Enough Is Enough.” An

Marlene Saunders, D.S.W., M.S.W., L.M.S.W.

Chairperson, DE-CTR ACCEL; Chairperson, Department of Social Work, Delaware State University, Retired

The disproportionate health disparities seen in the African American population today resemble the health inequalities that existed in the population during enslavement and up to the Civil Rights period when the group’s health status began to improve in the 1940s. Using life expectancy data, national health statistics show the difference in life expectancy of Black and White men decreased from a differential of approximately 11 years in 1940 to a 6-year difference in 1960. Despite this improvement, currently, African Americans are more likely to live close to polluted areas, have incomes below the poverty line, and live in substandard housing. Having connected presented day health inequality so apparent in the African American population today to structural racism dating back to pre-emancipation, Noonan, VelascoMondragon and Wagner have concluded that “The history of slavery and the current racial discrimination this group continues to suffer clearly underlie the inexcusable poor health status of African Americans as a whole.”

Using an historical-ecological perspective, this article will link present day health inequities in the African American population to the antebellum period (1861-1865). At first, African Americans were Christian indentured servants and no negative distinction based on ethnicity or color was attached to them. Then, around mid-1700, they became enslaved chattel and by law were ascribed slave status by virtue of color. The group’s caste status in American society by virtue of color and ethnicity prevails today. As Gunnar Mydral noted in his study of race in the United States, in 1944, [T]he caste or, as it is more popularly known, the color line – is not only an expression of caste di erences and caste con ict, but it has come itself to be a catalyst to wide di erences and engender con icts. To maintain the color line has, to the ordinary White man, the “function” of upholding the caste system itself, of keeping the “Negro in his place.”1

Accepting that health disparities in the Black population is a public health crisis, this article will utilize selective historical moments in Black history and public health as reference points for linking the county’s public health response to Black health disparities. The reprehensible murder of Mr. George Floyd at the hands of a police officer while unarmed and handcuffed, coupled with African Americans having the highest rates of infections, hospitalizations and deaths due to COVID-19, has generated the outcry, “Enough is Enough.” Millions of African Americans, along with their fellow Whites, Hispanics, and Asians; and young citizens from all age groups, all over the United States, are marching and demanding justice. Specifically, the demand is for justice from the courts that should hold police officers accountable for the deaths of Black men and women. These grassroots and professional advocates are also demanding social justice for African American citizens who are currently living under the burden of structural racism. The harmony among diverse individuals representing multiple ethnic groups and every socio-economic class is awe-inspiring. In fact, the hundreds of demonstrations, Zoom meetings, and interracial group discussions involving police officers, mayors, governors, ministers and former U. S. Presidents, highlight what appears to be an unprecedented, and genuine awakening to structural racism and its burden on the Black community, manifested as ongoing police brutality and in the high, differential impact of COVID-19 in the African American population. In-depth examination of racism and health began receiving serious attention in the literature in 1991. An important consequence of this historical moment of outcry is that it is prompting public health experts to look more closely at the efforts and impact of America’s public health system relative to reducing the on-going and sustained health disparities in the Black population. But, of course, thinking in this manner means that the public health workforce - physicians, epidemiologists, researchers, academics, social workers, nurses and others - must honestly discuss how the field has historically responded to persistent race-based inequities within the context of and with a clean acknowledgment of structural racism. HISTORICAL CONTEXT FOR SOCIAL JUSTICE In 1928, Louis Israel Dublin wrote,

An improvement in Negro health, to the point where it would compare favorably with that of the White race, would at one stroke wipe out many disabilities from which the race su ers, improve its economic status and stimulate its native abilities as would no other single improvement. Dublin’s analysis is applicable to discussions that connects current health disparities in the Black population to the group’s health status in the past. His statement brings attention to the fact that to be Black and of African descent in the U.S. in 1928 was a risk factor and one that impacted Black lives over the life span in many ways, including health. In 1920, the life expectancy of African American men was 47.6 years, compared to 59.1 for White males. For African American women, the life expectancy was 46.9, compared to 58.9 for White counterparts. There is no need to argue that if one stroke [of the opportunity wand] eliminated all barriers to optimal health, Black Americans would have boldly waved the wand. However, the opportunity wand has never been in the possession of African Americans, and they have never had the power to obtain or control it.

A review of the literature did not yield any definitions of public health that did not highlight and discuss social justice as its core value. For example, Turnock stated, “Social justice is said to be the foundation of public health.”2 Krieger and Birn discussed public health as social justice by precisely linking it to other movements, like anti-lynching, which emerged at the same time and were similarly grounded on the philosophical tenets of social justice.3

For the purposes of this article, Rawls’ definition of social justice provides a fitting foundation for measuring a public health response to health disparities in the Black population throughout history.4 His definition states that a society’s resources must be distributed in a way that benefits the least advantaged. His philosophy allows just societies to have a wealth/asset hierarchy where some members can have greater economic means than others.

Rawls’ definition, then, does not eliminate the opportunity for America to be a just society because of a class structure that ranks individuals according to their economic resources. However, Rawls’ theory does stipulate that the differences in such a hierarchy are acceptable only if those who are the less well-off benefit. A second premise of this article is that Rawls’ conception of social justice provides a rationale for a special approach to addressing health inequalities among African Americans henceforward referred to as “societal redress.” This concept refers to an accepted obligation on the part of society to compensate African Americans for the impact of enslavement and discrimination from 1619 to the present by providing comprehensive public health services and programs that will eliminate health disparities in the African American population. This application of social justice also accepts that having originated from structural racism, racial health inequalities impacting the lives of African Americans must be regarded as a social determinant of health. Indeed, a growing body of literature has revealed that racism is associated with poor physical and mental health. This concept maintains that racism has been and continues to be an environmental factor that is an impediment to optimal health. Equally important is the perennial situation where structural racism has and continues to be beyond the control of the African Americans to the extent of having the power to eliminate it as an obstacle to good health. Under this conception, social justice as a conduit for “societal redress” further accepts that the tools of structural racism that were employed by all of this society’s institutions, including public health, created significant economic benefits to American society as a whole social advantage to all White citizens (poor and wealthy) specifically in terms of superior social status and white privilege. In his article written for the New York Times’ 1619 Project, Mathew Desmond wrote “By the eve of the Civil War cotton cultivated by enslaved Africans was the nation’s most valuable export.” Respected historians Johnson and Smith have written,

By the mid-nineteenth century, slavery was the way

American breathed.5

Indeed, there may have been no America without it. It was an institution with thick, tangle roots, one that even touched the lives of those who had never owned slaves. Translating social justice as the tool by which society pays the debt the society owes to African Americans should not be interpreted as indifference to or a devaluation of the labor of other ethnic groups who contributed to America’s status as the dominant, global economic power. Nevertheless, the African American experience is unique because of constitutionally sanctioned and governmentally enforced slavery and its legacy. Perhaps placing “societal redress” next to an explanation of the rewards America derived from Black subordination clarifies the “societal redress” relationship to public health as social justice: Finkenstaedt wrote:

e Black has, in e ect, been responsible for the material success of America. His relegation to outcast status was how the nation reunited, centralized its territory and economy, consolidated a heterogeneous work force and burst on the international scene in two world wars as a productive giant.6

