Article Critique. attached is article to use

White Supremacy and the Core Functions of Public Health Sirry Alang, PhD, Rachel Hardeman, PhD, MPH, J’Mag Karbeah, MPH, Odichinma Akosionu, MPH, Cydney McGuire, MPH, Hamdi Abdi, MPH, and Donna McAlpine, PhD

ABOUT THE AUTHORS

Sirry Alang is with the Department of Sociology and Anthropology, and the Program in Health, Medicine, and Society, Lehigh University, Bethlehem, PA. Rachel Hardeman, J’Mag Karbeah, Odichinma Akosionu, Cydney McGuire, Hamdi Abdi, and Donna McAlpine are with the Division of Health Policy and Management, University of Minnesota School of Public Health Minneapolis.

Global outrage followed the murderof George Floyd by now former Minneapolis, Minnesota, police officers.

The outrage was targeted at police

brutality—police conduct that dehuman-

izes through the use of physical, emo-

tional, or sexual violence as well as verbal

and psychological intimidation, regardless

of conscious intent—one of the oldest

forms of structural racism.1 In decrying

police brutality, many public health orga-

nizations issued statements declaring

racism a public health crisis, with promises

of change. However, change is stymied

if we do not critically evaluate how the

discipline (scholarship, conceptual frame-

works, methodologies), organizations

(governmental, nonprofit, and private in-

stitutions that seek to promote population

health), and public health professionals

(in academia or practice) contribute to

structural racism that is manifested in

police brutality, among many other

outcomes.

“Structural racism” here refers to poli-

cies and practices, in a constellation of

institutions, that confer advantages on

people considered White and ideologies

that maintain and defend these advan-

tages, while simultaneously oppressing

other racialized groups.2 Structural rac-

ism is sustained through White su-

premacy: the glossary of conditions,

practices, and ideologies that underscore

the hegemony of whiteness and White

political, social, cultural, and economic

domination.3,4 White supremacy makes it

possible for structural racism to repro-

duce over time, albeit with different

mechanisms, from the enslavement of

Black people to mass incarceration.

Consideration of White supremacy

makes visible that structural racism is

“White controlled,”4 and without exam-

ining the former, we will not dismantle

the latter in public health.

Public health is organized in a

framework of three core functions—

assessment, policy development, and

assurance—and 10 essential public

health services (EPHSs). The framework

is meant to help public health “speak

with one voice” about what public health

is and what it aspires to do.5 This

framework has been immensely influ-

ential. Accreditation of public health

departments and educational programs

partially relies on EPHSs and is included

in some state statutes. The EPHSs are

taught in our classrooms, are used for

performance measurement and evalu-

ation, and have helped to communicate

to the public and policymakers what

public health is about.5

The revised EPHSs were recently re-

leased, 25 years after the original frame-

work was developed. The most important

change is that the framework now centers

equity, defined as a “fair and just oppor-

tunity for all to achieve good health and

well-being.”6 In the equity statement, rac-

ism is mentioned as one of the “forms of

oppression” that the EPHSs should ad-

dress. Living up to the potential of equity

requires directly addressing structural

racism and White supremacy. We provide

examples of strategies in the core func-

tions and EPHSs to do so (Table 1 pres-

ents a summary of these).

ASSESSMENT

The core function of assessment is a

focus on surveillance. The first EPHS is to

“assess and monitor population health

status, factors that influence health, and

community needs and assets.” The revi-

sion to this EPHS emphasizes “root

causes of inequities.” If police brutality

and structural racism are root causes,

then our health surveillance systems and

surveys, such as the National Health In-

terview Survey and the Behavioral Risk

Factor Surveillance System (BRFSS),

should routinely track experiences of

police brutality, as well as exposure to

structural racism. Embedding geocoded

information on racial inequities in socio-

economic status in the National Longi-

tudinal Study of Adolescent Health is a

good example of this approach.7 We

should assess indicators of structural

racism, such as racial inequities in

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opportunities, legislation, and policy

outcomes; criminalization and incarcer-

ation; and neighborhood- or zip code–

level inequities in assets, debts, political

participation, housing, and employment

patterns.8,9

In 2002, BRFSS added an optional

module, Reactions to Race, but few

states administered it. That our surveil-

lance systems do not routinely collect

data on racism is one indication of how

White supremacy plays out in public

health: ignoring everyday experiences

of, and exposures to, salient stressors

among Black people, Indigenous people,

and other people of color (BIPOC).

