Just Health: Treating Structural Racism to Heal America

Kiera Nevers Hayes, MD, MSc

Fam Med. 2023;55(4):273-274.

DOI: 10.22454/FamMed.2023.220127

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Book Title: Just Health: Treating Structural Racism to Heal America

Author: Dayna Bowen Matthew

Publication Details: NYU Press, 2022, 329 pp., $27.95, hardcover

The impact of the social determinants of health in the United States should no longer be novel for the family physician. What Dr Matthew’s book adds is a comprehensive look at the legal decisions that create and maintain these factors and the structural racism that leaves its mark on all our communities. She begins with her own story in the South Bronx, a segregated area of failing schools, pollution, limited food, and violence that her parents literally worked themselves to death to help her escape. She then weaves her story through a meticulous review of the impact of those social determinants of health and the health inequalities faced by minority communities in the United States.

Dr Matthew describes how the United States has created and maintained structural racism through dehumanization of Black bodies and legally supported inequality. Beginning with early colonized America, she reviews the differential treatment of Black Americans before and after the Thirteenth Amendment. Citing recent examples, she relates how research demonstrates that teachers expect challenging behavior from Black children and choose severe disciplinary actions. On a city level, she discusses how utility access continues to be unequally distributed in many parts of the country despite decades of requests for expansion. She also delineates multiple laws that uphold differential treatment prompted by both conscious and unconscious bias. For example, the Civil Rights Act of 1875 defines public amenities as civil rights and desegregated amenities as social rights; the latter are not covered. Supreme Court cases maintain these differences as well, such as Washington v Davis (1976), which concluded that the Equal Protection Clause protects only against intended racism. The result of this legal topography is income inequality; redlining and resultant unequal housing, zoning, and environmental pollutants; and attacks against affirmative action.

The state of the nation presented in this book can feel daunting, especially for those outside of the legal profession. However, Dr Matthew gives advice for clinicians hoping to improve their patients’ lives. Her focus is on strengthening and enforcing the Civil Rights Act of 1964, the Fair Housing Act of 1968, the Voting Rights Act of 1965, the Equal Educational Opportunities Act of 1974, and the Affordable Care Act of 2010. One specific suggestion is to rewrite Title VI of the Civil Rights Act to protect against unconscious as well as conscious bias. Support for this effort has already taken hold. In 2015, the Supreme Court held in Texas Department of Housing and Community Affairs v. Inclusive Communities Project, Inc. that those adhering to policies with a discriminatory effect were to be held responsible, even if their intent was not discriminatory. In addition to strengthening these laws to protect equal rights, Dr Matthew calls for a strengthening of the federal agencies that enforce them to combat such issues as the 350-day turnaround time on Title VI complaints to the Environmental Protection Agency.

Finally, she discusses the argument for reparations. Early examples of this precedent include money paid to White indentured servants, the Civil Liberties Act of 1988, and payments to families of those accused in the Salem witch trials. Among the ways to achieve reparations for the economic, social, moral, multigenerational, and multifaceted disruptions from structural racism, she cites essays and proposals. Specifically, she mentions HR 40 and S. 1083 led by Senator Cory Booker along with ideas such as rent control, freezing property taxes, tax credits, erasing criminal convictions, guaranteed minimum income, and affirmative action.

The final chapter of the book focuses on the history of physicians in the fight for racial justice and illustrates current activities of health care groups. For example, stable housing and environmental pollution have become targets of insurance companies such as United Healthcare and hospital systems from Missouri to Maryland, many of which involve hospitals creating housing with health facilities on-site. Prescriptions for Produce is one example of a hospital/physician partnership to address food insecurity while other programs connect patients with food banks and voucher programs. Medico-legal partnerships have many iterations, including multidisciplinary violence prevention, health clinics, and legal case management in schools.

As we encounter injustices in our communities, states, and the nation, this book is a reminder that we can join with multidisciplinary partners to advocate for a future that values every human life. Physicians who want to change the system that causes the social determinants of health can turn to this book for help in directing their voices to act at a political and legal level to create a future of equal opportunity for health and respect for all.

Lead Author

Kiera Nevers Hayes, MD, MSc

Affiliations: Community Health Care, Tacoma, WA

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