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WHITE PAPER
Court Decisions Demonstrate Need for Public Health
Economy: A Position Statement of Public
Health Liberation
Christopher Williams*, Public Health Liberation Board of Directors
Public Health Liberation, Washington, DC, USA
Abstract
Public Health Liberation (PHL) theory posits that the Public Health Economy is a major economy that warrants a
disciplinary shift in public health. This economy subsumes structural determinants of health under a single analytical
and intervention lens to explicate barriers to health. Following a series of US Supreme Court decisions, the PHL
nonprofit re-issues its call for a new field of study on the Public Health Economy. Their position statement situates
threats to health equity achievement within educational determinants of health, income inequality, persistent racial
disparities, and reproductive health.
Keywords: Health equity, Public health economy, Public health liberation, Determinants of health, Structural inequity,
Affirmative action, Reproductive rights
P
ublic Health Liberation (PHL) is a membership
nonprofit organization that seeks to accelerate
health equity through understanding and affecting
the Public Health Economy. There exist two major
distinct but interdependent economies - the tradi-
tional growth economy and the Public Health
Economy. The concept of the Public Health Econ-
omy is intended to broaden our view of the struc-
tural determinants of health through practice-base d
learning and transdisciplinary synthesis. The inau-
gural PHL manuscript characterized funda mental
features of the Public Health Economy in positing
public health realism.
1
PHL members represent
communities of practice that would most benefit
from better performance in this economy. A radical
reconceptualization of public health theory-build-
ing, training, and research is warranted.
Recently, PHL members gathered in solemn
reflection upon the Court's sw eeping decisions on
reproductive rights, affirmative action, treatment
of LGBT Q þ populations, and the Bruen decision
in 2022. We are experiencing many he ight ened
fears about our short- and long-term health,
safety, and liberty. Chief among them are the
diminishing educational and employment
opportunities for disadvantaged families of all
backgrounds and the immediate health effects on
women, particularly women of color. Social divi-
sion, national disunity, and false narratives on
colorblindness are disconcerting. The role of the
Dred Scott decision in 1857 is instructive of the
potential course of the nation. Ideological purity,
gun v iole nce, and e rodi ng constitut ional pro-
tections pose grave threats to the Republic and the
Public Health Economy.
The nation's founding documents have helped
with understanding this moment in time such as
James Madison's Federalist Paper No.10 (a faction
“united and actuated by some common impulse of
passion, or of interest, adversed to the rights of
other citizens").
2
For all of their faults, our Founders
were attentive to political factionalism (“malicious
exultation over its friends and partisans” that
“refuted their gloomy sophisms” of liberty).
2
Accepted 13 July 2023.
Available online ▪▪▪
* Corresponding author.
https://doi.org/10.53785/2769-2779.11 84
2769-2779/© 2023 Rochester Regional Health.
1
Williams and Board of Directors: Court Decisions Demonstrate Need for Public Health Economy: A Position Statement of Public Health Liberation
1. Equal protection, where?
Communities of practice of most interest to Public
Health Liberation will shoulder the burden result-
ing from these decisions d the concomitant “equal
protection problem” as Justice Sotomayor charac-
terized in her dissent.
3
The effects are likely to
compound suffering and to strengthen aspec ts of
the Public Health Economy that deepen health dis-
parities. The equal protection clause is being used
against communities, yet we do not see where it is
applied at all. Equal protection means that “a
governmental body may not deny people equal
protection of its governing laws. The governing
body state must treat an indi vidual in the same
manner as others in similar conditions and
circumstances.”
4
Whether in fair housing, economic development,
or environmental justice, we struggle to identify
where equal protection is present in our lives and
consistently upheld. In our inaugural manuscript,
we discussed our personal challenges to environ-
mental racism, gentrification, widening disparities
in life expectancy, and government- and landlord-
directed slum lording and displacement.
1
1 Legal
action is usually cost-prohibitive, too resource-
intensive, and yearslong. Often, we cannot find at-
torneys who are willing to take on our cases. Gov-
ernment often delays enforcing existing laws, if
ever, and irregularly pursues legal action against
bad actors.
Growing income inequality is a major social
determinant of health in the US. “ (T)he gap between
the finances of blacks and whites is still as wide in
2020 as it was in 1968".
5,6
“As of 2016, the most
recent year for which da ta is available, you would
have to combine the net worth of 11.5 black
households to get the net worth of a typical white
U.S. household."
5,6
“Strong evidence linking income
and health suggests that policies promoting eco-
nomic equity may have broad health effects."
