Population Health Blog

Population Health Blog

Why It Matters

Structural Racism & Public Health: Forging the Collaborative Foundation of the Next Civil Rights Movement

By Peter J. Hammer

The United States is facing two great crises; one of race and the other of health.  Beneath recent protests of Black Lives Matter against police violence are deeper embedded forces of structuralized racialization.  These historic forces produce and reproduce patterns of racially disparate outcomes in health, education, housing, employment and the environment.  The health crisis is one of costs and the inability to make lasting improvements in well-being without moving beyond narrow (and expensive) biomedical conceptions of care.  At the intersection of these crises lie a common set of factors, the social and economic determinants of health.

Out of crisis comes opportunity.  We need to forge a new Civil Rights Movement combining the efforts of those combating structural racism with those fighting for public health.  The synergies are numerous.  Public health provides a frame that can advance racial equity.  Racial equity provides a frame that can advance population health.Moreover, combined progress on these fronts is essential if the goal of universal health care coverage is to be accomplished in the United States and made economically sustainable.

Escalating health care costs are rooted in our narrow focus on the biological causes of illness and a focus on treatment that neglects the social and economic determinants of health.  In this hierarchy, the public health community is often treated as a distant cousin rather than an essential partner.  In truth, public health can serve as a bridge between extant biomedical orientations and the broader determinants of health.  That said, it must also be admitted that the reach of traditional public health thinking is also limited.  Public health can identify the significance of the social and economic determinants of health, but can do littleto answer the most important question:  What determines the social and economic determinants of health?

Contemporary theories of structural racism are helpful because they provide powerful insights into how this question can be answered.  Understanding the dynamics of racecan function like a social MRI, diagnosing the root causes of endemic inequity and the impediments to better health.  As such, a deep collaboration could be forged between those fighting structural racism and those fighting to improve public health.

What would an evolutionary path to change look like?  There are at least four core steps.  First, employ theories of structural racism to help diagnose the root causes of inequity in the United States.  It is not enough to say that poor housing, employment and education lead to poor health outcomes.  We need to understand the root causes of the inter-institutional dynamics that produce and reproduce these racially disparate outcomes over time.

Second, we need to focus on the social and economic determinants of health by assuring health in all policies.How can public decision making effecting education, housing, zoning, parks, employment and transportation be better informed to accommodate health concerns?  Jonathan Heller and Health Impact Partners have developed frameworks to guide this process and advance the goal of Health in All Policies:  1) make a judgment about how a proposed project will affect health; 2) highlight disparities in health between groups of people; and 3) provide recommendations to improve decisions.

We also need to ask basic public health questions about the more disruptive policies Detroit is pursing that affect the health and wellbeing of its residents.  What are the health impacts of water shutoffs, tax foreclosures, the failed school system, regional transportation and use of tax abatements for economic development?  What changes in these policies would better advance public health objectives?  What alternative policies could the City pursue that would have greater health payoffs?

Third, how could we better control health care costs by centering management of chronic illness in the community?  Chronic illnesses are the major long-term drivers of health care costs – diabetes, heart disease, asthma.  We need to center careof these issues in the community and to flip traditional notions of medical expertise by training and empowering members of these communities to be the front linemanagers of wellbeing.  With creative thinking, we could combine health management and community empowerment with new strategies of neighborhood-based economic development for even greater impact.

Finally, we need to generate a new political ethos for public action based on reverence for life and a recognition of our mutual interdependence and responsibility.  Again, issues of race and health come together.  In contemporary American politics, opposition tobasic government functions has been highly racialized.  Health policy has been captured and held hostage by this dynamic.  Racialized opposition to government prevents even the most common sense policies to improve health.  Members of the health care community must embrace a new Civil Rights Movement as a predicate to advancing a workable health policy agenda.

We need a new art of collaboration that forges a coalition between those fighting for public health and those fighting structural racism.  The health sector could play as great a role in this new civil rights struggles the courts did in the first Civil Rights Movement.

Peter Hammer is a professor of Law at Wayne State University Law School and is director of the Damon J. Keith Center for Civil Rights. He is a member of the Population Health Council and serves on the Education and Advocacy Committee.


Reflecting on the value of comprehensive testing for assuring public health

By Dennis L. Green

I’ve heard Gov. Rick Snyder’s complaints about the complex and confusing EPA regulations, but I find them specious. Codes and regulations are minimum standards for enforcement actions. They are not a recipe for unqualified people to interpret. They are not an excuse for not exercising due diligence. When the EPA regulation requires a test for a system over a certain size, it does not imply that testing of smaller systems should not be done. It is a delegation of responsibility, not a waiver. The American Water Works Association publishes volumes of recommendations that provide the collective experience of the industry regarding due diligence. In my experience as part of the management team for the construction of a new water plant at the Detroit Water and Sewage Department’s Water Works Park, we thought it unthinkable to put a plant on line without full testing. The guidelines call for testing over all four seasons to capture the effects of seasonal changes in the water source, but that didn’t suit the schedule of the money managers in Flint.

For any qualified water professional, it should be unthinkable to put an obsolete plant in service without the normal recommended testing protocol. The rationalization for omitting corrosion control was a fear that it would feed the growth of bacteria, but had the proper testing taken place, the bacteria problem would have been dealt with, before sending the water out to the customers.

