By Jhumka Gupta and Reginald Tucker-Seeley
In the summer of 2016, several threats to the public’s health dominated the headlines. At first, like so many other public health threats that came before (e.g. HIV/AIDS, Ebola), many may have viewed their spread as “someone else’s problem”, “happening far away”, or “not even threats at all.” Perhaps, we were infected with denial and thought that if we just ignored the seemingly isolated “outbreaks”, they would just go away. But then, the back-to-back news stories came out of Orlando, Baton Rouge, Minneapolis, and once again, Baltimore. Throughout the bombardment of race, gender, - and sexual orientation-based violent attacks, many may have continued to hope that the U.S. was immune to (or at least could temper) such contagion; yet, the voices of those shouting to “build that wall” or “ban all muslims” gathered so much momentum as to gain control of a major political party. We are not talking about a viral outbreak. We are talking about the public health threat of hate.
On the surface, public health juxtaposed with the term “hate” may seem like an unusual pairing. Especially if we view health as something that happens in a doctor’s office, or is mainly influenced by an “objective” physician’s orders. However, social factors, such as hate and discrimination, are closely linked to health status. To highlight this close connection, a recent editorial by physicians at the New York City Department of Health declared hate as a public health emergency. As two public health researchers of color, we wholeheartedly agree with this declaration. In our own work that collectively focuses on health disparities research and policy, socio-economic determinants of health, violence against women and girls, and immigrant health, we are acutely aware of the harmful health impacts of hate. Whether hate-driven social injustices occur in the forms of racism, ableism, heterosexism, sexism, or anti-immigrant sentiment, among others, our field has attempted to elucidate the impact that these “isms” have on the public’s health.
Take, for instance, the toll of racism on the health of African Americans. Overall, the death rate for African Americans is generally higher than Whites for heart diseases, stroke, cancer, asthma, influenza and pneumonia, diabetes, HIV/AIDS, and homicide. For example, compared to non-Hispanic White men, African American men are over twice as likely to die from prostate cancer; and although African American women are 10% less likely to receive a breast cancer diagnosis compared to White women, they are nearly 40% more likely to die from the disease. These differences in health do not just happen at the end of life, but occur throughout the lifespan. At the beginning of life, African Americans have twice the rate of infant mortality compared to Whites. During childhood, African Americans have higher rates and hospitalizations for asthma, are less likely to be treated for pain in emergency rooms when presenting with appendicitis, and are less likely to receive mental health care when needed, in comparison to White children. These differences are just the tip of the iceberg of racial/ethnic health disparities within the United States as they do not include differences that have been observed in other racial/ethnic populations, nor do they include disparities observed among populations who possess multiple identities that face oppression (e.g. being both gay and Muslim).
While genetics and access to healthcare and insurance can be important factors in determining our health, public health and social science have underscored how the exposure to racism also plays a critical role.The specific pathways through which racism impacts health are complex, as racism can operate at the individual and institutional levels. At the individual level, maltreatment due to racial group membership, such as being racially profiled by police, consumer racial profiling (receiving poorer service or being following around while shopping), and the subtle (and sometimes not so subtle) discrimination experienced in the workplace can trigger feelings of being “under threat”, and we often respond with coping strategies to help minimize or eliminate the perceived threat. While the body’s response to feeling “under threat” can trigger physiological responses enabling adaptation in the short-term, such responses can accumulate over time and lead to “wear and tear”on the body. At the institutional or structural level, the impact of racism is clearly seen across our many highly racially segregated cities, where a history of policies have played a large role in sorting individuals into neighborhoods by race, and the environments of these segregated neighborhoods shape the availability of choices that residents have regarding their health and health behaviors. For example, neighborhoods that are primarily racial/ethnic minorities have more fast food restaurants, more incivilities (e.g. litter, vacant and abandoned properties), and less green space, which may contribute to poorer health outcomes in those neighborhoods such as higher rates of obesity and chronic disease. The cumulative impact of racism is expressed as racial/ethnic minorities navigate our health care system: for example, African Americans are likely to have less access to health care (including mental health care), more likely to experience treatment delays (thus arriving to treatment at much later stages of disease), and to report lower quality of care when received.
