Introduction

Despite race being a social construct [1], there are unmistakable health disparities that run along racial lines in the USA. As a few examples, Black Americans are more likely than non-Hispanic White Americans to have a stroke, diabetes, asthma, and dementia [2,3,4,5]. This is part of what leads to shorter lifespans for Black Americans who live, on average, 2.8 fewer years than White Americans [6]. These differences in health quality are not the result of physiologic or biologic differences. Rather, disparities are embodied social inequities [7]. Black Americans report frequent experiences with discrimination in day-to-day interactions, referred to as interpersonal or everyday racism [8,9,10].

Black Americans also experience racism in the form of unfair systems and policies, unequal opportunities, and disproportionate risk exposure [11]. When this type of racism is perpetuated by one organization or sector, such as a school or employer, it is termed institutional racism [11]. Racism across institutions, and the overarching racism that ties all these unfair systems together across time, is referred to as structural racism [11, 12]. Structural racism includes policies, laws, or practices that are culturally embedded and are therefore interpreted as acceptable norms [13]. Systemic racism is then a combination of interpersonal, institutional, and structural racism working together to create and reify racial inequities [13].

While studies have found experiences of institutional racial discrimination are associated with chronic conditions such as diabetes [14] and obesity [15], there is little research focused on the relationship between structural racism and health. Similarly, the existing literature gives vivid voice to the experience of everyday and interpersonal racism and its relationship with stress and psychological welfare; however, there is little known about how older Black Americans view structural racism and its impact on their health over the lifespan.

Krieger’s Ecosocial Theory of Racial/Ethnic Discrimination and Health [7] served as the theoretical framework for this work. According to Krieger’s theory, there is a “cumulative interplay of exposure, susceptibility, and resistance across the life course” and societal power imbalances are responsible for exposures to inequities [7]. Krieger posits that health disparities are the manifestation of societal inequities, incorporating physical and social context into physiology [7]. To operationalize these pathways, in prior work [16, 17], we reviewed discrimination literature and conducted focus groups with discrimination researchers and community leaders. From that formative work [16, 17], we used the eight contexts from Zinzi Bailey’s work [11] and added civic engagement. Thus, the nine contexts across which exposure to structural racial discrimination/structural racism is most salient: education, employment, policing, civics, media and marketing, neighborhoods, income credit and wealth, healthcare, and environment. These nine contexts inform the research detailed here [18].

Key in Krieger’s Ecosocial Theory is an individual or community groups’ susceptibility to and resistance towards racially driven inequity [7]. An individual’s capacity for resilience is dependent upon a variety of factors ranging from deeply individual (cellular level) to larger societal factors, (community, national and geographic factors) [19]. Resilience responses to a stressor or traumatic event can be individual or structural and may manifest as recovery, resistance, or rebound [19]. Recovery indicates a return to baseline after a reduction in capacity or quality of life. Resistance refers to an individual’s ability to withstand stressors and maintain their baseline function despite adversity, while rebound highlights the ability to thrive and exceed prior capacity in the face of a challenge [19].

Methods

The purpose of this study was to develop a deep understanding of the lived experiences of structural racism and discrimination among older Black Americans’ and their perceptions of structural racism across their lives. We sought to evaluate and characterize the perceptions, experiences, and internalizations of structural racial discrimination from those who lived them. We also considered individual and community resilience capacity and response in the face of systemic racism.

To align our methods with the cumulative inequity central to Ecosocial Theory, we sought individuals with experiences straddling the civil rights movement [7]. Most of our participants were Black Americans who lived through legal segregation followed by subsequent decades of insidious but impactful forms of structural racism to explore racism’s impact over time [1]. Although many ethnic and racial minority groups have harmful experiences with discrimination, here we focus on Black Americans, and, in the future, we plan to expand this work to a larger population.

