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June 6, 2022
Population Health Health Inequities Health Disparities Racism
Simar Singh Bajaj
Fatima Cody Stanford
Jan 28, 2021
Dec 17, 2020
Nov 12, 2020
Back to The Milbank Quarterly Opinion
From the air people breathe to the pipes they drink from, both the natural and built environment help define society’s health. One’s ZIP code is a significant determinant of life expectancy, yet the environmental resources for a healthy life are far from equitably distributed, with racial and ethnic minorities disproportionately facing toxic conditions.1,2 The United States’ recent focus on infrastructure, from passage of the Infrastructure Investment and Jobs Act (IIJA) to efforts to break up the Build Back Better bill, has led to a whole-of-government approach to forge the America of tomorrow. However, this transition faces the challenge of simultaneously undoing present systems of oppression and building an equitable framework for the future. Despite recent policy initiatives to support the environmental health of vulnerable communities, current efforts are limited in scope and require a revised framework with explicit focus on health equity and environmental justice. Health care professionals are uniquely positioned to enact this framework and protect the environmental health of vulnerable communities.
Louisiana’s “Cancer Alley,” a region populated by majority Black communities with some of the most polluted air in the country, reflects of a long history of environmental racism in the United States. For 50 years, the city of New Orleans sent its industrial waste to this region to be incinerated and sprayed the ground with now-banned pesticides. In the 1980s, the city built low-income housing developments on top of this toxic landfill and encouraged Black residents to relocate there. The region now has cancer rates 50 times the national average.3,4 This disregard for Black lives is mirrored in 20th century redlining practices that pushed Black Americans out of suburban communities and into urban housing projects, and in interstate highway projects that uprooted and divided Black communities.5,6 These historical atrocities have been amplified by the COVID-19 pandemic, with the residential segregation and racist housing policies translating into higher rates of infection and mortality today. Black Americans are twice as likely to be exposed to air pollution than white Americans, and such exposure is as a risk magnifier for the most severe COVID-19 health outcomes.7 Environmental racism is especially pernicious because it precludes already disadvantaged communities from opportunities to build healthier futures.
While policies of harm, displacement, and segregation have institutionalized racial inequities in the United States, public policy also represents one of the most powerful tools in society’s arsenal to achieve health equity. For instance, the historic $1.2 trillion IIJA will make powerful strides in environmental health and racial justice with a focus on environmental remediation to clean up industrial waste sites, water infrastructure to protect against crises like that in Flint, and weatherization assistance for low-income households to support energy efficiency.8 While these provisions are encouraging, they are undermined by the IIJA’s primary investment in fossil fuel infrastructure—with almost three times more money for highways, roads, and bridges than public transit—that will likely continue to harm disadvantaged communities.9 With state transportation departments managing much of the money with few restrictions, the federal government’s efforts to protect against environmental harm and racial health disparities may be thwarted by business continuing as usual (e.g., building new highways and ignoring the resultant air pollution).
Figure 1. Fundamentals for policymakers to prioritize health equity and environmental justice on the infrastructure bill and beyond.
As such, when designing new infrastructure legislation, a whole-of-government approach for deracinating health inequities and environmental racism is critical (Figure 1). Communities must be at the forefront of these efforts with a bidirectional model of engagement; the present unidirectional approach leaves little opportunity for shared learning, thereby undermining the validity of stakeholders’ lived experiences. Meaningful community-based engagement requires consistency and patience to foster true collaboration and build trust. Focused investments are similarly necessary to improve health outcomes in marginalized communities, such as through remediating poor air and water quality and building pedestrian and bicycle infrastructure. Social determinants must be at the vanguard of environmental justice policy to begin tackling the harmful legacies of racism.
The Biden Administration’s Justice40 Initiative provides one structure for transformative environmental justice policy by requiring that at least 40% of all benefits from federal energy and climate investments are delivered to disadvantaged communities.10 With 21 priority areas ranging from the Superfund Remedial Program to the Low Income Home Energy Assistance Program (LIHEAP), Justice40 seeks to mobilize resources from all aspects of the federal government, including the Environmental Protection Agency, the National Science Foundation, and most executive departments. This comprehensive response emphasizes the intersectionality of environmental justice in that it is as much a health issue as it is one of urban development, homeland security, commerce, and more.
