By Natasha Phelps
Jurisdictions across the country are declaring racism as a public health emergency.
We are in a public health emergency. Racism—on a structural, institutional, interpersonal, and personal level—does not only result in trauma, lower quality of life, disease, injury, and death in a myriad of devastating ways for Black people, Indigenous people, and other communities of color (BIPOC). 1 It is also detrimental to society as a whole. Racism is expensive and unjust. It stunts our innovation, hurts our economic well-being, and leaves our democracy and national security vulnerable. It is an illness that plagues the United States and is detrimental to public health.
Although racism has been a public health issue for centuries, many jurisdictions across the country are now recognizing racism as a systemic public health crisis that can no longer be ignored. This recognition is a response to the pressing issues of this past year. From the global COVID-19 pandemic, catastrophic weather events, and domestic economic strife to the civil unrest following the murder of George Floyd, the most discussed issues of the past year have been substantially caused and exacerbated by racism. The culmination of these events has resulted in enormous health disparities for BIPOC communities. These disparities are unsettling to many and costly to all, especially when it comes to our public health. The leading cause of health disparities is not race itself, but racism. As a result, many jurisdictions across the country, including state and local governments in Minnesota, are declaring racism a public health emergency and resolving to address historical, deeply embedded racism in laws and systems.
What is public health and what does race have to do with it?
Health is more than our individual behaviors (e.g., diet, exercise, substance use, and sexual activity). It is also more than the decision to go to the doctor or even an individual’s access to quality health care. Individual health and the health of society are impacted by a person’s individual ability to make lifestyle choices, as well as social, economic, and environmental conditions of society. This holistic understanding of health makes it possible for us to effectively address public health issues facing individuals, small and large communities, and the country overall.
Public health is the science and practice of assessing, protecting, and improving the health of entire populations, subpopulations, and individuals within communities. The public can reach its full potential for good health when the entire population, including subpopulations within the overall population, has the same potential to reach good health. Populations do not currently have the same potential to reach good health. Equity is the vehicle in which we can strive to achieve equality. To improve public health (equal potential) is to advance health equity (addressing inequality). Dr. Paula Braveman defined health equity as “the highest possible standard of health for all people and giving special attention to the needs of those at greatest risk of poor health, based on social conditions.”2 Health equity is achieved by identifying, reducing, and eventually eliminating the social, economic, and environmental conditions that disproportionately face marginalized communities and create “obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”3 These social, economic, and environmental conditions can be referred to as “the social determinants of health.”
Health inequities, then, are health disparities among groups of people within a population that are avoidable, unfair, and unjust. Health inequity explains why some people are healthier than others and why some people generally are not as healthy as they could be. To illustrate health inequity in any population, one could assess life expectancy based on the social determinants of health between subpopulations.
Take Minnesota, for example, which is often hailed as one of the “healthiest states in the nation,” but is home to some of the worst health inequities in the country. How long a person born in Minnesota can expect to live varies dramatically based on their race, along with associated determinants of health. As a case in point, a baby born and raised in the 55411 ZIP code of North Minneapolis is likely to live almost 10 years less than a baby born and raised in the Bryn Mawr neighborhood of Minneapolis—just two miles apart from one another.4 Examples of health inequity can be obscure or abundantly obvious, but one thing is clear—the health of an entire population is ultimately only as good as the health across subpopulations.
While all forms of oppression and marginalization negatively impact health, racism is the foundation and strongest driver today of health inequity in the U.S. It is not only an aggravating factor of all the negative social determinants of health but also is, in and of itself, a social determinant of health. In other words, racism causes disparate social, economic, and environmental conditions that impact health and the actual, personal experience of racism also negatively impacts health. There is an abundance of evidence demonstrating that people who experience racism have poorer mental and physical health outcomes.5 Health disparities resulting from racism exist between white populations and BIPOC communities throughout the country and across a spectrum of health areas, but they do not affect all BIPOC populations in the same way or to the same degree. Black and Indigenous populations throughout the country have always made up the worst disparities across equity issues, and many populations in certain geographical areas are substantially affected as well, especially Latinx and Southeast Asian populations in urban areas.
