Boland S, Homdayjanakul K, Reed N, Wesner C, Basha E, Kaufman C, Jackson L, James K. Addressing the cycle of inaction: a DrPH student perspective on the decolonization of public health. HPHR. 2021;35.
An expansive body of literature confirms the existence of health inequities in the United States (U.S.), disadvantaging communities of color. These inequities reach beyond medical causes; they are the direct result of unjust sociocultural, behavioral, economic, environmental, and societal inequalities. Health inequities are perpetuated by centuries of bias and discrimination that continue to persist, especially toward communities of color.
To address health inequities, Doctor of Public Health (DrPH) students have a role and responsibility to be a nexus for systems-level change across public health practice, research, and education. DrPH students can make significant contributions through research, education, and practice, and lead advocacy efforts within their institutions for the decolonization of public health. Decolonization in public health can occur through the creation of new paradigms for funding agencies and training DrPH students as scholar-activists in ways that ground research, education, practice and dissemination in partnership with communities. A deeper and adaptive understanding of inequities and the needs and resources required along with a collaborative and collective effort across the entire public health system could inspire community-based policies and improve public health interventions.
As Doctor of Public Health (DrPH) students, we have the responsibility to lead and hold accountable institutions and structures that perpetuate systemic inequities. The purpose of this commentary is twofold: (1) we highlight the role of colonialism in perpetuating long-standing inequities among communities of color in the United States (U.S.) and abroad, and (2) we provide calls to action for decolonizing public health institutions from a DrPH perspective. In this commentary, we call for new funding paradigms that are informed by a truth and reconciliation (TR) process to acknowledge centuries of inequities, harm, and systemic racism (Truth & Reconciliation Commission, 2015). We also outline specific guidance for schools of public health, emphasizing the need for training DrPH students as scholar-activists.
An expansive body of literature highlights marked health inequities in the United States (U.S.), disadvantaging communities of color. The examples are extensive, including a maternal mortality rate for Black women four times higher than for non-Hispanic White and Latina women (Chinn, Martin, & Redmond, 2021), American Indian and Alaska Native (AIAN) youth suicidal ideation levels two to three times higher than for non-AIAN youth (Centers for Disease Control and Prevention, 2020), compromised mental health among Asian Americans due to the sharp increase in Asian xenophobia and racism during the COVID-19 pandemic (Cheng, 2020), and decreased access to healthcare services by Latinx immigrants because of fear of deportation (Rhodes et al., 2015). Although race may be falsely interpreted as the risk factor in each of these examples, it is a social construct. Racism is the driver of these inequities in health and life expectancy within the U.S. These inequities expand beyond medical causes; they are the direct result of unjust sociocultural, behavioral, economic, environmental, and societal inequalities. Health inequities are perpetuated by centuries of bias and discrimination that continue to persist, especially toward communities of color.
To effectively address health inequities, DrPH students have a role and responsibility to be a nexus for systems-level change and a bridge across public health practice, research, and education. DrPH students are often trained to lead outside of academic institutions and make significant contributions to public health research, practice, and education. Thus, DrPH students and professionals are well-positioned to advocate across public health institutions for the decolonization of public health, including prioritizing non-Westernized approaches in public health. Decolonization is the active and calculated resistance to the forces of racialized hegemony that systemically considers the interests of only one community at the expense of other communities (Waziyatawin & Yellow Bird, 2005). We believe decolonization of public health institutions can occur through the creation of new paradigms for funding agencies and training public health students, specifically DrPH students, as scholar-activists in ways that ground research, education, practice, and dissemination in partnership with communities.
Decolonizing approaches elevate community partnerships, which are especially important in understanding community-defined needs and cultural norms. Community-led approaches contribute to effective solutions and address barriers that lead to poor health outcomes, such as the case of delayed detection of breast cancer and lack of tailored treatment approaches which could increase survivorship (O’Mara-Eves et al., 2013). This gets at the heart of addressing health inequities and inclusion, and is critical to integrate into DrPH training. By amplifying communities’ voices and sharing their authentic stories, DrPH students can reshape the complex systemic and structural barriers that disadvantage communities of color, as well as influence researchers, public health practitioners, and policy makers. A deeper understanding of inequities and the needs and resources required, along with a collaborative and collective effort across the entire public health system could inspire community-based policies and improve public health interventions.
