Meeting Report: The UVA Healing Hate Conference examined new collaborations and socio-legal frameworks to tackle the injustices of health disparities. Professor Dayna Bowen Matthew. Part 4 or our Healing Hate Conference series.

A multitude of key health disparity indices show that we have not seen significant progress in narrowing the gap between minority and majority populations since the landmark report “Unequal Treatment” in 2003. In many cases, the health gap has widened. UVA Law Professor Dayna Bowen Matthew brought together leaders and experts in health equity, public health, civil rights, environmental justice, and social determinants of health, who together explored how socio-legal frameworks and environmental rights can be effective conduits for bringing about health justice. With host Rolf Taylor.

Episode Transcription

Podcast Episode 49:
Meeting Report: The UVA Healing Hate Conference examined new collaborations and socio-legal frameworks to tackle the injustices of health disparities. Professor Dayna Bowen Matthew. Part 4 or our Healing Hate Conference series.
Posted on June 17, 2020.

A multitude of key health disparity indices show that we have not seen significant progress in narrowing the gap between minority and majority populations since the landmark report “Unequal Treatment” in 2003. In many cases, the health gap has widened. UVA Law Professor Dayna Bowen Matthew brought together leaders and experts in health equity, public health, civil rights, environmental justice, and social determinants of health, who together explored how socio-legal frameworks and environmental rights can be effective conduits for bringing about health justice. With host Rolf Taylor.

Rolf Taylor: Hello and welcome to a special conference report edition of the Health Disparities Podcast, a program of the Movement Is Life Caucus. I’m Rolf Taylor, Movement Is Life steering group member and an executive producer for the podcast series.

The Healing Hate Conference was convened by the Equity Center at the University of Virginia in January of 2020. Focused on examining some of the environmental and health related injustices that have a disproportionate impact on communities of color, the conference examines civil rights with a public health perspective. It was sponsored by University of Virginia Schools of Law, Nursing and Medicine, the UVA Library, the Center for Health Policy, Change Lab Solutions, the Democracy Initiatives Equity Center, UVA, the Virginia Journal of Social Policy and the Law and the W. Montague Cobb NMA Health Institute, aiming to unravel some of the underlying and historical causes of health inequities and health disparities, the conference explored pathways forward. It was a conference in two halves. This podcast reviews the first day hosted by the UVA School of Law, which examined the more environmental and sociolegal aspects of health disparities. Second day at the School of Medicine added the medical perspective bringing disciplines together was the overarching theme of the conference, that the complex challenges of health equity can only be solved through multidisciplinary collaboration. For more insights into the second day of the conference, please listen to the podcast featuring interviews with Dr. Vivian Pinn, Dr. Ron Bailey and Dr. Randall Morgan. We asked UVA law professor and conference organizer Dayna Bowen Matthew to tell us why the conference is so important right now.

Prof. Matthew: The conference is important right now because we have reached a plateau, and in some places, we are actually going backwards. So, in 2003, we had the landmark report that told us that unequal treatment was responsible for health disparities and healthcare disparities. Well, since 2003, there have been many dollars spent, lots of ink spilt, lots of sincere people working and still when we look at key disparity indices such as maternal mortality, infant mortality as the gaps between minority and majority populations are as bad or worse than they were when we first started tackling this problem. So now is the moment for new solutions. Now is the moment for new frameworks and now is the moment for new partnerships to collaborate and address the injustice of health disparities.

Rolf Taylor: And you can hear more from Professor Matthew in her in depth interview, which is part of this podcast series. Opening the conference on day one with a keynote titled, “The Civil Rights of Health”, UC Davis law professor, Angela Harris, spoke about the importance of bringing together advocates across public health, civil rights and social justice to make structural discrimination more visible. To understand structural discrimination, we need to put three key terms in context: social determinants, health disparities and health equity. Professor Harris links these terms in a dynamic way, and that we must understand how social determinants are driving health disparities, and requiring a focus on health equity, and hence solutions. She outlined three P’s that provide context for understanding. Firstly, within the population, which is where social discrimination happens, in place, in the zip code and built environment determines so much of health and power, those things that give and take away the power to act, including the power to vote, personal autonomy, freedom from stress, not being abused and lack of trauma. Whereas the Affordable Care Act sought to extend health insurance to cover pre-existing conditions, to cover more people, and to bring down costs through reforms like value based or bundled payment models. There seems to be a strong alignment in 2020 that healthcare reform is consistently tied to the social determinants of health. Professor Harris discussed how chronic stress of social discrimination together with environmental toxins such as lead poisoning, can have biological impacts at the epigenetic level, adding to the disadvantages of certain groups, particularly people of color.

