By Lindsay F. Wiley and Ruqaiijah Yearby
As our digital symposium on health justice comes to a close, we have much to be thankful for and inspired by. We are honored to provide a platform for contributions from scholars spanning multiple disciplines, perspectives, and aspects of health law and policy. Collectively with these contributors, we aim to define the contours of the health justice movement and debates within it, and to explore how scholars, activists, communities, and public health officials can work together to engage critical perspectives in health law and policy.
As we described in our symposium introduction, the questions we posed to contributors focused their work on four main themes: (1) subordination (including discrimination and poverty) is the root cause of health injustice, (2) subordination shapes health through multiple pathways, (3) health justice engages multiple kinds of experiences and expertise, and (4) health justice requires empowering communities, redressing harm, and reconstructing systems. Most of the contributions to this symposium cut across more than one of these themes, but we present them here in four broad categories.
Subordination is the Root Cause of Health Injustice
Many contributors to this symposium focused on how health justice primes us to interrogate the laws, polices, and practices that reinforce subordination, which is the root cause of health injustice.
- Mary Crossley reflects on her career as a scholar of health inequity and her transition from playing “whack-a-mole” with instances of health injustice to seeing how “health inequality surrounds us, firmly embedded in American society” and therefore, “[w]e need to look deeper to find its roots.” She draws a rich analogy between the social determinants of health and “how immense, subterranean fungal networks continually interact with and change other life forms, with results both beneficial and deleterious.”
- Jennifer Cohen illuminates the systemic economic subordination that devalues the contribution of many low-wage workers, who are disproportionately women and women of color, and robs them of the power to protect their own health and the health of their families and communities. She argues that health justice requires (1) “acknowledging that the capitalist organization of work establishes and reinforces health disparities,” (2) “recognizing the gendered and racialized division of labor in the provision of care — including health care,” and (3) “reconsidering how markets allocate inputs to health and how people obtain health.”
- Rachel Rebouche focuses on anti-abortion laws, pointing out that “abortion access’s relationship to economic and racial inequality is often lost amid debates about privacy and choice.” She argues that a health justice lens reveals the full costs of the Texas “heartbeat” law and “how lack of access to abortion entrenches economic and racial inequality.” Her post highlights multiple connections between reproductive justice and health justice, including the emphasis of both frameworks on structural barriers and structural solutions.
- Aziza Ahmed highlights the failure of pulse oximeters to accurately detect hypoxemia for people of color and connects it to the history of spirometers used to measure lung capacity. Both are examples of how the development of medical technologies systematically disregards the health of non-white people and entrenches racism and racial science in health care. She writes: “When Black Lives Matters (BLM) activists say, ‘I can’t breathe,’ they are acknowledging that breathing is not simply biological — it is enabled or disabled by law and politics…. In fact, the legal and political environment shapes and legitimates the very tools we use to monitor our capacity to breathe.”
Subordination Determines Health through Multiple Pathways
Other contributors explored how the descriptive and normative power of the health justice framework are tied to the broad scope of inquiry and action that it embraces.
- Sridhar Venkatapuram emphasizes that health justice requires attention to more than health care access; it includes the need to address the “unjust social/structural causes of ill-health that occurs outside of the healthcare setting,” such as poverty, disability, minority status, and lack of access to safe housing. “Every individual’s moral right to health capability requires addressing harmful structural factors, no matter where we find them,” Venkatapuram writes.
- Matt Lawrence compares health justice to vulnerability theory (pioneered by Martha Fineman), identifying them as “invaluable, and largely complementary, frameworks for understanding health law and policy.” One key similarity is that both approaches “center the many causal points at which law may impact health” and “focus on the prevention of harms (including illness) by changing their upstream determinants.”
- Katherine Macfarlane uses a health justice framework to illuminate how employment laws and workplace policies harm the health of disabled people. In her examination of the harms caused by medical examination requirements for people with disabilities in the workplace, she finds that the “wider lens” provided by health justice “better captures the lived experiences of those who experience discrimination, including people with disabilities.”
- Heather Walter-McCabe argues that “the health justice framework allows advocates to move the work upstream to the root causes of” health disparities “rather than placing a band-aid” on them. She points to workplace discrimination, housing insecurity, and psychosocial stress caused by marriage and family laws that overtly discriminate against and stigmatize LGBTQ people in addition to discrimination within health care encounters as important pathways by which subordination affects health.