The histories of public health and colonialism are intricately linked. The field of global public health finds its historical roots in tropical medicine. It was a colonial-era discipline invoking images of disease-infested Black and Brown populations who were seen as disease vectors to the colonists (Holst, 2020). Hegemonic powers from the Eurocentric “Global North” sought to study infectious diseases found in colonized territories and to prevent the infection of colonizers and the subsequent spread of infection to the “Global North.” The study of diseases of the largely colonized tropics was rebranded into “international health” and now “global health.” However, the use of the term ‘tropical medicine’ still is widespread, primarily in hegemonic societies, despite the emancipation of nearly all colonies and expansion in scope (Holst, 2020). It is important to understand this history to understand how colonial practices still exist and perpetuate systemic racism in the U.S. and abroad.
Public health in the U.S. has a long-standing relationship with racism ranging from the “Better Babies Contests” beginning in 1908 and spanning over a decade where Black and Brown babies were not included, reinforcing the foundational aspects of white supremacy (Stern, 2002); forcible sterilization of the “unfit” through support of eugenics and Buck v. Bell in 1927 (Reilly, 2015); and harmful research agendas in Indigenous communities like those which affected the Havasupai Tribe in Arizona from the 1980’s to 2010 (Claw et al., 2018). Public health as a field is embedded within a larger American system of structural racism and violence. As a result, the field has been infused with racialized biological science, eugenics, and health-related stereotypes used to justify the unequal treatment of various communities based on race, income, and education. Practices that perpetuate the system of inequity are neo-colonialist in nature; historically oppressive practices evolved into extant structural oppressive systems. These systems continue to preserve racism and structural violence in Indigenous communities, communities of color, and low- and middle-income countries.
Current standards of public health research, evaluation, and data are grounded in schools of thought from the “Global North.” Knowledge from traditional practices and oppressed communities have historically been dismissed as secondary to the colonial settler’s way of knowing. This practice has far reaching impacts across public health (Lawrence & Hirsch, 2020). Neo-colonialism pervades the individual researcher’s approach and can be found in subsequent levels of the research enterprise, including the structural funding level. At the individual researcher level, neo-colonialist practices include approaches to collaboration that do not center the community, determination of research priority by the researcher, excluding community expertise, devaluing local knowledge, disallowing data ownership by the community in which research is being conducted, perpetuation of harm through use of colonialist language, and prioritization of the researcher and research team in manuscript authorship.
At the funder level, neo-colonialist policies include setting requirements that do not prioritize community-defined research objectives, project designs, evidence, and practices (Glickman et al., 2009). Adequate time to build trust with community partners and sustainable collaborations that build capacity are seldom placed at the forefront. Priorities for research and practice are usually determined by the funder, not the community. For instance, the U.S. Centers for Disease Control’s program funding in other countries is structured around what the U.S. considers as best practices, not necessarily prioritizing Indigenous ways of knowing (King, 2002). Current means of compensation beyond direct funding often emerges as offers of authorship on published works. Authorship should not be used as the primary currency in which to facilitate reconciliation for previous experiences of colonialism—it is only beneficial to those within academia.
Addressing neo-colonialism also requires intentional awareness of how the language used when working with communities can be a form of oppression and how certain terms were formed in the context of power and privilege. Terms such as “stakeholder,” “beneficiary,” and “Third World” preserve colonialist-era power dynamics and further advance the misguided tendency to save those who are seen as oppressed or disadvantaged (Abimbola et al., 2021). Language can be a tool used to redistribute power as much as it has historically been used to fortify centuries of oppression.
The need to decolonize and rebuild public health manifests in our most recent global pandemic, the COVID-19 pandemic, for which the World Health Organization’s Director-General called the response “a hangover of colonial mentality” because it has perpetuated structural violence against communities of color (BBC, 2020). This global pandemic has laid bare the lack of equality in U.S. and global health systems. Equity cannot be achieved until systems that uphold racism and structural violence are dismantled. DrPH students can address these issues head on by advocating for and leading public health research, practice, and education through a decolonization lens.
Public health institutions, including funding agencies and schools of public health, have the opportunity and responsibility to directly support decolonization efforts. Decolonization of public health involves creating a new paradigm for funding agencies that facilitates public health research and practice at the community level by centering community in every aspect of collaboration. To shift the paradigm in knowledge and leadership, schools of public health must support reflexive and critical public health practice. The following sections describe the transformative changes needed across these institutions and outline specific calls to action (Table 1).
