August 2000, Vol. 90, No. 81212 American Journal of Public Health
Going Public
Camara Phyllis Jones, MD, MPH, PhD
ABSTRACT
The author presents a theoretic
framework for understanding racism on
3 levels: institutionalized, personally me-
diated, and internalized. This framework
is useful for raising new hypotheses
about the basis of race-associated dif-
ferences in health outcomes, as well as
for designing effective interventions to
eliminate those differences.
She then presents an allegory about
a gardener with 2 flower boxes, rich and
poor soil, and red and pink flowers. This
allegory illustrates the relationship be-
tween the 3 levels of racism and may
guide our thinking about how to inter-
vene to mitigate the impacts of racism
on health. It may also serve as a tool for
starting a national conversation on
racism. (Am J Public Health. 2000;90:
1212–1215)
The author is currently with the Department of Health
and Social Behavior, Department of Epidemiology,
and the Division of Public Health Practice, Harvard
School of Public Health, Boston, Mass. She will soon
begin working with the Centers for Disease Con-
trol and Prevention, Atlanta, Ga.
Requests for reprints should be sent to Camara
Phyllis Jones, MD, MPH, PhD, Centers for Disease
Control and Prevention, 4770 Buford Hwy, MS K45,
Atlanta, GA 30341.
This article was accepted April 12, 2000.
Race-associated differences in health out-
comes are routinely documented in this coun-
try, yet for the most part they remain poorly
explained. Indeed, rather than vigorously ex-
ploring the basis of the differences, many sci-
entists either adjust for race or restrict their
studies to one racial group.1Ignoring the eti-
ologic clues embedded in group differences
impedes the advance of scientific knowledge,
limits efforts at primary prevention, and per-
petuates ideas of biologically determined dif-
ferences between the races.
The variable race is only a rough proxy
for socioeconomic status, culture, and genes,
but it precisely captures the social classification
of people in a race-conscious society such as
the United States. The race noted on a health
form is the same race noted by a sales clerk, a
police officer, or a judge, and this racial clas-
sification has a profound impact on daily life
experience in this country. That is, the variable
“race” is not a biological construct that reflects
innate differences,2–4 but a social construct that
precisely captures the impacts of racism.
For this reason, some investigators now
hypothesize that race-associated differences in
health outcomes are in fact due to the effects of
racism.5,6 In light of the Department of Health
and Human Services’ Initiative to Eliminate
Racial and Ethnic Disparities in Health by the
Year 2010,7,8 it is important to be able to ex-
amine the potential effects of racism in causing
race-associated differences in health outcomes.
Levels of Racism
I have developed a framework for under-
standing racism on 3 levels: institutionalized,
personally mediated, and internalized. This
framework is useful for raising new hypothe-
ses about the basis of race-associated differ-
ences in health outcomes, as well as for de-
signing effective interventions to eliminate
those differences. In this framework, institu-
tionalized racism is defined as differential ac-
cess to the goods, services, and opportunities
of society by race. Institutionalized racism is
normative, sometimes legalized, and often man-
ifests as inherited disadvantage. It is structural,
having been codified in our institutions of cus-
tom, practice, and law, so there need not be an
identifiable perpetrator. Indeed, institutional-
ized racism is often evident as inaction in the
face of need.
Institutionalized racism manifests itself
both in material conditions and in access to
power. With regard to material conditions, ex-
amples include differential access to quality
education, sound housing, gainful employment,
appropriate medical facilities, and a clean en-
vironment. With regard to access to power, ex-
amples include differential access to informa-
tion (including one’s own history), resources
(including wealth and organizational infra-
structure), and voice (including voting rights,
representation in government, and control of
the media). It is important to note that the as-
sociation between socioeconomic status and
race in the United States has its origins in dis-
crete historical events but persists because of
contemporary structural factors that perpetuate
those historical injustices. In other words, it is
because of institutionalized racism that there is
an association between socioeconomic status
and race in this country.
Personally mediated racism is defined as
prejudice and discrimination, where prejudice
means differential assumptions about the abil-
ities, motives, and intentions of others accord-
Levels of Racism: A Theoretic Framework
and a Gardener’s Tale
