Public health and racism in the US
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|American mayors declare
racism a public health crisis
September 2020: Public health in the United States is a shared responsibility of the federal, state, and local governments. In recent years, the local level has been the primary driver of changing perceptions of public health. Between May and August 2020, at least 51 cities and mayors and 23 counties in the US have officially declared racism a public health crisis. These local governments include some of the largest cities in the US, such as Los Angeles (population 4,016,000) and some of the smallest, such as Bloomfield, Connecticut (population 20,000). The focus on racism is the latest effort by local governments to expand the public’s understanding of the biological, environmental, and social factors that contribute to an individual’s physical and mental health.
Federal, state and local governments
share responsibility for public health
In the US, individual states have authority to craft their own public health responses to the Covid-19 epidemic and individual cities in some states are allowed to determine face covering requirements, rather than a uniform national strategy. In the US, public health is decentralized, and federal, state, and local governments assume specific responsibilities for ensuring the health of Americans.
The federal government surveys the health status and needs of Americans; establishes policies and laws; sets standards and regulations; supports research; and provides technical assistance and resources to state and local health systems. The federal government, generally, does not provide direct health services to the public.
Most of the federal government's public health initiatives are implemented through contracts and grants to state governments, local governments (cities and counties), and private providers. In order to receive federal funds, states, cities, counties, and private organizations must follow federal standards and policies. The federal role, in other words, is most often limited to policymaking, oversight, and technical assistance.
The 50 states have primary responsibility for protecting public health in the United States. State health departments carry out national mandates; collect and analyze data; oversee the delivery of environmental, educational, and personal health services; ensure access to health care for underserved residents; and direct the response to health hazards and crises within state boundaries.
Local city and county health departments generally are empowered by state governments to deliver health services directly to the public. The 3,000 local health departments in the United States have such responsibilities as conducting communicable disease control programs; providing screenings and immunizations; collecting health data; providing health education services and chronic disease control programs; conducting sanitation and inspection programs; running school health programs; and delivering maternal and child health services, public health nursing services, mental health services, and other home care and outpatient care services.
At the local level, other public agencies may also be heavily involved in public health. For example, local school districts may be active in child and adolescent health issues; local police and fire departments may have responsibilities for emergency care; and other local government departments may be involved in environmental protection, social services, and mental health.
It is also important to note that local governments may be responsible for ensuring the presence of such health services, but their provision is often shared by both the public and private sectors. Local governments often contract with private university medical centers, nonprofit agencies, and private businesses to deliver such services as primary medical care for the poor, crisis response, family planning, dental care, mental health, and home health care. Often, services are provided through formal or informal public-private partnerships. For example, the local government health department may have a substance abuse prevention program, while inpatient addiction services are provided by a private agency.
City mayors and the top officials of counties and independent school districts have the authority to manage local health systems and initiatives to meet local needs as long as there is no conflict with state laws and regulations. Mayors and other local officials may also convene task forces and public forums to discuss ongoing and emerging public health issues.
Environmental neglect, gun violence and
opioid epidemic all contribute to health crisis
In 2006, the former mayors of New York City (Michael Bloomberg) and Boston (Thomas Menino) founded Mayors Against Illegal Guns to educate Americans about gun violence. The original group of 15 mayors has now grown to a coalition of more than 1,000 current and former mayors of cities of every size and political orientation.
The leadership of the mayors influenced other prominent organizations. In 2016, for example, the American Medical Associationthe largest association of physicians in the US - declared gun violence a public health crisis. Local government health departments across the country are now involved in efforts to prevent suicide, domestic abuse, homicide, and other forms of gun violence, with the support of federal and state funds.
Gun violence is only one example of how mayors and other local officials take direct and immediate actions, which affect public perceptions and public behavior regarding health. There is a pattern in the US of health issues gradually coming to be seen as social as well as personal problems as a result of actions at the local level.
For example, as the understanding of the causes and control of tuberculosis and alcoholism and homelessness in cities advanced a century ago, so did Americans’ understanding of poverty. The current American epidemic of opioid overdose deathsoften labeled “deaths of despair” because of their relationship to economic hardship and inequality - is further expanding Americans’ awareness of the negative health effects of poverty and deprivation.
The environmental movement of the 1960s raised to public consciousness the health impacts of hazardous materials being produced and disposed of in the environment by industry, a consciousness further heightened by current concerns over food additives, plastic waste, and endocrine disrupters. Concerns about the behavior of soldiers returning from the Vietnam War led to a broader understanding of mental illness as arising from the trauma of war and other causes not solely related to the individual. More recently, trauma associated with persistent discrimination and poverty has been linked in widely-publicized studies to negative physical and mental health outcomes.