Flint’s problem is the result of politicians practicing engineering without a license. The simple cure is to remove water from politics. The bad decisions in Michigan result from politicians fighting for control of the billions of dollars in contracts involving water. Detroit’s exploitation of its regional system for its local economic development led to Flint’s defection to the Karegnondi Water Authority. Neither authority was putting the customers’ interests first.

Dennis L. Green is retired head water system engineer for the Detroit Water and Sewage Department

Building an Ethic of Shared Ownership for Health

By Kevin Barnett, DrPH

As the wealthiest nation on the planet, one committed to the idea of minimally regulated capitalism, we are engaged in a perpetual struggle between two versions of reality.  On one hand, we see ourselves through a lens of what some would refer to as a delusion of rugged individualism, where we are the masters of our own destiny, and all who work hard and “play by the rules” will succeed.  A more sober analysis leads to the recognition that there are winners and losers in our capitalist enterprise, and there is a need for resources to provide support and create opportunities for those who are less fortunate or capable of providing for themselves.  While providing this support is viewed as essential in an advanced society, determining what forms, how much, and when to provide it calls for an assessment of costs and associated returns on investment.

Inadequate investment in what we call the social determinants of health often results in costly negative outcomes. This is so whether we are talking about a lack of investment in disease prevention that yields high acuity and costly inpatient care, or a lack of investment in early childhood education and family support,which contributes to higher costs for special education in the medium term, and higher rates of incarceration in the long term.

In health care, fee-for-service (FFS) reimbursement is the predominant form of payment. FFS rewards the producers of increasingly costly procedures, equipment, pharmaceuticals, and facilities for the treatment of illnesses, many of which are preventable.The capital necessary to finance this medical care juggernauthas beenallocated at the expense of investments toimprove health and well-being, and more broadly, hascontributed to anerosion in the profitability of other economic sectors.The Affordable Care Act (ACA) put into play a series of changes that move us towards “pay for value,” a shift in financial incentives away from conducting procedures and filling beds and towards keeping people healthy and out of clinical care settings.

The challenges faced in the transformation of health care in the U.S. are myriad, but they are centered on moving from a fragmented system of resource allocations for treatment in acute care settings to the financing of a health producing enterprise at the institutional, community, and societal level.In this new world, acute care services are essential elements of a larger system of primary care, preventive services, and strategic investments in a social and physical infrastructure that together comprise the leading causes of life.The accounting for this system sees health systems as “nestled” enterprises that thrive when services, activities and investments are optimally aligned to foster life, liberty, and the pursuit of happiness.

Giving more focus to the social determinants of health and to geographic areas where health inequities are concentrated represents a shift from the question “Who is at greater risk for disease?” to “Why are some people at greater risk of preventable illness, injury and death than others?” The next, even more critical question, however is “What are we going to do about it?”

In the upcoming Authority Health 2016 Population Health Forum, we’ll take a look at the role of health care in this new era of transparency and awareness; where publicly available data on investments and associated outcomes offer the potential to inform a more strategic allocation of institutional and societal resources.  In the process, we’ll explore how to build an ethic of shared ownership across sectors for producing health and well-being in our communities; one that challenges us to better align and focus our efforts.  The opportunity to make a difference is before us…

Kevin Barnett, DrPH, MCP, is a senior investigator at Public Health Institute,Oakland, California. 



Providers need to address ‘marginalization, exclusion, discrimination’ in the populations served

By Esperanza Cantu

In the TED Talk https://www.ted.com/talks “Why your doctor should care about social justice,” Mary Bassett, MD, MPH, current commissioner of the New York City Department of Health and Mental Hygiene, speaks about her experience understanding the core of health equity and social justice after time she spent serving as medical faculty in Zimbabwe for almost 20 years.

During her time in Zimbabwe, she participated in multiple interventions that spanned the social determinants of health. Now, she recognizes that she was not advocating for the structural change that is necessary to truly impact population health. Specifically, she mentions the AIDS epidemic and how she and others likely regret not having done more earlier to save lives.

Biomedical epidemics reflect not just biology, but especially the impact of “marginalization, exclusion, discrimination related to race, gender, sexuality, class and more.” Bassett mentions the medical anthropologist Paul Farmer who refers to this as ‘structural violence’ because “inequities are embedded in the political and economic organization of our social world, often in ways that are invisible to those with privilege and power; and violence because its impact—premature deaths, suffering, illness—is violent.”

Inherent in her message is the need to sound the alarm to do public health right, and how to create real change together, despite how different stakeholders may feel uncomfortable talking about racism. Her call-to-action includes sounding alarms about “the impact of racism on health in the United States, the ongoing institutional and interpersonal violence that people of color face, compounded by our tragic legacy of 250 years of slavery, 90 years of Jim Crow and 60 years of imperfect equality,” and she considers this central to her current role in New York.

Health professionals are witness to great injustice consistently, and she believes we need to treat patients well and also sound the alarm and advocate for change; she notes that “rightfully or not, our societal position gives our voices great credibility, and we shouldn’t waste that.”

View her TED Talk here:


Esperanza Cantu is the 2015-16 W.K. Kellogg Fellow at Authority Health.