“What I’m saying might be profane, but it’s also profound.” ― Richard Pryor
Growing up, I always knew there were words my parents could say but I dare not utter — not even in recapping events using verbatim quotes. In an episode of TV sitcom Everybody Hates Chris — a series based on the upbringing of comedian Chris Rock — the main character (Chris) overheard his parents and their friends listening to a racy record of explicit Redd Foxx jokes. Chris was supposed to be fast asleep upstairs; unbeknownst to his parents he was eavesdropping just beyond their line of sight. He heard every inappropriate joke told by Foxx; who used all seven words that you cannot say on public TV. In his unyielding quest to be accepted and gain popularity during his adolescent years in high school, Chris went to school and retold each of the jokes — word for word — to his schoolmates. While gaining temporary celebrity among his peers, Chris eventually was caught and summoned to the principal’s office where he was confronted by the Principal and his parents for his profanity laden, low-level comedy tour around the school.
The public health profession faces a difficult situation in addressing the tragedy of diffuse and stubborn health inequity. My partners around the country and I have recounted experiences of pushback as a result of proposing joint ventures to address health inequities. Like the principal’s reaction to Chris’s shenanigans, potential partners response to the existence of and push to address health inequity as if they were asked to engage in profane endeavors, as if the very notion is an affront to the ideals on which the American experience is built. Why such disconcerting reactions? I will begin answering that question by defining health inequity which should not be confused or interchanged with health inequality.
Health Inequality vs. Health Inequity
For starters, health inequality refers to differences in health status or in the distribution of health determinants between different population groups. Health determinants comprise a range of personal, social, economic, and environmental factors that influence our health. For example, health inequality manifests as differences in mobility between elderly people and their younger counterparts or differences in death rates between people from different social classes. This may be attributable to biological variations (e.g. chromosomal abnormalities), free choice (e.g. forego routine exercise) or the natural environment (e.g. more frequent flooding due to climate change fueled shifts in weather patterns). For the sake of this post, my focus lies in health inequity.
Health inequity involves differences in health status or in the distribution of health resources between different population groups (e.g. Caucasian Americans compared to Latino Americans or urban dwellers versus rural residents), arising from the social conditions in which people are born, grow, live, work and age. Stated more succinctly by the World Health Organization (WHO), “health inequities are systematic differences in the opportunities groups have to achieve optimal health, leading to unfair and avoidable differences in health outcomes.” To further emphasize the point of health inequities, in the United States African Americans represent only 13% of the population but account for almost half of all new HIV infections. There is no biological or genetic reason for these alarming differences in health. With that, there must be social conditions, programs (or the lack thereof) and/or policy positions that fuel such a heinous public health and medical reality.
Health Inequity are Trigger Words, Not Profane
Now, back to the emerging categorization of “health inequity” as Rated R or MA (mature audience). Almost like Chris classmates’ eagerness to hear the inappropriate, profanity-filled jokes, potential partners provide their undivided attention when summoned to help their communities — at first. Potential partnerships fall apart when discussions related to addressing health inequity surface. It took me and my fellow public health folks time to learn that the phrase “health inequity” and related ones such as “health disparities,” “vulnerable populations,” and I would presume “social justice” seem innocuous to us, however they evoke different sentiments in others. These sentiments, fair or not, are filtered through a set of beliefs and values that are anathema to the advancement of public health — thus exacerbating health inequities.
We have learned that everyone does not experience public health events the same, even if they live within the same community. The unfazed may see the causes of public health issues different from those completely and undeniably displaced by them. I remember years back watching news coverage of New Orleans’ near full submergence of unfettered water from toppled levees because of Hurricane Katrina’s wrath. Hundreds of people lost their lives, still others were displaced and never returned to New Orleans. One guy, who I assumed was interviewed on the spot by journalists covering the recovery efforts, felt it apropos to exclaim, “they” should have better survival skills. “They” referenced New Orleans residents — most of whom were African Americans — trapped on rooftops of homes completely engulfed by floodwaters.
Others found themselves stranded on freeway overpasses with no reprieve from the blistering, muggy summer heat. Yet others were herded into the Super Dome for days on end — at times with no access to electricity and running water — which created an entirely different crisis. But, better “survival skills?” Even though this guy is not the spokesperson for everyone, it is reckless to think his sentiments are not shared among many — including those who are in positions of power and influence. Such individuals may be able to address health inequities by allocating resources and sharing words of encouragement – including directives to act – through their networks, which can yield extraordinary results.