7
Against this backdrop, poverty is the fourth leading
cause of death in the US.
8
The facility of th e Public
Health Economy to ful fill the public health mission
is at stake.
The US is far from perfect, but we need to
acknowledge and support its progress, including the
role that affirmative action had in rightsizing equal
access and opportunity. Affirmative action is much
construed as a pejorative in the Court's opinion, but
affirmative action was a necessary steppingstone to
our professional deve lopment and ability to
contribute to society as educators, community
leaders, and researchers. Despite the new reality,
affirmative action is our best hope for equal ity given
the unfinished work of justice and equality. We fear
a dark future of regressive decisions and state pol-
icies. Although the pace of change in the Public
Health Economy is too slow, the nation nonetheless
was building on its ideals that were centuries in the
making. The amicus briefs in favor of the univer-
sities in the affirmative action case were two-to-one
to those that opposed.
9
Diversity, equity, and in-
clusion were moving in the right direct ion.
There is growing fear that the Court's decision on
affirmative action will “discourage corporations
from putting in place ambitious diversity policies in
hiring and prom otion."
10
That is not all. At least one
justice suggests revisiting contraception and same-
sex marriage that “in future cases, we should
reconsider all of this Court 's substantive due process
precedents.”
11
Racial data collection may be threat-
ened and deal a major blow to public he alth data
collection and planning if colorblind posturing fol-
lows its logical end point, “the way to stop
discrimination on the basis of race is to stop
discriminating on the basis of race."
12
2. Worsening public health economy
The Public Health Economy is hardly close to
equity, which we fear will be more encumbered in
the future. US maternal mortality is worsening and
nearly three times greater than high-income coun-
tries overall.
13
Black maternal mortality is 2.6 times
higher rate than that of White women.
13
In the
aftermath of the Dobbs decision, a majority of sur-
veyed OBGYNs said that its effects have worsened
racial and ethnic inequities in maternal health
(70%), management of pregnancy related medical
emergencies (68%), and pregnancy related mortality
(64%).
14
“Regrettably, people who already had
poorer-than-average access pre-Dobbs face even
greater health burdens and risks."
15
Education is an overlooked major social determi-
nant of health. Educational attainment is strongly
associated with life expectancy, morbidity, and
health behaviors.
16
Some groups have been scape-
goated and unfairly marginalized in the affirmative
action debates. In undergraduate medic al educa-
tion. “Black or African American and Hispanic or
Latino medical students' percentage of U.S. medical
school matriculants has hardly changed since 1980;
respectively, 6.0% versus 7.1% and 4.9% versus
6.3%".
17
Justice Sotomayor's dissent portends a dire
future based on outcomes in California.
“At the University of California, Berkeley, a top
public university not just in California but also
nationally, the percentage of Black students in the
freshman class dropped from 6.32% in 1995 to
2
Advances in Clinical Medical Research and Healthcare Delivery, Vol. 3 [2023], Iss. 3, Art. 11
https://scholar.rochesterregional.org/advances/vol3/iss3/11
DOI: 10.53785/2769-2779.1184
3.37% in 1998. Latino representation simil arly
dropped from 15.57% to 7.28% during that period
at Berkeley, even though Latinos represented
31% of California public high school graduates.
To this day, the student population at California
universities still “reflect[s] a persistent inability to
increase opportunities” for all racial groups.”
3
Such a dramatic decline in enrollment of Black
and Latino students in US higher education, as in
California following voter approval of Proposition
209, is an untenable position.
Admissions practices such as legacy and use of
standardized tests have racially disparate imp acts
that disfavor Black and Latino applicants. Our
members discussed the conflation of SAT perfor-
mance with perceived worth and aptitude. Data
from the state of California show that race, family
income, and parental education account for 43% of
the variance in SAT score.
18
In other words, the
influence of these factors, which are outside of the
control of individuals, undermine the use and
quality of the SAT by suggesting that it may be more
affected by social class and family bac kground than
affirmative action critics are willing to admit. We
have personally experienced the social stigma and
emotional harm that poor reasoning on the meaning
of SAT performance has caused. These same critics
overlook the racially discriminatory practice asso-
ciated with legacy as a determinative tipping point
in college admissions.
The relevance of the SAT has been closely asso-
ciated with student outcomes during college.
18
We
find that this line of reasoning is fallacious an d
comes at great emotional and social cost to students
from modest income families, regardless of race. In
our experiences in the last three decades in higher
education as students, administrators, and pro-
fessors, the institutional culture and student
mistreatment within higher education have erected
barriers to a positive student learning environment.