Study Design, Setting, and Participants

We recruited community-dwelling adults aged 55 and older in and around Baltimore City who identified as Black, through community outreach, and by contacting research participants from prior studies of older adults in Baltimore. Participants who participated in prior work were engaged in a community aging-in-place intervention related to physical function and capacity and agreed to be contacted for different projects. No prior interviews were conducted with participants. Participants were excluded from the study if they did not speak English or if they lacked the capacity to participate in interviews. The Johns Hopkins University School of Medicine Institutional Review Board completed a full review and approved the study (IRB00206642). We used maximum variation sampling to ensure participation across gender, age, and socioeconomic status. Participants were recruited and interviewed iteratively until saturation was reached at 15.

Enrollment

A research assistant spoke with interested participants by phone, explained the study, and screened for eligibility. Prior to the COVID-19 pandemic, interviews were conducted in participant homes (n = 11). During the pandemic, interviews were conducted by telephone (n = 4). Participants completed a written (prior to COVID-19) or verbal (during COVID-19) consent prior to enrollment. Each participant who completed an interview received a US$25 gift card. The research assistant who completed recruitment and enrollment is a registered nurse who has worked with older adults in community-based settings for more than a decade. She has had formal training in interview facilitation and qualitative methods. We enrolled participants until we reached theoretical data saturation based on redundant findings on initial data analysis [20].

Data Collection and Analysis

We used a semi-structured interview guide to explore participants’ perceptions of structural racism. We first asked participants to engage in a life review to solicit input on exposure to racism at multiple points across the life course. Participants described their childhoods, families, and educational and work histories. We then asked participants to identify racism and discrimination within their social networks pertaining to specific institutions or contexts. We focused on participant experiences with discrimination at the institutional or structural level, though we invited participants to share any meaningful experiences of racism. After the interview was completed, the interviewer collected demographic information and asked participants to rate their overall health as “excellent, very good, good, fair, or poor.” However, the authors did not feel that the thematic results were linked to self-reported health status as this did not emerge as a topic of discussion throughout the interviews. One research assistant completed the interviews from January to August 2020. Interviews lasted an average of 49 min. Interviews were audio-recorded and transcribed verbatim.

Two study team members (AB and MN) used an inductive approach to create an initial codebook [21, 22]. We approached the analysis with a constructivist lens informed by critical race public health theory [1]. Both team members initially read between seven and eight transcripts taking notes and reflecting on the interviews. The coding team met to discuss and develop a codebook that reflected notes and initial findings across the nine contexts. The contexts were coded in a continuum where we captured endorsement of racial discrimination, racial discrimination as a non-contributor, or where participants denied the existence of structural racial discrimination. Transcripts were analyzed according to degrees of endorsement to fully explore the spectrum of perspectives on each context. We also used historical codes to help situate the experiences over a timeline. To capture variation in the discriminatory experiences, we included intersectional codes such as “gender” and “sexual orientation.” We developed codes to capture resilience factors protective against racism as well as codes that seemed to expedite black divestment. Experiences were coded according to the nine contexts, double or triple coding in some instances to help highlight structural discrimination crosscutting multiple domains of institutional discrimination. Coding was done in Nvivo Software version 20.7.1.

During data analysis, two team members reviewed the transcripts and documented initial reflections memoing and reflecting iteratively. They met weekly to discuss revisions to the codebook and emergent themes. Each member of the coding team read and coded each transcript allowing for coding comparisons and to discuss differences in data interpretation. The two team members met regularly to engage in reflexive dialogue regarding each researcher’s beliefs, experiences, and reactions to the transcripts. In particular, the researchers considered their roles as young academic researchers, both of whom are Black women, in analyzing the experiences of older Black participants. Every effort was made to allow participants’ authentic experiences to emerge in the data, but the results that follow inherently reflect the researchers’ positionality.

