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Dr Mary Bassett delivered the David Sanders Annual Lecture

Author: SOPH

Lecture available for download.

“The Annual Lecture celebrates the Found-ing Director of the School, David Sanders, and his leadership over many years in creating, growing and establish-ing the School as a leading player in Public Health in South Africa and beyond in the Continent and else-where.

As the title implies: Public Health and Social Justice, the Lecture is also a celebration and a commitment to a set of values: equity, social justice and inter-national solidarity that are the centre of our identity and endeavour as a School of Public Health...

#BlackLivesMatter is a social movement fighting for an end amongst others to racial profiling, police brutality, mass incarceration of African American, the militarisa-tion of many US Police Departments and the structural racism embedded in American society.

Dr Bassett’s opinion piece in the NEJM speaks against the silence and denial of this structural violence in public health and medical communities...These are themes that resonate powerfully here. We were very keen to have Dr Bassett come and talk to us about this challenge and what it means for us”

Prof Helen Schneider

Director, SOPH

The 2015 Annual David Sanders Lecture, established by UWC and the School of Public Health in honour of Emeritus Prof David Sanders, Founder and first Director of the School, was delivered by Dr Mary Bassett, Commissioner of Health of New York City.

Dr Mary Bassett, moved by the recent attacks on Americans of African descent in the US, addressed the link between race and health in her lecture, entitled “#BlackLivesMater”. Can such a link be made? Most definitely, argued Dr Bassett in an earlier editorial in the prestigious New England Journal of Medicine (NEJM, March, 2015). Her article provides statistics on health disparities as they affect people of colour and refers to the dearth of scholarly research on this link.

Race and health are critical issues that South Africans can relate to, both in terms of this country‟s past injustices and its present challenges. With her long medical and research background of work in Africa, Dr Bassett was ideally placed to highlight the link between health disparities and inequities and race in the US and South African contexts.

Dr Bassett concludes her NEJM article with a plea:

„As a mother of black children, I feel a personal urgency for society to acknowledge racism's impact on the everyday lives of millions of people in the United States and elsewhere and to act to end discrimination. As a doctor and New York City's health commissioner, I believe that health professionals have much to contribute to that debate and process. Let's not sit on the sidelines.‟

Excerpts from Dr Bassett’s Lecture...

It is wonderful to be in Cape Town to deliver the annual David Sanders Lecture in Public Health and Social Justice. The topic of my lecture is: #BlackLivesMatter: A Challenge to the Medical and Public Health Communities

Speaking about racial justice and population health in South Africa, as an outsider, is of course a huge challenge. So I want to first acknowledge that many, if not all of you in the room lived through apartheid and have powerful personal narratives. So although my talk will focus on the US, and primarily New York City – I plan to speak for 45mins to allow enough time for questions and dialogue, to discuss some of the similarities and differences in our struggles for racial justice.

While efforts to advance social justice are often local – taking place in the streets, in neighborhoods, in communities – injustice and oppression is reproduced through dynamics at a larger scale, so situating this discussion within the broader context of globalization and history, is important.

Our struggles are not independent.

As I am sure all of you are aware, there have been a number of widely publicized deaths of Black men at the hands of the police across the United States in recent months...

In response to these deaths, a powerful movement has emerged under the umbrella #BlackLivesMatter, led by three queer Black women.

While this movement was created in 2012 after George Zimmerman (not a policeman), was acquitted for the murder of 17yr old Trayvon Martin, the use of the hashtag became much more widespread in the last few years in response to police violence, and became a common slogan during demonstrations, with many groups using the language of “Black Lives Matter” to create a sense of urgency around addressing racism and police violence.

...But of course from a public health perspective, there may be unique health needs due to overlapping forms of exclusion and discrimination, as highlighted in the third infographic showing that the average life expectancy of a black transgender woman is 35years – a s hocking statistic on health inequity.

Before continuing, let me be clear that while I am using the hashtag #BlackLivesMatter in the title of my talk, it is to acknowledge that at this point in history in the United States there is real momentum, a movement. I am not directly part of or affiliated with the movement, although of course stand in solidarity with efforts to advance racial justice.

So the question is how should we as health practitioners engage with this movement and seize the opportunity of public outcry to advocate for change?

If we fail to explicitly talk about racism and health, especially at this time of public dialogue about race relations, we may unintentionally bolster the status quo even as society is calling for reform.

...Is there something unique about the skills or values we have as a health community, that could contribute to this public conversation?

And are there ways to work with the artists, journalist, politicians who are already engaged in this dialogue and expand the boundaries of public health practice to help undo injustice and transform power structures which perpetuate poor health for some?

... I am proud to say that the American Public Health Association has been very vocal making the case the health equity is about social justice. And almost two decades ago, in 1998, APHA released a policy statement, recognizing the Impact of Police Violence on Public Health urging governmental entities to increase the involvement of public health professionals in data collection and monitoring of police violence.

But I am not aware of a more recent organized response in support of the Black Lives Matter Movement.

In March I published a paper in the New England Journal of Medicine to encourage critical dialogue and action around racism and health and for health professionals to engage in the larger social movement spreading across the United States under the banner #BlackLivesMatter.

In that piece I argued that ongoing exclusion and discrimination against people of African descent across the life-course, along with the historical legacies of bad policies, continue to shape patterns of disease distribution and mortality. I believe we must be brave to use the term racism. And recognizing that the intent of the #BlackLivesMatter movement is to speak out about injustice more broadly, not only related to police violence, I believe doctors and public health professionals have much to contribute to this conversation.