The belief that society is obligated to protect and promote the health of citizens (except to respond to uncontrollable circumstances, e.g., hurricane) totally deviates from principles and values associated with individualism, the Protestant work ethic and obtaining society’s benefits (and largess) through merit rather than personal need. Regarding this matter, Turnock notes, social justice rests on the notion that “significant factors within the society impede fair distribution of benefits and burdens.”2 In the case of African Americans, structural racism is not only a social determinant for health disparities but, in addition, explains the occasions when public health abandoned its social justice mandate. Such historical moments resulted in uneven delivery of public health services, unethical conduct by physicians, social workers and researchers and patient abuse. SOCIAL JUSTICE WITHIN THE CONTEXT OF PUBLIC HEALTH

A third premise of this article is that social justice and public health should not be viewed as separate and mutually exclusive. Rather, combining Turnock’s and Rawls’ conceptions of social justice with “societal redress” considers public health an institutional means by which to ameliorate race as a social determinate of health disparities among Black Americans. The food deserts that characterize poor African American communities and pollution that is killing African Americans living in overburdened communities are examples of structural equality manifestations which include environmental racism, reinforced by redlining and gentrification. “Societal redress” through public health is an approach to mediate the problems of disparities in this population. This line of thinking is supported by the Institute of Medicine’s (IOM) conception of public health as social justice. In their 1988 report, The Future of Public Health, they stated the following:

As a part of the assurance function, in the interest of justice public health agencies should guarantee certain health services. Such a guarantee expresses a measurable public commitment to each member of society. In operational terms, this implies guaranteeing both that the services are available (present somewhere in the community) and, in the case of services to individuals, that the costs will be borne by the government for those unable to a ord them. When these services are not and cannot be present in the larger community, it is the public health agency’s responsibility to provide them directly.7

The objective of the discussion up to this point is to provide an historical and conceptual framework for comprehending present-day health inequities in the African American population as problems that are directly connected to the group’s caste status established when Africans were brought to the country as enslaved chattel over 400 years ago. This position has been inescapable. Therefore, the health disparities seen, for example, in the disproportionate high levels of COVID-19, as well as the belated responses on the part of public health profession to the crisis reflects a longstanding reluctance on the part of the public profession to: (1) acknowledge historical racism as an explanatory variable for the disturbingly high level of poor health in the Black population and (2) to consequently develop and advocate for policies and programs that frame public health services to African American communities within the context of public health for the purpose of social justice. The next section of the discussion that follows provides examples of structural racism in public health and the outcomes for African American during selected historical periods. PLANTING THE PERMANENT SEEDS FOR PERSISTENT RACIAL DISPARITIES IN THE AFRICAN AMERICAN POPULATION: ANTEBELLUM TO 1860 Diseases like smallpox, diphtheria, yellow fever and tuberculosis created massive illness and death for the White settlers in the New World and for Europeans who became city dwellers during the early processes of urbanization and industrialization. During the seventeenth and eighteenth centuries, attitudes toward the cause of disease changed, and methods of containing disease and public responsibility for assuring optimal health for all citizens evolved from isolation of the ill and quarantining of the exposed, to the establishment of voluntary hospitals and sanitation boards, to acceptance of public responsibility for the establishment of the first public agency for health. The New York City Health Department began in 1866. However, the perspective that public health should assure good health for all of society’s inhabitants did not apply to enslaved Africans after they arrived in the colonies. Interceding to ease the conditions under which enslaved Africans lived and worked was not compatible with the profit motives of plantation owners. Indeed, “the planters had reckoned that it was cheaper to lose and replace slaves then it was to feed them, treat their illnesses, punish them humanely, and keep them alive.” Though some plantation owners provided medical attention, an owner’s decision to dispense medical attention or authorize treatment by a physician was often determined by whether it was believed his human property was malingering. Under this mindset enslaved Blacks labored from dawn to dusk, doing continuous back breaking work. Work included picking cotton, digging ditches, and cutting and hauling wood. Their diets were nutritionally inadequate and insufficient to maintain the level of health and stamina their workload demanded. They lived in rudimentary quarters that exposed them to extreme heat and cold. The most dangerous work was cultivating rice. America’s Black unpaid workforce had to stand in water for hours at a time in the blistering sun. Although malaria was widespread in colonial America, life in a climate that contained malaria had given many West Africans (through the sickle-cell trait) a partial resistance to the disease. Living under such conditions created susceptibility to respiratory illnesses like pneumonia, tuberculosis, and infections caused by parasites. Working conditions were similarly inhumane for those working the tobacco, cotton and sugar cane fields where the enslaved Africans were expected to work from sun up to sundown regardless of the weather. Although the Public Health Act was passed in 1848, a social justice mandate was not used as leverage to stop either plantation doctors or the medical profession from routinely using African Americans for medical research without consent. This was an example of systemic racism within the medical profession, scientific research community and the health care system. Harriet Marineau, often identified as the first woman sociologist, once commented “[t]he bodies of the coloured are exclusively taken for dissection ‘because the Whites do not like it and the coloured people cannot resist.” Between 1845 and 1849, Dr. Mirian J. Sims, the father of modern gynecology, completed 30 operations on three Black women without anesthesia to develop a procedure for White women suffering from a condition that resulted in the leakage of urine through the vagina. Ignoring the Hippocratic Oath, “First do no harm” corresponded to the scientific racism of the period. Bogus research was the basis for describing Blacks as inferior, subhuman and possessing a physique that made them perfect for medical experimentation. After the procedure to treat was perfected, he used anesthesia when performing surgery on White women. Some have said that Sims’s abuse of African American women resolved a medical problem many women suffered. However, there is no ignoring that Sims’ grave injustice against African American women was among previous and future grave misjustices in medical health that created a situation where no group mistrusts the American medical system, particularly medical research, more than present-day African Americans. RACIAL DISPARITIES: CIVIL WAR AND RECONSTRUCTION 1861-1900 Although they were without civil rights, 186,000 formerly enslaved and free African Americans enlisted in the Union Army. The health status of Black soldiers during the Civil War revealed that disease and sickness had a more catastrophic impact for ex-enslaved men, compared to White soldiers. In 1864 in Camp Kentucky, hundreds of freed slaves died of malnutrition and exposure, while White soldiers in the same camps did not. The War Department also did not assign doctors to the Black encampments. This historical moment provides further evidence for a historical perspective that supports connecting longstanding health disparities in the Black population to structural racism that prevailed during this period. This reality stings even more with the realization that the measures used to improve the sanitary conditions in military camps with the intention of returning White soldiers to their families alive led to creating America’s organized public health system. This historical moment also highlights how neglecting the health needs of the African American population led to practices in public health that significantly benefits the country’s White population but were not equally applied to African Americans.