After all transcripts were coded, we conceptualized thematic trends emerging from the data and compared coding with the theoretical framework and hypothesized contexts to determine fit. One researcher contacted participants whose interviews had been rich or who had expressed perceptions divergent from other participants. If the participant agreed, they reviewed thematic study findings, highlighted the participant’s own quotes used to support findings, and asked the participant to identify ways in which the analysis did and did not reflect their experiences and perceptions [23]. Five were contacted; all five participated. Member checking occurred between phases of analysis, allowing time to process and respond to participant feedback. None of the participants disputed the coding but one participant disagreed with a developing theme, “community factors.” Her input was taken into consideration as we interpreted the totality of the data and led to new, more holistic views of the community environment which later developed into “Community Divestment.” We incorporated reflections from their member-checking interviews into these results. In the results that follow, participant identities are protected using pseudonyms. Findings are recorded in accordance with Consolidated criteria for Reporting Qualitative research (COREQ) guidelines [24].

Results

Table 1 depicts participant characteristics of 15 older Black adults living in Baltimore who participated in this study. Two-thirds were female. Participants’ education ranged from 8 years to master’s level, and income ranged from $9000 to over $110,000 per year.

Table 1 Demographic characteristics of participating older black adults living in Baltimore City
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Overall Findings

Despite their experiences with interpersonal racism and living through government-sanctioned discrimination via Jim Crow Laws, older Black adults living in Baltimore endorsed structural racism to varying degrees. Participants endorsed the full range of views on structural racism from vehemently denying its existence on one end to views that most disparities resulted directly from embedded structural racism. Most participants had limited input regarding the domains of environment, media, and civics with many reporting that they lacked sufficient knowledge of laws, policies, and practices in these areas. However, participants had strong opinions about the connections between slavery, Jim Crow, and racism undercutting the domains of education, employment, healthcare, income, policing, and neighborhood. Individuals varied in their views about the impact of structural racism endorsing its impact in one domain but denying or questioning its effect in other domains. This created a continuum both within and across participants. A sample of the range of participant perceptions of structural racial discrimination in those five domains is presented in Table 2.

Table 2 Spectrum of perspectives on structural racism across five common contexts
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Policing and Violence

Most of the sample reported institutional and structural racism ingrained into the systems of policing and violence in Baltimore City. This included participants who denied the impact of structural racism in other domains. In several cases, participants acknowledged this dissonance but felt that the evidence of structural racism in policing was overwhelming and undeniable. Some participants explained that the domains of employment, neighborhood, and education were all within their locus of control; with the right attitude and hard work, Black people could overcome disadvantages and improve their situations. But these participants also felt that no matter what they did or how they behaved, they would always encounter racism within carceral institutions. Peter, a 56-year-old male voiced that opportunity was linked to wealth, not race, but regarding policing practices, he also stated,

In Baltimore City, they build jails. Baltimore County, Harford County and I know Harford County, you pass three schools-- the elementary, brand new, the middle, brand new, the high school, not as brand new, but close to new. They build libraries. They build schools in the counties in what you might call the White neighborhoods. You come down here in the city, they’re building jails.

Participants acknowledged institutional racism seen in disproportionately high rates of incarceration among Black men and a perceived lack of justice for Black Americans who experience crime and violence in their communities. Additionally, all participants in our study articulated racism in interpersonal policing behaviors. This manifested through the policies’ verbal and non-verbal communication with Black residents, use of violence against Black Americans, and indifference towards crimes committed in Black neighborhoods.

Factors Impacting Black Resilience

The participants described several factors that facilitate resilience in the Black community. They described instances of individual or community activism and advocacy, religion and faith, and family and community support and trust as factors that lead to resilience. Historically, Black colleges and universities (HBCUs) and the military were also identified as community resilience factors. Further description of these factors is offered below.

