Structural Racism & Public Health: Forging the Collaborative Foundation of the Next Civil Rights Movement
By Peter J. Hammer
The United States is facing two great crises; one of race and the other of health. Beneath recent protests of Black Lives Matter against police violence are deeper embedded forces of structuralized racialization. These historic forces produce and reproduce patterns of racially disparate outcomes in health, education, housing, employment and the environment. The health crisis is one of costs and the inability to make lasting improvements in well-being without moving beyond narrow (and expensive) biomedical conceptions of care. At the intersection of these crises lie a common set of factors, the social and economic determinants of health.
Out of crisis comes opportunity. We need to forge a new Civil Rights Movement combining the efforts of those combating structural racism with those fighting for public health. The synergies are numerous. Public health provides a frame that can advance racial equity. Racial equity provides a frame that can advance population health.Moreover, combined progress on these fronts is essential if the goal of universal health care coverage is to be accomplished in the United States and made economically sustainable.
Escalating health care costs are rooted in our narrow focus on the biological causes of illness and a focus on treatment that neglects the social and economic determinants of health. In this hierarchy, the public health community is often treated as a distant cousin rather than an essential partner. In truth, public health can serve as a bridge between extant biomedical orientations and the broader determinants of health. That said, it must also be admitted that the reach of traditional public health thinking is also limited. Public health can identify the significance of the social and economic determinants of health, but can do littleto answer the most important question: What determines the social and economic determinants of health?
Contemporary theories of structural racism are helpful because they provide powerful insights into how this question can be answered. Understanding the dynamics of racecan function like a social MRI, diagnosing the root causes of endemic inequity and the impediments to better health. As such, a deep collaboration could be forged between those fighting structural racism and those fighting to improve public health.
What would an evolutionary path to change look like? There are at least four core steps. First, employ theories of structural racism to help diagnose the root causes of inequity in the United States. It is not enough to say that poor housing, employment and education lead to poor health outcomes. We need to understand the root causes of the inter-institutional dynamics that produce and reproduce these racially disparate outcomes over time.
Second, we need to focus on the social and economic determinants of health by assuring health in all policies.How can public decision making effecting education, housing, zoning, parks, employment and transportation be better informed to accommodate health concerns? Jonathan Heller and Health Impact Partners have developed frameworks to guide this process and advance the goal of Health in All Policies: 1) make a judgment about how a proposed project will affect health; 2) highlight disparities in health between groups of people; and 3) provide recommendations to improve decisions.
We also need to ask basic public health questions about the more disruptive policies Detroit is pursing that affect the health and wellbeing of its residents. What are the health impacts of water shutoffs, tax foreclosures, the failed school system, regional transportation and use of tax abatements for economic development? What changes in these policies would better advance public health objectives? What alternative policies could the City pursue that would have greater health payoffs?
Third, how could we better control health care costs by centering management of chronic illness in the community? Chronic illnesses are the major long-term drivers of health care costs – diabetes, heart disease, asthma. We need to center careof these issues in the community and to flip traditional notions of medical expertise by training and empowering members of these communities to be the front linemanagers of wellbeing. With creative thinking, we could combine health management and community empowerment with new strategies of neighborhood-based economic development for even greater impact.
Finally, we need to generate a new political ethos for public action based on reverence for life and a recognition of our mutual interdependence and responsibility. Again, issues of race and health come together. In contemporary American politics, opposition tobasic government functions has been highly racialized. Health policy has been captured and held hostage by this dynamic. Racialized opposition to government prevents even the most common sense policies to improve health. Members of the health care community must embrace a new Civil Rights Movement as a predicate to advancing a workable health policy agenda.
We need a new art of collaboration that forges a coalition between those fighting for public health and those fighting structural racism. The health sector could play as great a role in this new civil rights struggles the courts did in the first Civil Rights Movement.
Peter Hammer is a professor of Law at Wayne State University Law School and is director of the Damon J. Keith Center for Civil Rights. He is a member of the Population Health Council and serves on the Education and Advocacy Committee.