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Commentary

Commentary: Addressing Inequities in the Era of COVID-19

The Pandemic and the Urgent Need for Critical Race Theory

Ford, Chandra L. PHD, MPH, MLIS

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doi: 10.1097/FCH.0000000000000266
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A SHIFT toward understanding and addressing health inequities is occurring in Family & Community Health under the leadership of the editors and board. This shift is necessary and commendable for 2 reasons. First, it enables health-related fields to play more central roles in eliminating the root causes of inequities and promoting “optimal health for all” [italics added].1 The idea that optimal health must be available to everyone, not just to those with resources is the essence of the concept of health equity. Former American Public Health Association president, Dr Camara Phyllis Jones, offers a holistic definition of equity as assurance of the conditions necessary for everyone to attain health.

Persistent racial/ethnic disparities in rates of disease in the United States (US) are not new. They were first documented in 1985 with publication of a series of reports from the Secretary's Task Force on Black and Minority Health, which was commissioned by then US Secretary of Health and Human Services, Margaret Heckler.2 The first report of its type, it revealed that Blacks and other racial/ethnic minorities had discernibly higher rates of disease across most health outcomes.2 Research conducted over the last decade shows how structural racism, which drives the social marginalization of racial/ethnic minorities and other vulnerable populations, leads to inequities in morbidity and mortality.3,4 Second, the Journal's shift toward focusing on health equity is also timely. As the SARS-Co V-2, which emerged in 2019 (ie, COVID-19) pandemic takes root in the US, stark racial/ethnic inequities are beginning to emerge in diagnosed cases and in deaths due to the virus.5

As the COVID-19 pandemic expands across the United States, it is also revealing weaknesses in our public health infrastructure, including inadequacies in the approaches used to study, identify, explain, and address inequity. Needed are the more sophisticated understandings of racial phenomena available via Public Health Critical Race Praxis (PHCRP), an offshoot of the Critical Race Theory that originated in the field of law, which was developed for the purposes of conducting anti-racism health equity research.6–8 Gross racial/ethnic disparities in rates of hospitalization and mortality due to COVID-19 highlight the inadequacy of prevention strategies that focus narrowly on virology or pharmacology in mainstream segments of the population while overlooking marginalized, underserved populations. Such approaches ignore the unequal conditions that render some populations more susceptible to the virus than others and that render mainstream interventions less accessible to them; therefore, they represent missed opportunities to promote “optimal health for all.”1 To address the needs of marginalized populations while also addressing those of the overall population, what the nation and the world need now are aggressive interventions targeting racism as a root cause of racial/ethnic health inequities. Although the National Institutes of Health's initial focus on, for example, developing a vaccine is important, and it will address the most immediate concerns, ultimately the mere existence of a vaccine does not ensure the nation's most vulnerable populations can obtain it equitably. The field must acknowledge and address the fundamental role of racism and other social inequalities in shaping the spread of the virus and the capacity of socially marginalized communities and communities of color to overcome it.9

As mentioned, one powerful resource to which community health scientists can turn is the PHCRP. PHCRP researchers (ie, healthcrits) use empirical and nonempirical approaches to name racism explicitly and challenge specific ways in which systems of power operating in the field or in society contribute to racial/ethnic inequities.6 Despite its potential utility, the approach has only recently been introduced to the community health sciences.

As a result, the field continues to examine race, ethnicity, racism, and related constructs using approaches that lack the clarity and nuance available from critical race scholarship. The reliance on simplistic understandings to guide the study of racial phenomena pervades the field, making it difficult to identify and illuminate the underlying mechanisms by which social inequalities contribute to health inequities. For instance, standard approaches routinely misunderstand the role of intersectionality in the relationship between socioeconomic and racism-related causes of poor health.10 Many confuse racism-related causes of poor health with socioeconomic factors, or they underestimate the extent to which racism contributes to apparent economic barriers. The PHCRP provides a lexicon with which to explain racial/ethnic pathways incisively. Researchers draw on the lexicon to theorize, measure, and dismantle the root causes of racial inequities in health. Finally, standard approaches to community health sciences often acknowledge disparities, but do little to address social inequalities undergirding them, which subtly implies the problem is somehow the community—rather than the unequal society in which the community manages to survive. The more nuanced understanding available through the PHCRP also shifts the approach to intervention development from emphasizing a community's deficits to drawing on its assets and sources of resilience. The solutions it enables include community-engaged movements toward racial equity in health.

Inequities in COVID-19 are emerging not only in the US but also around the world. When applying the PHCRP to the study of global health inequities, it is important to remember that racial phenomena are context specific.11 Various forms of racism contribute to inequities within a country or between countries, especially between those in the global South and the global North, but exactly how they manifest is based on the region's historical, social, and political specificities. To enhance its utility, the PHCRP can be paired with approaches targeting imperialism, colonialism, and what Dalautzai and Rana12 refer to as the racecraft that buttresses global white supremacy.

Finally, 2 blind spots in the field hamper more widespread uptake of the PHCRP. First, the belief that scientific data somehow do not contain racial biases within them pervades the field. According to the PHCRP, however, all research contains subjectivities and biases. For example, the nature of funding opportunities may lead researchers to bend their research questions to make them fit within the guidelines of a call for research proposals. This influence on which questions are asked and how they are asked also influences what questions do not get asked and thus do not get answered. Consequently, this reinforces biases toward specific methodologies and metrics that silence or erase the lived experiences of the most marginalized populations. In contrast, the PHCRP views all research as inherently shaped by personal and other (eg, institutional) biases; therefore, it urges researchers to identify, acknowledge, and account for potential biases they may bring to any project through self-critique. Doing so enhances the validity and relevance of the research, though such approaches are not yet widely accepted within the health sciences. Second, although “centering the margins” is a central concept within the PHCRP, few research endeavors truly succeed in elevating community members' perspectives. This may happen if researchers are unwilling to share project resources or decision-making power with community partners more fully. It may also occur if the relationships researchers have with community are weak. These considerations can affect the appropriateness and sustainability of interventions, however, because they do not honor the lived experiences of community members. As with community-based participatory research, the PHCRP attempts to remedy this challenge by emphasizing that projects be informed by and accountable to communities.

The stark racial/ethnic inequities laid bare by the COVID-19 pandemic serve as both a warning and an opportunity. They warn that the standard approaches to community health sciences on which the field continues to rely have failed to eradicate inequities. Rarely do they target the role of racism as a fundamental cause13,14 of inequity. Anti-racism resources such as the PHCRP are now available, however; therefore, it is now professionally irresponsible not to address it. The lethality of this new coronavirus and the magnitude of the COVID-19 pandemic provide an urgent opportunity for the field to lead in addressing the root causes of inequity. One powerful tool on which to rely is the PHCRP.15

REFERENCES

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3. National Academies of Sciences Engineering and Medicine, Committee on Community-Based Solutions to Promote Health Equity in the United States. Communities in Action: Pathways to Health Equity. Washington, DC: National Academies Press; 2017.
4. Ford CL, Griffith DM, Bruce M, Gilbert K, eds. Racism: Science and Tools for the Public Health Professional. Washington, DC: American Public Health Association Press; 2019.
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