Activism and Advocacy

Participants described activism and advocacy journeys that spanned the life course and involved individual, neighborhood, state, and national movements. Participants described their commitment to staying up to date with local politics and speaking up, when necessary, as this participant noted “… People don’t complain. I complain all the time. I complain when something ain’t right, I complain” (Lorraine, Age 71). Many of these adults had a long trajectory of advocacy that included protests and civil disobedience, the development of advocacy organizations, and serving on local non-profit boards with a goal of advancing diversity, equity, and inclusion. One participant described an occasion when they provided testimony at the state house that informed the enactment of policy noting—“…And I testified, for many years. I testified on my 50th birthday in Annapolis. There was a hearing– well, I didn’t testify, but I brought a 16-year-old that testified” (Charles, Age 76). Advocacy efforts included educating others on Black history and how to speak up against past and present injustices. Participants also acknowledged the risks associated with activism. Despite the long-term benefits of activism, some families opposed activism, fearful for their relative’s safety. “My parents didn’t want anything to happen to their only son, and that it was a violent period. And they even opposed my going to the March on Washington” (Charles, Age 76).

Family Support

Family support was essential to securing financial stability. Family played a crucial role in childcare which allowed participants to continue their education and work, pursuing professional and financial goals. “My mom kept her [my daughter] on the weekend. I had this little weekend job at Mercy Hospital, on the weekends, three to eleven. So that’s how I managed to maintain” (Gloria, Age 66). Family support often appeared as cohabitation, sharing multigenerational and extended-family homes to reduce the cost of living and increase savings. Often participants described assistance that they received to move north or to urban areas for better opportunities. After the untimely death of his father in South Carolina, one participant noted, “my aunt’s sister [asked], ‘Why don’t you and the kids come to Baltimore and stay with me and my family?’ which we did” (Randy, Age 68). Family support evolved over the life course as participants shifted from dependents into the role of adult supporters themselves. This was especially true of older siblings, one participant described the role she and her brother played in supporting their younger siblings, “my brother and I, we all helped to finance them so they could go to college and get their education.” (Rhonda, Age 59). Sometimes, participants were called upon as children to assist the family, one participant recalled her discomfort as the only literate member of the family, “the burden of reading the bills and having to, you know, having to take on kind of a challenging role with an adult probably made me just kind of squirm a little bit” (Grace, Age 64). Due to circumstances outside of their control, some participants reported scarce family support, especially as children. Parents who were unable to be present because they worked multiple jobs often missed opportunities to guide crucial decision-making.

Community Trust

Most of the participants grew up in largely segregated neighborhoods either by circumstance or due to local and state regulations. Despite the disadvantages that accompany racial neighborhood segregation, participants remembered their childhood neighbors fondly and emphasized the strength of their community bonds. Trust was often articulated as financial assistance extended to friends and neighbors, even in business. “When we didn’t have the money, we would go over there and Mr. Weiner, he would mark it down, and on Thursdays, Dad would get paid, and he would give me his check and I’d go over there and Mr. Weiner would add up the bill and that was it” (Mary, Age 79). Neighbors helped one another through financially difficult periods and even helped one another to establish credit for future investment. Participants also discussed community trust in parenting and childrearing. Neighbors looked out for all the children in the community, not just their own. Adults would report poor behavior back to parents, or disciplined neighbors’ children themselves. Longing for the trust that they once felt, all of our participants reported neighborhood decline. As a result, many no longer trusted their neighbors with their children but this relationship was cyclical. One participant explained, “Back in the day, parents– like, our neighbors would spank us, would jump on us or something, but you can’t do it now. I’m not going to let nobody put their hands on my grandchild because they might just don’t like my grandchild. It’s the loss of trust” (Regina, Age 59). They also saw this shift in childrearing responsibility and discipline as a contributor to further moral degradation and community decline. Children today, they felt, lacked community support and supervision which bred substance use and crime. Reflecting over the life course, participants noted that within primarily Black communities were Black businesses and Black leaders who understood the experiences and needs of their neighbors. “My parents knew where there were safe places to go, even when we traveled. But there was the Black downtown, and my father was a small business– and he had his business at a Black bank, Black cleaners, Black movies” (Charles, Age 76). Participants saw local Black businesses as places where they could expect fair treatment informed by common racial ties. People patronized Black businesses not because they were forced to by Jim Crow laws, but because they were safe spaces that helped to build up the Black community.