No amount of self-efficacy or “survival skills” can address health inequities caused by less than ideal policies, programs, and imperfect research that led to building inadequate levees. They were toppled by a massive hurricane that, according to meteorologists, was larger and more powerful than what would have been the case had climate change not had its say. For the climate change deniers, even if Hurricane Katrina were a cyclical weather phenomenon that bore no relationship to well-document climate change, bellowing “survival skills” remains inappropriate.
Additionally, “they” were also the victims of a terribly executed evacuation plan that was exacerbated by insane gridlock due to a mass exodus from New Orleans once it was clear Hurricane Katrina was on her way. Increasing one’s personal responsibility is neither the sole solution nor the immediate culprit in most cases. Suggesting so, presents one reason why joint ventures in addressing health inequities is viewed through the lens of profanity — why should the collective “we” address a problem caused by the lazy and irresponsible “them?” Bootstraps!
No Point of Reference – An Inability Understand Health Inequity
There is the refusal to acknowledge forces working in the background (e.g. policies or the lack thereof allowing for redlining in real estate) that give specific groups of people advantages, forces that are not universally shared. Populations experiencing long-term health inequity are criticized at times for not doing better – not trying hard enough. For example, “they” – referring to vulnerable populations irrespective of race or location – should just eat better or go for walks to improve their health. “They” may not have transportation to venues that sell healthier foods which allows them to make healthier meals. Supermarkets providing opportunities to purchase fresh produce and lean cuts of meat may not be within reach. Until as recent as a February 2017 before the opening of a Publix Supermarket, there was not a single grocery store in Downtown Birmingham.
Furthermore, 88,000 residents in Alabama’s largest city — which had a 2016 population estimate of 212,175 – live in a food desert. An area — according to the American Nutrition Association — “vapid of fresh fruit, vegetables, and other healthful whole foods, usually found in impoverished areas” is considered a food desert. Bootstrapping to non-existent grocery stores does not a solution to health inequities make. Would the average American want to travel several miles, out-of-the-way in traffic to access a grocery store, especially if they have limited free time and scores of other issues clamoring for their attention? Probably not. That has nothing to do with a lack of “survival skills” and more to do with a failure of the market, which our culture so shamelessly worship, to meet a demand.
Its the Cellphone, Not Damaging Federal and State Policies
To really drive home to point of tone deafness surrounding the origins of health inequity, one Utah congressman stated during a TV interview, “maybe rather than getting that new iPhone, [those struggling to get access to healthcare services] should invest in their own healthcare.” Forgoing a cell phone purchase will not address Americans’ continued lack of access to healthcare insurance and thus public health and medical services even after the enactment of the Affordable Care Act. Sticking it to Apple and Samsung will neither curb escalating healthcare costs nor decrease the proliferation of healthcare professional shortage areas in rural America. Reviving old flip phones will not treat the poisoned drinking water in Flint – not to mention save enough money to treat the health ailments that accompany exposure to it.
Again, health inequity is not solely due to personal failure and poor individual choices. For clarity, I am not attempting to absolve individual people of the responsibilities they bear in promoting their own good health. I am stating a culmination of complex factors leads to health inequities not single-handedly renewing one’s cellphone contract. These communal health inequity problems arose from political incompetence, outright terrible policymaking, well-intentioned yet incomplete policies and programmatic decisions, inadequate budget appropriations, bureaucracy-induced inertia and the failing of uncheck private sector business practices. We as the public, political leaders – such as the abovementioned Utah congressman – and pioneers in the business sector, among others are responsible for addressing health inequities, not some struggling family in western Kansas whose head of household simply needs to rectify a so-called fallout due to his or her poor choices.
Partnership Development to Address “Select” Public Health Woes
Partners have described reactions of glazed over eyes and body language of disgust and disinterest in attempts to build cross-sector partnerships to address health inequities. Such reactions are not the case in all instances — it need not be — it only must be the case ENOUGH times. Some of my peers have shared responses of outright verbal condemnation — as if they cussed out potential partners — in the tone of “some people simply are not trying to do better” or some form of out-of-context bootstrapping rhetoric. Sure, there have been milder expressions of saying “no” such as unreturned phone calls, ignored e-mails and failed avoidance techniques turning into encounters of hemming and hawing. Others provide accounts of “well I managed to do x, so why can’t ‘they’” without considering again how different people experience public health phenomena in different ways. So, I ask, has uttering “health inequity” or similar terminology become too dirty for TV? Maledictory to developing public-private partnerships to address health inequity?
I am committed to a person who loves me for who I am. He and I have two dogs. Cascadia is home for us. I know for sure no one makes it alone; bootstrapping is a cliched dog whistle. I surround myself with truth tellers. I am healthy and grateful for what I have (on most days). I wholeheartedly believe reading gives us super powers. Vote. Exercise. Eat Healthily. Sleep Soundly.