Expanding analyses of the impact of

structural racism and White supremacy

on the distribution of needs and assets

in communities should be a critical as-

pect of assessment.

The second EPHS is to “investigate,

diagnose, and address health problems

and hazards.” Using the example of

police brutality, scholars need to con-

tinue to identify mechanisms such as

mass incarceration, stress proliferation,

institutional mistrust, and economic and

financial strain that link health with ex-

posure to and experiences of police

brutality.1 We must also investigate the

mechanisms through which other indi-

cators of structural racism and White

supremacy shape health outcomes.

Hitherto, public health has accounted

for race in health disparities research

but has rarely examined the role of

structural racism.10

POLICY DEVELOPMENT

Public health’s third essential service is

to “communicate effectively to inform

and educate people about health, fac-

tors that influence it, and how to im-

prove it.” Global protests against racism

and the attention to racial inequities in

the impact of COVID-19 present no

better time to confront White suprem-

acy in communication. However, public

health institutions such as the Centers

for Disease Control and Prevention did

not issue any specific official statements

on structural racism. Statements that

some other public health organizations

have released fall short. For example,

the American Public Health Association

stated:

TABLE 1— Public Health’s Core Functions and Essential Services as an Organizing Framework for Dismantling White Supremacy

Core Functions Essential Services Example Strategies for Dismantling White

Supremacy

1. Assessment

1. Assess and monitor population health status, factors that influence health, and community needs and assets

Routinely track and report respondents’ exposures to and experiences of police brutality and other indicators of structural racism and White supremacy

2. Investigate, diagnose, and address health problems and hazards affecting the population

Investigate the complex mechanisms through which White supremacy shapes health outcomes

2. Policy development

3. Communicate effectively to inform and educate people about health, factors that influence it, and how to improve it

Educate the public and policymakers on indicators of White supremacy and how these might shape the social determinants of health

4. Strengthen, support, and mobilize communities and partnerships to improve health

Ensure equitable allocation of resources and redistribution of power in community partnerships

5. Create, champion, and implement policies, plans, and laws that affect health

Policies must center the experiences of those most affected by structural racism and White supremacy

6. Utilize legal and regulatory actions designed to improve and protect the public’s health

Develop and enforce regulations and policies to dismantle practices that maintain structural racism and White supremacy

3. Assurance

7. Ensure an effective system that enables equitable access to the individual services and care needed to be healthy

Acknowledge racist systems, advocate antiracist policies, and link Black people, Latinx people, Indigenous people, and other people of color with a range of resources

8. Build and support a diverse and skilled public health workforce

Set clear expectations for education on equity. Schools of public health and public health institutions should set measurable goals on racial equity competency for students and practitioners

9. Improve and innovate public health functions through ongoing evaluation, research, and continuous quality improvement

Focus on critical race conceptual frameworks and antiracist methodologies. Mandate measuring and reporting diversity, equity, and inclusion efforts

10. Build and maintain a strong organizational infrastructure for public health

The infrastructure for teaching, research, and practice should be grounded in critical race theory so that the implications of historical and contemporary manifestations of White supremacy are addressed

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[Theorganization]denouncestheuse

of violent methods by law enforce-

ment against peaceful protesters. The

current protests are the result of the

American people rightfully demand-

ing an end to the racial profiling by

some police officers and a system of

structured racism resulting in dis-

proportionate harm to the health

of individuals and communities of

color.11

Although the full statement acknowl-

edges racism as a public health crisis,

it neither educates readers on the

meaning and manifestations of racism

nor implicates White supremacy. Public

health has largely failed to take advan-

tage of this opportunity to educate

the public about racism and White

supremacy, beyond well-intentioned

statements that can often be distilled to

“racism is bad” and “‘they’ [the police,

other institutions, and people who are

racist] need to do better.” Public health

organizations, institutions, and practi-

tioners must actively educate the public

about the role of racism in producing

health inequities. For example, speaking

up against the recent surgeon general’s

report on maternal mortality,12 which

does not mention racism as a funda-

mental cause of racial inequities in ma-

ternal health outcomes, and against

policies such as former president Trump’s

Executive Order 13950, which banned

training in critical race theory, are neces-

sary actions for educating the public about

factors that influence health.

