Connecting the Dots: Health Inequities, Power, and the Potential for Public Health’s Transformational Role

By Jonathan Heller

Illustrations by Jennifer Luxton

Across the country, public health has been moving its practice further and further upstream to address the root causes of health inequities. Over the last decades, we’ve evolved from a focus on behaviors to a focus on the social determinants of health.

More recently, many have been exploring how various forms of oppression — and specifically racism — impact health and health equity. Now, some health departments are strategizing about the root of the root causes: power.

Health inequities are systemic, avoidable and unjust health outcomes resulting from inequities in the social determinants of health. Inequities in the social determinants of health, in turn, result from power imbalances and forms of structural oppression (racism, sexism, ableism, classism, hetero-sexism) used to maintain them.

Simply defined, power is our ability, as individuals and as communities, to produce an intended effect.

Those who have power in society benefit from the status quo and often use that power to perpetuate social and health inequities (sometimes without explicitly understanding we’re perpetuating these imbalances).

We can and must help build power in communities that have long suffered from disenfranchisement — and consequently health inequities — in order to advance equity.

Below are 4 examples of health inequities and their relationship to power imbalances — including examples where public health could do more transformational work and an example where public health has actively participated in policy change for equity. For each, we describe the health inequity, one social determinant of health that leads to the inequity (though we recognize that there are almost always multiple social determinants of health that lead to each of these), the power imbalance, and what public health’s role is currently and could be.


Kids Getting Exposed to Toxic Levels of Lead

Health Inequity: Low-income and Black kids more likely exposed

Low-income and Black children are more likely to be exposed to toxic lead levels, which have been linked to lower academic achievement, behavioral issues, and life-long neurological impacts. (Sources: CDC and CDC)

Health Determinant: Poor housing conditions

Substandard housing conditions result in exposure to lead dust from paint. (Source: National Center for Healthy Housing)

Power Imbalance: Paint manufacturers, landlords not accountable

Courts have ruled that paint manufacturers are not legally responsible for the negative effects of the lead paint they produced and profited from decades ago. Landlords, even wealthy corporate landlords, are not required to carry out lead abatement in most jurisdictions, even when they know that their rentals have high lead levels. Both of these reflect that owners of large corporations hold tremendous power in the US, while those impacted by lead exposure — communities of color and low-income communities — and the organizing groups they form have much less power. (Sources: Mother Jones, SFGate)

Public Health’s Role: Support community-led initiatives

Often public health has taken a transactional approach to lead exposure — testing lead levels in kids, educating people impacted by lead exposure — in essence trying to put a bandaid on after the harm has been done.

Transformational actions public health could take (and have in some places):

  • Supporting community-led campaigns advocating for lead abatement requirements (and supporting the needs of lower-income landlords who might have trouble paying for this on their own).
  • Testifying and providing evidence of the widespread harm in ongoing lawsuits involving corporations that manufacture paint.
To learn more about this issue: Read our recent report, based on a consensus process with over 40 lead poisoning experts and advocates, Achieving Equity in Lead Poisoning Prevention Policy Making.

Loved Ones getting Hurt — or Killed — at Work

Health Inequity: Low-income, immigrant, Latinx at higher risk

Occupational injuries and fatalities are more common for low-income workers, those born outside the US, and Latinx workers. (Source: CDC)

Health Determinant: High-hazard jobs (that no one else will take)

These groups are more likely to work in high-hazard occupations, such as meatpacking and agriculture. (Sources: OSHA, OSHA, BLS, and NPR)

Power Imbalance: Corporate lobbies, employers bullying

Although the labor movement is a primary example of people’s power to organize and advocate for higher wages and better working conditions, the reality is that elected officials often prioritize the needs of corporate owners over low-wage workers.

  • Corporations have fought unionization, which can help workers gain power and reform working conditions through collective bargaining.
  • Corporate owners and alliances they form (e.g., Chambers of Commerce) push back against regulations (e.g., slower line speeds in meatpacking) by lobbying against them in Congress and with regulatory agencies like the US Department of Agriculture and the Mine Safety and Health Administration. (Sources: Work and Occupations Journal, Human Rights Watch)
  • Even when regulations exist, some employers retaliate against workers who report workplace hazards or otherwise assert their rights under health and safety law. These threats discourage many workers from coming forward, particularly undocumented workers who may face immigration-based retaliation for doing so (Source: Bloomberg Law).

Public Health’s Role: Listen and prioritize worker needs

Public health often focuses on education in the workplace. Public health agencies that might do more, like the Occupational Safety and Health Administration, are chronically understaffed (Source: EHS Today).

Public health could partner with directly impacted workers organizing for health, including unions and worker centers, to understand their most immediate needs and prioritize research, practices, or policies accordingly. With them, we can strongly advocate for passage and strict enforcement of worker safety regulations.