She referenced several information sources, including the black and white gap detailed by Huffington Post in their 2016 article, the “Seattle Civil Rights and Labor History Project”, which research the consequences of redlining in the past on people’s health today, and found that previously redlined communities have the highest incidence of illness and death today. Turning to rural health, Professor Harris also mentions the book dying of whiteness, which shows how many states that rejected Medicaid expansion have seen the worst impacts on life expectancy. Professor Harris also discussed adverse childhood events or ACEs as a marker for feelings of powerlessness. (If you’re interested in more on ACE scores, please reference episode six of the podcast.) Feelings of powerlessness are key to the process of subordination where certain vulnerable groups are subordinated by stronger or more privileged groups. In understanding this process, Professor Harris described four specific types of discrimination or bias. Firstly, interpersonal discrimination which is explicit, such as hate speech. Secondly, interpersonal discrimination which is implicit such as unconscious bias. Thirdly, institutional bias and fourthly structural bias. She makes an important distinction that in the case of implicit or unconscious bias, there is currently no legal remedy and very, little consequence. So, subordinated groups need protection from unconscious bias. So, we must bring together civil rights and public health advocacy in a socio legal framework, so that litigators can formulate solutions. What this potentially means is that organizations can be held accountable for patterns of unconscious bias within their processes of care, processes that negatively impact vulnerable individuals resulting in disparate care. Professor Harris believes that medical/legal partnerships and the resulting health reforms are not without risk. It’s certainly important to hold impact assessments that focus on race to provide data that can foresee consequences before reforms are codified into law. And there are barriers and challenges to socio legal projects in health reform. Firstly, in the US, there are very few positive legal rights or entitlements for health. Secondly, poverty is a powerful driver for health, but the poor are not well protected. And thirdly, an alliance between public health and civil rights could potentially cause harm through unforeseen consequences. This requires a mindful approach. One example is that researching and then documenting health disparities may in fact lead to stigmatizing certain groups or to characterizing certain populations as broken. As a call for action, Professor Harris calls for three-way partnership between public health, law and social movements together driving for health rights that can be enforced.

Responding to the keynote, a panel discussion examined aspects of the health justice movement concept. Sarah de Guia, CEO of ChangeLab Solutions, discussed how the law is both an expression of our values as a society and also a direct determination of our health. In fact, she says for far too long, discriminatory laws and policies prevented people from living healthy lives. Her group has defined five areas where specific strategies can address the fundamental drivers of health inequities. They are to reduce structural discrimination, reduce poverty and income disparities, reduce disparities in opportunities, reduce disparities in power and to leverage governance to promote health equity. You can find the full report by googling change lab blueprint.

Sidney Watson, Professor at St. Louis University School of Law, discussed how the Affordable Care Act did in fact incorporate health specific civil rights remedies to discrimination in its Section 1557. Although not the highest profile part of the bill, and not easy reading, she said, “It prohibits discrimination based on race, sex, disability and age, and in any federal programs created by the Affordable Care Act.” Section 1557 also references Title 6 of the 1964 Civil Rights Act and Title 9 of the 1972 Act. These historic acts have provided rights and protections in employment, which the ACA sought to extend to health rights. Alexander Tsesis, Professor at Loyola University School of Law, describe the processes of subordination through stereotyping. Hatred, he said is set into stereotypes that lead to discrimination and then the perpetuation of stereotypes, a vicious cycle. He described how subordination affects both healthcare and wider culture as negative over generalizations lead to harmful group defamation which is dehumanizing and becomes the basis for hateful behaviors.

Law professor Ruqaiijah Yearby directs the Institute for healing justice and equity, St. Louis University School of Law. She described how equality is sameness, but equity is fairness and we must humanize equity she said. So that those who are impacted most by inequity have the power to create solutions.

In a second panel discussion, so rights violations in the social determinants of health, focusing on housing, neighborhoods and the environment. The panel examined environmental justice. Vernice Miller-Travis from the Metropolitan Group described how cross referencing the locations of toxic waste sites with the locations of communities of color shows a definite correlation. But issues related to this proximity are under litigated by the EPA. She calls for environmental justice to be understood as a vital component in health disparities, particularly because environmental health is a focus and driver for the social determinants of health.

