Pittsburgh, Pennsylvania City Council held a Post-Agenda Meeting on Thursday, December 5, 2019 regarding legislation “Racism as Public Health Crisis” sponsored by councilmen Ricky Burgess and Daniel Lavelle.
Good afternoon. Thank you for this opportunity to share with you all today. My name is Dara Mendez, and I am an Assistant Professor of Epidemiology at the University of Pittsburgh, Graduate School of Public Health. Before I deliver my statement, I want to mention that I am not here to speak on behalf of my employer but to offer my expert opinion as someone who has been leading public health research and practice for over 15 years. The field of public health is specifically concerned with promoting and protecting the health of populations using science, research, policy and practice. My work focuses on the effects of racism, sexism and other forms of oppression on health equity and health outcomes related pregnancy, birth and women’s health.
In addition to my professional career on this issue, I was born and raised here in Pittsburgh. I’ve lived in Millvale and Penn Hills for a small part of my younger years but spent the majority of my formative years in the Lincoln-Larimer area or what I affectionately called ‘Sliberty or East Liberty- not the rebranded East End it is sometimes referred to today. We lived on Lincoln Avenue. The row houses where I grew up are all gone except for one remaining house, which is actually the one I lived in. I mention all of this because not only have I dedicated my professional career to this issue but I have “lived experience.” I lived in an area that experienced disinvestment, in schools that were not invested in, where Black individuals and specifically my peers who were suspended and imprisoned, and had limited employment opportunities; but I also come from a family line of brave, brilliant Black people, who migrated North from the South to work in the Steel industry in Pittsburgh and make a new way of life for their families. Some of those same families who experienced displacement and what Dr. Mindy Fullilove has called “root shock,” the traumatic stress and reaction to the loss and disruption of one’s ecosystem- their neighborhood for example; in her book Root Shock she discusses the displacement due to urban renewal policies in the 1950s and 1960s that targeted Black communities where she cites displacement of Black families in the Hill District and the lasting effects this has had on health and well-being.
My research, scholarship and practice in the area of health equity actually started as a college student at Spelman specifically on gendered racism and pregnancy outcomes under the guidance of leading Black women scholars who were some of the first to name racism as a public health issue particularly in relation to pregnancy and birth; and those scholars were Drs. Diane Rowley, Mona Phillips and Fleda Jackson. In this initial work, I was struck by early studies that demonstrated that even at levels of education that were meant to be protective such as having a college education, Black birthing people (meaning someone who may identify as a woman but also non-binary or gender non-conforming people who give birth) with a college education were almost 2 times as likely to have an infant death than their white counterparts and Black college educated birthing people were more likely to have to infant death than white birthing people without a high school diploma. This early work influenced my career trajectory. In this early work, I found that Black women in particular experienced the extreme burden of gendered racism. Dr. Philomena Essed defines gendered racism as racism and sexism that are so “intertwined and combine under certain conditions into one hybrid phenomenon.” This results in oppression not explained by racism and sexism alone. From the work of Dr. Jackson and in my own early work, not only did women experience gendered racism, but these experiences were not just a specific “incident,” but a part of “historically-created racial constructions and structural realities.” From this work, we also found that the stress and discrimination experienced was prevalent in the work place and with respect to caring for children- so in other words, the various institutions in which women and birthing people were coming into contact with on a daily basis had a detrimental effect on their health.
So with the postsecondary education I received outside of Pittsburgh, including a PhD and MPH in Maternal and Child Health and Epidemiology, I had the opportunity to first come back home in 2009 to address many of the issues I had been working on in other cities; and now actively conduct work with collaborators such as Jada Shirriel from Healthy Start, Alysia Tucker and Dannai Wilson from the Maternal and Child Health Division of ACHD (Allegheny County Health Department) and leaders of the Infant Mortality Collaborative in which I serve and LaTasha Mayes from New Voice for Reproductive Justice. These are just a few of the individuals and women leading work in this city on racism, gendered racism, and oppression as important public health issues and using an intersectional lens, reproductive justice and equity framework. For example, the Infant Mortality Collaborative in which I serve as an executive member held a summit in 2018 that addressed racism as a public health issue especially regarding inequities in infant mortality and maternal and infant health in general. The IMC continues to apply equity frameworks, root cause analysis and undoing racism and systems of oppression methods and approaches in our work.
