June 24, 2020

Guest Chair's Column: Dying to Belong: Racism as a Public Health Issue

By Montrece M. Ransom, JD, MPH, Vice Chair, Coordinating Committee on Diversity, ABA Health Law Section

I am obsessed with the phenomenon of belonging. For the past year, I’ve been studying, presenting workshops on, and writing about the importance of fostering a sense of belonging in all of our shared spaces.  In addition, the heart of my coaching practice is affirming to my clients that anywhere they are called or aspire to be, they belong. Belonging is a basic human need.  It is a sense of psychological safety and security. We all—no matter our background, ethnicity, age, gender, gender identity, race—have a need to feel a sense of belonging.

You may remember Abraham Maslow’s hierarchy of needs. Maslow, a psychologist who published prolifically in the mid-20th century, said our needs as humans fall into five tiers. At the bottom of Maslow’s hierarchy is the need for physiological well-being--the need to eat, drink, and sleep. Once satisfied, we then can move on to fulfilling our need for safety, and shelter. Once we have food in our bellies, a roof over our head, and sense of physical safety, we move on to what he called the “higher order need” of belonging. According to Maslow, the need to belong is so basic to our humanity that we must satisfy that need before we can fully develop our self-esteem and confidence. And the development of self-esteem and confidence must occur before we can reach our full potential, or as Maslow calls it, self-actualize.

A sense of belonging unleashes human potential. It is tied to dignity, and the ability to live without shame. But, so much of what is happening in our country today serves to embed in the soul of many Black Americans that we don’t belong. That we don’t belong in the gym, at the park, on the highway, at our workplaces, in our own homes, or in this country.  Events like the murders of Breonna Taylor, Manuel Ellis, James Spurlock, Ahmaud Arbery, George Floyd, and Rashard Brooks triggered in me, and many in the Black American community, a feeling of exhaustion, helplessness, anger, and hopelessness. And, much of the media and political response to these events has not been trauma informed.

Trauma informed messaging recognizes that traumatic experiences and their mental and emotional impacts tie closely into behavioral health problems. And, much of what I saw in my social media feed and on the news retraumatized me and others with histories of racism and discrimination related traumas. According to data from the Census Bureau, within a week of George Floyd’s death, anxiety and depression among Black Americans shot to higher rates than experienced by any other racial or ethnic group.1

These mental health statistics, when coupled with the disproportionate burden of illness and death among Black Americans from COVID-19, provide evidence of what many Black Americans in public health have been saying, and what research has shown—racism is a public health issue.

Studies show that the racism and discrimination that we Black Americans experience in our daily lives create stress that affect our internal organs and overall physical health. This results in a higher prevalence of chronic diseases such as high blood pressure, asthma, and diabetes, as well as shorter lifespans. As Will Jawando, Montgomery County (MD) Councilmember, said, “whether it is police-involved killings or disparate health outcomes where [Black-American] patients can’t get treatment because they are not seen as being sick, or financial redlining in certain ZIP codes, food deserts, or people of color getting hit by cars more often because their communities aren’t walkable -- it’s all ultimately due to racism.”2

Impacting infectious disease, this systemic racism has led to rapidly expanding inequity amidst the COVID-19 pandemic. Simply being a black American in this country is significant social determinant of health. As Christine Vestal notes in her article on the topic, “being black is bad for your health. And pervasive racism is the cause.”3

Want proof? Here are some stats:

  • Black women are up to four times more likely to die of pregnancy-related complications than white women.
  • Black men are more than twice as likely to be killed by police as white men.
  • The average life expectancy of Black Americans is 10 years less than white people.
  • A baby born to a Black American mother is three times more likely to die before his or her first birthday than a baby born to white mom.
  • Seven percent of white people are uninsured, while in Black Americans the uninsured rate is 30 percent.
  • Even after class and poverty are accounted for Black Americans still have worse health outcomes than white Americans; studies show that the health equity gap is even wider between wealthy Black Americans and their wealthy white counterparts.

In fact, when you consider most public health issues and conditions, you will find striking disparities based on race. These disparities are not the result, as one senator has suggested, of poor hygiene or lack of adherence to medical and healthcare guidance. They are the result of deep-seated systemic racism that exists across all segments of our society—from our courthouses, to our hospitals, to our schools, to our workplaces.  High rates of poverty, unemployment, poor housing, and toxic environmental exposure, as well as less access to quality medical care also contribute to health disparities. 

There is an old African proverb that says that the child who is not embraced by the warmth of the village will burn it down to feel its warmth.  The protests that followed George Floyd’s death have been a visual depiction of this proverb in real time.  The seemingly continuous killing of unarmed black people—right in the middle of a pandemic that has had a dramatically disparate impact on black and brown people—continues to serve as a painful reminder that for many Black Americans belonging in this country is based on conditions outside of our control, and which are applied, at best arbitrarily, and at worst with the intent to exclude. These events reminded many of us that far too often we don’t feel the warmth of the laws and legal protections outlined in our country’s founding documents. These events also signaled to the nation that our health, our lives, our existence depends on foundational, sustainable change on the individual, community, and systemic level. If we want to see change in the racial health equity gap, the status quo won’t work. Action is needed to reverse hundreds of years of racism that is built into the core of our country.

