by Jonathan Heller
Most public health practitioners, and those who work on health impact assessment specifically, want to improve the health of vulnerable populations. Most efforts to do so are well-intentioned, yet they often don’t lead to significant change. What do we need to do differently? Below is an analysis we at Human Impact Partners put forward.
What Do We Mean By Inequity and What Are Its Causes?
First, we are intentional in our choice of the word equity. Health inequities, as Margaret Whitehead said, are differences in health status and mortality rates across population groups that are systemic, avoidable, unfair, and unjust. This is different from disparities, which are simply differences in outcomes that might not fit into those categories. The fact that the elderly get cancer at higher rates than children is a health disparity, but it’s not an inequity. The fact that black women get with breast cancer tend to fare worse than white women with breast cancer is an inequity – their cancer is often more advanced by the time they are able to first seek medical care.
Equity is also different from equality. Equality implies that everyone has the same things while equity implies that everyone has what they need. Giving everyone the same things to achieve the same outcomes will only work if everyone is starting in the same place and needs the same things to succeed. That is not a reasonable expectation in the U.S. today.
Increasingly, public health focuses on the social, economic, and environmental determinants of health knowing that these determine over 50% of our health status, and impact health equity. Few, however, are going further and asking about the underlying causes of inequities in the determinants of health and what we need to do about those. Social and political factors – like racism, sexism, segregation, poverty, political participation, and power – are the “causes of the causes” of health inequities. Our work in public health must address these factors if we want to address equity in a significant and lasting way.
To Address Inequity We Need to Address Forms of Racism
Let’s start by looking at racism, which will be the focus in the coming year of Dr. Camara Jones, the president of the American Public Health Association (APHA). Interpersonal racism – bigotry – is on the decline, though by no means do we live in a post-racial society. Research has recently uncovered fascinating findings about internalized racism and its impact. But, because we deal at a population level within public health, institutional and structural racism are likely the most important forms of racism from a health determinants perspective.
Institutional racism is bias within an agency – in the policies and practices of, for example, the federal Housing and Urban Development agency, city police departments, and school systems.
Structural racism is bias that is cumulative – across multiple institutions and society – durable, and multi-generational. It is the compounded effects of a range of factors that systematically privilege white people and disadvantage people of color. As john powell says, “Structural racialization is a set of processes that may generate [inequities] or depress life outcomes without any racist actors.”
This NPR interview with Richard Rothstein of the Economic Policy Institute vividly brings to life many of these aspects of racism. He describes how FDR’s need to compromise with racists and segregationists during the New Deal era led to HUD policies with racialized outcomes. These policies resulted in whites being able to build wealth, while blacks were unable to. High poverty rates among blacks in turn has led to troubled inner-cities today and conflicts with the police in places like Baltimore and Ferguson. This history involves elements of interpersonal, institutional, and structural racism. And this racism has clearly led to inequities in the determinants of health – such as housing – and health – such as the physical and mental toll of excessive policing.
Race has also been used as a political tool. This played out historically during the New Deal and not just in housing policy. The Social Security Act of 1935 intentionally excluded agricultural and domestic workers, a large percentage of whom were African Americans.
In Dog Whistle Politics, Ian Haney Lopez delves deeply into this issue and describes how, beginning in the 1970s, Republicans used racial subtexts to build support among whites. Reagan perfected this approach with his use of images like ‘welfare queens’ to create an inaccurate but powerful popular perception that government primarily serves “undeserving” people (people of color and particularly black people). This narrative helped lay the groundwork for the small government ideology that pervades society today.
This understanding of how race affects the determinants of health and health equity also helps shine a light on why class matters, and gives us insight into how other forms of oppression – sexism, heterosexism, ableism, etc. – can affect health equity as well. Often people living the intersections of those forms of oppression – black women, transgender people of color, etc. – face the worst outcomes, often falling between the cracks of legal protections and services designed for each form of oppression in isolation. For the sake of brevity, I’ll leave those topics for the future.