The fourth EPHS is “strengthen, sup-

port, and mobilize communities and

partnerships to improve health.” The

revised version focuses on authentic

relationships to promote equity. Au-

thenticity is difficult to achieve given

inherent power differentials. Public

health leaders, most of whom are White,

primarily make decisions about the al-

location of resources for research and

practice, shape engagement of stake-

holders, and determine whether and

how the perspectives of community

members are used.13 Redistributing

power in community partnerships can

help challenge White supremacy. Our

community partnerships should be

characterized by frequent open con-

versations about power dynamics that

are at play. We also think it is time for

our funding agencies to not fund

community-based research unless re-

searchers demonstrate that the allo-

cation of resources is fair and there is

equitable compensation for commu-

nity partners.

Public health’s fifth EPHS is to “create,

champion, and implement policies, plans,

and laws that affect health.” The knowl-

edge that informs policy should be

grounded in the experiences of those

most affected. But policymakers and

academic researchers are predominantly

White.14,15 As a result, White intellectual

dominance characterizes the production

of knowledge, its translation into practice,

and the formulation of policy. As a pro-

fession, we need to address the reality

that research led by Black scholars who

have the experiential knowledge of how

racism and White supremacy affect

health is less likely to be funded than

research led by their White counter-

parts.16 We must also prioritize work that

centers the experiences of historically

excluded populations most affected by

White supremacy. One way forward is to

engage more meaningfully with grass-

roots organizations such as Black Lives

Matter and to extend our professional

responsibilities to include community-

engaged advocacy for the policy priorities

these organizations have articulated.

Public health must be intentional about

finding ways to create space for those

without formal power to influence deci-

sion-making through the expertise of

their lived experiences, especially expe-

riences of racism.13

The sixth EPHS is “utilize legal and

regulatory actions designed to improve

and protect the public’s health.” Public

health performs this service well when

it comes to enforcement in areas such

as immunization, tobacco, and alcohol

regulations. However, the field is yet to

develop regulations to dismantle prac-

tices that specifically uphold structural

racism and White supremacy. For ex-

ample, public health should be at the

forefront of enforcing regulations to

prevent disposal of toxic waste in Black

and Indigenous communities. Mandat-

ing restorative justice practices that

prevent the disproportionate incarcer-

ation of BIPOC is necessary.

ASSURANCE

Under the core function of assurance,

the seventh EPHS is ensuring “an ef-

fective system that enables equitable

access to the individual services and

care needed to be healthy.” We must

first recognize areas of significant need

and acknowledge how historical and

contemporary forms of racism act as

barriers to accessing services that meet

these needs. For example, public health

institutions and organizations should

address the ongoing mistrust in medical

institutions and the COVID-19 vaccine

hesitancy by first acknowledging the

harm science and medicine have inflic-

ted on Black, Latinx, and Indigenous

communities. Promoting vaccine uptake

must be done simultaneously with ad-

vocating policies to ensure access to

testing, treatment, and other resources

needed to survive the pandemic. For

communities to trust in public health

and utilize the services and systems we

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provide, public health must first be

trustworthy.17

The eighth EPHS is “build and support

a diverse and skilled public health

workforce.” We know that the public

health workforce is disproportionately

White, especially at the supervisory and

managerial levels.14 Schools of public

health are also disproportionately

White. In 2017, only 0.2% of tenured

faculty were Native American, 3.8% were

Black, and 7.4% were Latinx/Hispanic,

and those numbers have barely budged

in years.15 That a predominantly White

profession and discipline is charged with

educating and addressing the needs of

communities that are disproportion-

ately Black, Indigenous, and Latinx sus-

tains White supremacy within public

health. White frames dominate the in-

formation we convey, the interventions

we develop, and the policies we imple-

ment, all of which are often completely

disconnected from the experiences of

the people most likely to experience

health inequities.

The training that public health practi-

tioners often receive is partially respon-

sible for our inability to address structural

racism and White supremacy. Leading

textbooks intended for undergraduate

education often fail to critically analyze

the concept of race and barely touch on

racism. Moreover, a recent review of 59

accredited schools of public health found

that only 33% mentioned diversity, in-

clusion, or equity in their public mission,

vision, or values statements, and 20%

made no mention of any of these terms

in their goals, objectives, or strategic

plans.18 It is encouraging that the revised

EPHS now mentions building a workforce

that “practices cultural humility.” But

cultural humility in place of discussions of

structural racism and White supremacy

will not change much and echoes hang-

ing our hats on the term “implicit bias,”

rather than talking about forms of racism.

To begin to make antiracist training real,

it is imperative that the Council on Edu-

cation for Public Health set clear expec-

tations for education on equity and

racism and that schools and organiza-

tions set goals for racial equity compe-

tency for students and practitioners that

are measurable and for which someone

is accountable. Metzl and Hansen19 have

made the case for structural competency

to be integrated into medical education,

and the same should be promoted in

public health.

