the gentrification of low-income households constrict residents’ access to affordable and healthy food is one such example (Sullivan 2014).
5. Collective experiences of racism characterize the stress produced by the awareness of the effects of racism on the socio-economic and political conditions of members of one’s racial/ethnic group. This stressor is different from vicarious racism in that it does not require hearing or observing a specific incident of racism by an individual.
6. Transgenerational transmission of group traumas: This source of stress refers to the historical treatment of a person’s racial/ethnic group within their society. For example, community narratives about a group’s historical experiences of racial discrimination is passed down from one generation to another. The racial narrative about the group influences how its members understand and make sense of their present life experiences.
The Impact of Stress
For decades, health practitioners have emphasized the social and environmental context as a central determinant of health. Among the most noted contributor to both is stress. The Centre for Addiction and Mental Health (2018), Canada’s largest mental health teaching hospital, defines stress as “a normal response to situational pressures or demands, especially if they are perceived as threatening or dangerous.” The response involves, on the one hand, perceiving a threat or an environmental challenge and the body’s response to it, on the other. A stressful stimulus can be either external or internal to the person. For example, an external stressful event is the sudden occurrence of danger, like being chased by an aggressive dog, whereas, a stressful internal event may be the fear of bumping into a colleague with whom you have a conflict while at work.
When we encounter stressful stimuli, whether external or internal, the body sets off a chain of mechanisms that help prepare it for danger and difficulty. It releases hormones, such as cortisol and catecholamines, to signal the body’s need to prepare its physiological systems to respond (McEwen and Stellar 1993).
The degree of the stress response is weighted by the perceived realness of the threat (ibid.). This response to stress is vital to the body’s survival. The process is referred to as a ‘fight-or-flight response’, that is a mechanism that determines whether an individual engages with a perceived danger or threat, or flees from it instead. The response to stress is specific to the individual. Owing to the fact that our individual psychological, physiological, and social profiles influence our perception of the magnitude to the challenge or threat experienced.
 Cortisol is a glucocorticoid, a steroid hormone, produced by the adrenal glands. It is the principle stress-response hormone; it triggers other neurochemicals that respond to stress (Shalev and Bremner 2016). Catecholamines are neurohormones produced by the adrenal gland. The main catecholamines in the brain include dopamine, norepinephrine and epinephrine (adrenaline). They are important in the mediation of numerous central nervous system functions, including motor control, cognition, emotion, memory processing, and endocrine modulation (Gnegy 2012). Catecholamines are released into the bloodstream when we experience emotional or physical stress.
What happens when this evolutionary tool is activated too often?
The repeated activation of the bodies stress response, i.e. chronic stress, produces wear and tear on the body and impacts the body’s efficiency at turning the responses on and off. Neuroscientists Bruce McEwen and Eliot Stellar (1993) refer to this process as the ‘allostatic load’ (32). For example, when a person experiences chronic stress, the body’s physiological response system goes into overdrive, resulting in a high allostatic load (McEwen and Seeman 1999). Under chronic stress, the body is given little opportunity to return to a stable equilibrium (McEwen and Stellar 1993). As a result, the accumulated strain on the body adversely impacts one’s physiological and mental health.
Consequently, the cumulative effect of racism is a significant source of stress.
The Impact of Racism
Racism can negatively affect health outcomes through multiple pathways. As an example, institutional and cultural racism lead to differential opportunities for socio-economic status (e.g. in education, employment, and income), as well as access to a broad range of societal resources (e.g. medical care and housing services) (Williams and Mohammed 2013).
A systematic review of 138 studies on the association of self-reported racism and health outcomes found that racism was associated with ill health. Even when researchers accounted for socioeconomic and demographic factors including age, education, sex/gender, income/poverty, marital/partner status, racial/ethnic group, and employment/occupation, these factors did not moderate the effects of racism on health (Paradies 2006).
A growing body of epidemiological research presents consistent evidence of a direct association between racism and poor health outcomes (Braveman, Egerter and Williams 2011; Mays, Cochran and Barnes 2007; Din-Dzietham, Nembhard, Collins, and Davis 2004; Caughy, O’Campo and Muntaner 2004).
Scholars have found that experiences of racism are associated with various negative health outcomes, including, but not limited to the following: metabolic disease (Chambers et al., 2004), increased risk of cardiovascular disease and respiratory illness (Chae et al. 2010; Cobbinah and Lewis 2018), poorer prenatal and mental health (Collins et al. 2004), as well as other physiological effects (Smedley 2012).
 Research into the implications of racism on health is a new field of study in psychology and public health. Thus, the identification of the specific causal pathways between experiences of racism and health outcomes is an exploratory area of research (O’Brien Caughy, O’Campo and Muntaner 2004). While further research is needed to fully capture a comprehensive picture of the relationship between racism and health, existent research demonstrates a consistent a link between racism and adverse mental and physical health outcomes.
