On the surface, many health problems in the U.S. may seem apparent. But a more in-depth look reveals far more complex origins of many diseases and ailments that often have roots in social and economic inequalities. In 1928, Louis Israel Dublin wrote that improving the health of African Americans to equal that of whites would be the most significant step that would not only eliminate most of the disabilities the race suffers but also improve its economic status and enhance its native abilities (Noonan et al. 12). The compelling assertion on the social implications of African Americans remains valid today almost a century later at a time when this population is the least healthy ethnic group in the United States. In her TED talk “Why Your Doctor Should Care about Social Justice,” Mary Bassett explained how structural violence leads to health disparity in the United States and why doctors should be at the forefront in addressing social determinants of health. Structural violence is a contributing factor to health inequalities suffered by African Americans.
Basset started the talk by reflecting on her practice in Zimbabwe. In the 1980s, after the long war of independence, the government of Zimbabwe prioritized social justice as a part of its national health policy. It rolled out free healthcare services and education and massively expanded rural health centers. As a result of these efforts, immunization rates among Zimbabwean children rose from 25% in 1980 to 80 in 1990. As a part of the transformation, Bassett felt privileged to serve to improve the health outcomes of the citizens in her capacity as a doctor.
However, the country and many other African nations were ready for the HIV epidemic that followed (Basset 03:25). Within two decades, the infection rates rose from 2% to one in every four adults. The effects of HIV were devastating Bassett experienced colleagues, friends, her students, and hospital patients succumb to the illness. In response, she and her friends set up a clinic to treat the infected and educated the public on how to lower the risks infection.
Years later, she looks back at her experience in Zimbabwe and realizes that she did not talk about structural change. At the time, she did not consider her role as advocacy or a political one but focused on her technical skills, both clinical and epidemiology skills (Basset 03:48). Nevertheless, she was aware that socially marginalized populations were as disproportionate risk of contracting and dying of AIDS. One such group was workers on sugar plantations where the infection rate was 60% among pregnant women. She explained to them how the infection was not a result of moral failure but instead associated with a culture of male superiority, forced migrant labor, and colonialism. She argued that the approach by health professionals in tackling the HIV pandemic was weak. They focused on individual-level changes but ignored the underlying economic and political systems that were diving infection rates up. She regrets not speaking out about issues such as unequal access to life-saving drugs in Africa compared to developed nations or the government’s stance on AIDS (Basset 05:19).
Structural violence examines how historical, political, and social factors impact marginalized and disadvantaged groups in accessing equitable health (Farmer et al. 305). According to Farmer, structural violence is “sinful” social structures manifested by poverty and extreme social inequalities, including racism and gender inequality, and it is a form of violence perpetrated systematically and indirectly by people from a specific social class or gender (Farmer et al. 310). Additionally, one needs to focus on history, biology, and political economy to have a comprehensive understanding of structural violence. According to Basset, “epidemics emerge along fissures of our society, reflecting not only biology but patterns of marginalization, exclusion, discrimination related to race, gender, sexuality, class and more”; that is, structural violence (Basset 06:26, Farmer et al. 305). Structural because inequalities are embedded in the political and economic organization of the social world and violence as its impact premature death and suffering is violent.
Bassett urged doctors to go beyond the constraints of the doctor-patient relationship mandated by the Hippocratic Oath and its variants (Bassett 06:06). Doctors need to recognize social injustices, and the first step is sounding the alarm with the aim of rallying support to create real change together. In line with this call, Basset speaks out about a variety of things, mainly about racial disparity and institutionalized racism that is unfortunately present in society today, leading to the loss of many lives. Bassett argued that slavery and imperfect equality contributed to these disparities.
Basset, as New York City’s Health Commissioner, provided detailed statistics on health disparities experienced by African Americans in the state. African Americans have a 50% chance of premature death (Bassett 08:58). African American women have a ten-fold risk of dying from childbirth-related causes compared to white women. An African American child has three times the likelihood of dying in the first year of life compared to a white baby. The statistics are similar across the United States. A New York Times analysis reported that 1.5 million missing African American men across the country with more than one in every six aged 25-54 years missing from daily life either due to prison or premature death. Moreover, violence faced by young African American men daily is disproportionate, which is the focus of protests in #BlackLivesMatter.
The findings from a study by the National Institute of Health (NIH) on heart attacks correlates the what Basses noted on the enduring and disparate rates and the occurrence and outcome of common long-term medical conditions (Basset 10:22). The number of deaths attributed to lung cancer, strokes, and heart attacks in the U.S. in 2000 was more than half a million. Researchers attributed 245,000 deaths to low education, 176,000 to racial segregation, 162,000 to low social support, 133,000 to individual-level poverty, 39,000 to area-level poverty, and 119,000 to income inequality (Galea et al. 1462). Although the researchers did not find a direct link between such social factors and poor health, they suggested that contributing factors include inadequate access to healthcare, risky health behaviors, poor nutrition, work environments, or housing conditions. The report linked negative social interactions, including discrimination, to increased mortality rates as a result of adverse effects on physical and mental health and decreased access to resources (Galea et al. 1465). The researchers recommended a policy approach that addresses social factors to improve the health of populations.
Basset noted that the medical community is reluctant to use racism in research and work. She proposed for the medical community to not only focus on personalized and precision medicine but also on the big picture of the daily context that most importantly determine population health. In addition to caring for patients, the role of health professionals is to advocate for change, a practice facilitated by the societal position that gives the doctors’ voices high credibility (Basset 12:43). Like Basset, health professionals should use every opportunity they have to sound the alarm and rally support for health equity. Even though they may not have all the answers to call for change, all is needed is courage.
Basset is not alone in her efforts to address social injustice in the medical field. In the article “A Call to Service: Social Justice is a Public Health Issue,” the authors stated that physicians have much to learn from the struggles of their poverty, sexism, and racism. They argued that health professionals caring for patients should naturally lead to a contemplation of how to help patients in the broadest and most effective ways (Donohoe and Schiff 699). Also, medical students are beginning to actively participate in illuminating and working to address the social injustices that underlie several pressing health issues in the U.S.. In 2016, the Yale Health Coalition that consists of Yale medical students launched the #ProtectOurPatients campaign to oppose the repeal of the Affordable Care Act following the election of President Donald Trump (Vollman 1). A repeal of the Act has the potential to strip millions of Americans of health insurance coverage. WhiteCoats4BlackLives is another medical-student-led movement that targets to raise awareness of racism as a public health concern, ending racial discrimination in medical care, and preparing future physicians to be advocates for racial justice.
African Americans experience health inequalities facilitated by social injustice. Structural violence examines how health inequalities faced by African Americans stem from social injustices. Over the years, the medical community has stood on the sidelines despite witnessing the health inequalities and other injustices such as violence against African Americans. Basset and others of similar view advocating for health professionals to be at the forefront of fighting these social injustices by speaking out to raise awareness. Sounding the alarm is the first step in addressing these disparities, although not a solution by itself.