Racism as a public health issue
As we heard from other speakers (and will continue to hear), racial inequities in health outcomes are well documented. This includes specific inequities in maternal and infant health (as Jada and Noble discussed/will discuss), showing for example that Black birthing people in Allegheny County are 4 times as likely to have a maternal death compared to their white counterparts and 3 times as likely to have an infant death. But in addition to mortality, there are racial inequities in maternal and infant morbidity such as pregnancy-related hypertension, depression and preterm birth to name a few.
Recognizing and naming racism as a public health crisis is a critical first step in dismantling structures and systems of oppressions that not only impede health and well-being but are related to schooling/education, our food systems, housing, and employment to name a few. In geographer Dr. Ruth Wilson Gilmore’s definition of racism it is “state-sanction and/or extralegal (meaning not necessarily regulated by the law) production and exploitation of group-differentiated vulnerability to premature death.” Dr. Camara Jones, prominent public health expert and former president of the American Public Health Association defines racism as “a system of structuring opportunity and assigning value based on the social interpretation of race, that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources.” She further describes that racism can operate at 3 core levels, as institutionalized or structural, interpersonal or personally-mediated and then internalized.
The majority of empirical research on racial discrimination and health has focused on interpersonal or what Dr. Jones has termed personally-mediated racism (which includes the day to day experiences of racism that are mediated through individuals and a result of the structures and institutions that provide an environment for racist actions to occur, resulting in adverse health outcomes). This empirical evidence demonstrates that personally-mediated racism acts through stress pathways to dysregulate bodily systems, resulting in accelerating aging and adverse health outcomes; and that these daily stressors are cumulative where there is actual wear and tear on the body; also known as “weathering.” As a result, the body cannot reach equilibrium, reducing immune function, creating vulnerability and susceptibility to disease and limits the ability for the body to remain in a healthy state.
Additionally, within the larger context of the biological processes and the specific health consequences, there are the vestiges of structural and institutional forms of racism and oppression. That we cannot avoid the conversation about how institutions and structures are built to exclude, marginalize and reproduce adverse health. That the policies, practices, structures and inequities in power and privilege are fundamental in understanding and eliminated health inequities. Dr. Joia Crear Perry, Founder and Executive Director of the National Birth Equity Collaborative says “Racial disparities in health exist not because Black people are broken, or genetically inferior, or make poor choices, but because policy continually tries to break us.”
Dr. David Williams, leading US scholar on racism and health says “although institutional racism is arguably the most important mechanism by which racism adversely affects health, it is challenging to capture in traditional epidemiological research, and we have not fully quantified the impact of institutional racism on health.” I would add that we may never completely capture and quantify institutional racism in relation to health in any one study or series of studies given the complexity. However, it is worthwhile to do this because as Dr. Rachel Hardeman articulates it results in a focus on the level and type that could result in lasting change.
There is empirical evidence that speaks to institutional racism and its effect on health. Most of this empirical evidence measures residential segregation as a fundamental cause of health inequity. That segregation is a result of specific policies and actions that disproportionately affect communities of color, Black communities in particular and low income communities. That segregation has resulted in disparate social and physical environmental conditions, limited access to healthcare resources, inequities in housing and wealth attainment, influencing behaviors and ultimately health. In my own work and others in the field argue that residential segregation is the result of housing policy such as redlining, backed by the federal government whereby mortgage lenders figuratively color coded red neighborhoods that were considered “minority” and refused to make mortgage loans. Broadly defined, racial redlining encompasses not only the direct refusal to lend in neighborhoods of color and Black neighborhoods in particular, but also procedures that discourage the submission of mortgage loan applications from these areas, and marketing policies that exclude such areas. And we see the effects of this today. In my own empirical research, I highlight the intersections between lending disparities and health disparities and demonstrated that institutional racism, as measured by “residential redlining,” was associated with stress among pregnant women but not associated with birth outcomes. There are a few other studies that have demonstrated that novel measures of structural racism such as racial inequities in political participation, judicial treatment and employment and job status are associated with infant mortality, infants being born small for gestational age as well as myocardial infarction.