Byrd and Clayton describe Reconstruction as the “nadir of Black health status.”8 Following the Emancipation Proclamation, four million Africans transitioned from penniless chattel to helpless paupers beset with problems that included epidemics, poverty, poor housing, poor sanitation, and unequal access to formal healthcare and epidemics, all of which can be linked to structural racism. The Bureau of Refugees, Freedman, and Abandoned Lands, created in 1865, was designed to provide aid to formerly enslaved Black people. In their history of the Bureau, Franklin and Moss report that the organization provided public type services that yielded positive outcomes.9 For example, the death rate among formerly enslaved Blacks was reduced and sanitation conditions improved. This was accomplished before the advent of medical insurance.

Bowing to pressure from White politicians who viewed the Bureau as an encroachment on state’s rights, it was disbanded after a short seven years in 1872. After being enslaved for 250 years, seven years was certainly not sufficient to address the cumulative effects of disease and illness on African Americans. The continuing condition of ill health and disease would be apparent in the population as they settled in rural areas and cities.

In his classic study, the Philadelphia Negro, DuBois uncovered disparate health outcomes in the Seventh Ward, an area where Blacks were concentrated.10 Health disparities were apparent in death rates attributable to illnesses involving the urinary system, pneumonia, diarrheal diseases, cancer and tumor. For example, the mortality rate for Blacks due to pneumonia was 356.67 per 10,000 people, compared to 180.31 for Whites. His study uncovered tuberculosis as the leading cause of death among African Americans, noting “Bad ventilation, lack of outdoor life for women and children, poor protection against dampness and cold are undoubtedly the chief causes of this excessive death rate.” Consistent with DuBois’ reputation of holding the Black community accountable for some of their problems as well as their uplift, he also stated, e most di cult social problem in the matter of Negro health is the peculiar attitude of the nation toward the well-being of the race. ere have, for instance, been few other cases in the history of civilized peoples where human su ering has been viewed with such peculiar indi erence.

RACIAL DISPARITIES: THE GREAT DEPRESSION TO WORLD WAR II (1929-1945) The consequences of the Great Depression in the areas of health were devastating for White and Black Americans. Poverty, among other things, created homelessness and unemployment. This situation meant that people were not living in the most sanitary environments, regularly eating healthy foods, or maintaining sanitary habits. But, while the depth of poverty, hunger, sickness and mortality was severe for everyone, it was greater for African Americans. In 1929, the first year for which national figures are available, White life expectancy at birth was 58.6 years, and Black life expectancy was 46.7 years for men and women combined. By approving and carrying out the Tuskegee Experiment, public health earned a permanent stain on its reputation as an agency that contradicted its mission to prevent disease especially in a disadvantaged, underprivileged populations. Sponsored by the U. S. Public Service in Macon County, Alabama, this research followed the progression of untreated syphilis in more than 400 poor African American men, most of whom were sharecroppers or day laborers. The study was conducted from 1932 to 1972. Later research showed that there was, “no evidence that informed consent was secured from human participants in the study.” It was only after the study was reported by the Associated Press in 1972 that it was ended.11

RACIAL DISPARITIES: CIVIL RIGHTS PERIOD - PRE-COVID-19 (1960S-2020) The Civil Rights Era expanded the African American population’s pathway to health outcomes that are equal to those of White Americans. By doing so, the period demonstrated how civil rights laws and their enforcement added leverage to public health as an instrument for social justice. Literature not only links enforcement of civil rights laws to better health outcomes for African Americans, but also designates civil rights as a social determinant of health. For example, until the start of the Civil Rights Movement, hospitals in the North and the South either denied admission to African Americans or restricted their inpatient care to segregated wards, frequently situated in cold attics or damp basements. The 1963 decision in Simkins v. Moses H. Cone Memorial Hospital found that the separate-but-equal clause of the 1946 Hill-Burton Act, which provided federal monies for hospital construction, was unconstitutional. The ruling ended segregation in hospitals. Subsequent Medicare and Medicaid legislation in 1965 mandated the integration of hospitals; thereby, giving the African American population access to “decent,” mainstream health care after 300 years of indecent healthcare.

Hahn, Truman and Williams concluded that civil rights break down barriers to access to care and, in addition, reduce health disparities in the African American population.12 For example, following enforcement of Title VI of the Civil Rights Act, data showed that in hospitals that were previously segregated (most were in the South) between 1965 and 1971, the infant mortality rate among non-whites (approximately 99% of whom were Black) fell by 40% from 40 to 28 per 1,000 live births, while the rate among Whites changed little. Overall, it is estimated that between 1965 and 2002, approximately 38,600 Black infant deaths were prevented by implementation of Title VI of the Civil Rights Act. The Heckler Report, published in 1985 and authorized by then Secretary of Health, Education and Human Services, Margaret Heckler, produced the first complete examination of the burden of health disparities carried by African Americans and other people of color. She described health inequalities among disadvantaged African Americans and other minorities “as an affront both to our ideals and to the on-going genius of American medicine.” At the end of the Great Depression, the age-adjusted mortality rate for Black men was 53 percent greater than that for White men. By 1984, it was 46 percent greater. A National Center for Health Statistics Report published in 1985 indicated that African American children were twice as likely as White children to die before reaching one year of age.

Eighteen years later in 2003, the Institute of Medicine (IOM) would publish an incisive report that would also link health inequities in the Black population to structural racism.13 In its discussion of health disparities in the Black population the IOM’s review of the problem, said,

Despite steady improvement in the overall health of the

U.S. population, racial and ethnic minorities, with few exceptions, experience higher rates of morbidity and mortality than non-minorities. African Americans, for example, experience the highest rates of mortality from heart disease, cancer, cerebrovascular disease, and HIV/

AIDS than any other U.S. racial or ethnic group. The report also noted that when socioeconomic factors are equal among Whites and Blacks, inequality in quality of health care is still present and thus is a reason for concern.