Church/Religion

Church and religion played a central role for many of our participants. Unlike other facilitators of Black resilience like community trust, family support, and activism, participants had more difficulty articulating exactly how spirituality fostered individual and community rebound. One participant attributed his mental and emotional strength to his spirituality, “I know it [racism] can affect you mentally because it almost affected me, but I didn’t allow it to. Plus, I go to church. I believe in God. So, I don’t let a lot of little things get to me” (Michael, Age 63). Churches were seen as places of respite, and involvement ranged from weekly attendance to volunteering several times per week. There was also a full-time pastor within our sample. Church was a place for education, socialization, and even activism throughout the life course. Participants continued to see a role for the church in recovering Baltimore’s Black communities through sponsored projects like urban greenification. When contemplating crime in the city, one participant asked, “What could we do to get that set of people in church or on track?” and posed church activities like music ministry to keep youth positively occupied.

Schools/Historically Black Colleges/Universities

Participants demonstrated contradictions within and between persons when discussing the domain of schools and education systems. While many participants endorsed discrimination within the education system and interpersonal racism that occurred within schools, participants also discussed the importance that education played in their lives. Participants were quick to highlight their own academic achievements as well as the achievements of their children and grandchildren. Participants saw these triumphs as key to respectability and financial security. One participant described her mother’s insistence on academic excellence, “my mother always said that ‘Education is very important, and I never want to see you cleaning anybody’s house. Never want you to do the job that I do’” (Rhonda, Age 59). Participants talked about the role of individual teachers in counteracting interpersonal and structural discrimination. Children from sharecropping families who missed school to work during the harvest received make-up work to be done at home and additional tutoring from invested teachers. Other teachers provided support and encouragement to overcome the many barriers they faced. One participant described a meaningful exchange with her teacher, “She said ‘You just keep on climbing, keep doing good, and if anybody gives you any problems, you just come talk to me about it’” (Rhonda, Age 59). In some cases, these mentoring relationships carried on for years with teachers offering guidance and encouragement throughout childhood and adolescence. Within the education system, HBCUs offered a particularly welcoming environment for Black students who sought higher education within a cultural community. “I was accepted at Towson [University], but I was a little bit intimidated about going to Towson State. And I then decided just to go ahead to Coppin [a Historically Black College]” (Gloria, Age 66).

Armed Services

Four participants served with the US military. Though they were a small subset of our sample, these participants were vocal about the experiences and opportunities that the military afforded them. All participants described the military as a way of securing education, but they also discussed the opportunity for financial security through a military salary and pension. One participant saw the opportunity for financial growth via her brothers’ military income and later joined the military herself, “I had much older brothers. They were in the military. So, they would send money home to help support my mom” (Rhonda, Age 59). Participants described their service as a formative experience that broadened their worldview, exposed them to new ideas, and afforded them otherwise inaccessible opportunities for travel. Several participants described the military as an equalizer, bringing together people who would otherwise never interact. One participant illustrated this through a long-term friendship created in the army, “it was a great experience for me, for him, and for a lot of us. He never knew any Black people and such until he came to the military. Now, his granddaughter is now married to an African American” (Randy, Age 68). One participant recounted instances of housing discrimination within the military which she attributed to her race, gender, and socioeconomic status but also endorsed the benefits above.

Factors Contributing to Black Divestment

Older Black Baltimoreans in this sample offered a variety of theories that they felt contributed to Black poverty, community deterioration, and underachievement. Rather than naming the structural racism that shaped their experiences, many focused on institutional indifference, unsafe neighborhoods, and particularly personal deficiencies that led to individual failures. These three factors, reported below, were not identified a priori but were extracted from the data.