Finally, in our conversation about racism, we would be remiss if we did not talk about the intersections with sexism, classism, homophobia and other forms of oppression. I specifically mentioned gendered racism earlier but want to uplift intersectionality, coined by Afro-Brazilian scholar Lelia Gonzalez and Black US scholar and lawyer Dr. Kimberle Crenshaw; this work specifically talks about the unique experiences of Black women as a result of racism AND sexism as interlocking systems of oppression; that discussions and strategies are incomplete when talking about racism and sexism alone. And research has shown time and time again that the stress of being a Black woman or birthing person in America takes a significant toll on the body including during pregnancy and childbirth.
What we need moving forward (Recommendations)
This legislation as it stands is a critical first step to naming racism and specifically the effects of racism on health and well-being. However, there are critical elements that should be addressed in order to move forward, to be comprehensive and to have a lasting impact and before this legislation is approved and voted on.
It is critical to understand and apply intersectionality as a guiding framework. That we cannot discuss racism without discussing how racism intersects with sexism and classism for example.
If we are to identify racism as a public health crisis, it is critical to take an interdisciplinary approach that actively engages those within the field of public health. Elected official can be a vehicle to pass important legislation but in collaboration with experts in the respective fields. That public health practitioners, activists and scholars co-lead these efforts with others from sectors such as housing, education, and employment for example. Public health as a field and science trains professionals to think about and develop solutions from a “Health In All” lens, meaning asking the question of how might health and well-being of populations be influenced by a particular action; whether that is an action related to transportation, the built environment, climate change or housing security.
Health inequities are not disparities in that we are specifically talking about what is systematic, socially produced, unjust and can be avoided. Given this definition and framework from WHO and extended by Dr. Paula Braveman, the proposed legislation should specifically develop actions that interrogate and dismantle the systems that create inequities. A root cause analysis that specifically asks, how is racism, sexism and classism all together operating in this situation is critical.
The policies introduced should be in alignment with the Black Mamas Matter policy agenda which include applying an intersectional lens, centering those most impacted, and particularly holding existing systems accountable including healthcare and social service systems.
That in addition to understanding and acknowledging anti-Black racism and how racism impacts Black communities and the intersections, immigration policy has been identified as a mechanism of structural racism and anti-immigrant policies that also affect our Latinx and African born communities for example have been shown to lead to hostility, vulnerability and have adverse health.
With regard to the All-In Implementation Fund, that accountability measures be in place. That there be an annual report to the public on the projects and activities being funded, and how they help to address racism; and specifically a mechanism to ensure that a council of citizens from communities most impacted by racism and oppression determine how funds will be spent. Council must consider appropriate measures to ensure accountability to the public on spending and measure effectiveness of the projects that are selected. And that the fund itself in addition to development and entrepreneurial strategies invest in areas of additional sectors to address inequity.
Regarding the Leadership Forum, Council should ensure that the forum is inclusive of public health experts, as the current PolicyLink recommendations be expanded to include strategies to improve health outcomes.
Council should ensure that the leadership forum public meetings, although quarterly are hosted at a time and place to ensure the public to be engaged. Furthermore, a council of citizens from the specific communities most impacted by racism and oppression should be integrally involved in co-leading all processes; including citizens who may not be professionals in government, non-profit, education or public health.
And in closing, naming and identifying racism is a critical first step but multiple aspects are necessary to ensure systemic and long-term change.
Dara Mendez, PhD, MPH, is an Assistant Professor in the Departments of Epidemiology and Behavioral and Community Health Sciences at University of Pittsburgh's Graduate School of Public Health. Her work focuses on the complex intersections between racism, multiple forms of oppression, stress and place in understanding racial/ethnic inequities in pregnancy, birth and women’s health. Dara currently serves as the Health Equity Editor for Block Chronicles.