Including the deaths of African Americans at the hands of police officers in a discussion about race and health disparities and race and public health might seem out of place until the American Public Health Association’s (APHA) policy statement declaring police violence a public health crisis is considered. The statement, in part, states, “Physical and psychological violence that is structurally mediated by the system of law enforcement results in deaths, injuries, trauma, and stress that disproportionately affect marginalized populations…”14

With respect to African Americans, the salient literature includes research that shows that Black men in America are 3.5 times more likely to be killed by police, compared to their White counterparts. For Black women, the rate is 1.4 times more likely. In fact, other important studies reveal that the impact of police brutality goes beyond physical death and physical harm. That inequities in terms of the negative outcomes also include negative psychological consequences. For instance, two large studies revealed that African Americans were more likely than White respondents to report stress as a consequence of interactions with police. The APHA’s response is particularly instructive in the way it not only connects police brutality to structural racism but, in facilitating viewing the crisis through a historical lens. Accordingly, the association offers the ecosocial theory of disease distribution as a conceptual framework for such an approach, noting that the concept “holds that to meaningfully analyze and interpret the population distribution of health exposure, a grounding in historical context from which the exposure emerged is necessary. Having applied the theory to the status of Blacks before and after emancipation, the APHA maintained that

“U. S. policing was historically deployed for the social control of communities deemed socially marginal (i.e., in the 19th century, it evolved from ruling-class e orts to control the immigrant working class in the North and the slave patrols in the South.” Myrdal made this point in his classic study, An American Dilemma, in which he concluded, “In the policeman’s relation to the Negro population in the South…he stands not only for civic order…but for white supremacy.”1 Thus, the police brutality seen in African American communities is not a recent phenomenon but rather represents part of a legal institution with interlocking policies and procedures that support a system of discriminatory policing that creates and maintains a disproportionately high burden of health disparities in the form of death, physical injury and psychological trauma and other form of mental disorders in the African American population. Furthermore, this situation is not a recent phenomenon. Its origin can be traced to periods before the Civil War, from 1619 to the Civil War, and after African Americans’ emancipation from enslavement in 1865. This ascribed position immediately translated into inequities in the areas of health and law enforcement that are long standing and have pointed the eyes of public, public health professional and the health care system, in general to an even deeper look toward history as a conveyor to the present day health disparities so readily apparent in the African American population

The past really does inform the present. Accordingly, this paper supported the point of view that the “Enough Is Enough” protests that erupted across America following the death of George Floyd, and the longstanding health inequities the COVID-19 pandemic brought front and center for many Americans can be traced back to the 17th century. During the mid-1600s the ancestors of present-day African Americans were relegated to the lowest rung of American society legally and in terms of social status. The rationalizations for the rulings and subjective judgements that placed this population in a caste position were based on race, color, scientific racism, and, the need for a free labor force that was the life line for the economic future of the colonies. The laws that held enslaved Africans and maintained their descendants in an unequal status did so not because they were poor, or because they were vagrant or because they were guilty of committing crimes, “but simply because they were African” and of African descent. Their ancestry and ethnicity became the maker for indelible subordination and inequality. This situation, in turn, directly contributed to health inequities that have persisted up to present day. Thus, the outcomes have been cumulative and have negatively impacted the health status of millions of African Americans.

Herein lies the essence of this article. Namely, the “caste status” to which African Americans were assigned during the country’s formation created immediate and on-going inequities in health outcomes that are continual and diffuse in today’s African American population. The article emphasizes that the differentials in health status are manifestations of structural racism that have impacted generations of Black people. Moreover, not just the public health profession, but the health care system, as a whole, has been complicit in the persistence of health disparities we are witnessing. In other words, structural forces and interconnected systems including, but not limited to, discrimination, segregation and police violence combined to create long-standing structural racism as a factor that explains the situation where African Americans were and remain less healthy physically and psychologically, compared to their White counterparts. Therefore, this article maintains that structural racism should be included in the social determinants of health.

Unless the public health profession declares the elimination of health inequality in the African American population as its top priority, the health disparities among African Americans will remain a major healthcare problem for health care professionals, medical researchers and policy makers. Furthermore, this article has demonstrated that including history as a variable in the analysis of the morbidity and mortality gaps between Black and White Americans certainly provides a basis for framing public health as a medium for social justice. That is, redressing deliberate public health and health care policies, the results of which include health disparities, that created cumulative health outcomes since the 1700s that are readily apparent in the health disparities that exist today. A historical context gives credence to specific recommendations that can lead to equity in health outcomes for African Americans:

1. Public health for social justice should be grounded on an historical understanding of the manner by race and related structures, processes, ideologies, and connected institutions (e.g., healthcare, law enforcement) in uence present day health outcomes for African Americans.

Although there is research that suggests that past events have substantial impacts for future generations, few studies focus on health outcomes or health inequities.

2. Public health organizations should frame necessary policies, programs and services to African Americans as a form of material restitution for enslavement and the burden it exacted on African Americans for 400 years.

3. Public health organizations and the medical profession in general should address the widespread mistrust among African Americans toward medical research.

Such acknowledgement should begin by acknowledging the notorious ethical misconduct by public health o cials and practicing physicians that occurred and the group’s understandable reluctance to participate in medical research. e mea culpa should be followed by research universities, medical institutions and research agencies giving African Americans clear explanations regarding need for participation in medical research on the part of African Americans. African Americans desperately need the medical advantages and revelations that only ethical, essentially therapeutic research initiatives can give them.15

4. e health profession should expand the number of community-based health and public health programs that include a required community-engagement component. Membership on advisory and research boards must include ordinary people who can o er workable and e ective ways to: (1) obtain community buy-in to research and (2) o er the kind of knowledge, insights and creative solutions based on lived experiences that cannot be provided by mainstream-oriented professionals who do not reside in the communities most beset by health inequities. Such programs involve grassroots residents in every step of the research process including identifying the problem, selecting methodology, collecting and analyzing data, and disseminating and advocating for policies and programs to legislators, governors, and other constituents. e DE-CTR ACCEL and Citizen Science o er concrete examples of participation in research with satisfactory results for both scientists and citizen participants.

5. Structural racism should be included in the social determinants of health; that is a condition in which people function that impacts quality of life. Structural racism - historical and contemporary - as an impediment to access to health care and as an explanation for health disparities among African Americans that have passed from generation to generation is a social determinant of health. However, obtaining healthcare does not necessarily lead to reducing health inequities. Mathew,

Reeves and Rodrique report health care alone accounts for only approximately 10 percent of health impacts, where social and environmental factors account for 20 percent, genetics, 30 percent and behavior 40 percent.16 ey also note that closing the gap in health outcomes for Blacks and Whites means addressing inequity in upstream social and environmental factors that impact health.

6. Public health professionals should more frequently employ ethnographic research models that provide contextual data in the areas of behavior, culture, physical, psychological status and history that cannot be gleaned solely from quantitative data.

7. Undertake recruitment e orts that aim to increase

African American health professionals. Health inequities are connected to cultural and psychosocial factors related to patient views of health, health status, and the health care system, all of which determine health care-seeking behavior and are in uenced by structural characteristics of our health care system. A Stanford study revealed that, when patients and doctors had an opportunity to meet face to face, patients assigned to an African American doctor increased their request for preventive measures, even invasive procedures.