To justify SAT based on student outcomes mini-
mizes the adversity and added stress that disad-
vantaged students had to overcome.
3. The future of public health economy study
on race
We also discussed the social and political con-
struction of race. Rather than wish away race and
racism, we should lean into it d preserving race
and ethnicity while enriching and modernizing
analytical approaches. There is much to study and
affect for descendants of families of slavery and Jim
Crow, families experiencing intergeneratio nal
poverty, victims of environmental injustice and
racism, those experiencing labor exploitation, in-
come-driven or forced displaced populations,
exposure to poverty, and chronically low-resource
environments.
Racial identity is central to Black Americans. “A
majority of non-Hispanic Black Americans (78%) say
being Black is very or extremely important to how
they think about themselves."
19
Black Americ ans
are not a monolithic group with an exclusive share d
history, culture, or set of beliefs, even racial identity.
Yet, racial identity shapes cultural, religious, and
political expression. The philosophy of colorblind-
ness by “deeming race irrelevant in law does not
make it so in life."
3
There is no genetic basis for race,
but the racialization of US society cannot be denied,
“centuries of racism in this country has had a pro-
found and negative impact on communities of color.
The impact is pervasive and deeply embedded in
our societydaffecting where one lives, learns,
works, worships and plays and creating inequities
in access to a range of social and economic bene-
fitsdsuch as housing, education, wealth, and
employment."
20
Racialization of US society, borne
out of slavery and reinforced over centuries, has
come at great costs to African Americans. Yet,
through their collective struggle and liberation, this
racialization has solidifi ed th e foundation on which
they have sustained and thrived within hostile
conditions.
Latinx members of PHL shared that race is not a
readily accessible concept. Indeed, the history of
racial construction in the US has largely posited a
dichotomy between Blacks and Whites and forced a
false choice for a sizable share of the Latinx popu-
lation. Forty-two percent of Hispanic or Latino re-
spondents selected “some other race” in the 2020 US
Census.
21
Hispanic and Latinx identity remains
strong.
Public Health Liberation is sensitive to all pop-
ulations most disadvantaged in the Public Health
Economy. As such, we must endeavor to understand
and define those who are most burdened by and
would most benefit from accelerated gains in the
Public Hea lth Economy without jettisoning race.
Our research should reflect richness and cultural
sensitivity to the value of racial identity. For health
equity advocates, it will do us no favor to support
racial erasure. That is not to say that we cannot
conduct subgroups analyses. In fact, a substantial
body of evidence has shown public health benefits
for examining Hispanic/Latinx ethnicities (e.g.,
Puerto Rican, Cuban, Mexican) to better explain
health disparities.
22
3
Williams and Board of Directors: Court Decisions Demonstrate Need for Public Health Economy: A Position Statement of Public Health Liberation
White ethnicities exist too, as former US Virginia
Senator Jim Webb reminded us in his book on the
Scots-Irish of Appalachia, “Their cultural identity
reflected acute individualism, dislike of aristocracy
and a military tradition, and, over time, the Scots-
Irish defined the attitudes and values of the military,
of working-class America, and even of the peculiarly
populist form of American democracy itself."
23
West
Virginia delegates took part in the Poor People's
Campaign in 1968. Here in our community of
practice in Washington, DC, their interracial
contingent was housed right in our neighborhood.
They wanted the same as other attendees d eco-
nomic justice for poor people.
Public Health Liberation strongly believes that the
study and effectuation of the Public Health Economy
must be the new frontier of public health. Consid-
ering recent decisions, public health would
strengthen disciplinary training by examining how
health inequity is made and reproduced. For
example, PHL members considered in our recent
meeting how debates over states' right loom large in
judicial determinants of health d ahallmarkofUS
political history from its inception. In Roe v. Wade,
the Court decided, “A state criminal abortion statute
of the current Texas type, that excepts from crimi-
nality only a lifesaving procedure on behalf of the
mother, without regard to pregnancy stage and
without recognition of the other interests involved, is
violative of the Due Process Clause of the Fourteenth
Amendment."
24
Essentially, the states' right issue
was re-argued under different political and judicial
conditions in the Dobbs decision. It benefits public
health discourse to understand this point d and a
broadened view of the Public Health Economy.
Conflicts of interest
The authors have no conflict of interest.
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Advances in Clinical Medical Research and Healthcare Delivery, Vol. 3 [2023], Iss. 3, Art. 11
https://scholar.rochesterregional.org/advances/vol3/iss3/11
DOI: 10.53785/2769-2779.1184