The ninth EPHS is “improve and in-

novate public health functions through

ongoing evaluation, research, and con-

tinuous quality improvement.” It has

been 10 years since Ford and Air-

hihenbuwa20 laid the foundation of how

critical race theory could help examine

and address health inequities, but much

of public health research still documents

how health risks, behaviors, and out-

comes vary by race, rarely naming rac-

ism10 and with the concept of White

supremacy almost invisible. We fully

support the recommendations of Boyd

et al.21 for standards that include

rejecting the publication of articles that

use race but do not examine racism.

Dismantling White supremacy through

quality improvement also requires us to

make diversity, equity, and inclusion a

meaningful part of the Public Health

Accreditation Board and Council on

Education for Public Health accredita-

tion standards by requiring institutions

and organizations to publicly report

student, faculty, and workforce statistics

by racial group.

The 10th EPHS is to “build and

maintain a strong organizational infra-

structure for public health.” This service

emphasizes ethical leadership, trans-

parency, inclusivity, accountability, and

equitable distribution of resources.

Yet, many public health teaching insti-

tutions reside on land and have built

endowments by selling land taken from

Indigenous people through displace-

ment and genocide.22 The wealth of

other institutions is grounded in the

selling of Black persons who were

enslaved.23 Public health institutions

have to thoughtfully engage with the

reparations movement within their own

institutions and nationally. And the in-

frastructure for teaching, research, and

practice should be grounded in critical

race theory so that the implications of

historical and contemporary manifesta-

tions of White supremacy are addressed.

CONCLUSIONS

The core functions and EPHSs have al-

ternatively been called “guidelines,” “vo-

cabulary standards,” a “framework,” and

“principles.” They provide a way of mak-

ing sense of what public health is to us

and to others. It is encouraging that the

most recent revision centers the concept

of equity. But to live up to equity in our

EPHSs, they must also tackle structural

racism and its roots: White supremacy. In

the tradition of public health, we advo-

cate going upstream to deliver the

EPHSs, but fully going upstream requires

naming and dismantling White suprem-

acy. Success requires building alliances

across systems to address the range of

social determinants of health caused by

White supremacy.

Assessment must include data collec-

tion, monitoring, and reporting racism

pertinent to the health of BIPOC. Policy

development must center on communi-

cation about White supremacy, building

authentic community partnerships, elimi-

nating regulations that sustain White su-

premacy, and centering the experiences

of people most affected by White su-

premacy. Assurance requires us to

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analyze the impact of White supremacy

on training curricula, scholarship, the

racial composition of the public health

workforce, and the public health

infrastructure.

Sustained underinvestment in public

health is a considerable barrier to achieving

equity in the EPHSs, but this barrier fades in

comparison with the disproportionately

greater underinvestment in people who

are more likely to experience early mor-

tality because of White supremacy. We

believe that addressing White supremacy

does not require more money; it requires

the reallocation of resources.

Although the strategies presented

here are based on deeply and honestly

examining the field and profession of

public health, we echo an earlier call for

self-reflection by individual scholars and

practitioners: “We must ask ourselves if

our own research, teaching, and service

are fundamentally and unapologetically

antiracist.”1(p664)

CORRESPONDENCE

Correspondence should be sent to Sirry Alang, Associate Professor of Sociology and Health, Med- icine and Society, Lehigh University, 31 Williams Dr, Suite 280, Bethlehem, PA 18015 (e-mail: sma206@ lehigh.edu). Reprints can be ordered at http://www. ajph.org by clicking the “Reprints” link.

PUBLICATION INFORMATION

Full Citation: Alang S, Hardeman R, Karbeah J, et al. White supremacy and the core functions of public health. Am J Public Health. 2021;111(5):815–819.

Acceptance Date: December 20, 2020.

DOI: https://doi.org/10.2105/AJPH.2020.306137

CONTRIBUTORS

S. Alang and D. McAlpine conceptualized the article and wrote the initial draft. R. Hardeman, J. Karbeah, O. Akosionu, C. McGuire, and H. Abdi edited sub- sequent versions. All authors contributed to the final revised version.

ACKNOWLEDGMENTS

We thank Paul Erwin and the reviewers for their thoughtful comments. We are grateful to all public health scholars and practitioners who are doing the work of dismantling White supremacy.

CONFLICTS OF INTEREST

The authors have no conflicts of interest.

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