It is important to note that inequity also exists within racial categories, and health outcomes can vary significantly within overall racial population data. The negative personal and systemic impact of racism can be even more significant for those who hold additional marginalized identities. Not only do these people and populations face racism and oppression against their other marginalized identities (e.g., transphobia), they also face particular oppression because of their intersectional identity (e.g., Black women and femmes experience racism, gender discrimination, and misogynoir—anti-Black misogyny that specifically targets Black women). This leads to unique social determinants that seriously impact the health of BIPOC subpopulations (e.g., sexual violence against Indigenous women on Tribal lands by non-Indigenous men).
Further, it is important to look at subpopulations within overall racial and ethnic categories for a more complete picture of health disparities. For example, the average premature birth rate for Asian Minnesotans (overall) is 9%, only slightly higher than the overall state prematurity rate of 8.3%. But when we dissect the data by subpopulations, sectors of the Asian Minnesota population—specifically Cambodian and Laotian Minnesotans—actually have significantly higher prematurity rates than other Asian groups (e.g., South Asian/Indian, Chinese, and Japanese).6
In short, public health is about protecting and improving the life of an entire population by avoiding and ultimately eliminating health disparities that face subpopulations and intersections thereof. We cannot advance public health without addressing racism. Race is one of the (and oftentimes the) top indicators of health because racism, as it was formed in the U.S. and across the globe as a racial hierarchy upholding white supremacy, is foundational to the laws and systems that result in the social, economic, and environmental disparities that impact health. This is not surprising—the intention of racism was and is to create inequity in a multitude of ways.
Laws and policies are essential tools for supporting and improving lives, as they can assign access, rights, protections, and liberties. They reflect, reinforce, and shape social norms and community values. In the U.S., law and equality have not gone hand in hand. Racism is the foundation of the laws and systems of the U.S., legalizing disparate treatment of some people and creating unfair advantage for others, which “saps the strength of the whole society through the waste of human resources.”7
Racism is “the systemic oppression of a racial group to the social, economic, and political advantage of another.”8 Racism in the U.S. is grounded in white supremacy, or “the social, economic, and political systems that collectively enable white people to maintain power over people of other races.”9 Any competent lawyer can accept the overwhelming historical and current evidence that the law has had a vital role in creating race-based disparities. Our systems are not broken; they are operating as they were intended to function. The intention (and in some cases, the reckless neglect that some call “unintended consequences”) of racist laws and policies was to create inequity. As a result, we are faced with serious race-based inequities that cause disease, death, and poor quality of life. This is why racism has always been a public health emergency.
Nature determines our physical features and genetic heredity. Ethnic and tribal groups, skin color, cultural practices, and physical distinctions have been of neutral, positive, and detrimental social significance throughout world history. The kinship, group connection, and genetic impact of racial groups is very real. Race itself is not problematic, but the use of race by an oppressive power to intentionally demean, dehumanize, oppress, and result in inequality is problematic. Being “colorblind” or ignorant of race is ineffective and harmful. It is necessary to look back and identify how racism was legalized and institutionalized to undo its harms.
Racial hierarchy was created in the 16th century to support colonialism. For example, when the English began to colonize India, the term “white” was used by colonizers to refer to people who looked like themselves, and the idea that white people “were inherently smarter, more capable, and more human than nonwhite people became accepted worldwide.”10 The concept of whiteness grew to encompass more ethnicities and people, eventually becoming “a constantly shifting boundary separating those who are entitled to have certain privileges from those whose exploitation and vulnerability to violence is justified by their not being white.”11 As such, whiteness became fluid, existing in opposition to an “other” in a racial hierarchy. Once we define the “others,” whiteness defines itself and makes it possible to assign rights, privileges, and protections to those who do not fall within that group. It then allows for colorism and the assignment of partial privilege for those that are not furthest away from whiteness (anti-Blackness).