8. Increase funding to Historical Black Colleges and

Universities to develop training centers for African

American public health professionals. In 2018, gures published by the American Medical Association reported that among practicing doctors, 56.2 percent self-identi ed as White, 17.1 percent Asian, 5.8 percent

Hispanic and 5.0 percent Black or African American.17

Of the top ten undergraduate feeder institutions applying to medical schools, three HBCUs- Spellman, Howard and Xavier (LA)- are the top producers of individuals who plan to become doctors.

9. Increase funding to support universal public health system that has the capacity to assure equal access and quality and non-disparate outcomes. Correspondence: Dr. Marlene Saunders, marlenesaunders145@gmail.com

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Morrow and Company, Inc. 7. Institute of Medicine. (1988). The Future of Public Health.

Washington, DC: The National Academies Press. https://doi.org/10.17226/1091 8. Byrd, W. M., & Clayton, L. A. (1992, February). An American health dilemma: A history of Blacks in the health system.

Journal of the National Medical Association, 84(2), 189–200. https://pubmed.ncbi.nlm.nih.gov/1602519/ 9. Franklin, J. H., & Moss, Jr., A. A. From slavery to freedom: A history of African Americans (3rd ed.). New York: Alfred A.

Knopf. 10. DuBois, W. E. B. (2007). The Philadelphia negro: A social study.

Series Editor Henry Louis Gates. New York: The Oxford Press. (Original work published 1899). 11. Turner, G. (n.d.). Disease does not discriminate but U.S. public health does. Retrieved from https://www.mphonline.org/racism-public-health/ 12. Hahn, R. A., Truman, B. I., & Williams, D. R. (2017). Civil rights as determinants of public health and ethnic health equity: Health care, education, employment, and housing in the United States. SSM-Population Health, Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5730086/citedby/. doi:10.1016/j.ssmph.2017.10.006 13. Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.). (2003).

Confronting Racial and Ethnic Disparities in Health Care.

Washington, DC: Institute of Medicine. 14. American Public Health Association. (2018). Addressing law enforcement violence as a public health issue. Retrieved from https://www.apha.org/policies-and-advocacy/public-health-policystatements/policy-database/2019/01/29/law-enforcement-violence 15. Washington, H. A. (2006). Medical apartheid: The dark history of medical experimentation on Black Americans from colonial times to the present. New York: Anchor Books. 16. Mathew, D. B., Reeves, R. V., & Rodrigue, E. (2017). Time for justice: Tackling race inequalities in health and housing. In M.

O’Hanlon (Ed.), Brookings: Big ideas for America, pp. 28-47.

Washington, DC: Brookings Institution Press. 17. American Medical Association. (2019). Diversity in medicine:

Facts and figures, 2019. Retrieved from https://www.aamc.org/ data-reports/workforce/interactive-data/figure-18-percentage-allactive-physicians-race/ethnicity-2018

Spring and summer 2020 were trying seasons, provoking multiple reactions including despair, confusion, and anger, but also hopefulness and a determination that once and for all, conditions must change for the better. As America’s emergency departments filled with COVID-19 patients, America’s streets filled with protesters in response to more murders of unarmed Black people by police. In addition to the profound sadness and anger about what were preventable and unjustifiable deaths, millions of Americans were asking what could be done to convert the outrage into actionable transformation. They were asking, how can we plant the seeds of meaningful change?

Essential elements to bringing about such change involve acknowledging and overcoming structural racism and its impact on communities of color across multiple sectors including education, housing, employment, healthcare, policing, and criminal justice. This will not be easy, given how thoroughly racism in the United States is baked into the nation’s systems and structures, devaluing the lives of people of color, but it is work that must be done.16

Racism impacts people of color in nearly every facet of their lives from where they live, to where they go to school and work, to where they shop and feel safe. Racism and its legacies are often at the root of the conditions in today’s communities of color that drive disproportionately poor health outcomes. The COVID-19 pandemic made this reality starkly obvious. According to CDC, as of July 2020, Blacks have died from COVID-19 at a rate that was double the rate of deaths for whites, 92.3 deaths per 100,000 people for Blacks, and 45.2 deaths per 100,000 people for whites.17 As of August 2020, age-adjusted COVID19 mortality rates showed that Blacks died as a result of the virus at a rate 3.6 times higher than whites; Latinxs died at a rate 3.2 times higher than whites and Pacific Islanders died at a rate 3 times higher than whites.18

tetiana.photographer / Shutterstock.com

Additional examples of the impacts of structural racism include the fact that Black women are up to four times more likely to die due to pregnancy related complications than white women19 and Black men are twice as likely to be killed by police than are white men.20

A higher proportion of Black people have underlying medical conditions such as heart disease and diabetes due largely to policies that have created obstacles to healthy, affordable foods, opportunities for physical activity and safe and affordable housing.21

In addition, during the COVID shutdown, a higher proportion of people of color are working in jobs designated as “essential,” such

as frontline jobs in grocery stores, healthcare and mass transit systems.22

Another factor that impacts the health status of Black Americans, and, puts them at greater risk of a serious outcome during an infectious disease outbreak, is the cumulative effect of having to navigate a racist world.23

These experiences range from police violence to perpetual microaggressions which can result in continual stress and damaging physiological changes.

The consequences of disparities in health insurance coverage and access to high quality care also impact the health of people of color during so-called normal times, and are exacerbated during public health emergencies. Increases in the

Source: The Aspen Roundtable on Community Change

numbers of American Indian/Alaska Native, Black and Hispanic families with health insurance coverage created by the Affordable Care Act began to slip in 2017 due to changes in the program. According to the Kaiser Family Foundation, in 2018, almost 22 percent of the American Indian/ Alaska Native community did not have health insurance. Within the Hispanic and Black communities, the uninsured rates were 19.0 and 11.5 percent respectively. Approximately 8 percent of Native Hawaiians and Pacific Islanders were uninsured and slightly over 7 percent of Asian Americans were uninsured. The uninsured rate for whites is 7.5 percent.24 Dr. Gail Christopher, the chairperson of TFAH’s Board of Directors, asked the following question in an essay published in The Crisis Magazine: “Could this pandemic help us, as a whole society, to finally see and understand the dire consequences and overwhelming implications of racism? If a critical mass of people is now seeing and recognizing our structural inequities — some for the first time — the next step involves acknowledging the consequences of those inequities.”25

Structural racism requires systemic and structural responses. Institutions within society from schools to workplaces and housing, from healthcare to policing and criminal justice are in dire need of significant change. The only way to ensure everyone has the same opportunity to live a long and healthy life is to reconstruct the institutions that are rooted in racist legacies and, once and for all, remove the societal barriers to good health in every community.

Racism in the United States has robbed people of color of their physical safety and economic opportunities for generations. It has impacted their physical and mental health and it has cut short too many lives. Collective change is urgently needed.

THE PROBLEM

Public health emergencies are not only growing in frequency, severity and complexity, they happen in the context of an already inadequate public health system. These new threats include the growing risks associated with climate change, environmental toxins, health inequities, and increasing levels of chronic and infectious disease. The nation’s public health and emergency preparedness infrastructure does not currently possess sufficient resources to ensure the well-being of all communities during health emergencies.