Table 1: Calls to Action for Decolonizing Public Health Funding and Academic Institutions
Schools of Public Health
Funding agencies that support public health systems, research, and practice are key drivers of public health agendas. As a decolonizing approach, TR should be institutionalized in global and domestic funding agencies that support public health systems, research, and practice. The process of TR may include establishing a commission tasked with developing a comprehensive report on inequities, harm, and stories from the people and communities affected; endorsing calls to action and responding to the recommendations outlined in the report; establishing a protocol for ongoing relationship building with communities who have experienced harm; integrating calls to action into organizational strategic plans; and developing organizational policies that promote learning about TR (Smylie, 2015; McNally & Martin, 2017). New funding paradigms will emerge through institutionalizing these practices—paradigms that prioritize and scale resources to address systemic inequities, such as using vertical equity (targeting funding to communities in greatest need) as a model for public health funding (Joseph, Rice, & Li, 2016) and equitable funding for researchers of color (Ginther et al., 2011). Furthermore, these new paradigms align with principles of data sovereignty, which include honoring the inherent rights of Indigenous peoples and communities, data ownership and disaggregation, research ethics, and self-determination at all stages of research, including data collection (Kukutai & Taylor, 2016).
The COVID-19 pandemic has disproportionately affected communities of color resulting in excess morbidity and mortality and exacerbation of health, socioeconomic, and educational inequalities due to long-standing structural injustices (Fortuna et al., 2020). To sustain progress toward advancing health equity with and for these communities, funding agencies should scale investment in addressing racism—a key social determinant of health and driver of health inequities (Paradies et al., 2015). Decolonizing funding paradigms center community priorities, align with principles of community-based participatory research (CBPR) and its evolving methodology, legitimize non-Western research methodologies, and employ anti-racist approaches (Blue Bird Jernigan et al., 2015; Israel et al., 2010; Wallerstein, Duran, Oetzel, & Minkler, 2017; Walters & Simoni, 2009). Moreover, decolonizing funding paradigms endorse systems thinking and call for multi-level interventions that address social determinants of health and improve quality of life (Blue Bird Jernigan et al., 2015; Jernigan, D’Amico, Duran, & Buchwald, 2020).
To decolonize public health practice and research, training programs, namely schools of public health, must also be transformed. Equity must be embedded in the very framework of schools, including in educational content. Only recently, in 2016, the Council on Education in Public Health (CEPH), which accredits and sets educational standards for U.S. and international public health training programs, added a competency that touches upon anti-racism: “Discuss the means by which structural bias, social inequities, and racism undermine health and create challenges to achieving health equity at organizational, community, and societal levels” (Hagopian et al., 2018). CEPH accredited schools are required to demonstrate their students are trained in and proficient in each competency. However, adding just one competency did not dramatically alter school priorities. A 2019 study found that one-third of CEPH accredited schools did not promote diversity, equity, or inclusion (DEI) as central tenets of their school (Merino, 2019). The racist murders of 2020, including but not limited to Ahmaud Arbery, Breonna Taylor, George Floyd, Tony McDade, and Rayshard Brook (McCluney, King, Bryant, & Ali, 2020), spurred many CEPH schools to add DEI language to their landing page, mission statements, and strategic plans. Words, however, are only as strong as their supporting actions. Thus, we call on schools of public health to publicly denounce racism and other forms of discrimination and look internally at their own teaching practices and classroom environments in order to decolonize the profession.
One strategy that shows promise in the public health classroom is modeling critical reflexivity, the practice of questioning assumptions, and the power to raise consciousness (Freire, 1973; Wigginton, Fjeldsoe, Mutch, & Lawler, 2019). Reflexivity fosters partnerships, empowers patients and communities, and improves the quality of public health research (Aronowitz, Deener, Keene, Schnittker, & Tach, 2015). One approach to modeling reflexivity is to teach a course on it, such as at the core public health promotion course created at the University of Queensland in Australia (Wigginton et al., 2019). In this course, students proposed solutions to real-world scenarios and subsequently considered issues of identity, power, and ethics in their response. We need more courses like this in the CEPH DrPH training curriculum that require students to consider how their values and lived experience shape their current and future practice. We would also like to see schools teach Public Health Critical Race Praxis (PHCRP), which provides a framework for public health researchers and practitioners to challenge their own praxis (Butler III, Fryer, Garza, Quinn, & Thomas, 2018). Central to PHCRP is the practice of “centering in the margins,” whereby the perspectives of socially marginalized groups and individuals are prioritized (Ford & Airhihenbuwa, 2010). Instructors can practice both critical reflexivity and PHCRP by challenging which authors and languages they include in the course curriculum, choosing to elevate voices of color and other marginalized identities. Instructors can also challenge how they teach and model public health practice, bringing in non-Western methods and traditional ways of knowing. Our language and actions have the power to either replicate or disrupt unequal power distributions.