This racial hierarchy was embedded into the earliest of U.S. laws and systems to further colonize a land already occupied by Indigenous people and to solidify its new capitalist economy with the kidnapping and permanent enslavement of Black Africans. It is important to highlight the systemic oppression and marginalization of Black and Indigenous people in the early U.S. to understand how racism became embedded in the systems that lead to modern-day health inequities because the legalization of inequitable treatment toward Black and Indigenous people created the systemic racism that went on to impact all BIPOC for centuries and through today.
Colonialism required “the imposition of Western authority over all aspects of Indigenous knowledge, languages and cultures.12 In order to do this, people indigenous to the land we now call the U.S. became subjects of dehumanizing and racist legislation, characterizing them as “savage.” To reflect the colonial narrative that the original land inhabitants were inferior and thus less deserving of rights, privileges, or sovereignty, lawmakers developed systems and passed legislation that, for example, established “necessary conditions which had to be met if Indigenous peoples wanted to become citizens (of their own lands).”13 By creating legal distinctions between white Americans and Indigenous people, lawmakers have been able to “legally” strip Indigenous people of land, resources, and culture for centuries and in a variety of ways. Cultural and spiritual practices of Native people have been criminalized. Indigenous people have been displaced, separated by boarding schools, and otherwise marginalized. This generational oppression, trauma, and marginalization are reflected in the incredibly alarming health disparities tribal communities face today. Indigenous people across what has now become the Americas have survived and thrived despite genocide and occupation of their traditional, ancestral, and contemporary lands.
The legal condemnation of Blackness is rooted in and permeates laws and systems throughout the U.S. This began with the colonial intention to solidify the U.S. as a capitalist democracy by defining who was a “slave.” While humans have enslaved other humans throughout history, the practice of human slavery changed with the transatlantic slave trade of kidnapped Africans that stripped people of their known ancestry and culture. Slavery became an inescapable, intergenerational, fixed condemnation legally tied to the natural, physical distinctions of the Black, African-descendent race in the U.S. with few exceptions. Enslaved people were then not afforded the rights, privileges, and power that would make it possible to be free or healthy. Perhaps most infamously, the Dred Scott v. Sanford decision ruled that Black people were not only not U.S. citizens in the eyes of the U.S. Constitution, but also “inferior beings” with “no rights” “which the white man was bound to respect.” The life and health of enslaved Black people was recognized by the law only as a value of proprietary concern. By declaring Black people as degenerative and suitable for perpetual service during slavery and criminalizing education, mobility, and uprising of Black people, it was all too easy to perpetuate that “free” African Americans were more likely to commit crimes, more tolerable of pain, less connected to family, and less intelligent, and false “natural law theories” that supported anti-Black laws and policies long after the Emancipation Proclamation.
Even the abolition of slavery led to a legal loophole that allowed for the continued enslavement of African Americans—the 13th Amendment and the criminality of new attempts by Black people to survive and exercise any political or economic rights. This expanded the explicit legality of anti-Black treatment, creating systems, laws, and policies that would ensure continued racism, oppression, and marginalization of the “negro race” throughout the entire country. Decisions like Plessy v. Ferguson not only made racial segregation legal but also upheld the white supremacist myth that any separation of white versus the “others” was “separate but equal.” Anti-Black racism endured throughout 20th century society, where laws and systems criminalized and incarcerated African Americans, stripping them of their rights and forcing them back onto plantations as sharecroppers under the threat of punishment or death. Scientists, philosophers, legal scholars, and lawmakers from the nineteenth century to now have legitimized the same racism that was codified into the law since defining what a “slave” was. Black Americans continued to be harmed, marginalized, and exploited through Jim Crow laws, family separation, poverty, police violence, environmental injustice, mass incarceration, and many other forms of torture, violence, and suppression of rights. The trauma and health harms of Black people of African descent in this country due to centuries of anti-Black systemic and personal racism and violence cannot be overstated.
