The field of public health has identified racial health disparities as a chief concern for decades. Although there has been a myriad of published articles in which researchers describe the severity and complexity of these disparities, they persist into present day relatively unchanged. We believe this lack of progress can be explained, in part, by a failure to acknowledge that racism is at the root of these racial disparities. Many children’s health advocates believe more should be done to address our country’s systemic racial inequities, but few of us feel able to create meaningful change, and even fewer feel that it is our responsibility. As a result, many opt to pursue programmatic fixes and Band-Aid solutions over addressing the underlying systemic, interpersonal, and historical racism. We hope to empower children’s health advocates by introducing a solutions-centered framework for addressing racism as a root cause. This approach can help guide and structure the important work of dismantling racism so Black, Indigenous, and other racially marginalized families can finally have an equal opportunity for good health.
Children’s Health Advocates Are Overdue in Addressing Racism as a Root Cause of Racial Health Disparities
Racism in the United States is a deeply intractable problem. It negatively shapes all aspects of a person of color’s world and literally steals years from their life.1 For decades now, we as a society have worked to eliminate racism in our midst, and yet we have little to show for our efforts. Black and Indigenous families, children, and communities in the United States continue to be disproportionately incarcerated, systematically excluded from economic opportunity, and, in outcomes as diverse as preterm birth and coronavirus disease 2019 death, bear a disparate proportion of disease. Our society has started to recognize that historical and present-day racism, rather than biology, is a root cause of health disparities.2 This understanding has evolved over the course of centuries, yet our impact has been limited because we have failed to successfully develop interventions that address the core issue of racism.
In this article, we present the Racism as a Root Cause (RRC) approach as a new framework for developing strategies, policies, and mechanisms to address the root causes of health disparities. Addressing racism as a root cause is critical to advancing population health, yet it is still rare for systemic racism to be mentioned explicitly in academic journal articles today,3 and in these publications, authors often fail to offer a pathway for repair. Recognizing that Black and Indigenous communities, as well as other communities experiencing racism, cannot bootstrap themselves out of centuries of injustice, we introduce the RRC approach to offer a clear and corrective framework for advocates seeking to dismantle long-standing inequities.
To help explain the urgency of this issue, we provide an analogy of a Monopoly game.4 Imagine a family playing a long, tense game of Monopoly for 4 hours. Over the 4 hours, the family has been deliberately refusing to let one of the siblings participate, forcing them to do household chores. Over this time, properties are amassed, $500 bills are hoarded, and empires are built. Once the family members are satisfied with their wealth, they invite the sibling to join them. Do you think the new player stands a chance at being successful in the game? Unless the family decides to redistribute their wealth or change the rules to account for the disproportionate advantage they each have for the additional 4 hours of passing Go, the sibling is never going to be able to catch up.
However, this is not a game. The painful histories and present-day manifestations of racism impacting the lives of Black and Indigenous families, children, and communities are not an allegory. That is not to say that other racial and ethnic groups do not experience racism and discrimination; we acknowledge the painful histories and realities of racism toward Latinx communities and other groups of color. Yet, even within Latinx communities, the duration and pervasiveness of the injustices wrought on Black and indigenous Latinx people is particularly injurious, and their healing must be prioritized.5 This 4-hour Monopoly game analogy represents centuries of brutality, genocide, slavery, oppression, and dehumanization that has been specific to Black and American Indian people, resulting in extremely poor health outcomes today.5
Pediatric health professionals have taken a critical step toward equity and have declared racism a determinant of children’s health.6 However, the vast majority of children’s health interventions are individually focused programs rather than structural interventions (such as political advocacy or systems change) that specifically address racism; moreover, research reveals that interventions focused on individual factors are more likely to perpetuate inequalities.7
RRC Approach: 4 Components
The RRC approach has 4 principles that function as guideposts to direct advocates trying to tackle a problem as big as racism. An intervention using the RRC approach will (1) prioritize a specific, racialized group for a precise, rather than universal, impact; (2) work to change policies, systems, or environments, as opposed to changing people; (3) be institutionalized and sustainable to create a long-term impact; and (4) repair historical injustices by shifting resources, power, and opportunities to racially marginalized groups (see Table 1).