The class and school climate must be cultivated to support critical conversations that balance “emotional safety and honest truth-telling” (Peek, Vela, & Chin, 2020). Due to inequitable power dynamics within a school, students of marginalized identities may not feel safe speaking up in the classroom. Instructors are responsible for ensuring confidentiality and showing their own vulnerability. In our own education, learning from speakers of diverse identities cultivated empathy and reflection. Explicitly naming racism and injustice in the classroom is also critical to increasing student self-awareness and the ability to identify injustices (Abuelezam, 2020).
The scope of public health can have far-reaching effects that touch individuals and communities in multiple ways – water sanitation, vaccination, even the display of fruits and vegetables in a grocery store. However, despite the varying ways in which public health research or practice may incrementally benefit some communities, inequities continue to rise in communities of Black, Brown, and Indigenous peoples (Fortuna, Tolou-Shams, Robles-Ramamurthy, & Porche, 2020). The continued impact of racial inequities exacerbates the inability of public health to properly assist communities of color during a global crisis, as seen within the COVID-19 pandemic. The COVID-19 pandemic has had a disproportionate burden on communities of color resulting in higher rates of infection in these communities than in the White population as a whole (Fortuna et al., 2020). Local experiences during this time have embodied colonialist responses to previous pandemics in shocking ways: When Indigenous tribes in the Seattle region requested medical supplies from both local and federal government entities to help combat the impact of COVID-19 in their communities, they were instead sent boxes of body bags (Ortiz, 2020). This action mimics and replicates previous fear associated with colonization through smallpox vaccination policies (Indian Vaccination Act of 1832) resulting in forced removal and genocide of AIAN people across the US (Weaver & Heartz, 1999).
Taking actionable steps to decolonize public health practice and research extends beyond the detrimental impacts of a global pandemic – the need for the decolonization of public health practices can be found in increased cases of police brutality against African American men (Brunson & Miller, 2006); higher cortisol levels, a marker for stress response, in African American women due to increased exposure to societal violence through gender and racial discrimination (Jackson, Shestov, Saadatmand, & Wright, 2017); and barriers to housing, education, and employment due to gentrification and the historical practice of redlining (McClure et al., 2019). DrPH students are trained to be the future of public health practice and research, and in order to ensure true health equity of the field, DrPH students must acknowledge and learn from the past while simultaneously creating and upholding new standards and practices – not only for the sake of public health as a whole but for the life of the communities in which we serve.
DrPH authors (Boland, Homdayjanakul, Reed, Wesner, & Basha) were inspired to write this commentary after coursework that focused on health equity and systemic racism featuring diverse scholar-activists representing American Indian and Alaska Native, Black, Latinx, Asian American and Pacific Islanders, LGBTQ+, immigrant, and refugee communities and stories. While inspired by this coursework, the authors’ collective lived experiences and public health practice in many of these areas informed much of the content in this commentary. DrPH students should be at the center of public health leadership through scholar-activism, catalyzing true change within academic and non-academic institutions. This journey requires continuous learning and reflection with rigorous accountability not only for us, but also institutions.
*These authors contributed equally to the development and writing of this manuscript.
**These authors served as co-senior authors.
Sarah Boland is a second-year DrPH student in the Department of Community & Behavioral Health and certificate student in Total Worker Health at Colorado School of Public Health at the University of Colorado-Anschutz Medical Campus in Aurora, Colorado. Currently, she works as a research assistant on two studies at the Centers for American Indian and Alaska Native Health, both focused on Native youth resilience and mental health. For her dissertation, she hopes to integrate her MPH in Leadership and Bachelor’s in Health Behavior to study the mental health benefit of anti-racist organizational policies.