More than 20 cities and counties, and at least three states, have heard this call and declared racism a public health issue. These declarations are meant to catalyze change across all sectors of government and engender impact across all social determinants of health—criminal justice, education, healthcare, housing, transportation, budgets, taxes, economic development, and social services--all toward the goal of shrinking the health gap between Black Americans and the rest of the population.

This policy approach underscores the fact that the law itself is also a critical social determinant of health. Laws and regulations, how they are enforced, who they are enforced against, and the structural frameworks they create have a profound effect on population level health.  The racism built into our system of laws, structures, and institutions has resulted in a system that significantly limits the access that black Americans have to the services and conditions required to be healthy.   

Even as states, cities, and counties declare racism as a public health issue, it will take more than a declaration or words on paper to see real change.  We already have a lot of really good words on paper that say that discrimination is illegal. So, while naming the problem is a good first start, without financial resources, mandates, or a prescription for action, many of us are not convinced that these efforts will result in the meaningful, comprehensive, systemic change that is needed.

It can’t just be talk or words on paper. It is time for action.

What can you do to SPARK Change?

Many of my white friends have expressed guilt and have mentioned that they are not comfortable talking about these issues. I’m here to say, if it’s uncomfortable for you to talk about it…don’t.

Instead, focus on learning about these issues on your own. The challenge is often moving from understanding Black Americans and other people of color through the lens of how you would wish to be understood, to understanding us how we want to be understood. But it is important that you do this work on your own. Please don’t ask us to carry this water for you. Interestingly, about 75 percent of white people in the United States don’t even have a black friend, so if you want to spark change on the individual level, that might be a good place to start. Focus on opening yourself up to new people and new experiences and seek to understand the Black American perspective and experience.

And, then, act. Do something. 

As members of this Section, we each have an individual responsibility to foster a greater sense of racial equity and belonging in the field of health law, and in all of our shared spaces. The five step SPARKTM Model for Fostering Belonging that I use in my workshops might be helpful as a framework for action. At the heart of the SPARKTM model is valuing and affirming each other for our authentic identity—our uniqueness.

1.      Step 1: Make SPACE for authenticity –it takes commitment, intention, and courage for leaders and organizations to create environments that are conducive to authenticity and humanity—do it anyway.

2.      Step 2: Learn to be PC: No, not politically correct. Instead be Professionally Competent, People Centered, and Personally Compassionate.

3.      Step 3: Develop an ACCEPTANCE mindset – Remember, no one wants to be tolerated, othered or tokenized. 

4.      Step 4: Sponsor and encourage REPRESENTATION – purposely include more Black Americans at the table and in positions of power; this is one of the best ways to recruit more diverse candidates across the board.

5.      Step 5: KNOW your biases, both covert and overt—we all have them. Learn what yours are and do the work to overcome them.

Belonging means you recognize that I bring my unique background, my race, my ancestry, my culture, my ethnicity, my gender or gender identity, my socioeconomic status, my veterans’ status—all of who I am to the table. And, you accept me as I am. Belonging means that you not only recognize what I bring to the table, but that you value my differences and lived experiences as the asset they are. The reality is that our interests, motivation, health, and happiness are inextricably tied to the feeling that we belong to a greater community that may share common interests, aspirations, or mission. Belonging is the gateway to full self-esteem and true self-actualization.

As a nation, that should be the ideal for each and every one of our citizens, regardless of race.

  1. Fowers, A. and Wan, W., Depression and anxiety spiked among black Americans after George Floyd’s death, June 12, 2020. Washington Post. Retrieved from https://www.washingtonpost.com/health/2020/06/12/mental-health-george-floyd-census/?arc404=true.
  2. Vestal, C., Racism is a Public Health Crisis, Say Cities and Counties, June 15, 2020. Stateline Article. Pew Trusts. Retrieved from https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2020/06/15/racism-is-a-public-health-crisis-say-cities-and-counties.
  3. Id. 

Montrece McNeill Ransom, JD, MPH is the Health Law Section’s 2019 Champion of Diversity and Inclusion Awardee. She is a Speaker, Leadership and Empowerment Coach and Belonging Strategist, and also has experience leading public health law related training and workforce development initiatives. She is the co-editor of the forthcoming textbook, Public Health Law: Concepts and Case Studies, expected to be published in the fall of 2020 by Springer Publishing, and is currently working on a book entitled, “The Little Book on Belonging: How Leaders can Spark Change.” The contents of this column are solely the responsibility of the author and do not represent any agency determination or policy.

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