How Public Health Contributed to Structural Inequity
Updated: Jan 19, 2022
Learning the history of public health
During my graduate studies, I became increasingly interested in patient-provider communication and the processes and procedures of discussing health topics with the community. As I wanted to learn more about health communication (with a lens other than public health), I elected to take a course in the communication department. Although excited about learning in a new environment, I was shocked to discover that my view of public health was quite different from how other disciplines viewed it. To put it more directly, some students in the course derided public health, considering it a profession that perpetuated colonialism and harm across the globe (think tropical medicine and population health). Was this the same field of study I’d come to love and wanted to be a member? Well, yes.
Learning the legacy of colonialism and racism in public health
For the first time in my years in public health, I heard people discuss how public health practice upholds the status quo, ignores the needs of the socially marginalized, and allows capitalism, patriarchy, and neoliberalism to shape it. Additionally, I learned that the origins of public health were rooted in ensuring that the western world, those in power, and predominantly white nations existed, maintained control, and exploited the global south and other communities for profit.
Furthermore, my professor and the other learners in the course (who ultimately also became my educators) critiqued how professionals and industries practiced health communication and its effect on population health. The underlying and dominant narratives in health communication promoted and examined individualism rather than the larger systems that establish and distribute opportunities or disadvantages. Additionally, the course was not relegated to the interrogation of public health praxis in the U.S. We reviewed a diverse and global literature (including Paul Farmer’s Pathologies of Power), with many detailing the same thing -- political choices create systems of inequity and that the subjugation of vulnerable populations was a form of structural violence. It became alarmingly clear that some in public health are blind to their abuse because they have only ever viewed public health as a healing profession, not one that helped colonizers strip indigenous people of their culture, communities, and resources.
We currently see how public health is failing to communicate with the public about COVID-19. For example, the early discourse around COVID-19 vaccination in the U.S. focused on hesitancy. Black people were explicitly “targeted” in articles and news media as wrongfully and ignorantly expressing that they were unsure of or would not get the COVID-19 vaccine once available. Although many articles cited historical medical mistrust in the Black community, a primary example used to describe this phenomenon was the Tuskegee Syphilis study, although there are countless others. Often absent from these conversations is the ongoing mistreatment and abuse Black people and other socially marginalized groups continue to face in this country, along with issues in access to the vaccine in communities with fewer resources. And when engaging in what they believe to be protective factors, communities of color and those in low resource areas are blamed for the high rates of morbidity and mortality rather than examining the systems that initially created and continually perpetuated their mistrust and abuse. The emerging “anti-science” movement is partly in response to irresponsible public health practice, indicating that public health has missed the mark in serving communities and must work to restore trust.
Learning the practice of sexual and reproductive public health
In sexual and reproductive health, this historical context is essential for understanding the ongoing fight for sexual and reproductive health and well-being. As Ross and Solinger write in Reproductive Justice: An Introduction, achieving reproductive justice “depends on access to specific, community-based resources including high-quality health care, housing and education, a living wage, a healthy environment, and a safety net for times when those resources fail (page 9).” The idea that this reality can be actualized without these resources in place for everyone is faulty. Furthermore, the idea that we can realize optimal health while primarily focusing on changing individual behaviors or blaming those who have historically and contemporarily been marginalized in society and excluded from the distribution of resources is ridiculous, if not harmful. Extracting opportunities and wealth from communities yet suggesting that they exercise resilience (which the discipline (over)praises) and overcome significant hurdles and barriers to better life chances and outcomes is counterproductive to the promise of public health. In my work, I have often been discouraged by those who say that the solution to ineffective and harmful care experiences is to teach patients to navigate these “challenges” and become better patients.
A similar example is when Westerners enter global communities and try to educate people to “be” better global citizens by having fewer children, just telling sexual partners "no" (having “self-efficacy”), and pursuing educational and economic opportunities rather than continuing to live in poverty. Instead, let’s examine why there is no universal scientifically accurate and affirming sex education (in the U.S. or other parts of the world), why access to contraception and abortion is not readily available and affordable, why providers pressure and coerce people to make certain health decisions, why people blame those with fewer resources and opportunities for the environmental crisis rather than the actual mass producers of environmental degradation, and why public health continuously fails to address structural violence and its effects on health and well-being.
The transformation of the field and practice of public health lies in our collective ability to acknowledge the past, learn from it, and mitigate these injustices by addressing the underlying systems and structures that have proliferated inequity. First, it requires that we see ourselves in an unjust system and state our role in it. Then we can start to heal from a legacy of harm and chart of new course toward justice and equity.