Effects on Physical Health
Due to the advancement of neuroimaging, researchers can map the complex circuits and structures in the human brain and indicate the effects of stress on the neuroendocrine system, which is pivotal to the body’s response to stress. Neuroimaging can map hallucinations, locate brains structures associated with emotion, and capture how external events affect internal brain activity (Mays et al. 2007). Brain mapping also reveals that when the brain is processing social information, there is neural activity in the structures of the brain that activate the stress response (ibid.).
During times of stress, the two important structures in the brain are the amygdala and anterior cingulate cortex (ACC). The amygdala is one of the systems that regulates the physiological and behavioural stress processes (McEwen and Gianaros 2010). It is central to the processing of emotions such as sadness, anger and fear, as well as the forming and storing of memories of emotional events (Mays, Cochran, and Barnes 2007). Studies on the fear response reveal that the amygdala activates the stress response in the body, and the body in turn readies itself to either fight or flee.
The ACC is the body’s neural alarm, indicating something has gone wrong (Botvinick et al. 2001, 2004; Braver et al. 2001; Carter et al. 1998; Eisenberger et al. 2005; Weissman et et al. 2003 as cited in Mays et al. 2007, 212). The ACC also registers the experience of social pain and social exclusion (Eisenberger & Lieberman 2004, Macdonald & Leary 2005). To the degree that the experience of race-based discrimination is interpreted as a form of social exclusion, Mays et al. (2007 ) find race-based experiences of discrimination induce a similar brain response.
When the stress is acute, both systems are put into overdrive. Consequently, the elevated activity strains the physiologic systems and raises the allostatic load. Chronic stress, research shows, not only has a weathering effect on the health of the body, but is also an important factor in the expression of disease and overall health (Geronimus et al. 2010; McEwen and Seeman 1999).
Research on the health implications of race-related stressors has provided critical insights into the physiologic effects of racism (Mays et al. 2007). Studies show that race-based stress is associated with increased systolic blood pressure, somatization, and smoking (Paradies 2006). According to Executive Director of the National Collaborative for Health Equity Brian Smedley, repeated subjection to racial discrimination is connected to higher blood pressure levels and increased diagnosis in hypertension (12).
Other studies highlight the impacts of racism on differing racial groups. Among African Americans, research finds the experience of racism increases carotid intima-media thickness — a risk factor in cardiovascular health (Troxel et al. 2003). An another study found that the experience of racism and race-based discrimination at work increase the likelihood of developing hypertension (Din-Dzietham et al. 2004). Following a similar health trajectory, research indicates that, among Asian Americans, the experience of everyday discrimination is associated with high blood pressure, hypertension, cardiovascular reactivity, chronic back and neck problems, frequent or severe headaches, chronic pain, and ulcers, and suggests greater odds of developing a respiratory condition (Gee, Spencer, Chen, and Takeuchi 2007).
The experience of racism also has important implications on the health of expectant and new mothers. There is increasing concern among maternal health practitioners about the impact of racism on pregnancy and childbirth. Research demonstrates that the weathering effect of chronic stress on the body is linked to pregnancy complications, such as preterm birth (Martin and Montagne Renee 2017; New York City Department of Health and Mental Hygiene 2016). Recent studies among expectant and new mothers reveals that, even when education and socioeconomic status are accounted for, African American women experience higher rates of preterm birth and low birth-weight babies compared to any other group of Americans (Martin and Montagne 2017; Meadows-Fernandez 2017).
 The National Collaborative for Health Equity is a project examining and promoting issues of health equity. For further information see http://www.nationalcollaborative.org/about-us/
Effects on Mental Health
Psychological functioning and well-being is also linked to stress. Research shows a consistent relationship between experiences of racism and negative mental health outcomes. Racism-related stress, for example, is positively associated with decreased self-esteem (Jones et al. 2007) increased post-traumatic stress, depression, anxiety (Williams et al. 2017), and somatization (Paradies et al. 2015)A recent meta-analysis of 293 studies focused on the relationship between racism and health outcomes found that racism was associated with poorer mental and physical health (Paradies et al. 2015; Paradies 2006).
Similarly, in a systematic review of 121 studies on the effects of racial
discrimination on the health of children and youth (aged 12-18 years old), researchers found a statistically significant association with racial discrimination and mental health outcomes, including depression and anxiety (Carter 2007; Coker et al., 2009; Priest et al., 2013; Priest et al., 2010). The cumulative literature evinces a consistent relationship between the impact of race-related stress and adverse health outcomes.
 The study reviews population-based studies on the relationship between self-reported racism and mental and physical health outcomes from 293 studies published in English between 1983-2013, conducted predominantly in the US.
The objective of this paper is to bring attention to the impact of racism on health outcomes. The findings of stress on the health of the human body offer an important pathway in which to analogize the mechanism activated by race-based stressors; it also points to the harmful effects on overall health.
Future research in this area is needed to further elucidate the cumulative impact of race-related stressors over the life course. As a working paper, we welcome the insights and research findings of researchers, scholars, and health care professionals working in this area.