The existing racial hierarchy grounded in anti-Blackness and the oppression of Indigenous people in the U.S. came to apply, in part, to other racial and ethnic groups that came to the U.S. Racist laws and systems also expanded to capture additional languages, cultural practices, certain countries of origin, and other non-white identifiers as a pretext for legal discrimination and oppression. A few out of an enormous list of examples include the Chinese Exclusion Act of 1882, which included a number of anti-Chinese immigration measures; an alarming surge in racially motivated violence against Asian Americans following racist rhetoric used during the COVID-19 policy discussion; the forced deportations of Mexican-Americans after the Great Depression; 14 segregation of Latinx children in schools, and lynchings of Latinx in the Western U.S.; and hate crimes and civil rights violations against Arabs and South Asians in the aftermath of the 9/11 attacks. As if navigating life in a country with centuries-old systemic and interpersonal racism did not impact health enough, there is plenty of qualitative and quantitative data to show that the trauma, stress, and exhaustion from the experience of racism is extremely detrimental to the health of BIPOC Americans.
Systemic racism is a huge issue in Minnesota.15 In fact, one could say it is the epicenter of racial inequity. Minnesota’s history includes the forced removal of the Dakota people in 1851; discriminate enforcement by public land managers against Hmong refugees engaging natural resource-related activities in the 1980s; and the displacement of Black Minnesotans in the Rondo Community with the construction of Interstate 94. Today, we see disparate hospitalization and ICU admission rates of Indigenous and Asian Minnesotans diagnosed with COVID-19; the highest age-adjusted death rates for Black and Latinx Minnesotans diagnosed with COVID-19; and the low educational attainment rate of Indigenous and Latinx communities in the state. Minnesota is fraught with racial injustice.16
Racism continues to be codified into law, perhaps less explicitly than before. Whereas “others” were legally defined in the aforementioned ways throughout the last 500 years, today the legalization and systemic incorporation of racism looks like politicians that work to block, suppress, and delegitimize systems, laws, and policies that protect or support the ability of BIPOC communities to survive, thrive, and participate in governance. It looks like old and new federal, state, and local systems, laws, and policies that result in negative social determinants of health and health disparities facing BIPOC communities in the U.S., especially during the COVID-19 pandemic. It looks like the public health emergency that we face today, because the health of BIPOC communities reflects how legalized, systemic racism was always meant to be: inequitable.
Declaring racism a public health emergency can advance public health.
The understanding that racism is such a deeply-embedded problem in our society could also lead one to believe that it is too complex a problem to be fixed—that we are too tangled in the knot of racism to get out. Surely there is a question as to whether the current civic and economic systems in the U.S. are rectifiable, but there is a lot that we can do right now to make things better. After all, racism is human-made in substantial part through human-made systems. Declaring racism as a public health emergency and resolving to address it with actionable items is one promising step communities can take to identify, reduce, and ultimately eliminate the health disparities caused by racism.
A situation becomes an emergency when the “scale, timing, or unpredictability” of a consequential event “threatens to overwhelm a community’s ability to address it.”
Public health emergencies provide public health emergency powers that permit designated officials—typically chief executive officers and their top health officers—to use reserve resources and take extraordinary legal actions to respond to emergencies related to health. These emergencies can be based on the health consequence as well as the cause or precipitating event. A situation becomes an emergency when the “scale, timing, or unpredictability” of a consequential event “threatens to overwhelm a community’s ability to address it.”
17 Public health emergencies can be declared by different levels of governments. At any level, most responses to public health emergencies offer immediate relief, while also calling for the development of capabilities to prepare for long-term, ongoing, and foreseeable risks, often in response to an issue that has been declared an epidemic or a pandemic. Regardless of the timeline of the emergency relief, public health emergencies require large-scale solutions that can be evaluated for effectiveness.
