Vernellia R. Randall
action, intentional or unintentional, that is based on race or skin
color and that subordinates an individual or group based on skin
color or race is racism. Racism can be enacted individually or
However, much of the scholarship on racial issues over the last 40
years has focused on individual racism.14
Nevertheless, institutions are just as capable of being racist.
Institutions can behave in ways that are overtly racist (i.e.,
specifically excluding Blacks from services) or inherently racist
(i.e., adopting policies that result in the exclusion of Blacks).
Most of the underlying causes for the health inequities are due to
institutional racism. As Professor Mary Douglas explains:
“When individuals disagree on elementary justice, their most
insoluble conflict is between institutions . . . . The more severe
the conflict, the more useful to understand the institutions that
are doing most of the thinking. Exhortation will not help. Passing
laws against discrimination will not help. . . . Only changing
institutions can help. We should address them, not individuals, and
address them continuously, not only in crises.”15
Institutions can respond to Blacks and Whites differently.
Institutional behavior can injure Blacks, and when it does, it is
racist in outcome, if not in intent.
is both overt and covert, and it takes three closely related forms:
individual, institutional, and systemic. Individual racism consists
of overt acts by individuals that cause death, injury, destruction
of property, or denial of services or opportunity. Institutional
racism is more subtle but no less destructive. Institutional racism
involves polices, practices, and procedures of institutions that
have a disproportionately negative effect on racial minorities’
access to and quality of goods, services, and opportunities.
Systemic racism is the basis of individual and institutional racism;
it is the value system that is embedded in a society that supports
and allows discrimination.
Institutional and systemic racism establishes separate and
independent barriers to access and quality of health care.
Institutional racism does not have to result from human agency or
intention. Thus, racial discrimination can occur in institutions
even when the institution does not intend to make distinctions on
the basis of race. In fact, institutional discrimination can occur
without any awareness that it is happening..16
Although data on institutional racism iis scarce, it does exist.
To understand institutional racism, it is important to understand
the interaction between prejudice and discrimination. Prejudice is
an attitude that is based on limited information or stereotypes.
While prejudice is usually negative, it can also be positive. Both
positive and negative prejudices are damaging because they deny the
individuality of the person. No one is completely free of
prejudices, although they may not have any significant prejudice
against a particular group. Oppression is the systematic subjugation
of a social group by another social group with access to social
power. Power is the ability to control access to resources, the
ability to influence others, and access to decision makers.
Discrimination is behavior, intentional or not, which negatively
treats a person or a group of people based on their racial origins.
In the context of racism, power is a necessary precondition for
Racism depends on the ability to give or withhold social benefits,
facilities, services, opportunities etc., from someone who is
entitled to them, and is denied on the basis of race, color or
national origin. The source of power can be formal or informal,
legal or illegal, and is not limited to traditional concepts of
power. Intent is irrelevant; the focus is on the result of the
the interaction of prejudice and discrimination, an institution can
be a “non-racist”, “reformed racist”, “reluctant racist”, and “overt
racist.” (Chart 01) Using Blacks as the focal group, a “non-racist”
is an institution that has no negative biases or prejudices against
Blacks and no discriminatory behaviors. It is very rare that an
institution has neither racial bias nor prejudices and engages in no
discriminatory behavior. When institutions take the position that
they are non-racist, it is possible that the institutions operate in
arenas where they have very little contact with Blacks. However, it
is more likely that they are in denial about the existence of either
prejudices or discrimination.
racist” institution has definite biases or prejudices against Blacks
but does not act on them. For example, an institution could hold a
belief that Blacks are more likely to abuse pain medication, but
notwithstanding those prejudices, pain medications are prescribed to
Blacks equitably. In this situation, the institution makes no
difference in health care based on race. This form of racism
involves institutions that harbor biases or prejudices but are
either too timid to discriminate or who are actively working on not
discriminating. The prejudices or biases are still present, but
these institutions do not act on them.
An “overt racist” institution has definite bias or prejudice and
definite discriminatory behaviors. For example, individuals in an
institution could hold a belief that Blacks are more likely to abuse
pain medication, and because of those prejudices, pain medications
are prescribed to Blacks differently than they would be to Whites.
Most people are familiar with this form of racism. Overt racism
involves actively and intentionally expressing bias or prejudice and
actively discriminating against others in public and private ways.
Most discrimination in health care is not overt.
“reluctant racist” is an institution that purports to have no
negative biases or prejudices against Blacks but has definite
discriminatory behaviors. For example, an institution could hold no
negative beliefs about Blacks but prescribe pain medications
differently to Blacks as an indirect result of some other policies.
This is the most pervasive form of racism and also the hardest to
challenge. Reluctant racism occurs due to mistaken stereotypes,
biases or prejudices that are acted out in an unthinking manner or
through policies, practices, or procedures of institutions that have
a disproportionately negative impact on Blacks.17
Often, the behavior is motivated by non-race based reasons (e.g.
economics). Because of this non-racial motivation, individuals
leading and managing institutions often do not believe that their
institutions are being racist. Furthermore, it is even more
difficult for the institutions to change the behavior. For example,
some teaching hospitals do pelvic exams on unconscious female black
patients in surgery without the patient’s consent in order to train
interns, and the hospitals do so without a conscious desire to
discriminate. These hospitals would fit into this category of
reluctant racist. As Kwame Ture (a.k.a. Stokely Carmichael) and
Charles Hamilton explained in their landmark book, “Black Power: The
Politics of Liberation”:
“When White terrorists bombed a Black church and killed five Black
children, that is an act of individual racism, widely deplored by
most segments of the society. But, . . . [when] Black babies die
each year because of the lack of proper food, shelter, and medical
facilities, and thousands more are destroyed and maimed physically,
emotionally, and intellectually because of conditions of poverty and
discrimination in the Black community, that is the function of
institution becomes aware of the discriminatory impact of its
policies and practices and yet fails to change the policies and
practices, then the institution is no longer a “reluctant racist”
but an “overt racist”.
States Commission on Civil Rights,
The Health Care
Challenge: Acknowledging Inequity, Confronting
Discrimination, and Ensuring Equality, Volume I, the Role of
Governmental and Private Health Care Programs and
Initiatives, 287 No. 902-00062-2 (September 1999).
How Institutions Think
T. Schaefer, Racial
and Ethnic Groups 76-78 (2000); Kwame Ture & Charles
Hamilton, Black Power:
the Politics of Liberation (1992).
of Medicine, Unequal
Treatment: Confronting Racial and Ethnic Inequities in
Health Care, Brian D. Smedley, Y. Stith, & Alan R.
Nelson, Editors, Committee on Understanding and Eliminating
Racial and Ethnic Inequities in Health Care 9-12
Ture & Hamilton, Black
Power, supra note 16.