Addressing the structural forces that perpetuate inequality

I recently published an article on that garnered a lot of attention. It was titled,”The Myth of the Entitled Single Mother Remains as Relevant as Ever.” In it, I reversed the popularized notion that single mothers are a societal liability and suggested that instead, they are powerful forces in our local economies and influential leaders of future generations. I presented the idea that how society thinks about single mothers affects how we fiscally prioritize their needs. The point was, stigmatizing public rhetoric informs pubic policy in ways that perpetuate inequality and contribute to poor health. In response, however, I received a number of comments, many from other physicians, suggesting that such a topic was not “medical” enough to warrant physician concern.

That sentiment sits at the crux of one of the most contentious debates in medicine and frames one of the most important questions facing clinicians today. If inequality drives poor health, what is the physician’s role in addressing the structural forces in society that perpetuate inequality?

To answer this question, we must first unpack the ways enduring public narratives inform our institutions and shape opportunities in America. We must talk about how structural forces in society can align to create predictable patterns of disenfranchisement, including inter-generational poverty and poor health. Let’s get started!

The archetypes society erects to distinguish populations, commonly by race, gender, socioeconomic, martial, or immigration status, are not simple social tropes that define broad categorizations of people. Overtime, and historically in fact, these social constructs lay deep roots in the political processes that govern society, processes that in turn, inform many of the institutions on which society relies, including the justice system, the education system, and the public health system. This pattern of influence is problematic because it allows shared public stereotypes to drive major public policy. This institutionalizes bias and creates inequality. And as we know, inequality drives poor health.

Let’s take one example of this and flesh it out. Look at the effect of race and gender on incarceration rates in America and the associated health consequences.

African-Americans make up 13.1% of the US population and yet African-American males alone, make up 38% of those incarcerated in federal and state prisons today. That means black males are 6 times more likely to be incarcerated than White males and if these trends continue, 1 in 3 black males will be imprisoned at some point in their lifetime.

The origin of the stark racial disparities in the US criminal justice system is complex and multifactorial. It is, in part, related to the disproportionately high rates of poverty,* unemployment, and low educational attainment in African-American communities. But it is also driven by a public narrative that associates black males with criminality. That is why, even when you control for the crime rate, black males are more likely to be arrested, once arrested, more likely to be convicted, and once convicted, more likely to face longer prison sentences than their White peers. This criminalization of African-American males is far from benign and, in fact, may have adverse health consequences for black children and black families.

When 1 in 3 African-American males are projected to be removed from their communities, often at the age of greatest productivity, it has profound effects on the communities in which these men live.** Without their earning potential, these families disproportionately rely on the income of single mothers, many of whom live on the brink of poverty.*** Children who live in poverty are more likely to have poor health as adults, including increased risk for cardiovascular disease, high blood pressure, diabetes, arthritis, and depression. What is more, there is evidence to suggest that these risks persist, despite changing social class in adulthood. That means, there are physiologic pathways whereby systems of inequality and social stress may act to create immutable changes to children’s bodies, affecting everything from their brain development to their DNA. These changes can potentially be passed down to future generations, allowing under-resourced social environments to create predictable patterns of disease.

When considered in this way, it is easy to see how shared public narratives can become entangled in policies that systematically disenfranchise families and communities, dismissing productive members of society, shaping local economic opportunities, and informing the health of our future generations. When the life expectancy of a child can be predicted by the zip code in which they live, it exposes important drivers of health and disease in America. As physicians, we must dissect the threads that connect sociopolitical environments to biological consequences. If that is not “medical” enough to warrant our concern, I don’t know what is.

This is the future of medicine and it requires physicians confront issues of stigma and inequality as a function of their clinical duty to promote health and wellness. Doing so will certainly be a challenge. Success will rely on our ability to understand the impact social, political, and economic environments have on the population’s health and, to systematically incorporate this framework into the canon of medical scholarship and medical education. From there, we will need to build interdisciplinary models that bridge political action with health impacts. Jonathan Metzl and Helena Hansen have mapped a way to do that in their article entitled, “Structural Competency: theorizing a new medical engagement with stigma and inequality.” There is much to do be done. Let’s get to work!

* Communities in poverty have higher rates of crime regardless of racial composition.

** This lends a new urgency to addressing the national gender wage gap, a gap that is wider for women of color, as communities of color may disproportionately rely on the income of women. It also underscores the importance of creating pipelines to higher education for men and women of color, to both supplant the pipeline to prison and to position women of color to occupy leadership roles in the community.

*** Many states also legally revoke prior felon’s voting rights and increasingly, laws and policies are being enacted to limit prior felon’s ability to: obtain employment, receive government benefits like food stamps, access public housing, or qualify for student loans. This results in 1 in 13 African-Americans no longer being able to vote today and prevents countless others from making meaningful contributions to their families and communities.