The root causes of health disparities lie in policies and practices that distribute power and resources such as housing, education, employment and health services inequitably. For example, law enforcement agencies—including police and Immigration and Custom Enforcement (ICE) officers—disproportionately target, surveil and perpetrate state violence against communities of color. Ample research shows that the unjust government practices associated with the enforcement of immigration policies, the war on drugs or the criminal legal system damage health and reduce life chances for entire marginalized communities, playing a key role in creating health disparities.
The paradox here is that the government and taxpayers are funding both the state violence that causes these public health problems and the public health attempts to address them. While hundreds of billions of dollars fund unjust state violence practices, public health agencies are directing a fraction of their limited funds to the alleviation of the very health disparities caused by this state violence. In few instances is this paradox clearer than immigration enforcement. As our public health research shows, government-funded immigration enforcement is not only damaging to the individuals who are its targets, but to their families and communities as well. In this series, we highlighted the way in which home raids are likely to influence the presence of post-traumatic stress disorder (PTSD) and trauma symptoms. Public health agencies will ultimately fund the interventions to address these negative health effects, such as PTSD. Given this paradox, what do we as public health researchers and practitioners do about future health equity work in the United States?
Public health programs addressing health disparities and inequities should be dedicating at least as much vision, creativity and funding to tackling root causes—including state violence—as they do to interventions that help communities cope with the resulting inequities. Many (but certainly not all) of the existing programs addressing health disparities insufficiently highlight unjust state violence as a key root cause of health disparities and thus refrain from taking the steps to address it. This means that too often “health equity”/”health disparities” work focuses downstream from the root causes like state violence.
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For example, the US provides after-school programs for youth whose families have been ripped apart by mass incarceration and offers free pre-natal care to immigrant mothers who are anxious about getting deported. However, these are stop-gap measures, and we have yet to fully grapple with the complexity of dismantling these government-funded root causes and identifying evidence-based root causes interventions. Despite the good intentions of upstream-minded public health professionals, the current financial, political and creative restraints often limit our capacity to actually intervene upstream. We stop short of the advocacy and activism needed to dismantle these unjust systems. This is where future health equity work needs to focus.
We suggest four steps to make this possible:
- Coordinate more extensively with community organizers who are pushing for policy changes. For example, the Michigan Power to Thrive Initiative has brought together community organizers who are focused on criminal legal reform alongside public health practitioners (including state and local health officials) to identify the ways in which they can support each other. This work can add strength, data and a public health lens to organizers’ messages and link public health officials to community organizers to improve responses to community-identified priorities.
- Lobby and advocate for funding streams that support public health research, programs and advocacy that address racism and state violence as root causes of multiple health issues. There is a great need to build the evidence base for public health strategies that play a role in combating state violence or institutional racism. Currently, there are very few examples of these type of root causes interventions, and even fewer that have been rigorously evaluated. Funding agencies — especially the National Institutes of Health (NIH) and Centers for Disease Control and Prevention (CDC) — need to move beyond their siloed disease categories and pool funds to address these larger root cause issues. A public health program addressing institutional racism or an unjust policy will have an impact on many health issues (e.g. chronic diseases, violence, cancer, etc.), and thus funding currently allocated to preventing these diseases should be pooled to increase the funding available for root cause interventions. The RWJ Foundation or Ford Foundation are good examples of funding agencies that are focused less on disease categories and more on inequities. But, compared to the NIH and CDC, these foundations represent a small fraction of our national funding for public health efforts.
- Be explicit in our research and dissemination on both the historical and contemporary root causes of the health issue and the limitations of current interventions to fully address that issue. When we fail to mention the root causes explicitly, it is easy to lose sight of the larger issues at play and continue funding, researching and programming the same status quo approaches. Policy-makers and decision-makers who are exposed to public health research may be naïve to the root causes if we do not make it explicit. Academic journals, calls for proposals and conference presentations could start requiring a short section on “root causes of the health issues” so that proposals and research dissemination are framed with this lens.
- Speak out boldly in support of movements against racism and other inequities. For example, the American Public Health Association has several policy statements against state violence and spoke out firmly against family separation policies, though they recently failed to pass a policy statement on police violence. Human Impact Partners, along with their recently formed group Public Health Awakened, has excellently framed topics such as criminal legal system reform, tax reform and immigration reform as public health issues. Major governing bodies need to take their lead and put their weight behind solutions to these issues that are oriented around public health. Researchers and practitioners should get involved in framing these current debates (e.g. tax reform, criminal legal system reform, immigration reform) as public health issues by writing op-eds, contacting policy-makers, and threading this perspective into their organization’s communication and dissemination efforts.
If the public health industry is serious about eliminating health disparities and inequities, we will need to make significant changes in the coming years. The foundation laid by preeminent scholars and public health practitioners has given us the social epidemiological data and community-based participatory tools to take this next step. Now it’s on us — the current public health workforce — to make the hard and difficult push to create a “public health of consequence” that plays an important role in framing state violence and racist policies as health issues and undertaking interventions to dismantle them.