Community Deficiencies

Participants attributed poverty, drug use, crime, and unemployment/underemployment to a lack of discipline and individual underachievement. Participants felt that this was manifested through poor parenting, a loss of Black pride, and a degeneration of community values which had resulted in a “lost generation” of young people. Older Black adults were frustrated about younger generations who they perceived as absent a value system. One participant voiced, “It’s like a generation is missing and I can’t say what happened and why. I don’t know if it’s our fault not paying attention” (Yvette, Age 75). This view was often in direct opposition to the role of structural discrimination, “[The pervasive sentiment in Black communities that] The white man, he gets everything.’ I just don’t believe that that is the problem now…I really believe that opportunities have opened up for the African-American, and if you have a desire to get an education, to get a trade, to better your life, go to school, I feel like the opportunities are there for you to take advantage of. But so many of them don’t want to” (Josephine, Age 74). In many cases, participants highlighted drug use and the opiate epidemic as a cause of Black divestment. This sentiment was tied directly to participants’ thoughts about the neighborhood decline.

Unsafe Neighborhoods

Participants voiced their dissatisfaction with crime and safety in their neighborhoods. Older adults felt afraid to walk the streets due to gun violence and rampant drug trafficking. This too was attributed to people experiencing drug addiction and lack of personal accountability. When asked what was driving neighborhood crime, one participant quickly distilled the sentiment of several participants, “Personally, I think it’s parents not taking care of their kids. They’re not taking responsibility for their children” (Regina, Age 59). Other participants felt that an abundance of charity was feeding complacency and loss of pride in the neighborhood. A female participant asked, “Is it a hand up or is it a handout? I tend to think as long as you keep giving me a handout, you don’t help me to say that I need to go to work every day, I need to take a walk every day, I need to do what we used to do, is clean the stoop, sweep the streets and beautify my neighborhood” (Grace, Age 64). Participants voiced that this lost sense of community paved the way for Black-on-Black crime and a higher tolerance for neighborhood crime. “We came up under different parents and different morals and different principles” (Ruth, Age 65). Participants felt that all these factors, drug use, poor parenting, and loss of pride all contributed to increasing crime rates and a sense of fear in Black communities.

Institutional Indifference

Many participants blamed the indifference of enduring academic and medical institutions in Baltimore for neighborhood decline. Some participants accused these institutions of sanctioning the spread of urban blight, because it allowed the institutions to purchase and redevelop property cheaply. “Oh, we lived the urban– I mean, at the heart of the hood, the new hood that Johns Hopkins had just taken over and redone for other purposes. They didn’t do it when we were coming up. They did it for their purposes and their plans” (Ruth, Age 65). Participants felt betrayed by institutions that they felt profited off Black Baltimoreans but ultimately contributed to further damage in their communities. They also noted that city and state officials were inattentive noting “one thing about the city, our leaders…there are not doing their job.” (Sharon, Age 71) Our participants voiced that these institutions paid lip service to their mission statements about community engagement and lacked the desire to effect lasting positive change.

I see Johns Hopkins Hospital that, when I was a kid, the front door-- the front door was 600 Broadway, right?… The years subsequent to that, what do I see now? We have turned the front door to Hopkins to 600 North Wolf Street, on the other side. So we’ve turned our back to the community, right? By design. Architecturally. And then, what’s the first thing I see when I go into Hopkins now? I see a security guard challenging me, questioning me. Someone almost accosting me. So the totally-- how I look at that institution, how I feel that institution looks at me, how it sees me-- it sees me as a threat. It no longer sees me as a patient. (Randy, Age 68)

Participants centered their frustration about violations of research ethics and healthcare disparities on individual institutions rather than overarching policies and systemic injustice.