The magnitude of the impact of COVID-19 would be staggering by itself, but sadly, it also magnifies a life-threatening pattern, that is, a public health system that is only considered important during a crisis.

THE SOLUTION

The nation’s public health system must be comprehensive and nimble. It should focus on prevention and be able to meet everyday priorities as well as surge its capacity during an emergency. It requires not only increased funding for disease-specific prevention programs but also increased and more flexible investments to rebuild a strong and robust public health infrastructure.

In addition to a strong infrastructure, the public health sector needs increases in its categorical, i.e. issue or disease specific, funding. Such funding will allow it to address critical issues, such as the impact of climate change and the continuing epidemics of suicide, substance use, and obesity and the devastating impacts of structural racism.

The public health system is most appreciated in the midst of a crisis, but typically neglected at other times. The result of this habitual underinvestment is a public health infrastructure unprepared to meet 21st century health challenges. The COVID-19 crisis is a stark illustration of the degree to which the public health system needs to be rebuilt and protected against politicization.

A 21st century public health system needs to be grounded in expertise in disease surveillance, data analytics, environmental monitoring, emergency preparedness, illness and injury prevention, health equity, and the social determinants of health. Unfortunately, in the United States today we are facing 21st century health challenges armed with 20th century tools. This weakened system is a threat to Americans’ health and welfare.

To meet the nation’s growing public health demands, the sector needs to both be prepared for short-term priorities and adopt a Public Health 3.0 approach. The Public Health 3.0 model is designed to meet health risks and to address the social determinants of health and health inequities. The 3.0 model enables public health leaders at the local level to be chief health strategists for their communities, working across sectors and leveraging data to improve health at the population level.26

Public health infrastructure refers to the essential core components of a health department including:

l A well-trained and well-resourced workforce.

l A state-of-the-art data and information system to assess and monitor population health status and factors that influence health and community needs. l A public health laboratory system that can rapidly and accurately meet the demands of a steady flow of viruses and other organisms, novel and long-standing.

l Empowered public health leaders able to make recommendations and decisions devoid of political considerations.

l An emergency preparedness system that is well prepared and equipped to address all hazards at the earliest possible point and surge capacity when necessary.

l The capacity to address social determinants of health, end health disparities, and promote optimal health in all communities.

l Community partnership development, including engagement with key groups representing populations experiencing health disparities.

Foundational Areas:

l Communicable disease control

l Chronic disease and injury prevention

l Environmental public health

l Emergency preparedness and response

l Policy development, support, and evaluation

l Advancing health equity

l Addressing the social determinants of health

l Maternal, child, and family health

l Healthy aging

l Social, emotional, and behavioral health

l Access and linkages to social services and clinical care Foundational Capabilities:

l Health monitoring and assessment including surveillance, epidemiology and laboratory capacity

l All-hazards preparedness and response

l Policy development and support

l Public communications

l Community outreach and partnership development

l Organizational and administrative competencies, i.e. leadership, governance and health equity

l Accountability and performance management

FROM HEALTHY PEOPLE 2020 AND 203028

Why Is Public Health Infrastructure Important?

Public health infrastructure provides communities, states, and the nation the capacity to prevent disease, promote health, and prepare for and respond to both acute (emergency) threats and chronic (ongoing) challenges to health. Infrastructure is the foundation for planning, delivering, evaluating, and improving public health.

All public health services depend on the presence of basic infrastructure. Every public health program—such as immunizations, infectious disease monitoring, cancer screening, asthma prevention, drinking water quality, and injury and suicide prevention—requires health professionals who have cross-cutting competencies and technical skills, upto-date information systems, and public health organizations with the capacity to assess and respond to community health needs. Public health infrastructure has been referred to as “the nerve center of the public health system.” While a strong infrastructure depends on many organizations, public health agencies (health departments) are the central players. Federal agencies rely on the presence of solid public health infrastructure at all levels of government to support the implementation of public health programs and policies and to respond to health threats, including those from other countries.

Rebuild and modernize the public health system by creating a mandatory $4.5 billion per year Public Health Infrastructure Fund to support foundational public health capabilities at the state, local, territorial and tribal levels. These infrastructure needs include modern facilities and health information and data systems. The funding may focus on “bricks and mortar” and systems development, but it should also include ongoing support for the workforce necessary to successfully leverage the investment. For example, skilled laboratory workers as well as up-to-date public health laboratories and equipment and sophisticated data managers and analysts as well as hardware and software investments, are needed. Additional funding should be provided to allow CDC and other federal agencies to have the internal resources to meet their own infrastructure needs and to provide data, technical assistance, oversight, and evaluations of resources to states, territories and tribes. Preserve and protect the Prevention and Public Health Fund. The Prevention and Public Health Fund was created by the Affordable Care Act and is the only dedicated, mandatory funding source for prevention and public health programs within the federal budget. By statute, it is intended “to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public healthcare costs.”29 Due to funds being directed to other spending, the Prevention Fund has lost nearly $12 billion.30 Congress should restore funding to the level of $2 billion per year and direct that all future spending from the fund be focused on critical public health needs.

Congress should create a Health Defense Operations budget designation. TFAH supports a bipartisan call for Congress to exempt health security funding lines from Budget Control Act spending caps to enable sustainable resources for relevant programs at CDC and other U.S. Department of Health and Human Services (HHS) agencies.31 Such an exemption is needed to ensure responsible funding that meets the needs of the nation’s health security, rather than leaving health security subject to sequestration and other budget constraints.

Modernize public health surveillance and data. The nation’s public health surveillance infrastructure currently relies on antiquated, disconnected systems and methods for tracking and responding to diseases. Local, state, and federal data systems have not kept pace with current technologies and result in delayed detection and response to public health threats. The COVID-19 crisis illuminates many of these weaknesses, as public health officials try to track disease patterns with incomplete data and archaic reporting mechanisms. Cross-cutting investments are needed to revitalize the CDC’s data infrastructure, as well as to shore up state and local public health surveillance capabilities.

TFAH supports an additional $450 million in immediate funding and $100 million per year over the next 10 years to modernize the public health surveillance enterprise and build secure, interoperable systems and a highly trained workforce. $50 million was included in the FY20 spending bill as a down payment on public health data modernization, and $500 million was including in the Coronavirus Aid, Relief, and Economic Security Act (P.L.116-136) but more immediate and annual funding is needed to modernize and sustain these systems.