The Justice40 framework is also critical because it recognizes that, given the unequal distribution of societal resources, a rising tide does not lift all boats. As such, there is a need to center conversations on the needs of the few versus the needs of the many (Figure 2). Although the federal government is inherently distanced from local contexts, it can provide criteria for discretionary grants to ensure direct engagement with marginalized communities. Furthermore, the federal government can require impact assessments to optimize for both short- and long-term health outcomes of infrastructural investments. Although not all states conduct environmental impact assessments themselves, the National Environmental Policy Act (NEPA) requires all federal agencies to assess the environmental impact of “major federal action significantly affecting the quality of the human environment.”11 NEPA also provides a mandate for interdisciplinary analyses, such as ones that integrate environmental, health, and equity-based impact assessments. Policymakers must focus their attention on the most vulnerable and underrepresented to ensure health equity is not simply a lens to don when convenient but a foundation for all their work. With a consistent whole-of-government basis of equity, a productive path forward can be paved for historically disadvantaged communities.
Figure 2. Focusing on the needs of the many versus the needs of the few. Taken with permission from Interaction Institute for Social Change | Artist: Angus Maguire.
Successful implementation of this framework will require health care professionals to lead policy discussions because all infrastructure is health infrastructure.12 Indeed, infrastructure policy acts on various social determinants operating upstream of poor health outcomes, from the neighborhood and built environment to the social and community context. Given that nonmedical factors account for 60-70% of modifiable contributors to population health, health care professionals have a responsibility to go beyond traditional medical care by investigating the systems of racism sickening their patients and advocating for policies that propel health equity forward.13 This responsibility can include testifying at city council hearings on the beneficial (or adverse) health impacts of infrastructure proposals, working with professional organizations to promote healthier community design, and other public-facing responsibilities that reflect the larger physician-population relationship.14
Bearing direct witness to the deadly impacts of environmental racism, whether in the form of asthma, obesity, or other chronic conditions, health care professionals are also especially poised to help politicians focus on environmental health, lending their trust, expertise, and authority to the cause. In Cancer Alley, for example, local physicians have spearheaded campaigns against petrochemical industry expansion and have played an important role in the fight for racial equity.15 Undoubtedly, health care workers must partner with public health professionals on this environmental justice advocacy, but we call attention to health care professionals in particular because they typically operate on the individual level but have the capacity to make population-level change as well.14 With environmental racism and health inequities silencing the poor and disadvantaged, health care workers have a responsibility to lend their voices to ensure policy is crafted with justice at its heart.
The connections between infrastructure and health are robust, from the benefits of green spaces, physical activity, and clean air to the consequences of water pollution, community severance, and environmental contamination. Recent efforts to revitalize the Build Back Better bill and pass it in parts underline the national focus on infrastructure and rebuilding America. The present moment is a once-in-a-generation opportunity to begin abolishing long-standing pillars of environmental racism, or conversely perpetuate these histories of displacement and segregation. For public health stakeholders, the goal of all policy should be harm reduction and health promotion with specific focus on justice and equity; infrastructure is simply one vehicle to preserve and protect the environmental health of vulnerable communities.
Simar Singh Bajaj is a rising junior at Harvard University, studying the History of Science and Global Health & Health Policy. He served as a policy intern in the Office of Minority Health in the Centers of Medicare and Medicaid Services, was chair of the Harvard Kennedy School Institute of Politics Health Policy Program, and directs policy for the American Lung Cancer Screening Initiative—through which he has drafted resolutions passed by the U.S. Senate. Given his passion for education and health literacy, Simar hosts That Medic Podcast and leads the World Pre-Health Conference, developing programming for over 800 students from 40 countries around the world. As a researcher at Massachusetts General Hospital and Stanford University School of Medicine, Simar has also had his work published in journals like The Lancet, The New England Journal of Medicine, Nature, and the British Medical Journal, spanning topics as diverse as cardiothoracic surgery education, obesity pharmacotherapy, and oncological disparities. In addition to being a TEDx speaker and John Harvard Scholar, Simar is the recipient of the Veritas Award, the National Student Leadership Foundation scholarship, and the President’s Gold Volunteer Service Award.