Unfortunately many health professionals recognize that what they witness daily in terms of the different health experiences and outcomes of their Black patients is unfair, but they stumble toward inaction because tackling racism is daunting and often viewed as divisive and requiring action outside our purview.

I would like to believe that there are at least three types of action through which we can make a difference: critical research, internal reform, and public advocacy. In this talk I will talk primarily on the role of research, data collection and visualization, and how that can be used for advocacy.

Of course, these ideas aren‟t new, and build on nearly two centuries of calls for critical thinking and action advanced by black U.S. physicians and their allies.

And it‟s important to remember this history, good and bad, so that we can really talk about this moment as a movement with roots.

... Critical Research.

I use „critical‟ as an adjective to describe research that is not simply a „technical‟ exercise about using methods correctly, but research which is thoughtful, and grounded in theory.

Theory is essential to ensure that the right questions are being asked, and that the results and policy implications derived are meaningful and effectively communicated. For example, simply showing that people of African descent have poor health outcomes is not useful if there is no discussion/theorizing about responsibility and accountability – who is responsible for the conditions, how can we change them, and when?

... So where are we? I believe that we have come a long way to describe the social roots of disease – and the resurgence of social epidemiology is truly welcome, but we have done little to develop an antiracist model of disease causation – although there are some notable efforts underway.

In policy circles and among those responsible for action on health equity the socio-ecological model (or a version of it) is the most commonly referenced model which incorporates the social determinants of health. This has also been embraced by the CDC in many of its prevention efforts, as you can see in this slide.

But I find the socio-ecological model misleading because it places the individual at the center of concentric circles and creates a visual distance between the outer circles, such as policy, and the individual. This implies that action at the individual level may be more immediate or more impactful, and that policy does not directly „touch‟ the individual – since visually they do not touch - which we know is not true.

At the same time this is still a descriptive model. While it may be a useful model to categorize the social determinants of health, it says little about inequities in the distribution of power and resources, or time (blind to historical events) and place.

Even in the most equitable society, the social determinants of health would be important for public health to consider. But when disparities are as stark as they are in NYC, or South Africa, we must explicitly discuss class inequality, racial/ethnic inequality and gender inequality and talk about the social and political determinants of inequity.

... Models of determinants of population health are not the same as models of determinants of health inequities. This is important... I wanted to point out three things.

First: Population distribution health is at the center – not the individual. This helps us get away from victim-blaming ideologies

Second: Different forms of inequality are explicitly named. By studying ways in which racial inequality, alone and in combination with other forms of social inequality (such as those based on class, gender, or sexual preference), harms health, researchers can spur discussions about responsibility and accountability.

Third: There is a reminder that we must think about the lifecourse, as well as the broader historical and geographic context

... So let me give some examples of how this can be done.

In the mid-1960s there was a distinct convergence of Black infant death rates in the Jim Crow and non-Jim crow states – but this was not the case for White infants.

In 1960-64, the Black infant death rate was 1.19 times higher in Jim Crow than in non-Jim crow states. Between 1965-69, that relative risk declined to 1.07. And because nearly two thirds of all Black infants born in the 1960 to 1964 were born in Jim Crow states, this decline is particularly important.

Of course as you can see this convergence occurred against a general trend of declining infant death rates, and a persistent Black-White gap which continues to today.

NYC’s Sickest NeighborhoodsAsthma HospitalizationsHIV/AIDS DeathsDiabetes DeathsDrug Hospitalizations

And it is important to stress that the racial gap can stay constant and even increase, even when the overall trend is one of progress. This is what we are seeing in New York City. While the numbers are small and there is therefore some variation, as you can see there hasn‟t been a significant narrowing of the racial gap, despite the fact that overall infant mortality rate has dropped to 4.6 per 1000 live births in 2013 as compared to 6.7 in 2000.

In 2013, the infant mortality rate among non-Hispanic blacks was 2.8 times higher than among non-Hispanic whites, down from 3.3 in 2004 and 3.1 in 2012, but worse than in 2000 when the gap stood at 2.5.

A similar persistent and unjust racial gap can be found in the rates of maternal mortality in NYC.

... I believe an area for further collaboration between academic institutions and departments of health, as well as graphic designers and communications folk, is around mapping inequality.

This has a dual purpose:

1) Maps make injustice visible to generate outrage and political will for action/change; and

2) Maps give us information to target interventions appropriately to places with highest need

... Almost a decade ago, as a Deputy Health Commissioner, I helped set up three District Public Health Offices in locations with the greatest need – namely the South Bronx, East and Central Harlem, and Central Brooklyn. When I became Commissioner last year we looked at the data again to see if the targeting was correct, and sadly, although there had been improvements in health in these areas, premature mortality is still concentrated in these same neighborhoods.

Because New York City is highly segregated residentially by race and poverty-level, neighborhood-based approaches and geographical targeting of resources are by default health equity strategies.

But rather than seeing our work at the Department as simply supporting the “neediest” communities, it is important to see this work as “undoing injustice” -- recognizing that the unequal distribution of resources is because political power is concentrated in the hands of too few (often as a result of racism).

With this in mind, as Commissioner I have asked the Department to take community engagement seriously, building real partnerships with those who are at the forefront of social justice activism and supporting community organizing as a tool to effect change across the different sectors that affect a community‟s health outcomes.

Click below to access the lecture slides.

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