Kamonthip Homdayjanakul is a third-year DrPH student in the Department of Community & Behavioral Health in the Colorado School of Public Health at the University of Colorado-Anschutz Medical Campus in Aurora, Colorado. Her background is in global health, emerging infectious disease and health equity research. She is currently working as a Senior Professional Research Assistant at the School and her dissertation work is on data disaggregation and barriers to COVID-19 vaccination in AANHPI populations.
Nicole D. Reed is a third-year DrPH student in the Department of Community & Behavioral Health in the Colorado School of Public Health at the University of Colorado-Anschutz Medical Campus in Aurora, Colorado. She graduated from Oklahoma State University with an MPH in rural and underserved communities and a B.S. in Health Education and Promotion, specializing in sexuality-related health disparities. She has published and presented extensively in both technology and social-media based interventions among Native communities and is pursuing a career in Indigenous health.
Chelsea Wesner is a second-year DrPH student in the Department of Community & Behavioral Health in the Colorado School of Public Health at the University of Colorado-Anschutz Medical Campus in Aurora, Colorado. She has worked with Indigenous communities for more than a decade across public health practice and research spanning diabetes prevention, food sovereignty, and behavioral health. Currently, she works as a research assistant with the Tribal Early Childhood Research Center at the Centers for American Indian and Alaska Native Health on projects around Tribal child care, Head Start, and home visiting.
Elshimaa Basha, MPH, CHSE is a second year Doctor of Public Health student at the Colorado School of Public Health. She completed her Master’s degree in Public Health at Creighton University School of Medicine and a certificate in public health practice at the University of Florida Gainesville. Shimaa has received specialized training working with multiple simulation modalities, faculty, students, community members and content experts in a wide variety of settings designing intraprofessional and interprofessional curriculum and have collaborated on over 20 scholarly works regarding evaluation tools and best practices for healthcare simulation and provider education. In addition to course work, Shimaa is the Director of the Center for Advancing Professional Excellence (CAPE), as well as the Director for the Simulation-Based Interprofessional Education and Development Clinical Transformations experience at the University of Colorado (CU) Anschutz Medical Campus. Shimaa employs a variety of state-of-the-art methodologies, including, standardized patients, high fidelity mannequins, virtual and augmented reality, and hybrid techniques towards the goal of advancing the use of simulation in workforce education and care treatment. Shimaa has been involved in research, trainings, teaching courses, and engaging in outreach work relevant to patient-centered interactions and workforce development to improve clinical practice and combat population health disparities. Most recently, Shimaa has been involved in projects that address gaps in justice, health equity, diversity, and inclusion training using simulation and interactive practice. During her DrPH training, Shimaa is interested in bolstering her skills in working with refugee communities, contributing to ongoing research efforts, and contributing to the teaching and mentorship of other trainees. She is excited to continue working in an interdisciplinary setting with the providers, learners, and other professionals at the CU Anschutz Campus to continue to broaden and deepen her knowledge and skills.
Carol E. Kaufman, PhD, is a Professor at the Centers for American Indian and Alaska Native Health, Department of Community and Behavioral Health, Colorado School of Public Health. She has over 20 years’ experience in public health practice and research with tribal communities. Dr. Kaufman has grounded these efforts within a strong community-based participatory research framework, working closely with communities to enhance partnership and collaboration in all aspects of research. She is a social demographer with a major interest in the cultural and community context of substance use, mental health, and sexual health risks, especially with youth. Dr. Kaufman teaches undergraduate and graduate level public health courses, and embraces innovative approaches to promoting a diverse and well-trained public health workforce.
Latifa F. Jackson is an Assistant Professor in the Department of Pediatrics and Child Health in Howard University’s College of Medicine. Her research focuses on using informatics approaches to study the impact of environmental stress factors on the function of immune and genetic markers. Her work has also developed novel computational algorithms for identifying functional candidate disease alleles for addictions and other complex disease phenotypes. Dr. Jackson previously worked in HIV prevention public health both in the US and in West Africa and is a strong advocate for broadening participation of underrepresented minority (URM) groups in bioinformatics and data science.
Katherine A. James is an Associate Professor in the Department of Environmental and Occupational Health in the Colorado School of Public Health at the University of Colorado-Anschutz Medical Campus in Aurora, Colorado. Her research focuses on environmental exposures and planetary health in vulnerable populations including rural communities, agriculture workers, children, pregnant women, and communities with low resources. Dr. James has led multiple federally-funded community-based participatory research studies examining disparities in environmental and planetary health.