In your essay, Shifting from Technocratic to Democratic Solutions: A Radical Vision for Health and Racial Equity, you position the lack of basic health resources for poor Americans as a form of policy violence. Please say more about the concept of policy violence and how it connects to health outcomes.
Policy violence1 is the absence of affirmative policymaking in the face of abject need, and it results in policies that perpetuate structural racism and poverty. The concept of policy violence challenges the notion that the state is somehow a benign or passive referee when, in fact, policymakers sometimes make choices or actively practice neglect that causes harm.
The first time I heard about the concept of policy violence was when I heard Rev. William Barber2 talk about all of the ways that the state practices violence against poor people. He passingly made reference to this notion of policy violence, and I liked the concept. It stayed in the back of my head until a few years ago when we were planning an American Public Health Association plenary panel on violence. I realized that the conversation could address “traditional” violence first; and then the most explicit form of state-mediated violence, such as police killings; and then policy violence, the concept of radical neglect—the idea of looking at a problem, recognizing it’s a problem, but throwing up your hands and saying we can’t solve it.
In the United States, the clearest example of policy violence involving health is the absence of a universal health care system and the fact that we have so many millions of people still uninsured, despite hundreds of studies showing how the lack of health insurance compromises your health. Policymakers’ successful resistance to universal health care schemes, for several decades, is a uniquely American form of policy violence that chooses to ignore the science and the overtly tragic human costs of indifference.
Another form of policy violence in the health space is the movement of new hospitals and health care infrastructure away from places where the medical need is greatest to places where the insurance coverage is best. That’s happening because of policies that privatize hospitals and health care services, so now they’re making market-based decisions about where to operate and whom to serve. There have been egregious cases of this, including by state-funded institutions. For instance, the University of California at Davis closed its MediCal [Medicaid] primary care practice and moved those resources to a suburb where there are higher levels of private insurance.
A third example has to do with stress. We all experience stress; it’s what happens in the body when the brain perceives a threat. That threat may be physical, such as an out-of-control truck veering toward you as you cross a street, or a snarling dog charging at you. It may be economic, such as the fear of eviction because you can’t pay your rent. Or it may be a social threat, in the form of racism directed toward you. In each case, our brains perceive threats in our hypothalamus, which sends a message to the pituitary gland at the base of the brain. The pituitary sends a signal to the adrenal glands, which release so-called stress hormones. The hormones help the body respond quickly and hopefully successfully to the immediate threat. This acute stress reaction is a normal physiological response, and it happens within fractions of a second. When multiple threats are presented simultaneously and over time, the stress becomes chronic. Chronic stress changes the body’s physiology, altering the functioning of the immune, gastrointestinal, cardiovascular, and reproductive systems. Chronically stressed people may experience disordered sleep, anger, and agitation. Over time, chronic stress may contribute to heart disease, high blood pressure, diabetes, and mental disorders such as depression and anxiety.
Research shows that residents of poor neighborhoods, who most often are Black or Latino, are more likely than residents of more affluent neighborhoods to experience chronic stress and negative health outcomes, including a shorter lifespan. But it’s not enough to just know these facts; we also have to understand how the conditions were created. And we know that the residents of poor neighborhoods in the U.S. are disproportionately Black or Latino because of long-standing federal, state, regional, and local policies of racial segregation.
This is what I’m talking about when I refer to policy violence in the health context. Conscious choices and practices like these are essentially meting out violence against people who lack resources and political power.
What types of policy violence are you most concerned about right now?
The lack of an American social contract is the biggest form of policy violence. If you look at other Western, developed countries you see a strong social contract that’s made up of some core universal policies: universal health care, universal childcare and support, universal paid leave and vacation policies, highly subsidized education (including re-education for folks whose industries have closed). Strong social contracts anticipate those needs. But if you look at the U.S. and ask what the universal policies are that make up our social contract, you come up with very few. That in itself is policy violence.