Discussion

These older adults provide a unique insight into how older Black Baltimoreans experience, perceive, and understand the structural discrimination they have endured throughout their lives. Some of the theorized contexts, such as education and justice, were more widely discussed by participants than other contexts, such as media and environment, and views on racism varied from person to person as well as from context to context. Overt experiences of discrimination, such as attending a racially segregated school, appeared easier for older adults to name as racism than covert circumstances such as poor air quality or the myth of “pulling yourself up by your bootstraps.” Surprisingly, there was a pervasive and unprompted identification of strategies, contexts, and tools that bolstered individual and community resilience allowing for resistance against the harms of racism. While Kreiger’s ecosocial theory helped us to frame the study, Ford and Airhenbuwa’s Public Health Critical Race (PHCR) praxis and Szanton and Gill’s Society-to-Cells resiliency model helps us to frame the diverse findings below.

Experiences of Racism

Participants readily shared examples of racism within the education and policing systems; however, fewer participants shared specific examples of racism in the contexts of environment, marketing, or civics—as these may be more covert manifestations of racism and difficult to parse out due to their ordinariness in everyday life [1]. Participants also varied on their own views of structural racism, sometimes naming external agents and other times naming themselves as the source of disparate outcomes. Some participants, particularly older participants, named specific external agents as accountable for disparities between Black and White experiences, such as lack of institutional investment in Black schools and neighborhoods, or interpersonal discrimination encountered in schools and workplaces. However, other participants instead cited personal or community deficiencies that they felt directly contributed to disparities. For example, participants thought that “with the right attitude and hard work” (i.e., bootstrap theory), Black people could overcome disadvantages and improve their situations [25]. However, they failed to consider that “attitude and hard work” are not solely responsible for how opportunity is structured and distributed. Similarly, while voicing that opportunity is about wealth and not race, one participant did not connect how racism structures the opportunity to build wealth. The differential structuring and distribution of opportunity and advantage is precisely the goal of racist ideologies and structures and is effectively how racism works. Thus, the idea that Black people can “pull themselves up by their bootstraps” is another manifestation of racism, and when Black people start to accept this as a fact, it then becomes internalized racism that limits their own humanity, autonomy, and dignity [26].

Experiences of internalized racism imposed upon Black older adults through experiences of structural and interpersonal racism can be seen in their disapproval of the perceived changes in the parenting of Black children, the supposed decreased desire for advancement, and the presumed lack of discipline for today’s adults and youth. These sentiments and the rhetoric used to describe them can potentially be linked back to white supremacist ideologies and narratives perpetuated by the media [18]. One participant cited a “lost sense of community” as the cause for increased neighborhood crime, but this is not only a personal or community deficiency as they described it, but it may also be a manifestation of the disinvestment in Black communities. The experiences and sentiments expressed in these interviews are illustrative of how structural racism operates—it is the interlocking and interworking of institutional, interpersonal, and internalized manifestations of racism. Despite all these levels of racism functioning to disadvantage older Black adults in Baltimore, the study participants also shared various factors that contributed to their ability to resist and/or rebound from the insidious and deleterious effects of racism.

Factors of Resilience

Our interview guide did not ask participants to explicitly identify resilience factors, but resilience emerged repeatedly throughout the data. Older Black Baltimoreans were able to explicitly and implicitly identify how they were resilient in the face of discrimination and resisted the effects of racism. The PHCR praxis, structural resilience work by Szanton and Gill, and the data suggest that assessing and understanding resilience in older Black Americans is likely as important as assessing exposure to discrimination [1, 18, 19]. The PHCR praxis emphasizes the need to focus on the assets and strengths of marginalized communities in order to shift the narrative from a deficit-focused viewpoint. Similarly, Szanton and colleagues highlight the need to understand and measure resilience as the antithesis of discrimination that can lead to effective interventions and supports [18]. Among our sample, a resilience rooted in individual or community strength was central to the mental and emotional health of people who experienced discrimination over the life course. Most studies of resilience outside of the disaster literature focus on the individual level [27], but our participants’ perceptions of the importance of the military, HBCUs, and the church suggest more attention is needed at the community and societal levels.

