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Nancy Krieger On
Looking Backwards, Looking Ahead—Structural Racism, Health Inequities,
And Epidemiology
[Editor’s Note:
In light of
her previous talk on these topics and the new focus on them following
the death of George Floyd, we invited Dr. Krieger to share her
perspective at this critical time. She is Professor of Social
Epidemiology, American Cancer Society Clinical Research Professor,
Department of Social and Behavioral Sciences, at the Harvard T.H. Chan
School of Public Health].
Back in 2008, when I gave this presentation on “The
science and epidemiology of racism & health in the United States: an
ecosocial perspective” at the University of North Carolina (UNC)
Minority Health Conference, it was the 29th annual
conference in this series, and the 10th annual William T.
Small, Jr. keynote lecture (1). I thus was in a long line of those who
shared the concerns of the original organizers of this conference, the
UNC Minority Student Caucus.
Background
Founded by students of color in the early 1970s, its
two-fold objectives were to raise awareness about need for more
research and action focused on racial/ethnic health inequities and to
increase the number of students and scientists of color (2). Inspiring
its work were the monumental changes of the 1960s, with the organizing
of social movements leading to passage of federal Civil Rights,
Voting, and Fair Housing Acts, the War on Poverty, the establishment
of the Occupational Safety and Health Administration, and the
Environmental Protection Agency.
When I spoke in 2008,
it was nearly a decade after I wrote the first review article on
epidemiologic research on discrimination and health – and nearly 30
years after the 1980 onset of the economic and social backlash to the
progressive changes of the 1960s and 1970s (3). In this interim, a
small albeit growing number of epidemiologists and other public health
professionals were expanding research demonstrating that racism is a
key determinant of population health and health inequities. However,
our frameworks and evidence were still outside of the mainstream of
the field of epidemiology, and to talk about racism and health in 2008
put one on the fringe.
Leap in Awareness
And here we are in
2020, just 12 years later – and there is a new leap in awareness, with
possibilities for real action, to take on racism in the US and its
myriad impacts, including but not limited to how it harms health.
Roger Bernier, the editor of Epidemiology Monitor, invited me
to write this reflection on my 2008 talk, which he had previously
reported on in the pages of this bulletin, on June 19 of this year –
that is, Juneteenth, a day celebrating and marking the emancipation of
those who had been enslaved in the US.
In the past two weeks
over 20 US cities and counties and 3 states have declared or are in
the process of declaring that racism in a public health crisis,
following in the steps of the first city to have done so: Milwaukee,
in May 2019 (4-6). Major public health, epidemiological and medical
societies and organizations have newly made similar declarations
(7-9).
Recent Events
What is occasioning
this sudden change is not some dramatic new discovery of something
unknown – or, at least, not unknown to those most affected by and
those concerned about health inequities and their origins in long
histories and present realities of white supremacy and kindred police
brutality (10,11). Rather, it is a new broader awareness galvanized by
the organizing around the horrific murder of George Floyd by
Minneapolis police on May 26, 2020, who died because he could not
breathe, because a police officer knelt on his neck – in open view,
and as videoed for all to see – for an agonizing 8 minutes and 46
seconds.
This upsurge of public
protest builds on the leadership and organizing of so many groups,
including but not limited to Black Lives Matter, which itself was born
in 2013 in response to the acquittal of Trayvon Martin’s
vigilante murderer, George Zimmerman, followed by the murder of
Mike Brown by Ferguson police officer Darren Wilson in
2014 (12). It is also being fed by the disproportionate impact of
COVID-19 on the health and economic well-being of US Black, Latinx,
and American Indian populations (13-15), coupled with post-2016 rising
hate crimes and overt expressions of racism at the highest levels of
US government (16, 17).
What Will The Future
Bring?
What comes next? Will
these declarations that racism is a public
health
crisis turn out to be simply empty words? Or will they lead to
transformative change, affecting governance, political priorities,
budgets, and programs?
My hope, as an
educator, epidemiologist, and activist, is that there are kinds of
knowledge which, once learned, cannot be unlearned. It is encouraging
to witness – and to help abet -- the opening up of minds and hearts in
the US of so many, including in public health and epidemiology, to
understandings that systemic racism truly exists and is so deeply
harming the health and well-being of Black, Indigenous and other
people of color in the US. At issue are harms tied to the very
founding of this country as a settler-colonial nation and slave
republic, and to their progeny of massive wealth and income inequities
in the US, harms which require acknowledgment for repair to be
feasible (18-20).
Work For
Epidemiologists
Social movements are
what makes change possible. In our professional roles, I encourage
epidemiologists to step up and offer our skills in monitoring and
analyzing determinants of health inequities and in evaluating health
equity impacts of health, economic, and social policies, in order to
generate rigorous and useful knowledge that can inform the work of the
organizations, activists, and policymakers working for racial and
health justice.