The next panelist was Professor Marianne Engelman-Lado from Yale. She examined the overall concept of environmental justice, which she says challenges the idea that marginalized people are of less value. Environmental justice is intrinsic to social determinants of health and achieving health equity, she said. She also discussed the importance of bringing together the interdisciplinary groups, which is one of the overarching themes of the conference as we mentioned. That means combining advocacy strategies with civil rights strategies and demanding that EPA responds to complaints. People she says do have a fundamental right to political, economic, cultural and environmental self-determination. Using Duplin County, North Carolina as example, she showed how data and mapping tools prove that the proliferation of pig farming has displaced historical populations of color and making vast areas unlivable and unhealthy, a clear example of both environmental and health injustices. In several examples used by the panel, geo-location and mapping tools can show that roads, gas pipelines and pig farms have all been planned and located in historic communities of color, destroying businesses, cultures and degrading the environment with subsequent health impacts. Data, another consistent theme of the conference is becoming increasingly available. Data is a powerful ally in the use of legal remedies for inequities.

Over a working lunch discussing civil rights and health legislation in Virginia and in the nation as a whole, conference heard from Cameron Webb. Dr. Webb embodies the interdisciplinary ethos of the conference, holding both a JD and an MD, and having served in the White House during the time the Affordable Care Act was developed and written into law. He recommended the audience listen to the 1619 podcast, a collaboration between UVA and the New York Times and mentioned in particular episode four, in which the role of Dr. W. Montague Cobb played in fighting for the first major American health reform in Medicare and Medicaid, and how this shows that the Civil Rights Movement led the fight for universal health. It’s notable that Dr. Cobb gained not only an MD, but also a PhD in anthropology, illustrating again the power of interdisciplinary approaches. Dr. Webb believes that expanding access is now one of the most important parts of policymaking, and that overall affordability is the biggest issue. He also advocates for health in all policies, which means tying all five domains of the social determinants of health to health outcomes, to health policy, and considering the impact on population health of all policymaking.

The final panel of the day returned to the social determinants of health, education, immigration, LGBTQ rights, religious and civil rights. Paul Harris is an assistant professor at the Curry School of Education and Development at UVA. He spoke about the concept of identity foreclosure, how stereotypes that subordinate groups lead to that foreclosure. Young black men may arrive in college with athletic scholarships, he said, but not thrive. He explains that when they find they do not have a professional career in sports, but at the same time, no clear academic path, a crisis of identity or identity foreclosure can be the psychologically catastrophic result. Professor Harris discussed how opportunity and achievement disparities can lead to despair, with the experiences of being part of an oppressed or subordinated group, making it harder to have a positive and resilient identity. He believes the moral imperative is to facilitate hope, based on a non-athletic path in life by sidestepping the stereotyping that pushes young black men towards athletics and away from academics. This needs to take place during counseling at our high schools, where stereotyping can steer young minds in typical directions and obstruct the path of people fully capable of following a non-athletic career path.

Craig Konnoth, associate professor of law at the University of Colorado Boulder, described how although the law may be used as a medicine to advance civil rights claims, the law can also be used to oppress as well as liberate. Historically, homosexuality has been regarded by the law as a disease or a condition, although one of choice he says. In this way, there are established myths, misconceptions and stigmas about sexuality that drive bias in a similar way to those that drive bias in race and ethnicity. Anti-gay initiatives that have negatively impacted the mental health of subordinated groups are often implemented in the name of religious freedom, itself a civil liberty, he says. Another example he gives is drapetomania, a conjectural medical condition attributed enslaved Africans fleeing captivity, medicine being used to oppress.

And finally Luis Oyala, community organizer at the legal aid Justice Center, talked about how many legal Hispanic immigrants who are doing low paid work and eligible for certain programs such as food stamps that can help with the health of their families are shunning such benefits in case they impact their applications for permanent residents. Moreover, he said, the toxic hostility they encountered from people who have power over them takes its toll.

To end the day, a workshop led by the change lab solutions team brought us back to the health justice framework developed by Professor Angela Harris, in a format designed to support attendees’ future advocacy and policymaking.

Hear more from interviews with conference presenters Professor Matthew, Dr Vivian Pinn and Dr Rahn Bailey in other episodes of this Health Disparities Podcast series. I’m Rolf Taylor. Thank you for listening, and until next time, goodbye.