When assessing the problem under a public health emergency framework, we can see clearly that racism is a public health emergency: Racism in the U.S. (1) affects a large number of people (certainly directly affecting BIPOC populations and essentially a large sector of the U.S. population); (2) has threatened the health of BIPOC populations for centuries, most recently heightened by the COVID-19 pandemic; and (3) requires large-scale solutions because systemic racial injustices are rooted in federal, state, and local laws, policies, and systems.
The federal government18 as well as many state and local governments has recognized the grave collateral damage caused by racism and inequity in the U.S. Accordingly, across the country, hundreds of state and local governments19 have passed legislation declaring racism a public health crisis or emergency. These actions are not limited by geography. Many local boards and commissions throughout the Southern U.S. have passed resolutions declaring racism as a public health crisis and in March 2021, the state of Virginia became the first Southern state in the country to name racism as a public health crisis. Additionally, many governing bodies, including the U.S. House of Representatives,20 have introduced, but not yet passed, resolutions declaring racism as a public health emergency.
Minnesota is also on the map, with the Minnesota House of Representatives passing a declaration in July 2020 requiring, among other actions, the creation of a House Select Committee to assure an intersectional race equity lens on House legislative items. Many Minnesota localities have passed these declarations as well, from Hennepin County and the city of Minneapolis to Olmsted County and the city of Bloomington.
These declarations are an important first step in the movement to advance racial equity and justice, but to be effective they should explicitly contain declarations of racism as a public health crisis (i.e., a stated purpose and intent) and resolutions to act (i.e., the action items, timelines, and allocation of resources for strategic action). Effective resolutions address challenges upstream (i.e., changing systems) and downstream (i.e., effecting personal experience of racism). While the action items can vary by jurisdiction, what matters is that the resolutions have “teeth” with explicit deadlines, so that they are not simply performative. Typical action items include directions to perform new or updated research on racial equity issues in the jurisdiction, the creation of a work group or task force comprised of community members to identify policy solutions to well-established racial justice issues in the area, and the establishment of a racial equity assessment for all legislative action or government agency processes
There are many subject matter areas Minnesota communities can work on to address the significant health inequities in their resolutions. To name a few: elder care (e.g., food bank delivery, racial differences in nursing home residents’ quality of life), court systems and policing (e.g., police brutality, access to competent legal representation), child development (e.g., early education, access to childcare, youth counseling services, the school-to-prison pipeline), housing (e.g., quality and access, home ownership and appraisal rates), income (e.g., poverty, minimum wage), social services (e.g., child welfare system), health care (e.g., maternal health, equitable vaccine distribution), environmental injustice (e.g., community gardening, clean water), and other chronic and infectious disease concerns (e.g., flavored tobacco, HIV/AIDS treatment, access to culturally competent and healthy foods).
By explicitly resolving to address racial disparities that create the most health inequity within a jurisdiction, declarations of public health emergency solidify for the public and the government that racism, not race, causes the health disparities that have led us to this crisis.
Conclusion
Racism has always been a time-sensitive, urgent concern that has resulted in trauma, poor quality of life, disease, and death. It has impacted human beings on every level imaginable. It affects our health—physiologically and psychologically. Genetically. Individually and collectively. Health is one of the biggest reflections of racism in the U.S. because so many factors contribute to our health. Our health, in turn, determines how we fare in many other ways. Law and policy are essential tools for improving public health and addressing the social determinants of health. The cyclical nature of health is why laws that declare racism as a public health emergency can help us untangle the knot of racism and health inequity in this country. This urgent, bold action to end the suffering of those impacted by racism and the detrimental impact of racism on society cannot wait.
Natasha Phelps is a lead senior staff attorney at the Public Health Law Center, where she provides legal technical assistance on commercial tobacco control and equitable public health policy issues to public health professionals and organizations, legal professionals, and advocates throughout the United States. Phelps also leads PHLC’s Race and Health Equity group and manages a team of PHLC attorneys that provides tailored legal technical assistance on local and state tobacco law and policy to communities, organizations, and governments in Minnesota.