And We Need To Change the Distribution of Power
Power is another of the “causes of the causes” – the social and political factors that determine our health – that is not considered enough in public health practice. As the Final Report of the World Health Organization’s Commission on the Social Determinants of Health says:
Any serious effort to reduce health inequities will involve changing the distribution of power within society and global regions, empowering individuals and groups to represent strongly and effectively their needs and interests and, in so doing, to challenge and change the unfair and steeply graded distribution of social resources (the conditions for health) to which all, as citizens, have claims and rights.
Why is the distribution of power so important? Because those who currently hold power benefit from the status quo and they work hard to maintain their power. For example, real estate developers donate large sums of money in local elections because they want, for example, land use and development policies that help maximize what they can do with their land and minimize what’s required of them. Employers profit more when they don’t have to provide benefits to workers and the minimum wage is low. Pharmaceutical companies don’t want pricing regulations, and so they use their power to influence health care laws.
In contrast, those who face the greatest inequities have the least power and ability to influence decision making in ways that benefit them. That will need to change if we are to achieve health equity.
Power is a complex concept, but it fundamentally means having the potential to shape our lives and the world around us. As the Grassroots Policy Project describes, there are multiple dimensions of power, including:
- Influencing political decision making directly, which involves organizing people and resources for political involvement in visible decision making;
- Shaping what is on the political agenda which means building the infrastructure of organizations connected functionally to shape what politicians debate, what the media finds worthy to cover; and
- Shaping ideology and worldview, which means shaping people’s conscious and unconscious understandings of the world, in particular in ways that change their ability to ask questions.
Our work in public health needs to address all these aspects of power. We can conduct our community engagement so that it empowers communities facing inequities, for example by supporting community organizing groups working to organize low income people. But we need to go further and change what is on the political agenda. We can’t let the NRA dictate that the CDC can’t do research on gun violence. Rather than being on the defensive constantly about the social safety net, we need to put expansion of that health-promoting safety net back into the debate. And we need to help people understand the importance of the government’s role in promoting health and wellbeing, changing currently held worldviews of the role of government.
Bringing it All Together
If we want to improve health in low-income communities and communities of color, we must address the social determinants of health. But the existing power structures work to maintain the status quo. So, to change the determinants of health, we need to change the distribution of power, so people gain control over the factors that affect their lives. And, because race, class, gender, and other forms of oppression are sources of inequity and are used to maintain the existing power structures, we in public health must address those in our work as well.
This is not easy work, but it must be done if we are truly dedicated to reducing inequity.
Jonathan Heller is co-director of Human Impact Partners, an Oakland, CA nonprofit that conducts community-based studies of the health and equity impacts of public policy.
While aI agree with most of what was written here. I also think we need to talk about the deeper structure of our economic system in which poverty is essentially a built-in feature. This actively creates power inequities, which lead to disparities. Race, class and gender got us here, but what keeps us here is the material economic structure of our society.
Too often, we embrace neo-liberal solutions which propose technical reforms ("better" schools, transportation, jobs programs, etc.) as solutions to problems of poverty - poor health, educational outcomes, low wages, etc. While I agree with these programs as better-than-nothing, they are ultimately expensive band-aids for a system that actively creates inequality by allowing low wages, and property inequality (ghettos) to exist at all. As a society, we can invest millions of dollars in trying to repair poverty by offering people interventions as a "way out". But what if we designed a system in which people didn't need a way out to begin with?
I used to teach, and instead of spending vast sums of money to make up for broken families, what if we focused on not allowing them to break to begin with? What if we established a guaranteed income that was tied to measurable self-improvement outcomes, such as good grades, enrollment and participation in health, education and community mentorship programs?
I'm not pretending that any of these are silver bullets, but I'd like us to think bigger and bolder about eradication of poverty, which itself creates inequity and disparities.