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Excerpted from: Dorothy E. Roberts, The Most Shocking and Inhuman Inequality: Thinking Structurally about Poverty, Racism, and Health Inequities, 49 University of Memphis Law Review 167 (Fall, 2018) (79 Footnotes) (Full Document)


DorothyRobertsIn 1966, Dr. Martin Luther King, Jr. singled out one form of inequality as especially egregious: “Of all the forms of inequality, injustice in health is the most shocking and inhuman.” A year later, Dr. King launched the Poor People's Campaign, which connected the ongoing movement for black people's civil rights to a new call for the *168 radical redistribution of political and economic power. He identified racism, poverty, and militarism as related evils that systematically fueled an unjust social order and that had to be fought together to build a better world. By highlighting injustice in health, Dr. King recognized the relationship between gaps in health among populations living in the United States and the institutionalized racism and economic inequality that were at the heart of a widening civil rights struggle.

Today, health disparities continue to be the focus of scientific and policy debates. Biological scientists are investigating whether gaps in health between social groups result from differing social environments or from differing genetic predispositions. Congress is deciding whether to treat health care as a human right or to cut funding for medical services for the poor and allow discriminatory restrictions on their receipt of benefits. Dr. King indicated these questions concerning health, along with debates about inequality in criminal justice, education, employment, and voting, were critical to his dream of a Beloved Community--a society based on justice, equal opportunity,  and love of one's fellow human beings. According to Dr. King, affirming our equal humanity required guarantees of certain basic human rights, including adequate income, food, shelter, and health care.

This Essay interrogates Dr. King's attention to health inequality to illuminate three aspects of the structural relationship between poverty, racism, and health, with a focus on Black Americans. First, health disparities are structured according to political hierarchies in our society. Health status tracks social status. Striking gaps exist in health between black people and white people, poor people and wealthy people, and other socially disadvantaged and socially privileged people in the United States. Health inequality is especially shocking and inhuman because these gaps are so large and cause so much suffering to the most marginalized people in our society. Second, health inequities are structured by the intersection of poverty and racism. Because institutionalized racism has excluded Black Americans from equal participation in the national economy, concentrating poverty and discrimination in their communities, their higher rates of mortality and morbidity are caused by racism and poverty combined. Finally, biological explanations for racial gaps in health that obscure the role of poverty and racism help to more broadly support structural injustice. This Essay concludes by recommending strategies to dismantle structural impediments to good health as well as to reject biological explanations for social inequality.

[. . .]

Dr. King's identification of health inequalities as a key human rights issue calls us to think structurally about the relationship between poverty, racism, and health. To close the appalling racial gaps in health, we must develop strategies to end the structural impediments to good health that are grounded in intersecting economic and racial inequities and supported by biological explanations for social inequality.

These structural interventions occur at many levels. First, to achieve the Beloved Community Dr. King worked for, we must recognize health care as a human right by guaranteeing universal, state-supported, high-quality health care. This includes not only maintaining and generously funding Medicaid, Medicare, and the Affordable Care Act but also working to transform government provision of medical care to ensure coverage for all residents of the United States.

Second, ending health inequities requires eliminating the living conditions that unjustly damage the health of socially disadvantaged communities. This means enacting policies aimed at changing the structures, systems, and institutions that unequally distribute resources that affect people's health. For example, understanding the relationship between lead toxicity and residential segregation led researchers to recommend policies addressing “landlord neglect of private housing conditions and institutional neglect of the indoor environments of daycare centers and schools,” “neighborhood reinvestment,” and “city infrastructure projects.” At the same time, we must end carceral approaches that lock up and punish people for having health problems, such as drug addiction and trauma from experiencing violence. Efforts directed at ending mass incarceration and police violence, which disproportionately involve black people, are critical to achieving health equality in the United States.

Finally, health inequities should be addressed by training health professionals to be more structurally competent. Medical education in the United States typically perpetuates biological concepts of race, the racial concept of disease, and stereotypes about racial differences that contribute to inferior treatment of black patients. Rather  than grapple with racist ideas embedded in the curriculum, medical schools have sought to address physician bias by requiring students to be trained in “cultural competency” to better understand patient lifestyles and attitudes. A growing movement called “structural competency” radically departs from these biological and cultural approaches by contending that “many health-related factors previously attributed to culture or ethnicity also represent the downstream consequences of decisions about larger structural contexts, including health care and food delivery systems, zoning laws, local politics, urban and rural infrastructures, structural racisms, or even the very definitions of illness and health.” Health-care providers need to be more competent at recognizing and addressing these upstream structural factors that determine patients' health and create health disparities.

In 1967, a year before his death, Dr. King reflected on the issues of science, racial injustice, and poverty of the spirit. He stated:

When we look at modern man, we have to face the fact that modern man suffers from a kind of poverty of the spirit, which stands in glaring contrast to his scientific and technological abundance. We've learned to fly the air like birds, we've learned to swim the seas like fish, and yet we haven't learned to walk the Earth as brothers and sisters.

Dr. King was not speaking against science and technology but against a society that promotes science and technology without concern for the equal humanity of all people. A more just society would be healthier for everyone.

George A. Weiss University Professor of Law & Sociology, Raymond Pace and Sadie Tanner Mossell Alexander Professor of Civil Rights, Professor of Africana Studies, University of Pennsylvania.

Vernellia R. Randall
Founder and Editor
Professor Emerita of Law
The University of Dayton School of Law