- Aysha Pamukcu and Angela P. Harris argue that the criminal legal system is an important determinant of health. They reflect on how “[a] health justice perspective invites us to imagine a far more robust set of institutions in service of community security — and pushes us to prioritize science, rather than a punitive morality, in designing them,” which they connect to the movement to defund the police.
- Solange Gould notes that health justice is a central tenet of public health because at its core, “public health is the radical concept that everyone has a fundamental right to the conditions required for health and well-being.” During COVID-19, the public health departments that had strong relationships with community power building organizations were able “to respond to COVID’s equity impacts, resist pushback against government, and mobilize communities to engage in a just response and recovery,” which should be the model for achieving health justice.
- Daniel Dawes reminds us that the political determinants of health lay the foundations for many of the pathways by which subordination shapes health, and, as such, should also serve as the means to realize health justice. Specifically, “the legal profession has not only the ability, but also the responsibility, to address the longstanding systemic harms that have led to inequities.” This insight “provides an opportunity for health justice to become a reality. But in order to accomplish that, we have to be willing to see the harm, and envision a better future.”
Health Justice Engages Multiple Kinds of Experiences and Expertise
Health justice bridges research, scholarship, and activism across multiple sectors. Many of the contributions in this symposium illustrate how efforts to realize health justice engage personal experiences and professional expertise across multiple disciplines and aspects of community life.
- Alexis Etow and Thalia González focus on how “health justice serves as both a conceptual framework for reform for legal academics and an accessible roadmap for change for policymakers and public health law professionals” in their collaborative work on school discipline policies as determinants of community and individual health.
- Monica McLemore highlights research justice and reproductive justice as essential frameworks for realizing health justice. She reflects on being accused of intellectual promiscuity for becoming a methodologist and argues that her focus on research methods was born of necessity upon her realization that health justice demands reconstruction of research as a foundation for what we know about health disparities. To “test interventions with, for, and by the most burdened people with poor health outcomes: Black women … requires multi-modal approaches and novel methods.”
- Wendy Epstein focuses on combining health justice with the economic analysis of health disparities and argues for “[m]aking the economic case for health justice” rather than relying on moral imperatives alone. She suggests that health justice — which she equates with rights-based arguments that characterize health care as an entitlement — is “bolstered by notions of both fairness and efficiency.” Moreover, “as a practical matter, getting legislative and regulatory buy-in to fund initiatives to address health inequities requires making the economic case.”
- Liz Tobin-Tyler and Joel Teitelbaum note that “health justice means change.” They point to the importance of medical-legal partnerships — “collaboration[s] between health care organizations (hospitals, health centers, managed care organizations, etc.) and public interest law organizations (typically a civil legal aid agency, but oftentimes a law school clinic) to address health-harming social needs that have civil law remedies” — in supporting those changes.
- Yael Cannon highlights how inter-professional training fosters the next generation of health justice leaders. “[P]rofessional training and community-based partnerships” equip students across disciplines “to identify gaps, patterns, and problems with the law and pursue reforms to advance health justice.”
- Dayna Bowen Matthew shares how her personal experiences within contrasting communities of the South Bronx — which had polluted air and “stinky, dimly lit apartment buildings” — and Riverdale, NY — which had clean, breathable air and “sprawling homes on manicured lawns and opulent apartments overlooking Central Park” shape her work on health justice. She defines health justice as seeking to ensure that all members of the human race can live in neighborhoods with clean drinking water, clean breathable air, and safe and affordable housing. “To achieve health justice, America must enforce its self-proclaimed commitment to equality. Health justice requires laws that both equally distribute the resources humanity needs to be healthy, and protect against inequities that unfairly disadvantage some humans while advantaging others.”
Realizing Health Justice Requires Empowering Communities, Redressing Harm, and Reconstructing Systems
Health justice is fundamentally tied to community life. Communities are a locus of health-related harms and a source of power for defining the meaning of justice in health. Many contributions to this symposium highlight empowering communities (through truth, reconciliation, and redress) as a critical path for realizing health justice.
- Charlene Galarneau connects health justice to community justice, even as she explores how the boundaries of health justice “communities” are contested and should be interrogated. She argues that “health and health care are social at multiple levels of collectivity, including global, national, community, and family levels.” Each of these levels of community offers a site of “meaning making” where “we learn and create particular meanings and values regarding health, illness, and health care.”