All of these issues and others were first confronted in cities by social activists and reformers, health care professionals, and city governments. As these issues came to be seen as social as well as personal problems, the definition of public health expanded, as did public support for increased government involvement.
Mayors, cities and counties declare
racism a major public health crisis
In the three months following the death of an unarmed African-American, George Floyd, by white police officers in May 2020, at least 74 mayors, cities, and counties issued proclamations or resolutions calling racism a public health crisis. The cities with resolutions vary in size and political leadership and include Charlotte, Denver, Indianapolis, Memphis, Minneapolis, Springfield, Massachusetts, and Warren, Ohio. The number of local governments adopting resolutions grows weekly. In addition, four states have proclaimed racism a public health crisis.
Mayor Doug Pfau of Ardmore, Oklahoma (population 24,600) said his city’s June 2020 resolution was inspired by the nationwide protests after the death of George Floyd, including one in Ardmore. “We had such a great protest that was positive and not violent,” Pfau told a local newspaper. “We’re just so thankful to those people. This [racism] is such a problem in our country and it has been for a very long time. If we don’t make changes and try to improve this it will continue because it has over and over again.”
Mayor Marty Walsh of Boston (population 710,000) expressed a similar commitment to change. "We're determined to accelerate our work towards systemic change," he said during a media conference in June to announce Boston’s resolution. After thanking those in the minority community who shared with him "how racism shapes lives and hurts communities" Mayor Walsh promised that "what I'm announcing today is the beginning."
The local government resolutions are the beginning of a bold effort to expand the awareness of the conditionsthe social determinantsthat all Americans need to stay healthy.
The Resolution Declaring Racism a Public Health Crisis adopted by Columbus, Ohio (population 922,000) in June 2020 is typical of local government resolutions in the US. It commits the City of Columbus to “honestly and directly addressing minority health inequities, including a systematic, data-driven focus on poverty, economic mobility, and other factors that impact the social determinants of health [emphasis added]. Minorities are impacted more greatly by challenges and inequities in many areas, including but not limited to Crime, Social Capital, Education, Transportation, Employment, Food Access, Health Behaviors, Socioeconomic Status, Environmental Exposure, Access to Health Services, Housing, and Public Safety.”
The World Health Organization defines social determinants of health as “the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels... social determinants of health are mostly responsible for health inequitiesthe unfair and avoidable differences in health status seen within countries.”
The resolutions by cities and counties in the US declaring racism a public health crisis essentially place a spotlight on the relationship between power and resource imbalances and health status. They identify specific areas and needs for collective action by local governments.
On one plane, public health in the United States can be seen as a continuous effort to expand the awareness of the subtler and more institutionalized forms of inequity and the suffering born of it. Control of epidemic diseases, safe food and water, maternal and child health, mental health and other issues have gradually come to be seen as having not only personal but also social roots in, for example, poverty, trauma, and, now, perhaps, racism. Public health has evolved from preventing death and disease to improving quality of life and now, perhaps, to ensuring equitable life opportunities.
On another plane, tension between professional expertise and politics can be seen throughout America’s multi-level public health system. Thus, President Trump and many of his supporters can disparage wearing a mask during a pandemic despite evidence of masks’ effectiveness in reducing the spread of the disease, to give a recent extreme and disconcerting example. Because of the structure of the health care system, newly-identified health problems in the US can be expected to provoke conflicts about individual versus collective rights and responsibilities, the growth of government, and government spending in health.
George Floyd was killed in Minneapolis. The subsequent protests in cities throughout the United States were notable for their calls for fundamental, systemic change by governments at all levels, businesses, and individuals. "Systemic racism is among the greatest long-term threats our city and nation are facing," said Minneapolis Mayor Jacob Frey in a press release issued by the city. "For Minneapolis to be a place where everyone can live and thrive, we must recognize this crisis for what it is and approach policymaking with the urgency it deserves."
It’s not clear how quickly, if at all, the American public will accept racism as a threat to the public's health or what might be accepted as appropriate governmental action. What is clear is that whatever happens will likely be the result of actions at the local level.
Institute of Medicine Committee on Assuring the Health of the Public in the 21st Century.
The Future of the Public's Health in the 21st Century. Washington, DC: National Academies Press, 2002. Accessed at: Link
American Public Health Association. Declarations of Racism as a Public Health Issue. Accessed at: Link
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