To learn more about this issue: Download and explore the Work and Health Equity curriculum from the UCLA Labor Occupational Safety and Health program. You can also organize or join an event for Workers’ Memorial Week 2019 (April 22–28)!

Loved Ones Getting Locked Up for Substance Use

Health Inequity: Criminalizing Black, Latinx people

While substance use and addiction are common across many demographics, the inequity arises from the way some populations — Black and Latinx people in particular — are criminalized for it, while others (mostly White people) are supported through it. (Think about our collective response to crack cocaine in the 1980’s versus our recent response to heroin.) (Source: ACLU and Drug Policy Alliance)

Health Determinant: Involvement in the criminal justice system

Criminal justice system involvement is harmful for individual, family, and community physical, mental, and social health. Black people are over-represented in the criminal justice system, including for substance abuse. (Source: RWJF)

Power Imbalance: Elected officials relying on fear-based tactics

Politicians use overt and/or implicit racism and fear that manifest as ‘tough on crime’ or ‘law and order’ platforms to win office. Once in office, they pass policies and budgets that punish those struggling with substance abuse in order to appease a voting base that has yet to deal with their own anti-Black racism and thereby maintain their positions of power. White communities are complicit in this, perhaps as a way to maintain their own power vis a vis Black marginalization.

Historically disenfranchised Black communities and formerly incarcerated people are organizing and making headway, e.g., with the recent restoration of the right to vote for people with felonies in Florida, but still have relatively little power compared to White people. (Source: The Atlantic)

Public Health’s Role: Advance health-focused community safety

Programs to address substance use and education about drugs are vital, but public health must go further and work to de-stigmatize addiction, eliminate racialized outcomes for those struggling with substance abuse, and promote health-focused rather than punishment-focused responses to what has been legally deemed criminal behavior.

To learn more about this issue: Explore our Health Solutions Create Safety resource, with over 50 examples of programs, interventions, and policies that use public health solutions to address community safety. You can also develop your own analysis and narrative on justice using our Transformational Criminal Justice Narrative Toolkit!

Taking Time Off From Work to Care for Loved Ones

Health Inequity: Low-income workers

People working low-paying service jobs — 85% of restaurant workers for example — lack paid sick days to care for their families or themselves when ill, which increases the spread of influenza and norovirus, unnecessary emergency room visits and hospitalizations, and emotional and financial stress on workers and their families. (Source: HIP)

Health Determinant: Employment, economic security

Access to paid sick days is related to employment and economic security, including working conditions and job benefits.

Power Imbalance Disrupted! Corporations vs. Workers

Corporate owners and the associations they form (e.g., Chambers of Commerce) often use the power they have to propagate a neoliberal worldview that focuses on free markets and reduced government regulation, and to successfully lobby against anything that might impact their short-term profits. But over the last decade, paid sick days advocates have been able to build power so those most impacted by the lack of paid sick days could hold elected officials accountable and, in doing so, bring about change in the legislative arena.

For example, groups organized restaurant workers (e.g., Restaurant Opportunities Center), Latina women (e.g., Mujeres Unidas y Activas), and mothers (e.g., MomsRising). They listened to their members about the issues that affect their lives, built their members’ skills and leadership, worked with them to develop policy solutions, and built their collective voice to demand change.

Those organizing groups also formed alliances with organized labor and other advocates, in formations like Family Values @ Work nationally, and its member group, the California Work and Family Coalition. They built broad and diverse alliances with others, including small business owners. Those alliances were able to further amplify community voice and successfully put forward a different narrative — one based on facts and evidence — about paid sick days that gained prominence: that the lack of paid sick days affected everyone’s health and well being — not just restaurant workers, but anyone who ate in a restaurant; not just day care providers and nursing home workers, but anyone with a child in daycare or a parent in a nursing home. These strategies have led to the passage of guaranteed paid sick days in many places around the country.

Public Health’s Role: Data and a health frame

Public health played a key role in achieving paid sick day policies by providing advocates with data about disease outbreaks and avoidable hospitalizations, contributing to the transformational narrative advocates used, and by advocating publicly and giving testimony in favor of paid sick days.

To learn more on the need for public health to focus on power, check out Power Matters: Transforming Systems to Advance Health and Equity.

These are just examples of a few health inequities and their connection to power. We’d posit any health inequity can be tied back to a power imbalance.

Challenge: Identify the power imbalance in other health inequities

Pick a health inequity from this list of health inequities from the CDC, think about a social determinant of health that causes it, and analyze the power imbalances that lead to that social inequity.

Let us know what you find by adding a response to this post or sending us a tweet: @HumanImpact_HIP.


Jonathan Heller is co-founder and co-director of Human Impact Partners. Jonathan co-directs the organization with Lili Farhang, setting its strategic direction and advancing its mission.

📌 Did you know? Human Impact Partners provides health equity capacity building to public health organizations. Contact us to learn more about our offerings at info[at]humanimpact.org.