COVID-19 unveiled this policy violence in all of the issues related to health insurance, paid leave, and childcare that essential workers in the U.S. experienced when their children’s schools were closed. We have so many uninsured people who were unable to get health care, who couldn’t get paid time off to be evaluated for illness, who had no doctor to consult, who had to work in order to make money to pay their rent—yet we were blithely telling people who had COVID-19 to stay home and consult their doctor. It was absurd. While in Europe, many countries had proactive policies that paid employers to keep workers on their payrolls rather than firing them or laying then off and then trying to manage the situation through unemployment compensation. Those are the kind of anticipatory policies that make up a strong social contract.
You have said that policy violence inflicts collateral damage. How does this happen?
American poverty violence is unique in that its roots are directly tied to racism, segregation, and American apartheid—and yet, people of color aren’t the only ones harmed by policy violence. For example, we don’t have universal policies for core supports because policymakers never intended for these policies to cover Black people or other people of color. As a result, when poor and low-income White people need [core support] they can’t find it, and they also end up suffering health inequities. We think of this as collateral damage that is the product of racism.
Does the philanthropic community do enough to stop or dismantle policy violence?
The philanthropic community is not a monolithic community. There is a mature philanthropy community that recognizes the weakness of our social contract and has invested in a corresponding way to try to strengthen our civic infrastructure, so that we strengthen the policy base in our society. But other parts of the philanthropic sector are either new or conservative, and many of them see their role as providing pure charity. They take a transactional approach of just trying to paper around the edges where the system is spitting people out, and trying to minimize or reduce the severity of the failure of that system. Another segment of the philanthropic community is obsessed with the notion of disruptive innovation—the idea that there’s a killer app that can solve all of these profound social and political problems. So, I would say there’s a maturity issue in philanthropy: People have to make mistakes in order to learn that you can’t solve this just with disruptive technology and that this is more than a charity issue.
Is the concept of policy violence a frequent topic in discussions about how to frame philanthropic strategies?
I don’t think it has a lot of traction, even in mature philanthropy. People understand the general concept, because during the Trump Administration they saw overt policy violence at the [U.S.-Mexico] border, with kids put in cages and all kinds of other harmful interpretations of existing policies. But I think many people just associate that type of policy violence with malintent at the individual level by people who are determined to exclude certain populations. The kind of policy violence I’m talking about is the bigger concept of a state’s neglect: leaving people on their own to figure things out, coupled with a sense that it’s unsolvable, or we tried something and it didn’t work—”we declared a war on poverty and poverty won.” That’s the kind of poverty violence that I think is most despicable, because it’s papered over by a lie and it represents an unwillingness to explore solutions that actually work.
You write that “patterns of racial health disparities that appear at the macro level cannot be explained by micro-focused concepts of risk behaviors, access to health care, or genetics.” Please explain the difference between macro and micro frameworks for thinking about health, and what the implications are for the strategies used to address health inequities.
One of the biggest problems we have in our public health and health policy conversation is the failure to develop macro frameworks for analysis and, instead, the insistence on applying micro frameworks to macro problems.
In the field of economics, we’re capable of having a back-and-forth conversation about macro and micro analyses. So, for example, when we look at the global financial crisis in the late 2010s, on the micro side—in which the core unit of behavior typically is that of an individual institution or individual actor—we see that people borrowed money on what were basically adjustable-rate mortgages, and when the adjustment happened they couldn’t meet the payments and had to give up their homes. On the macro side, we see the creation of mortgage-backed securities and derivatives that over-leveraged the financial sector, causing it to start to collapse as well.
We seem to be totally incapable of having the same conversation about macro and micro frameworks in the health space. Instead, we tend to apply one of three paradigms. The first is behavioral, and it explains bad outcomes in terms of “bad people” behaving badly: People will experience poor health outcomes if they smoke, drink, drive without seatbelts, have sex without condoms, and so on. The second paradigm involves access to health care, and it’s basically a transactional analysis: The more that people can access doctors, wonder drugs, and medical technology, the healthier they will be. The third paradigm focuses on genetics: Some people are lucky and were born with good genes, and some are unlucky and got bad genes.