Many decades of research in public health and social science have documented the pernicious impact of racism on the mental and physical health of people of color. So clearly, the focus on hate (manifesting as racism and other “-isms”) in public health work is not new; and this nation’s history is replete with examples of hate and discrimination. The question is, why should the public health field act with urgency now?
In this current age of a 24/7 news cycle and social media, public health professionals, along with all other Americans, have become what may feel like non-stop, first-hand witnesses to violence and hate. We can all be exposed to police brutality, a gold star Muslim American mother being attacked for appearing “submissive”, a pre-teen exuding misogyny towards the first female presidential candidate at a political rally, and a political representative making unapologetically white supremacist statements on national television. The question is, what can the public health field do to address such hate, that is above and beyond its ongoing efforts to combat discrimination as a social determinant of health? The American Public Health Association’s president has already announced her plans to launch a national campaign against racism. The stated goal of this campaign is to begin a conversation where racism is explicitly named as a threat to the health and well-being of all society. Simultaneously, the Robert Wood Johnson Foundation, the nation’s largest philanthropy organization solely dedicated to health, has launched an initiative to create a “culture of health”. Central to this initiative is recognition that health is not solely or primarily influenced by health care. Rather, social factors play a critical role, and that “health is influenced significantly by where we live, learn, work and play.”
In essence, health happens as we live our daily lives in our neighborhoods, workplaces, and other social environments; health does not just happen in clinics or hospitals. Also, as we see from the media headlines, hate-fueled speech and violence occur as we live our daily lives too: such as going dancing on Latin night at an LGBTQ club, going to a weekly bible study or gurdwara, driving while Black/Latino/Native American, or simply doing your job as a reporter or behavioral therapist.Therefore, as public health professionals, we should carry out our mission of “fulfilling society’s interest in assuring the conditions in which people can be healthy”, by naming and speaking out when we see social injustices and hate where we live, learn, work, and play. We know that those day to day instances (which may occur within and outside of our specific work-related projects), are impacting the very health issues that we have dedicated our careers towards improving. Thus by calling out injustices, such as policies that promote neighborhood segregation or community hyper-policing, we can begin to disrupt the connection between the various “isms” and health. Furthermore, as stated by Garcia and Sharif, we can’t primarily leave it to public health professionals who already focus on racial and ethnic health disparities, or public health professionals of color (or other marginalized groups) to call out the “-isms”. In fact, the public health professionals who are part of the communities that are bearing the brunt of police brutality, violent attacks, and hate speech may also be directly or indirectly impacted (e.g. by witnessing violence against people who they share identities with).
Just as a country’s problems cannot be fixed by merely one person, no single field or discipline can dismantle hatred alone. Moreover, the clustering of hateful acts that we are all witnessing this summer is only reflective of symptoms of an underlying epidemic of hatred that existed before and will likely persist beyond the length of one person’s political candidacy or an election cycle. However, the public health field can play an important role in combating this root cause of poor health. This can be done by continuing to document the harmful health impacts of discrimination and hate, engaging policy makers and communities, and incorporating principles from social justice organizations (such as Black Lives Matter) that do not necessarily have an explicit focus on health. Our country needs interventions that not only make it possible for individual people to achieve their best possible personal health, but also bold approaches that span multiple sectors (e.g. housing, education, urban planning, economic development, and health) to restructure the very systems that give rise to health disparities in populations. We need to speak out and work against hate in all aspects of life and society, as these are the very arenas where optimal health can be cultivated,or conversely, threatened.
Dr. Reginald Tucker-Seeley is an Assistant Professor of Social and Behavioral Sciences in the Center for Community-Based Research at the Dana-Farber Cancer Institute, and in the Department of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health. Dr. Tucker-Seeley’s research focuses on the social determinants of health, such as the association between the neighborhood environment and health behavior, and he serves on the Rhode Island Commission for Health Advocacy and Equity. Follow Dr. Tucker-Seeley on Twitter: @RegTuckSee