Utilizing structurally-informed frameworks in public health research and practice
Lately, when invited to speak or lecture, I have shared about my research trajectory and how I came to use critical theories and other structurally-informed frameworks. I describe my early public health education as detailing the "what" or, as I often refer to it, "public health 101" – Black people and other communities of color have the worst of the worst health outcomes. My early public health educators presented it as a matter of fact with little analysis of why these communities suffered the most. Additionally, when people interrogated the "why," they often framed the problem as individual shortcomings (e.g., income, education, zip code, relationship status, insurance status) that caused Black and brown folks to have poor health outcomes and experiences (i.e., high rates of diabetes, HIV, cancers, maternal mortality, unsatisfactory health care encounters).
I began to think that the issue reached beyond the individual level and could be explained through the interpersonal interactions with the health care system. I thought that's it –ensure people have access to health care and improve their health care experiences by equipping providers to address individual’s lack of health knowledge and low health literacy. I soon learned that the interpersonal level of understanding could not and would not address these issues adequately; we needed to move even further upstream. We needed to discover why when using multi-level approaches to address persistent health inequalities, we did not reach the structural level. Addressing health inequities without a racialized and social justice lens ensured that the root cause was never identified or ameliorated.
Structural oppression and vulnerability are not arbitrary barriers to care, health, and well-being, instead they are pointed and ubiquitous. Unfortunately, it's the ubiquity that many try to deny. As a result, we often have interventions and studies seeking to address unequal and unjust realities without ever acknowledging or seeking to mitigate these pernicious drivers. Using structurally-informed frameworks like critical race theory (CRT), public health critical race practice (PHCRP), and reproductive justice (RJ) suggest that structural oppression is a known and undisputed reality. A reality affirming that for conscientious investigators, there is no solution in which we should avoid questioning the roles of racism, sexism, bias, ableism, transphobia, homophobia, or other forms of marginalization in maintaining and/or creating unjust and unfair outcomes.
Even now, as I am learning more about structural frameworks and their application in public health research, translational science, and intervention work, social science and clinical disciplines are navigating a world that calls racist policies, practices, and epistemologies racist. However, the reality for those of us doing this work or interested in justice and well-being is that racism is so ordinary that our counterparts and colleagues scrutinize, if not vilify us, for examining these realities. Online and in the public discourse, you will see someone refer to an anti-racist practitioner as "the racist," the one upholding racism and being "divisive" by mentioning people's racial and ethnic identities or the structures that may discriminate based on social identities. As PHCRP suggests, we have to re-examine how we produce knowledge, what we describe, and how we define our work, positionality, and who we consider an expert. Transforming the culture of education and knowledge production is the beginning of a long journey to use science to eradicate social and health inequities. It starts with centering people who have been and are marginalized and minoritized in society. Furthermore, we must clearly articulate the structures that create and uphold systems of oppression and marginalization while finding mechanisms to abolish the distribution of disadvantage. Using structurally-informed frameworks are tools that can help us recognize these impediments to achieving social and health equity for all.