The problem is that this medical-model approach to health is a micro solution, and we’ve tried to apply it at the macro level even though all of the science indicates that the analysis doesn’t apply. Those paradigms may work in the doctor’s office where one clinician and one patient are trying to enhance the wellbeing of one person. But they don’t work in the macro context to explain patterns of premature mortality, when there is a 30-year difference in life expectancy across different neighborhoods in the same city. You can’t explain that disparity by individual genetics, access to health care, and behaviors. The only way you can explain it is by understanding, at the societal level, the political overlay of differences in power. Inequity is not merely a technical problem to be solved with a program or service but the result of failed democracy.
Therefore, we have to treat the upstream or root causes of inequity in order to address health disparities. In 2003, leaders at the Alameda County Public Health Department created a health equity framework to visualize and organize public health interventions and strategies across a spectrum, from downstream to upstream. The Iton-Witt Framework for Health Equity situates interventions along a continuum and illustrates how inequity at one end of the continuum leads to health disparities at the other end.
The problem is that our politics are so broken, we don’t even have the ability to have the conversation about macro-level analysis that’s necessary to get us to a solution. As a consequence, our country is experiencing an unprecedented decline in life expectancy, and the limited gains we have made have been well outstripped by other developing countries over the past 30 years. We’re spending disproportionately more on medical care and much less on the social contract, on social benefits and services. And we’re getting poorer and poorer results.
Does the need to work at the macro level put a premium on foundations working ever more closely with public agencies and elected officials?
Absolutely. I do think philanthropy is definitely at the threshold of this, knocking at the door, but I think we’re still importing a bit of the medical model mindset and thinking we can solve this with a single intervention or policy fix, instead of recognizing that the mechanism we need is a more robust, participatory democracy. We tend to rely on people with lots of degrees behind their names to say the solution is about housing policy, or education policy, or something else, when the reality is that every single major policy is creating adverse health outcomes because of the way that the system is tilted against people who lack political power.
How do you see the power-building framework fitting with a policy-change framework?
In Building Healthy Communities, we initially thought of policy change as the end goal and power building as the means to the end. We definitely learned that policy is not an end in itself, and that power is not just a means but really the end goal. If you think that getting the policy win is the end, and then you can say “mission accomplished,” you’re sadly mistaken, because that policy will either not be implemented or will gradually be eroded because of the power dynamics in the institutions that are charged with applying policies. If you don’t build power in community to hold those institutions accountable, your policy win will likely be for naught. So, power building is critical not just to achieve a policy win but also to hold institutions accountable, for the duration of that policy, in an equitable way.
Very few philanthropies are investing in power building. What would have to change in order to engage more of them?
I struggle with philanthropy’s role all the time. If you’re a student of history, you know that change comes from the people most impacted—not from well-heeled, well-intentioned philanthropic institutions. Power building is so fundamental to the success of our society, and to fundamental forms of justice, that it has to come from impassioned, ethical, equity-focused leaders and movements. Philanthropy hasn’t earned the right to be at the tip of the spear.
What has to change? Philanthropy has to reduce the level of hubris it brings to these issues; recognize that social movements are the sine qua non of the kind of change that we’re looking for; and figure out how to play a constructive role in encouraging, nurturing, supporting, strengthening, facilitating growth, and fueling social movements. Black Lives Matter didn’t come from philanthropy. Occupy Wall Street didn’t come from philanthropy. Yet, philanthropy brought their concepts into the public domain, and these concepts are now helping to shape policies around income inequality and racial equity.
Obviously, philanthropy should not be in the way. That’s probably a low bar, but some philanthropy is in the way. When you’re reinforcing transactional approaches to change, you’re basically legitimizing the injustice of the status quo. Philanthropy has to not only challenge the injustice of the status quo but also recognize its role in maintaining and reinforcing the status quo. Even at The California Endowment, we’ve realized that we still use some terms that represent the status quo, such as “program officers” who do “due diligence” on grants. That terminology is all about growing and holding onto assets; it has very little to do with social change or social movement.
You focus in your essay on how Building Healthy Communities worked to build agency—social, political, and economic power—among residents of historically under-resourced communities, like Fresno. Why is community-level agency so important to health equity?