Recruiting and retaining the public health workforce. A 21st century public health system, equipped to address emergencies and serve as chief health strategists for communities, requires a 21st century workforce. The most recent Public Health Workforce Interests and Needs Survey found that the public health workforce faces major challenges in turnover and attrition, putting the public’s health at risk.32 Reductions in federal, state and local public health budgets have undermined efforts to hire, train, and retain a strong public health workforce, which in turn limits governments’ ability to effectively protect and promote the health of their communities. In the 10 years following the 2008 recession, local public health departments lost an estimated 26,000 (16 percent) FTE staff positions due to federal, state, and local budget cuts.33

Already operating from this deficit, the loss of state and local revenues due to COVID-19 is likely to have a similar, if not worse impact on the public health workforce. Short-term funding from COVID-19 response packages do not allow for permanent recruitment and retention of public health staff. Congress should prioritize development of the public health workforce, including public health national service programs; funding incentives to enter and remain in the public health workforce, such as loan repayments; recruiting and retaining a workforce with needed skills, such as informatics; and improving training.

Empower public health officials to make decisions based on science and devoid of political considerations. Any efforts to infuse politics into public health decisionmaking puts the public’s health at risk.

Provide full-year funding for federal agencies to allow for uninterrupted planning and program implementation. Many federal agencies play a role in protecting and improving public health. When the government is operating under a short-term continuing resolution—or worse, a shut-down—public health and other programs that promote health can be crippled.34 Temporary funding through emergency supplementals or short-term continuing resolutions, followed by stagnant budgets, do not allow for recruitment and retention of highly skilled, full-time workers nor long-term project planning. Congress should enact full-year appropriations measures that fund federal agencies for the entire fiscal year. This is essential for effective and efficient use of taxpayer dollars and for planning and maintaining the workforce, supplies, and other capacities necessary to support all public health functions.

THE PROBLEM

Structural racism, systemic inequities, discrimination, and poverty have existed in the United States for generations and have been documented as predominant drivers of health inequities.35 Their impact results in higher rates of deaths from illness and injury among people of color,36 and this increased risk of poor health persists even when controlling for socioeconomic factors.37

Many marginalized groups, including communities of color, gender and sexual minorities and people with disabilities, have been historically prevented from obtaining what is necessary to be healthy – a safe place to live, a job that pays a living wage, and access to quality education and healthcare services. Therefore, an explicit focus on ending systemic discrimination is fundamental to advancing equity, providing everyone fair and just opportunities for optimal health, and improving the nation’s health outcomes.

THE SOLUTION

To achieve health equity, opportunities and community conditions that allow all residents to live the healthiest life possible regardless of who they are, where they live, or their income level, are needed. This means overcoming centuries of inequitable policies and practices and addressing discrimination that persists today in virtually every sector, including education, employment, healthcare, housing, environment, policing and criminal justice. Central to addressing these inequities is acknowledging the history and current practices that have caused them, addressing their root causes, and taking action steps in multiple areas of social, economic and health policy to drive systemic change and to overcome the harmful barriers to health and well-being.

Health disparities are preventable differences in the burden of disease, injury, violence, or in opportunities to achieve optimal health experienced by socially disadvantaged racial, ethnic, and other population groups, and communities.38 While the underlying causes of health inequity and healthcare disparities are complex and interwoven, the COVID-19 pandemic has put a spotlight on the alarming disparities between people of color and whites, further heightening the urgency and critical need for leadership, commitment, and increased and directed resources to address these disparities.

An expert committee of the National Academies of Sciences, Engineering, and Medicine affirmed that, “Health inequities are the result of more than individual choice or

random occurrence. They are the result of the historic and ongoing interplay of inequitable structures, policies, and norms that shape lives.”43

The drivers of health inequities largely stem from structural racism, which fuels poverty and discrimination, undermines equity and opportunity, and is far reaching in health, education, economic opportunity, employment, housing, transportation, and criminal justice, among many other systems.39, 40 The toll from racism is evident in the impact of the disinvestment in and marginalization of communities of color, unhealthy social, economic, and environmental conditions, and the lack of opportunities within those settings, which result in deaths at earlier ages and high rates of chronic and infectious diseases.41 It is important to note that health inequities continue to exist even when controlling for socioeconomic factors such as income or education level.42 Because the structural drivers of these disparities are largely rooted in system-level inequities, socioeconomic drivers, and biases, a multi-agency, multi-sector, coordinated effort will be required to correct them.

People of color have a shorter life expectancy of 10 years or more than whites in neighboring areas.44 For example, researchers have tied the legacy of historic redlining, which has led to intergenerational, concentrated poverty and environmental health risks, to persistently higher rates of asthma,45 obesity,46 and mortality from chronic disease.47 The infant mortality rates among Black infants and American Indian/Alaska Native infants are respectively 2.3 times and 2.0 times that of non-Hispanic white infants.48, 49 Blacks, Latinxs, American Indians/ Alaska Natives, Asian Americans, Native Hawaiians, and Pacific Islanders have higher rates of diabetes than non-Hispanic whites.50, 51 Black and American Indian/Alaska Native women die from pregnancy-related causes at rates approximately three times higher than that of non-Hispanic white women.52 Similar disparities have borne out in the COVID-19 pandemic. While all populations, regardless of race, ethnicity, socioeconomic status, age, and sex are at risk for COVID19 infection, people of color have experienced disproportionate health and economic impacts from COVID-19. The death rate among Blacks is nearly two times their percentage of the U.S. population;53 the Navajo Nation has the highest per capita rate of infection in the United States;54 and Latinxs and Native Hawaiians and Pacific Islanders represent a greater percentage of confirmed cases than their share of the population in several states.55

Other groups face additional challenges. LGBTQ+ individuals face health disparities linked to societal stigma, discrimination and denial of human rights.56 Individuals with disabilities are less likely to receive preventive health services, are at higher risk for poor health outcomes, and may be overlooked in public health data.57

These disparities are compounded at intersections of demographics, such as Black LGBTQ+ people, who are subjected to higher rates of violence than white counterparts.58

Daily occurrences of prejudice and discrimination result in adverse mental and physical health effects such as chronic stress, trauma, and elevated blood pressure. There is strong evidence that discrimination is associated with unhealthy changes to the body that can take their toll over time, such as long-term stress.59, 60 A 2017 survey found that 92 percent of Blacks and about 75 percent of Latinxs

and American Indians reported being treated differently when seeking health services, looking for housing, interacting with the police and even doing day-to-day tasks.61 Such treatment can result in the avoidance of necessary healthcare and can reinforce social isolation.

Given the longstanding existence of health inequities, it is not realistic to expect a single program or policy to solve the nation’s health inequities. Action steps, however, can be taken to promote health equity. Policy, systems, and environmental changes with an intentional focus on health equity can lay the foundation for transformative efforts to end inequities. Attention

should be paid to the allocation of resources to the populations most impacted and to meaningful and authentic engagement of members of those communities to set priorities and develop and implement initiatives to promote equity. Other sectors must also be involved as is the case when addressing the social determinants of health. For example, the elimination of racial segregation requires involvement from the housing, community finance, transportation and educational sectors. Approaches are needed to reduce health risks such as identifying the most pressing health needs in every community and prioritizing those areas for investment.