- Medha Makhlouf argues that “health justice provides a framework for understanding how universal access to health care protects collective, as well as individual, interests” — one that is needed now more than ever as “the pandemic has underscored the collective nature of the health and wellbeing of every person living in the United States, regardless of immigration status.” The pandemic examples she describes “illustrat[e] the utility of health justice for catalyzing cross-sector initiatives to improve health, reducing the role of bias in the design of interventions to address health disparities, and ensuring that such efforts are serving the needs of historically subordinated communities,” including immigrants with “diverse health needs, goals, and experiences.”
- In her critique of the Supreme Court’s decision to strike down the Centers for Disease Control and Prevention’s eviction moratorium, Yolonda Wilson highlights the Black feminist conception of justice that “foregrounds the needs of the overall community,” versus only prioritizing the rights of those with power. “The community rises and falls together, and so justice must account for the whole, not merely the well-heeled.”
- Keon Gilbert and Jerrell DeCaille note that the health justice movement connects social justice models, equity frameworks, and community engagement. Public Health Critical Race Theory, a social justice model and equity framework, provides guidance for realizing health justice, because it “calls into question research that creates inopportunity and renders communities invisible; provides researchers with a lens to consider how a public health challenge inequitably limits health-promoting opportunities; and requires those who engage in research to promote equitable outcomes that include social, structural, and ecological determinants of health.”
- Liz McCuskey identifies health justice as a critical lodestar to ensure incremental reforms are moving in the right direction by “judging health reforms on their equitable distribution of the burdens and benefits of investments in the health care system, and their abilities to improve public health and to empower subordinated individuals and communities.”
- Melissa Creary warns that “[p]ublic health and technological policy responses that do not address … 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.” Moving beyond bounded justice requires us to listen when communities “tell us exactly what they need” and to acknowledge those needs as “multidimensional and connected to past and current embodiments of inequality.”
- Amber Johnson issues a powerful call for truth and reconciliation in health care, “a process whereby parties who have been harmed and parties who have caused harm are able to share their experiences and revise ahistorical narratives, so that they reflect the truth and seek justice in the form of reconciliation, reparations, or some form of resolution.” Truth and reconciliation is an important mechanism for healing and for operationalizing three commitments — “community empowerment, structural remediation, and financial and structural supports” — that are central to health justice. “[W]hen narratives and lived experience drive the agenda for social change, humans are more likely to collaborate to end human suffering versus ignoring it or fighting against change.”
- Jamila Michener invites us to infuse health justice with “love, freedom dreaming, and power building.” Her description of health justice in terms of what she wants for the people she loves is powerfully intimate. She recognizes that “health justice is not only an outcome we would like to achieve, but a process we must advance” and this “process-oriented view of health justice sensitizes us to power.”
- Sarah deGuia, Rachel Davis, and Kiran Savage-Sangwan share an example of community based organizations working to attain health justice. These organizations are often left out of the decision-making processes that directly affect the communities they serve. After interviewing more than 20 California community based organizations (CBOs) about the ways they met community needs during the pandemic, the authors recommend that to attain health justice for communities, local health departments should coordinate “closely with CBOs, providing them with funding and technical assistance, sharing power with them for policy and decision-making, and listening to the concerns they raise.”
The Health Justice Initiative Continues
This symposium is part of the Health Justice: Engaging Critical Perspectives in Health Law & Policy Initiative launched in 2020. The initiative is ongoing. In 2022, we’ll be co-editing (along with Brietta Clark and Seema Mohapatra) a special symposium issue of the Journal of Law, Medicine, and Ethics and hosting an in-person conference (if the public health situation improves) at UCLA Law. This initiative is cosponsored by American University Washington College of Law’s Health Law and Policy Program, St. Louis University’s Institute for Healing Justice and Equity, the Satcher Health Leadership Institute at Morehouse School of Medicine, and ChangeLab Solutions.
Lindsay F. Wiley is a Professor of Law and the Director of the Health Law and Policy Program at American University Washington College of Law.
Ruqaiijah Yearby, J.D., M.P.H. is Co-Founder and Executive Director, Institute for Healing Justice and Equity, Saint Louis University and Professor of Law and Member of the Center for Health Law Studies, Saint Louis University, School of Law.