To do so well requires
learning the history of our field and the ways it has been shaped both
by long histories of scientific racism – and efforts to oppose it,
fueled by more expansive understandings about the embodied links
between social justice, human rights, and people’s health (21).
Moreover, for our work
to have impact, epidemiologists – as scientists – need to understand
the obstacles posed by interests that jointly and deliberately
undermine both good governance and public health and are indifferent
to or seek to conceal the health inequities that these interests
foster (22). For epidemiology to advance the people’s health, this is
the least we can do.
REFERENCES
(1) Krieger N. The
science and epidemiology of racism & health in the United States: an
ecosocial perspective. Invited presentation: the 10th Annual William
T. Small Keynote Lecture for the 29th Annual Minority Health
Conference, University of North Carolina School of Public Health,
Chapel Hill, NC, February 29, 2008
https://unc.live/3fMGCBR
(2) Students
Minority Health Caucus. Our Mission. UNC Gillings School of Global
Public Health, Chapel Hill, NC.
https://unc.live/317cvAU
;
accessed: June 20, 2020.
(3) Krieger N.
Embodying inequality: a review of concepts, measures, and methods for
studying health consequences of discrimination. Int J Health Serv.
1999; 29(2):295-352.
https://bit.ly/2BqDn4d (open access)
(4) Milwaukee
County Executive. Milwaukee County Executive Chris Abele signs
resolution declaring racism a public health crisis. May 20, 2019.
https://bit.ly/3eo0gUE ; accessed: June 20, 2020.
(5) Singh M. ‘Long
overdue’: lawmakers declare racism a public health crisis. The
Guardian, June 12, 2020.
https://bit.ly/3dvU5N6 ; accessed: June 20, 2020.
(6) Vestal C.
Racism is a public health crisis, say cities and counties. Pew
Stateline, June 15, 2020.
https://bit.ly/2V8q0N6 ; accessed: June 20, 2020.
(7) American
Public Health Association. Racism is an ongoing public health crisis
that needs our attention now. May 29, 2020.
https://bit.ly/3djcYTe ; accessed: June 20, 2020.
(8) Society for
Epidemiologic Research. A statement on Racism from SER. June 3, 2020.
https://bit.ly/3dkIMHb ; accessed: June 20, 2020.
(9) American
Medical Association. AMA Board of Trustees pledges action against
racism, police brutality.
https://bit.ly/2NiwXa7 ; accessed: June 20, 2020.
(10) Krieger N,
Chen JT, Waterman PD, Kiang MV, Feldman J. Police Killings and Police
Deaths Are Public Health Data and Can Be Counted. PLoS Med
2015; 12(12): e1001915.
https://bit.ly/37Qo9Sa (open access)
(11) American
Public Health Association. Addressing law enforcement as a public
health issue. Policy Number 201811, November 13, 2018.
https://bit.ly/2AQfW4z ; accessed: June 20, 2020.
(12). Black Lives
Matter. Herstory.
https://bit.ly/316E3qk ; accessed: June 20, 2020.
(13) Chen JT,
Krieger N.
Revealing the
unequal burden of COVID-19 by income, race/ethnicity, and household
crowding: US county vs ZIP code analyses.
Harvard Center for Population and
Development Studies Working Paper Series,
Volume 19, Number 1. April 21, 2020.
https://tinyurl.com/ya44we2r
(14) Chotiner I.
The interwoven threads of inequality and health. The coronavirus
crisis is revealing the inequities inherent in public health due to
societal factors, Nancy Krieger, a professor of social epidemiology,
says (Interview with Nancy Krieger).
The
New Yorker,
April 14, 2020. https://bit.ly/2Yqq393
(15) Pilkington E.
As 100,000 die, the virus lays bare America’s brutal fault lines –
race, gender, poverty, and broken politics. The Guardian, May
28, 2020.
https://bit.ly/2YrG8LP
(16) Hassen A.
Hate-crime violence hits a 16-year high, F.B.I. reports. New York
Times, November 12, 2019.
https://nyti.ms/2YmvsOl ; accessed: June 20, 2020.
(17) Boghani P.
Racism in the Era of Trump: An Oral History. Frontline, January
13, 2020.
https://to.pbs.org/37TYBDW ; accessed: June 20, 2020.
(18) Dunbar-Ortiz
R. An Indigenous Peoples’ History of the United States. Boston:
Beacon Press, 2014.
(19) Kendi IX.
Stamped from the Beginning: The Definitive History of Racist Ideas in
America. New York: Nation Books, 2016.
(20) Du Bois WEB.
Black Reconstruction; An Essay Toward a History of the Part Which
Black Folk Played In The Attempt To Reconstruct Democracy In America,
1860-1880. New York: Harcourt, Brace, 1935.
(21) Krieger N.
Epidemiology and the People’s Health: Theory and Context. New
York: Oxford University Press, 2011.
(22) Krieger N.
Climate crisis, health equity, and democratic governance: the need to
act together. J Public Health Policy. 2020; 41(1):4-10. https://bit.ly/3eotnqI
(open access)
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