The administration and Congress should make advancing health equity and eliminating health disparities a national priority. Policy, systems, and environmental changes must have an explicit focus on equity to yield the desired outcome of preventing and reducing disparities. Moreover, evaluation of these efforts is vital to monitor progress, demonstrate impact, and ensure accountability for federal policies and programs.

l Create a Truth, Racial Healing and

Transformation Commission and fund communities to begin the process of acknowledging the history of racism and working to dismantle the myth of hierarchy based on race.

The process of racial healing and transformation is a necessary building block for reforming the systems and beliefs that inhibit health. This process should be complemented by grants to local communities, built from the framework developed by the W.K. Kellogg Foundation, to implement multisector truth, racial healing and transformation collaborations at the local level.62, 63

l Reinforce the senior-level, federal interdepartmental task force on advancing equity for the nation, including a review of federal policies and programs in housing, employment, health, environmental justice and education that have contributed to health inequities. Federal departments must hold senior leadership accountable for developing concrete goals that are matched by policies, resources, and public reporting.

l All HHS Operating and Staff Divisions should be required to establish goals, develop related strategies and actions and annually and publicly report on efforts and progress towards achieving health equity goals. Investment in the design of rigorous and innovative evaluation methods will be needed to effectively capture the impact of comprehensive, upstream interventions and strategies including policy analyses and evaluation. All HHS Operating and Staff Divisions should assess and heighten the impact of policies, programs, and resources decisions to reduce health disparities and advance health equity.

l The HHS Office of Minority Health, the National Institute on Minority

Health and Health Disparities, and the agency Offices of Minority Health (Agency for Healthcare Research and

Quality, CDC, Centers for Medicare & Medicaid Services, Food and Drug

Administration, Health Resources and

Services Administration, and Substance

Abuse and Mental Health Services

Administration) are all vital to minority health and health equity leadership, infrastructure and expertise within

HHS. The COVID-19 pandemic has underscored the importance of these offices and institutes, in light of the greater impact of the pandemic on communities of color. These offices and institutes must have the authorities, budget, and resources comparable to other offices, institutes, and centers within the respective agency and/or aligned to the statutory mandate of that office or institute.

Further develop and expand funding for programs that serve under-resourced and marginalized communities. Longstanding disinvestment in and marginalization of many communities of color across the country has resulted in fewer

resources and services for optimal health. These limited resources and services manifest as less access to healthcare services, less availability of healthy food grocers, and fewer community-based and social services.

l Congress should enact, fund and build on the Health Equity and Accountability

Act (HEAA) and similar legislation to improve healthcare access and to reduce disparities among communities of color and populations at higher risk.64 HEAA can serve as a framework for multiple federal agencies to address underlying causes of health inequities.

l Congress should increase funding for existing programs that address health inequities such as CDC’s Racial and

Ethnic Approaches to Community

Health (REACH) program and

Good Health and Wellness in Indian

Country program so that every state has targeted resources for promoting health equity.65, 66

l The HHS secretary and all HHS operating and staff divisions should review HHS grant programs to ensure that such programs are directing their federal funding to close gaps in health outcomes in the most affected communities and evaluate the impact of such programs on health inequities.

l Congress and HHS operating and staff divisions should expand and fund programs throughout the

Department to address health inequities that disproportionately impact people of color.

Ensure that federal funding to address equity engages those within the most affected communities.

l Establish policies, trainings and technical assistance to ensure that funded agencies establish meaningful mechanisms for community members to be involved in all program planning, implementation and evaluation. Provide funding for community leaders development programs.

l Adapt grantmaking practices to account for differential needs, resources, and capacity: federal agencies should consider disease burden and social context when determining grantmaking eligibility criteria, so that communities with the greatest health-related needs can benefit from competitive grant mechanisms.

l Create mechanisms within the grant funding process across all federal agencies that assist underresourced communities and build capacity for those communities and organizations which are most often at a disadvantage in the grant application process, allowing them to develop competitive and successful grant applications.

Congress and state legislatures should create and appropriately fund programs to assist in the recruiting, hiring, and retention of a diverse public health workforce at all levels, including in senior leadership roles. Workforce

diversity is essential to improving the quality of services, reducing health disparities, and advancing health equity. Studies document that minority practitioners are more likely to practice in underserved and minority communities.67, 68 Evidence has shown that organizations with a more diverse workforce provide higher quality services and more culturally and linguistically appropriate services.69

Furthermore, an organization with a workforce that reflects the

community it serves can help build trust amongst community members for that organization. Diversity should exist at all levels of an organization, including in governance and leadership to promote organizationwide commitment and action to equity. Given the growing cultural diversity and changing racial and ethnic demographics of the U.S. population, a diverse public health workforce is imperative to meeting the needs of the population. Such programs could include tuition assistance or student loan forgiveness programs.

l The Office of Personnel Management should create and publish a government-wide diversity and inclusion strategic plan, and follow-up annual reports, including disaggregated data by race and ethnicity of federal workforce leaders. The plan should set goals to ensure that the composition of the federal workforce leadership reflects and is responsive to the nation’s diverse population such that varied perspectives are represented to address longstanding systemic inequities.

Improve publicly reported data collection quality and availability, require all agencies collect, disaggregate and report health data in such a way that the impact of health conditions, policies or interventions on specific population groups are known. In order to eliminate health disparities, it is vital to have quality, comprehensive, and consistently available disaggregated data to identify disparities, develop targeted, culturally and linguistically appropriate policies and programs, and monitor progress in reducing health inequities. The gaps in data are due in part to the nation’s fragmented and antiquated public health surveillance systems and the lack of interoperability between clinical and public health systems, all of which make it more difficult for clinicians to collect and report accurate data to public health agencies. The COVID-19 pandemic magnified the inadequacy of currently available disaggregated data and the challenges to data surveillance systems that are essential to monitoring testing; collecting data on confirmed cases, hospitalizations, and deaths; and developing tailored interventions, in particular among communities of color. If public health officials and policymakers cannot accurately assess differences in the health of different population groups, including at a more granular demographic level than broad racial categories, they cannot effectively address health disparities and disease prevention.

l Sustain and grow investments in public health data modernization at the federal, state, tribal, territorial and local levels, including by enabling electronic case reporting to state and local health agencies, educating providers on data collection and reporting, and reducing duplicate reporting systems to the federal government. All data should be collected and disaggregated by race and ethnicity.

l Ensure that all HHS programs and public health agencies collect and publicly report standardized health and administrative data in a timely fashion and disaggregated by race and ethnicity, in accordance with the

Office of Management and Budget

Standards for the Classification of

Federal Data on Race and Ethnicity,70

as well as by age, sex, primary language, disability status, sexual orientation, gender identity, and pregnancy status.