One of the earliest proponents of the concept of agency was Professor Leonard Syme at UC-Berkeley. He was a key contributor to the 1986 Ottawa Charter and the World Health Organization’s Commission on the Social Determinants of Health, which argued that countries must “tackle the inequitable distribution of power, money, and resources—the structural drivers of those conditions of daily life—globally, nationally, and locally.”4
In 1990, Syme hypothesized that the degree of control someone has over their life is fundamental to health. He made this suggestion after observing that risk factors, such as inadequate medical care, unemployment, low income, racism, poor nutrition, poor housing, and poor education, failed to explain why rates of disease increased progressively as one moved down the socioeconomic ladder. It was well understood that risk factors explained why those at the bottom of the ladder endured poorer health than those at the top, but they could not explain the differences between people just a few rungs apart. Syme observed that the one thing that changed with every rung is the degree of control you have over your life. He suggested that control likely encompassed things like money, power, information, and prestige (i.e., social standing). The California Endowment built on that idea by incorporating agency, along with belonging and changed conditions, as the ABCs of Building Healthy Communities.
What are the three most important things you’ve learned about helping to engender and support community-level agency?
First, you’ve got to invest heavily in engaging community organizers, people who know how to build and maintain power and how to identify and nurture indigenous leadership.
Second, and this was a big awakening for us, you have to create time and space for racial healing and reconciliation, particularly in low-income communities where people have been sidelined for generations in terms of decisionmaking. There is a lot of pent-up frustration, anger, and in some cases rage about having been excluded; and it can surface, in ways you wouldn’t have anticipated, between groups within the community that perceive having been slighted by other groups.
Third, there will be blowback. You will be attacked. The forces of the status quo—the mayor, the chamber of commerce, the school superintendent—will attack you and the people you’re working with. And that is the clearest sign that you’re having an impact.
How does narrative enter into the equation?
When we came into Building Healthy Communities, we talked about building power in a sort of nostalgic, Saul Alinsky style, almost reminiscent of union organizing to take on The Man and to show that together we are one, and we can stand up against tyranny. We didn’t quite recognize the role of narrative—the stories we tell ourselves about our collective identity. Political and social narratives shape policies, and the policies create conditions that produce health inequities.
We learned, relatively early on, that narrative is absolutely critical to reordering the policy landscape, especially when working with the formerly incarcerated, undocumented, or LGBTQ+ populations. Because the two questions that came up were, Who are we doing this stuff for—who’s a Californian, who belongs? And, Who decides what the agenda is? Narrative helps to shape both of those two things.
One of the biggest discoveries for us is that there are really only two narratives in the history of America, and everything else is derived from one or the other. Historically and today, most policies stem from an exclusionary narrative that values different people differently and dehumanizes those who are positioned as “others.” A simple example would be how a narrative of racism produced policies of slavery, racial segregation, job discrimination, redlining, racially restrictive covenants, and disparate housing and education opportunities—steering resources away from those who most need them and leading to stark and outrageous social inequities. Another example is former President Trump’s frequent invocation of exclusionary rhetoric against immigrants, describing them as “criminals” who are “infesting” the U.S., which led to draconian border policies and practices that caused young children to be locked up in cages like animals. The trauma-induced psychological and physical health consequences for these children will be lifelong and may well be passed on to their children.
The other narrative is one of inclusion, which is about diversity being our strength. A narrative of inclusion humanizes vulnerable populations by allowing them to tell their own stories. It promotes the goal of health and racial equity for everyone, drawing people away from an us-versus-them mindset. Policies shaped by an inclusive narrative seek to share resources and benefits more equitably, which improves conditions and can lead to health equity.
We also learned that these narratives were not immutable; you can actually build a narrative of inclusion. So we started doing that work, particularly with social media, to tell the story about who we are at the end of the day.
One of biggest lessons of this work is that philanthropy can play a big role in creating an inclusionary narrative. We tend to jump right to policy, particularly on the progressive side, and skip narrative—and you do that at your peril. You have to help create a narrative of inclusion and tell a story of a community, a state, and even a country that is about an identity where people see themselves as belonging. This used to be harder to explain to people before Trump. For all his faults, Trump was an expert at expressing a narrative of exclusion, and he took narrative from being a quiet, seemingly mysterious domain into being an obvious and critical domain about shaping policy and policy-creating conditions.
