Achieving Health Equity after November 8

By Kristin Jones

“As a black mother, black academic, a black woman and a member of the black community, I am in mourning.”

So started a talk that was supposed to go very differently. Rachel R. Hardeman, PhD, MPH, an assistant professor in the Division of Health Policy and Management at the University of Minnesota School of Public Health, had been scheduled to give this lecture on racism and health inequities for months. But she hadn’t anticipated this; two days earlier, the nation had elected Donald J. Trump to be president, a turn of events she found personally devastating.

“For me,” Hardeman continued, “the decisions our country made on Tuesday, November 8th are not simply about who is going to run our country for the next four years, but the fact that I walk among, work among, play among and send my 3-year-old to preschool among people who were willing to offer a racist, sexist, misogynistic person the chance to make decisions about my family, my daughter, my community’s livelihood and well-being.”

As it happened, this turn of events, and Hardeman’s reaction to it, illustrated one of the themes of her lecture: racism affects health, in a thousand different ways, every day.

The talk she gave, in a coffee shop in the historically black and gentrifying Denver neighborhood of Five Points, was part of The Colorado Trust’s Health Equity Learning Series, which invites national experts to Colorado to talk about health equity, and how to achieve it. The talks frequently delve into the issue of race, but usually from a safe distance of academic or public health discourse. They have rarely seemed as personal as on Thursday, Nov. 10, when the wounds of a divided country were fresh and painful.

“What I offer you today must be put within the context of this major setback we have faced in our journey towards achieving health equity,” Hardeman said. “Now more than ever, we have so much work to do.”

It was time to talk about white supremacy, said Hardeman. Not individual discrimination, she emphasized, but the systems and structures that perpetuate inequities.

“I don’t often start my talks here with the topic of white supremacy,” she said. “But today, knowing just how much is at stake, it feels wrong not to.

“White supremacy is what changed our political climate overnight, and we need to understand what it is and what it looks like if we are going to have any more forward traction in eliminating health inequities and health disparities.”

Hardeman defined white supremacy as “a historically based and institutionally perpetuated system of exploitation and oppression of continents, nations and peoples of color by white peoples and nations of the European continent, for the purpose of maintaining and defending a system of wealth, power and privilege.”

It was also, she said, a political ideology that maintains domination by white people, as evidenced by structures like the Atlantic slave trade, Jim Crow laws in the U.S., and apartheid in South Africa.

White supremacy, she said, is at the root of the persistent health inequities faced by black and other communities of color.

Structural racism infuses all aspects of our society, Hardeman said, from history and culture to politics and economics. This is not about any one person being racist, but unfair systems. She gave example after example: the disproportionate and prolonged exposure of black children to lead in the water in Flint, Mich.; the lack of access to fresh food in some neighborhoods; the housing segregation perpetuated by policies that consider race in determining mortgage eligibility.

A focus of her research has been on how structural racism affects prenatal care and birth outcomes. Why is it that African-American women have low birthweight and preterm babies at such a higher rate than white women in this country? There’s evidence to show that the stress of experiencing racism plays a role; so do inequities in things like income, employment and education.

Hardeman offered solutions. One idea: Raising the minimum wage, as Colorado voters recently did. A study published recently in the American Journal of Public Health estimated that if all states had raised the minimum wage by a dollar in 2014, there would have been 2,790 fewer low birth-weight births and 518 fewer babies dead before the age of 1.

Another, she proposed, are culturally centered birth centers. There is such a place in Minneapolis, called Roots Community Birth Center, a black-owned business that provides comprehensive prenatal care, a midwifery practice, and acupuncture and chiropractic care to mothers in a welcoming, inclusive environment. That makes a difference, she said.

Hardeman recently co-wrote an article in the New England Journal of Medicine about how health care providers can support black lives by acknowledging and naming racism. They can work to understand the racist roots of U.S. history, examine their own implicit biases, and measure, study and discuss racism’s impact on health.

The article was written at a time of despair, after the police shooting death of Philando Castile, an unarmed black man, outside of Minneapolis in July.

That was before the election.

Apart from his threat to reverse the health care coverage gains of the Affordable Care Act, Trump demonstrated dismissal or outright contempt of communities of color, immigrants and women during his campaign. Could there really be further health equity gains under his administration? Could the advances of recent history be safeguarded? Hardeman confessed to a lack of hope.

Still, she ended on a reminder of how high the stakes are now.

Hardeman read aloud the following excerpt from an op-ed written by civil rights activist Harry Belafonte in the New York Times on the day before election:

What old men know is that everything can change. Langston Hughes wrote these lines when I was 8 years old, in the very different America of 1935.

It was an America where the life of a black person didn’t count for much. Where women were still second-class citizens, where Jews and other ethnic whites were looked on with suspicion, and immigrants were kept out almost completely unless they came from certain approved countries in Northern Europe. Where gay people dared not speak the name of their love, and where “passing”—as white, as a WASP, as heterosexual, as something, anything else that fit in with what America was supposed to be—was a commonplace, with all of the self-abasement and the shame that entailed.

It was an America still ruled, at its base, by violence. Where lynchings, and especially the threat of lynchings, were used to keep minorities away from the ballot box and in their place. Where companies amassed arsenals of weapons for goons to use against their own employees and recruited the police and National Guardsmen to help them if these private corporate armies proved insufficient. Where destitute veterans of World War I were driven from the streets of Washington with tear gas and bayonets, after they went to our nation’s capital to ask for the money they were owed.

Much of that was how America had always been. We changed it, many of us, through some of the proudest struggles of our history. It wasn’t easy, and sometimes it wasn’t pretty, but we did it, together.

“The national U.S. election results are what they are: terrible, devastating and frightening,” concluded Hardeman. “But Harry Belafonte’s words remind us that we changed it before, and we will do it again.”

The night of Hardeman’s presentation, thousands of protesters marched through downtown Denver. They carried signs reading “Black Lives Matter,” “Unite Against Hate,” “Still We Rise.” They were men holding hands; women in hijabs; students draped in rainbow flags; children wearing the red T-shirts of Padres & Jóvenes Unidos protests. All of them were shouting for a vision of America that on Monday appeared achievable, and on Thursday, fragile.