Precise Impact on a Prioritized Community
Because of racial marginalization and discrimination, broad programs targeting all lower income people will not create the same benefit within communities experiencing racism as they do within white communities. Take federal education loan programs as an example: because of racism in hiring, promotions, and wages, racially marginalized students who are able to graduate college with the assistance of loan programs do not experience the same benefit from this program as white students. Racially marginalized people with degrees earn less than their white counterparts and are much less likely to be able to build wealth when compared with students not experiencing racism.8,9 Likewise, the same is true regarding public insurance in this country: although programs like Medicaid and Children’s Health Insurance Program provide insurance for many children and families, including many who are racially marginalized, these programs do nothing to address the differential quality of care and service that Black, Indigenous, and other people experiencing racism face.10 As a result, racial disparities in care access, quality of care, and ultimately health outcomes persist even with the availability of public insurance.10 These universal programs are unable to address the differential needs of the populations they were meant to serve.
RRC approaches must, consequently, be precise in their population focus and their intended impact. Although this may feel contrary to how many of us have been taught to practice clinical and public health, we need to give ourselves permission to explicitly focus on specific racially marginalized communities, rather than engaging in colorblindness and equality frameworks (see Table 2). An accounting must be made for a given racial group’s differential access to resources and for the specific barriers the community is facing.
In addition, it is important to recognize that although many populations of color are impacted by racism, Black and Indigenous families, children, and communities are most negatively impacted by racial inequities across the spectrum of health and society.5 Their marginalization is evidenced by their high rates of infant mortality, poverty, youth unemployment, educational alienation, and potential life lost (among other indicators).5 These racial inequities cannot be explained by differences in individual health-related behavior, or biology, and are not solely reducible to socioeconomic status; rather, they persist across social determinants because of historical and present-day racism.5,11,12 In other words, racism operates as the underlying determinant of the determinants, as described by Krieger.13
Agencies should consider the particular manifestations of racism burdening a given community when developing strategies to address that community’s social determinants of health. It is essential, therefore, to ensure all RRC approaches are designed and implemented in close partnership with the prioritized community. The lived experience of negotiating racism on a daily basis is an important form of expertise, and this expertise must be centered, valued, and paid for in the development of any RRC approach.14
Often, our interventions are focused on trying to create behavior change within individual members of communities facing racial disparities. The implicit assumption underlying these types of programs is that a lack of education, efficacy, resilience, and/or motivation is what keeps some communities from achieving their maximum health potential. This perspective fails to reckon with the larger social structures that shape all of our lives.15 Although most families know that fast food is unhealthy, racist structures make it much less likely that racially marginalized families will have access to affordable, healthy, fresh foods.16 Furthermore, racism in fast-food chain distribution and advertising increases the chances that these families and children will be exposed to fast-food restaurants and ads, many of which target people of color specifically.17 No amount of health education or nutrition counseling will change these systemic factors.
Many of us who have grown up in and/or worked in marginalized communities understand that it is not the shortcomings and poor choices of individuals within these communities that drive health disparities but rather the outrageous odds and impossible structural barriers, which members of these communities have to overcome to achieve good health.18 As providers, we have experienced how useless patient education sheets and motivational interviewing can feel for families facing food insecurity, housing crises, discrimination at school, and a lack of physical safety. RRC approaches require us, therefore, to shift our focus from changing individuals to changing the structures and systems that surround individuals. This is best achieved by focusing on structural interventions like shifting institutional and legislative policy, identifying strategies to bring employment opportunities and investment into these communities, and prioritizing interventions that focus on changing the social and physical environment around children facing health disparities. Rather than repeatedly asking families facing marginalization to increase their effort to overcome racial disparities and build their resilience in the face of ongoing racism, children’s health advocates should be working tirelessly to lighten the burden for these communities.