Because of the historical and cultural acceptance of racism, the harmful impact of systemic racism on people of color is often dismissed as exaggerated, misplaced, or even imagined [28]. The Public Health Critical Race Praxis refers to this as the “ordinariness of racism,” where racism is so pervasive that it is underestimated [1]. Though at times counterintuitive, some manifestations of racism may also be resilience mechanisms used to preserve personhood in the face of discrimination, social erasure, and dehumanization. These manifestations may include high-effort coping (e.g., bootstrap theory), a denial of structural racism and hyperfocus on personal/community deficiencies (e.g., internalized racism), and the ordinariness of racism.

High-effort coping, or John Henryism, is a coping strategy that involves a commitment to hard work and may help to mediate the relationship between discrimination and health disparities, particularly among people who are exposed to high levels of structural discrimination [29]. However, as with the story of Black folk hero, John Henry, who summons monumental strength to outwork a machine and then dies of exhaustion shortly thereafter, high-effort coping and continuous counterpressure to resist the stress of racism may also contribute to the disparate incidence of chronic health conditions [30]. High-effort coping strategies paired with the American narrative that the country is a free and fair society and those who have not “gotten ahead” have not tried hard enough to achieve economic equality may inadvertently give some control back to marginalized populations, allowing them to persevere. In other words, rather than succumbing to systemic racism and an Afro-pessimistic narrative, individuals may strive for environmental control and highlight personal accountability despite monumental disadvantage in an optimistic response to pervasive discrimination.

Additionally, the omnipresence of racism in everyday society in America may desensitize individuals and communities to its presence, causing individuals to conflate racism with socioeconomic factors or personal failings and downplay both its existence and impact on their own lives [1]. This too can be protective. Black individuals who do not see racism undergirding these domains may not experience the mental and emotional harms of racism that are known contributors to poor health in the literature. The ordinariness of racism may foster resilience, providing hope for a better future while simultaneously playing into the myth of John Henryism. The conceptualization, operationalization, and measurement of resilience on a structural level have evaded scholars for some time. However, the Society-to-Cells Resilience Theory is an appropriate framework for the measurement of resilience because it emphasizes resilience as a trait, at the cellular, physiologic, and individual level, and as a factor within communities and societies [19]. Improving our understanding and measurement of resilience is an important next step to advancing this work and effectively using the information gathered here.

Strengths and Limitations

This study has many strengths, including the inclusion of participants from a variety of socioeconomic circumstances and an established theoretical framework to guide data collection and analysis. It also has limitations. Participants were only recruited in and around Baltimore, MD. In the future, we hope to expand this research to a wider range of participants. Also, because of the COVID-19 pandemic, some interviews took place by phone which may have made it more difficult for participants and the interviewer to communicate (e.g., lack of nonverbal cues, difficulty hearing). The researcher who completed recruitment and data collection is a White female, which may have influenced participants’ openness. However, discrimination is an essential contributor to health disparities and public health, so we cannot expect any one group to carry the full burden of its study. To mitigate this limitation, the researcher emphasized she would not be offended by or skeptical of described perceptions of discrimination. The study team was co-led by Black researchers who helped to reflect on data interpretation and to contextualize unexpected findings.

Conclusions

In this study of older Black Baltimoreans, we found varied perspectives on the influence of structural racism in different life contexts. Most endorsed everyday discrimination and structural discrimination in contexts of policing, education, and employment with more difficulty identifying structural racism in covert contexts possibly due to the insidious and pervasive nature of racism in America. Within the context of this ordinary racism, older adults highlighted the importance of resilience factors like family support, HBCUs, and religious institutions that helped them to resist, recover, and rebound from structural racism. Conversely, personal and community deficiencies highlighted by participants as factors limiting Black success may in fact reflect structural racism and resulting structural divestment of the Black community. Future studies designed to explore institutional and structural resilience will play a role in combating the legacy of structural racism in the USA.