Anthony Zhong is a graduate student at the University of Ottawa’s School of International Development and Global Studies, supported through the W. L. Mackenzie King Memorial Scholarship, and an incoming medical student at Harvard Medical School. He served as an analyst for the Harvard Kennedy School Institute of Politics Policy Program, a summer fellow at the Harvard Global Health Institute, and currently supports the Canadian Delegation to the World Health Assembly and Pan American Sanitary Conference as a Youth Committee Member. His research interests include the prevention of chronic diet-related diseases, transnational health risks, and international health systems strengthening through the intersection of science and policy. He served as an associate editor for the Harvard Health Policy Review and has conducted research at the Radcliffe Institute for Advanced Study, the Harvard T. H. Chan School of Public Health, and the Canadian Institutes of Health Research.
Bhav Jain is a recent graduate of the Massachusetts Institute of Technology (‘22), where he pursued a Bachelor of Science in Computer Science and Brain & Cognitive Sciences. As the 2022 Truman Scholar from Pennsylvania, he is interested in global health care delivery and transforming clinical care as a future physician-policymaker. His research spans oncology delivery, health disparities, and health systems transformation, and has been published in outlets such as Nature Medicine, JAMA Oncology, American Journal of Public Health, the Annals of Surgical Oncology, and American Journal of Managed Care. Additionally, he engages with undergraduate students and physicians across 20 states through his nonprofit organization, The Connected Foundation, which forges intergenerational connections between youth and seniors, and partners with health care systems to support seniors transitioning from inpatient or clinical to home-based care.
Dr. Fatima Cody Stanford is an Associate Professor of Medicine and Pediatrics who practices and teaches at Massachusetts General Hospital (MGH)/ Harvard Medical School (HMS) as one of the first fellowship-trained obesity medicine physicians in the world. Dr. Stanford received her BS and MPH from Emory University as a MLK Scholar, her MD from the Medical College of Georgia School of Medicine as a Stoney Scholar, her MPA from the Harvard Kennedy School of Government as a Zuckerman Fellow in the Harvard Center for Public Leadership, and her executive MBA as a merit-based scholarship recipient from the Quantic School of Business and Technology. She completed her Obesity Medicine & Nutrition Fellowship at MGH/HMS after completing her internal medicine and pediatrics residency at the University of South Carolina. She has served as a health communications fellow at the Centers for Disease Control and Prevention and as a behavioral sciences intern at the American Cancer Society. Upon completion of her MPH, she received the Gold Congressional Award, the highest honor that Congress bestows upon America’s youth. Dr. Stanford has completed a medicine and media internship at the Discovery Channel. An American Medical Association (AMA) Foundation Leadership Award recipient in 2005, an AMA Paul Ambrose Award for national leadership among resident physicians in 2009, she was selected for the AMA Inspirational Physician Award in 2015. The American College of Physicians (ACP) selected her as the 2013 recipient of the Joseph E. Johnson Leadership Award and the Massachusetts ACP selected her for the Young Leadership Award in 2015. She is the 2017 recipient of the HMS Amos Diversity Award and Massachusetts Medical Society (MMS) Award for Women’s Health. In 2019, she was selected as the Suffolk District Community Clinician of the Year and for the Reducing Health Disparities Award for MMS. She was selected for The Obesity Society Clinician of the Year in 2020. In 2021, she has been awarded the MMS Grant Rodkey Award for her dedication to medical students and the AMA Dr. Edmond and Rima Cabbabe Dedication to the Profession Award which recognizes a physician who demonstrates active and productive improvement to the profession of medicine through community service, advocacy, leadership, teaching, or philanthropy. She is the 2021 Recipient of the Emory Rollins School of Public Health Distinguished Alumni Award.
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