Long-term or Sustainable
Racial hierarchy has long been an organizing principle of this country, so it is unrealistic that a program lasting a few years will have much impact on structural racism. Any attempt to dismantle and repair racism must, therefore, be long-term and have ongoing funding sources and/or have a clear path to sustainability.19 Long-term investment has been revealed to be a successful path to community wellness and can reveal that a community is valued. Conversely, short interventions can harm the relationship between social service agencies and Black and Indigenous communities (and other communities of color). Over many decades, expensive, long-term government interventions like the New Deal, The Homestead Act, and the GI Bill have revealed this significant return on investment within white communities that were the primary beneficiaries of these programs.20 RRC approaches demand that we value and invest in communities experiencing racism with the same money and sustainability we have invested into this country’s white population.
Although it is often necessary to first do a pilot project to reveal the efficacy of a large-scale and costly intervention, RRC pilots should have a clear path to sustainability before they begin. These efforts can be sustained through institutional policy, local and state legislation, budget advocacy, block grants, and changes to Medicaid reimbursement policies. Following the example of paid parental leave legislation, advocates can leverage policy to forge long-term, sustainable interventions.21
Many Americans problematically believe that Black Americans and Indigenous communities should be able to lift themselves out of poverty, and any inability to do this is related to individual shortcomings rather than racism.22 This perspective, however, ignores centuries of oppression experienced by racially marginalized groups, the cumulative impact of which has left them at a significant economic disadvantage.20 As in the Monopoly analogy described earlier in this article, even if all players now have what seems to be an equal opportunity to compete, the players who were not allowed to participate for most of the game will never be able to catch up without some type of corrective action. This perspective also fails to recognize that racist patterns and practices persist into present day in this country despite civil rights laws, which were passed to prevent them.19 The Brown versus Board decision is a good example of this phenomenon. Although this decision specifically forbids separate and unequal public education, the vast majority of our nation’s public schools are still highly segregated and unequal.23 There is a similar pattern, of de facto discrimination, persisting in voters’ rights, housing, mortgages, the justice system, and hiring.24–27
Using RRC approaches, we recognize the impact of present-day and historical injustices and seek to correct these inequalities. Although the specifics of the injustices suffered by a given community may be difficult to ascertain, racism in the United States has almost always involved an extraction of resources, power, and opportunity from impacted populations.19 Consequently, RRC approaches will always involve transferring resources, power, and opportunities back into these communities.
Often, public and philanthropy dollars are used to create programs that have layers of bureaucracy, high indirect and administrative costs, and are run by people from outside the target community. Although these programs may create some benefit for the community, they are not addressing racism as a root cause because the decision-making and budgetary power remains concentrated within white-led institutions, and the money and career opportunities are primarily circulated among racially privileged individuals. RRC approaches include a strategy for building capacity and for empowering the community to be leaders in the work. Advocates must ensure that the majority of the resources and job opportunities available for a given program actually reaches members of that community. RRC interventions are structured so that the majority of the dollars allocated to the program end up in the pockets of the target community. Agencies must make an honest assessment of the flow of resources, power, and opportunities when creating interventions to address racial disparities to ensure movement in the right direction.
RRC Approach: A Typical Example
It is difficult to provide a real-life example of the RRC approach supporting racially marginalized groups; were they common, we would likely see diminishing racial disparities with each passing year. We can, however, look to history to see how effective this type of approach has been in lifting up a racially privileged group. The establishment of the Federal Housing Administration (FHA) demonstrates how America’s white community was lifted up by an approach that incorporated all 4 components of the RRC approach.