Notes
1 This article uses the term “Black, Indigenous, and People of Color” (“BIPOC”) to refer to Black people of African descent (Black, African-American, and Black African immigrants); the Native and Indigenous North and South American; nonwhite Latinidad; South Asian, Asian and Pacific Islander; nonwhite Arab (e.g., Middle East, Northeast African); and other nonwhite communities that have faced racial oppression in the U.S.; as well as the intersections thereof (e.g., Black Natives, Afro-Latinx).
2 Braveman P. (2014). What are health disparities and health equity? We need to be clear. Public Health Reports (Washington, D.C.:1974), 129 Suppl 2(Suppl 2), 5–8. https://doi.org/10.1177/00333549141291S203.
3 “What Is Health Equity?” Robert Wood Johnson Foundation. https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html
4 North Minneapolis resident (74.8 years life expectancy), Bryn Mawr neighborhood resident (83.5 years life expectancy); Robert Wood Johnson Life Expectancy calculator (2020), available at: https://www.rwjf.org/en/library/interactives/whereyouliveaffectshowlongyoulive.html.
5 E.g., “Clinicians’ Implicit Ethnic/racial bias and Perceptions of Care among Black and Latino Patients,” Blair IV, et al. Ann Fam Med. 2013 Jan-Feb; 11(1):43-52.
6 “Eliminating Health Disparities Initiative: Fiscal Years 2015 to 2018” (March 2019), https://www.health.state.mn.us/communities/equity/reports/legislativerpt2019.pdf.
7 “Racism and Health,” American Public Health Association, https://www.apha.org/topics-and-issues/healthequity/racism-and-health.
8 “Racism.” Merriam-Webster.com. 2021. https://www.merriam-webster.com (8 March 2021).
9 “White supremacy.” Merriam-Webster.com. 2021. https://www.merriam-webster.com (8 March 2021).
10 National Museum of African American History & Culture. “The Historical Foundations of Race.” https://nmaahc.si.edu/learn/talking-about-race/topics/historical-foundations-race.
11 Paul Kivel. (1996). Page 19. Uprooting Racism: How White People Can Work for Racial Justice. Gabriola Island, BC: New Society Press.
12 Tuhiwui Smith L., Decolonizing Methodologies: Research and Indigenous Peoples. London: Zed Books, 1999.
13 Id.
14 It is also important to note that Indigenous Mexicans/Chicanx who were thrust into the U.S. territory as the result of the Mexican-American war were also impacted by racist laws and policies and anti-Chicanx laws and policies.
15 Mni Sota Makoce (Minnesota) is still and always will be Indigenous land, homeland of the Dakhóta people despite the genocide, treaty violations, and colonial theft and violence of the Minnesota state and federal government.
16 See Minnesota Legislature’s House Select Committee on Racial Justice Report to the Legislature published in December 2020 for more information on how systemic racism has shaped inequity in the state of Minnesota.
17 “Conceptualizing and Defining Public Health Emergency Preparedness,” Nelson, C., et al. (2007). Am. Journal of Pub. Health, 97 Suppl 1 (S11). https://doi.org/10.2105/AJPH.2007.114496.
18 E.g., Presidential Action of Joseph R. Biden, Jr. Executive Order on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government. Jan. 20, 2021.
19 See the American Public Health Association database for a summary of some of the RPHE [Racism is a Public Health Emergency] action items passed–“Racism Is a Public Health Crisis” https://www.apha.org/racism-declarations.
20 H.Res.1069, Declaring racism a public health crisis. https://www.congress.gov/bill/116th-congress/house-resolution/1069/actions.
A situation becomes an emergency when the “scale, timing, or unpredictability” of a consequential event “threatens to overwhelm a community’s ability to address it.”