Fairness and Public Health.

In public health, we are concerned both with the overall well-being of populations, and with the degree to which that well-being is shared by groups within populations—and with the moral implications of when it is not. I have written previously about these moral considerations within the context of social justice. Given today’s proximity to two holidays—Easter and Passover—that have historically inspired reflection on promoting justice, I would like to use this note to discuss a concept that is closely tied to justice, and no less vital to our work—that of fairness.

Fairness has been defined as “the state, condition, or quality of being fair, or free from bias or injustice; evenhandedness.” The issue of fairness in our society—or often, the lack thereof—has played a key role in our public debate. Politically, it has animated both sides of the partisan divide. During the last election, Hillary Clinton and Bernie Sanders both referred to the issue of economic unfairness, and the system being “rigged” against certain Americans. Donald Trump also bemoaned an economic system that he said, not without some justification, marginalizes the middle class.

Beyond politics, however, the promotion of greater fairness is central to public health, in keeping with public health’s abiding preoccupation with human rights, social justice, and the safeguarding of vulnerable and marginalized populations. The Universal Declaration of Human Rights, a document key to the ethical outlook of public health, alludes repeatedly to the quality of fairness, insisting in its various articles that all people have a right to “equal protection of the law,” “equal access to public service” within a country, and “a fair and public hearing by an independent and impartial tribunal” in the event of legal difficulty.

The aspiration expressed by the declaration is, of course, just that—an aspiration, one that we as a society too often fall short of. Few would deny that there is tremendous unfairness in the world. Many of us learn this inescapable truth at an early age, as the cartoon below well illustrates.

Low as the stakes may be in Calvin’s case, his dilemma sheds light on one of the more pernicious aspects of unfairness: Not only is the world unfair, but its unfairness can disproportionately favor some, at the expense of others. This is particularly true in the case of health.

As we know, the United States spends more on medical care than any other country in the world. Yet in terms of access to care, we still face staggering racial and socio-economic gaps (Figure 2).

Perhaps more egregiously, recent efforts by various states to deny women access to basic reproductive care show how easy it is for some politicians to embrace a policy of unfairness and seek to codify it at both the state and national level. In the area of race, unfairness, frequently the unhappy result of deep-seated biases, can be equally easy to observe. A recent study, for example, asked a group of white medical students about the degree to which supposed biological differences between blacks and whites were true or false, including the “facts” that black patients have thicker skin than whites, that their nerve endings are less sensitive, and that their blood coagulates more quickly. The study found that half the sample of 222 total participants agreed with at least one of these false facts; those who did were likelier to report lower pain ratings for black patients, and under-prescribe medication.

The study of population health is, in many ways, the study of unfairness. Often this unfairness is institutional, and deeply rooted in societies. The undertreatment of black pain is just one symptom of the larger problem of racial health disparities that go back generations in this country. One of the main structural drivers of these disparities—and yet another case of how government can promote unfairness—is the ongoing problem of racial segregation. While the 1968 Fair Housing Act (FHA) made housing discrimination illegal, a look at the demographic breakdown of the Boston area makes it plain that, 50 years on, our cities are by no means fully integrated (Figure 3). This is due to a number of factors, including economics, lax enforcement of the FHA, and the legacy of government policies that codified housing discrimination and made it difficult for citizens of color to obtain loans to buy and repair homes. This state of affairs has done much to undermine our collective well-being. The harmful effects of segregation on health are profound and well-documented. These effects include greater exposure to violence and pollution, and less access to nutritious food.

What can public health in general, and we in particular, do to ease the burden of unfairness? Given our school’s threefold objectives to think, teach, and do, I suggest that our approach to tackling unfairness might take the form of the following three steps.

First, and most pressingly, we must name unfairness when we see it. It can be easy to dismiss something like racial disparities in pain treatment, or glaring gender gaps, as simply “the way it is,” especially when the problem is deeply entrenched. Health disparities are often liable to be ignored by groups that are not directly affected by them. Creating a greater awareness of the widespread unfairness in society can therefore be an uphill climb. A 2010 survey found that of 3,159 American adults, only 59 percent were aware of racial and ethnic disparities that affect black Americans and Hispanics or Latinos. And while 89 percent of blacks who took the survey were aware of disparities between black and white Americans, just 55 percent of whites had this understanding. Additionally, only 54 percent of blacks were aware of the HIV/AIDS disparities between black and white populations, and just 21 percent of Hispanics were aware of this disparity between their group and whites.

With this lack of awareness in mind, we must make it clear in our messaging that unfairness is widespread, and that it ultimately harms everybody, not only the populations it seems to most directly affect—leading, as it can, to “spillover effects” like violent crime, drug abuse, and infectious disease, which spell trouble for us all. It is for this reason that we must work to make the acceptable unacceptable, and ensure, through our outreach and our advocacy, that unfairness is never written off as simply an unchangeable part of our cultural landscape. On our translation agenda we stand to heighten public awareness of health disparities through our engagement with the media.

Second, we must see to it that our scholarship reflects the reality of unfairness as it currently exists in our world. This means being both effective teachers and conscientious learners. As educators, our first priority is, of course, to communicate an understanding of unfairness to our students; however, we must also remain open to all that our students have to teach us about the problem of unfairness. The Millennial generation—the generation that most of our students belong to—is proving itself to be an uncommonly astute and activist one, keenly aware of the injustices that they have inherited from past generations and admirably determined to correct the problems they perceive on both college campuses and in society at large. It seems to me that we have a particular responsibility to be receptive to the perspective that our students bring to our community, and to evolve and adapt our approaches to reflect student engagement in all we do.

Finally, we have a responsibility to engage with the political present. This may seem obvious, but we are living in a moment when partisanship at the federal level threatens to obscure the capacity of politics to make the world a fairer place. Just as legislators hold the power to codify and entrench injustice, they also possess the means to create dramatic improvement, sometimes at a single stroke. Consider, for example, the Pure Food and Drug Act of 1906—an emphatically political victory that banned the sale of misbranded or poisonous foods, medications, and drinks, making the marketplace less hazardous for consumers. This victory was orchestrated by the coordinated, methodical work of journalists and advocates, who, together, moved the needle on this vital issue. It is, likewise, in part our responsibility to work towards creating the conditions for change at the cultural and political level through our scholarship, education, and action.

I hope everyone has a terrific week. Until next week.

Warm regards,

Sandro

Sandro Galea, MD, DrPH
Dean and Robert A. Knox Professor
Boston University School of Public Health
Twitter: @sandrogalea

Acknowledgement: I am grateful to Eric DelGizzo for his contribution to this Dean’s Note.

Previous Dean’s Notes are archived at: https://www.bu.edu/sph/tag/deans-note/