The FHA was established in 1934 to increase rates of homeownership for Americans in the wake of the Great Depression.20 By guaranteeing home loans, the US government was able to extend the opportunity of homeownership to lower income families that were previously ineligible. The intervention had a precise impact because the FHA overwhelmingly backed the loans of white homeowners to the exclusion of other racial groups (this discriminatory practice became known as redlining). This FHA intervention was focused on systems change because, rather than attempting to change behavior and persuade individual white Americans to work more or spend less so they could afford a home, it made homeownership more accessible and affordable for this prioritized population. The FHA was established through federal legislation and existed until 1968, over 30 years. It can, therefore, be considered long-term. It is difficult to assess the reparations component of the FHA intervention because the white American community as a whole did not experience centuries of racial injustice that required reparation. Note, however, that many of the beneficiaries of the FHA intervention were middle and low-middle income white Americans, many of whom lost a lot during the Great Depression. This subpopulation of white people did experience a transfer of resources and opportunities from the federal government, and the impact was tremendous. As a result of this government investment, many white Americans were able to secure stable housing and accumulate wealth at a disproportionate rate.28 Research reveals that housing stability and intergenerational wealth positively impact health; thus, by leveraging the 4 components of an RRC approach, the FHA was able to cultivate the conditions that produce healthy outcomes for a significant proportion of America’s white population.29
Applying the RRC Approach
The work of addressing racism in a meaningful way is difficult. When disrupting these long-standing systems of power, advocates will face opposition from many sources, including from people who have always professed allyship in these issues. Furthermore, any children’s health advocates might be reluctant to tackle racism from a systems-level perspective because (1) we may not know how to effectively create structural change impacting racism, (2) challenging the root causes of racial disparities has the potential to compromise our job security, and (3) we are socialized (although we may not realize it) to maintain the status quo.30 Particularly for those of us working in government and other large institutions, children’s health professionals are rarely supported with an authentic pathway to think boldly and creatively. We understand the real potential of losing jobs by advocating for meaningful change in the communities we serve, yet we often inadvertently weigh our personal risk more heavily than the risks our clients must face every day as they navigate unaddressed racism. As a result, we see ineffective programs continue to live on, with public health organizations and clinical programs making little to no impact on the factors perpetuating individual or structural racism. Although some children’s health advocates have made important strides, our field as a whole has been slow to acknowledge that individual-level interventions will never be able to overcome the cumulative disadvantage borne of centuries of racial oppression.
There are several possibilities for integrating the RRC approach into the field of children’s health. (1) Develop a new initiative that specifically uses the RRC approach to structure the program’s components. (2) Use the RRC framework for assessment and evaluation of existing interventions. Identify whether the programs meet the four criteria of the RRC approach and then make improvements to the program that will transform it into an effective RRC intervention. Although including all four criteria will likely have the maximum impact, each component on its own can make a difference in addressing racial disparities. (3) Use the RRC criteria to structure requests for proposals for grants targeting racial disparities. Grant monitoring can be an opportunity to ensure the quality and effectiveness of antiracist interventions. (4) Integrate the RRC approach into needs assessments and action planning, including (but not limited to) strategic planning, budgeting, scoping, and personnel decisions in the workplace.
These instances represent optimal opportunities to be proactive by developing strategies that will have maximum impact to address racial disparities. Institutional inertia, implicit or unacknowledged racism, and fear will be perpetual barriers when pursuing RRC approaches. Nevertheless, advocates must form strong networks of support and resist the temptation to dilute or ineffectively compromise. At any point in our work, it is possible to create pathways toward justice by leveraging each RRC approach criteria: precise impact, systems change, long-term sustainability, and reparations.
An Urgent Call to Action
Black and Indigenous people are being killed by racism right now.31 Every day, infants are being unnecessarily orphaned, mothers are needlessly losing their children, and precious Black and Brown lives are being wasted because of our failure to address racial health disparities in a meaningful way.1,5,32,33 This work may seem big, but this framework should not be relegated to only large-scale projects. RRC approaches can target racism anywhere from the neighborhood level to the federal level. The size of the target population is less important than the way in which the resources are invested. Racism is at the root of many health disparities; addressing racism meaningfully will have a positive impact on all health outcomes in racially marginalized communities.
In children’s health, we have the resources to address racism as a root cause. Every one of us has some sphere of influence from which we can advance change. The question we must ask ourselves is, “Do we have the will?” If we want to make a lasting impact on racial disparities, we do not have another option. The work ahead is difficult but also visionary. The path forward is fraught but also liberating. We know the call to action is enormous and daunting, but we also know another decade of inaction is indefensible. The next generation is counting on us.
Dr Malawa, Ms Gaarde, and Ms Spellen conceptualized and developed the idea for the manuscript, drafted the initial manuscript, and reviewed and revised the subsequent versions of the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.