Is philanthropy figuring out a fundamentally more strategic role in the era of COVID-19 and the revitalized racial justice movement?
There’s an effort now to figure out ways, particularly with local government, to strengthen relationships with organizations that are working in a highly trusted way with highly vulnerable populations. In the COVID-19 setting, it became clear that populations that are vulnerable as the result of policy violence—people who are afraid of immigration authorities, the police, the health department, who are worried about eviction, who are desperately worried about continuing their employment—those folks generally don’t have relationships with government, with philanthropic organizations, or with private-sector organizations. So, when we began to do our education campaigns to tell people where they could get COVID-19 testing and treatment, we realized we were not talking to the populations at greatest risk. They didn’t get their information from our typical channels, and even if they did, they didn’t trust us as entities that could help them navigate this situation. We had to find new relationships, typically with fledgling grassroots organizations that provided grassroots services and had relationships of trust with the populations most at risk.
These frontline organizations do fundraising to keep their lights on, but typically they don’t have the capacity or infrastructure to get government contracts or grants, they don’t have anyone whose job it is to do development, so they don’t seek out grants. We had to create mechanisms for government, philanthropy, and the private sector to be able to interact with these frontline organizations. It took some shoe-leather investigation to figure out which organization was working with whom to ensure they knew of resources—what organization was working with sexually trafficked minors on the San Pablo corridor in the City of Oakland, for instance, or with African immigrant street vendors, the homeless, day laborers, and with other highly vulnerable populations.
We built that infrastructure somewhat de novo for COVID-19 purposes, while we also worked assiduously with the governor’s office and with Blue Shield as they were trying to push out testing and vaccinations. Now that COVID is starting to settle, we’re wondering why we didn’t have these relationships before. They’re critical for everything we want to do for the census and for health care outreach.
Part of the lesson learned is that this infrastructure of grassroots community organizations needs to be embraced, and funded, and respected for its critical role in helping the larger society manage something like COVID-19. We need to build and maintain the capacity to work with these organizations before we run into a pandemic or other emergency, and then when the emergency happens we can leverage it.
What can the fields of policy advocacy, philanthropy, and civic leadership do to amplify and expand the progress toward health equity that Building Healthy Communities has achieved?
Change the narrative. There is some question of how much role philanthropic institutions ought to have in crafting the narrative, or whether we can create mechanisms by which that narrative has indigenous roots. That question is important, but I also think philanthropy’s bully pulpit is important. We have an identity as an organization, so how do we use and leverage that identity in helping strengthen the narrative of inclusion? That’s a question we’re grappling with right now.
Support racial healing and reconciliation. We’re not going to get past this kind of constipated moment that we’re in unless we recognize how we got here, and that requires unpacking the history of discrimination and then creating meaningful space for healing and reconciliation.
Create opportunities for dialogue. We’re not going to move forward without addressing the huge rift between groups that identify themselves, literally, as belonging to different tribes and see themselves as not being in solidarity. We need meaningful dialogue to begin to find common values and common purpose, to repair the polarization that has gripped the country for the past several years, if not decades.
Support organizing and power building. We have a democracy, but we don’t invest in that democracy. Why not? And I’m not just talking about amongst the people we consider to be our friends; we also have to organize rural conservatives and others who have different perspectives, so they feel they have a way to express their voice and their values.
1 The term “policy violence” was first used in the 1960s by the original Poor People’s Campaign. More recently, the revived Poor People’s Campaign has used the term to change the narrative around poverty, positioning it as the consequence of immoral public policy choices that promote and sustain structural racism and inequality.
2 Rev. Dr. William J. Barber II is the President and Senior Lecturer at Repairers of the Breach and co-chair of the Poor People’s Campaign: A National Call for Moral Revival. He also sits on the national board of the National Association for the Advancement of Colored People (NAACP) and headed the NAACP’s North Carolina state chapter in 2016-17.
3 Described in Iton’s accompanying essay.
4 “Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health.” Final Report Executive Summary. (2008). World Health Organization, https://www.who.int/social_determinants/final_report/csdh_finalreport_2008_execsumm.pdf.