By Melissa S. Creary
Public health interventions aimed at Black and Brown communities frequently fail to recognize that these communities have, over and over, been made sick by the systems that shape their lives.
When we fail to recognize that these problems are happening repeatedly, we are likely to address the most recent and egregious error, ignoring the systemic patterns that preceded it. Public health and technological policy responses that do not address these underlying structural and historical conditions are a form of bounded justice, i.e., a limited response sufficient to quiet critics, but inadequate to reckon with historically entrenched realities.
By only responding to the acute crisis at hand, it is impossible to attend to fairness, entitlement, and equality — the basic social and physical infrastructures underlying them have been eroded by racism.
To achieve health justice, we must move beyond bounded justice. Rather than simply recognizing the existence of underlying social determinants of health, we must do the hard work to create and re-create systems, interventions, policies, and technologies that account for that erosion and offer high-grade reinforcements.
To illustrate the challenges of this task, consider Michigan Governor Gretchen Whitmer’s April 2020 executive order to create a Coronavirus Task Force on Racial Disparities.
At the time, 40 percent of reported coronavirus deaths in the state were Black residents, though Black people make up only 14 percent of the state’s total population. Recognizing early that Black people across the state were being infected and dying at rates higher than their proportion of the population, she signaled that it was not just the epidemiological data that needed attending to, but the socially contextual data as well. That is, we can’t just count disease cases, we need to also consider where people live, work, and play, and the institutions that have historically shaped each of those.
Aiming to provide more than just a band-aid fix to this immediate problem, the Task Force’s mandate is to tackle the underlying causes of inequity. It plans to do this by creating policies that aim to mitigate environmental and infrastructural factors — like segregation and redlining — contributing to increased exposure, and by improving systems for supporting long-term economic recovery.
While we should be supportive and optimistic of such policymaking efforts, it is necessary that the Task Force recognize the weight of history and how social inequality makes us sick, as well as the need to remove unfair, unjust, and avoidable barriers to good health and well-being that disproportionately affect the most disadvantaged populations. The summer of 2020, a time in which the global pandemic of COVID-19 intersected with an onslaught of police brutality, brought with it a surge of conversations which spurred individuals and institutions to tackle systemic change. Fortunately, the conversation has not waned, but it is critical that we consider the limits and unintended consequences of justice-oriented interventions like those of the governor’s task force.
The concept of bounded justice is useful because it provides a way of theorizing how embodied outcomes of accumulated injustice and exclusion inhibit the receipt of justice even via intentional, well-meaning, well-researched programs, policies, and technologies. It thereby allows us to better consider the realities of the intended benefitting constituents.
How do we adequately frame and fight for health equity — social justice in health — as a human right? Even if health equity can never be fully achieved, given the forces of racism and other -isms, as bounded justice suggests, it is our role as policymakers, practitioners, interventionists, and technologists, to design programs, policies, interventions, and technology with this limitation in mind, and then redesign as necessary.
If praxis means “moving back and forth in a critical way between reflecting and acting on the world,” and we are compelled to create a more just world, we must theorize, study, evaluate, re-design, re-evaluate, act, and then return to the cycle — with reflection embedded throughout — to determine the most effective ways to distribute justice.
Solutions to the problems must involve institutional commitment, but not without the deep entanglement of community-based stakeholders and the considerations of the long histories of systemic oppression. There is a relational positioning between vertical equity (justice distribution) and how deeply we must dig to unearth the real needs of a community. If we listen, community will tell us exactly what they need — the needs will be multidimensional and connected to past and current embodiments of inequality.
The global pandemic and the current mobilization around racism has ushered in an urgent conversation around the politics of need and the mobilization of moral arguments around suffering; who deserves health care and what suffering we will tolerate as a society.
In this moment, public health practitioners, policymakers, and activists must double down and work to address foundational challenges. In this call for action, there may be a sense of frustration at the lack of a bounded justice checklist. We must be mindful of how we are prescriptively trained to respond immediately to injustices as they become more apparent. The undertaking of “unbinding” justice might be akin to the development and implementation of impact assessments as discussed by Osagie Obasogie in Beyond Bioethics: Toward a New Biopolitics. Impact assessments are evaluative mechanisms used by government agencies to analyze the risks and benefits of new proposals to promote individual and social well-being and the process could be lengthy and take years. In the meanwhile, we do not ignore the problem in the moment, but we plan parallel processes that attend to it, using a framework that meaningfully includes community, and we acknowledge that the urgency that fuels the process will lend itself to failures, so we also plan for sustained, better-funded, long-term investment in trust building and power sharing.
If we turn our attention back to Michigan, it is clear the Coronavirus Task Force on Racial Disparities acknowledges that health outcomes are the products and expressions of unjust social, economic, and political institutions. Yet, similar convenings have often withered on the vine or become overwhelmed under the weight of the magnitude of the problem (another interpretation of bounded justice).
We will have to watch and observe the efficacy of the Task Force and its policies. In a state that is still languishing with the legacy of the water crisis in Flint and a deeply unresolved cry for justice from that community, it may be hard to live up to their promises — but it is imperative that they try.
Melissa S. Creary, PhD, MPH is an Assistant Professor of Health Management and Policy at the University of Michigan School of Public Health and Senior Director of the Office of Public Health Initiatives for the American Thrombosis & Hemostasis Network.