The Health Equity Case for Reparations

By Amani Echols

Over the past year, racial health inequities have been pushed into the national spotlight. Prompted by the Black Lives Matter protests in response to the murders of Breonna Taylor and George Floyd, and the stark reality that the COVID-19 pandemic disproportionately impacts Black and Brown communities, racism was declared a public health issue in 135 jurisdictions nationwide between January 2019 and July 2020. This historical moment presents a critical policy opportunity to advance drastic public health measures to improve the health of Black Americans. Restorative action is urgently necessary to increase Black people’s access to health resources, and thus, now is the time to make reparations a public health priority to redress (not address) health inequities among Black people.

For Black Americans, today’s health inequities are rooted in slavery and centuries of policies designed to prevent their access to health-promoting resources. These historical and current traumas manifest in health outcomes across generations. Reparations acknowledge the legal obligation of a state to rectify the consequences of violations they committed or failed to prevent, and express its commitment to addressing the root causes of past violations and ensuring they do not happen again. Reparations usually result in financial compensation to surviving victims.  

Reparations are in no way novel in the U.S.: they have been distributed to Indigenous Tribes to compensate for stolen land (1946), Japanese Americans interned during World War II (1988), survivors of the Rosewood, Florida massacre (1994), Black men a part of the Tuskegee Syphilis Study (1997), and surviving victims of the North Carolina state eugenics program (2010-present). The recipients ranged from individual survivors to entire communities and funds ranged from $2.1 million to $1.3 billion. However, reparations for descendants of enslaved people have never been meaningfully explored.

When the federal government liberated millions of Black people from slavery, it did little to ensure that Black people could thrive socially and economically. And as a result of more than a century and a half of both neglectful and blatantly racist policy, Blacks now have the lowest wealth accumulation compared to other races in the U.S. and their health is paying the price. Blacks face systemic barriers to high-quality education, nutritious food, decent and safe housing, reliable transportation, culturally sensitive health care providers, health insurance, and clean water and non-polluted air, which are all linked to greater access to the health care system and better health status. Addressing systemic barriers to social determinants of health (SDOH), which are often rooted in racist policies, is fundamental to decreasing health inequities. That said, reparations should not be a substitute for improving Black people’s access to basic public goods, such as quality public education and social services that should already be provided by the government.

Public health practitioners have an ethical obligation to eliminate health disparities because they are morally wrong. It is immoral when Black Americans, who bear the same societal burden as the entire population, do not receive the same basic societal benefits. Additionally, these health disparities do not benefit any group—whites are not any healthier because Black people have significantly worse health. Due to the shared cost of healthcare through insurance premiums and taxation, health inequities disadvantage the entire U.S. population and the nation’s prosperity depends on the entire population’s health.

Reparations could improve U.S. health, and address health inequities that have been incurable for generations by increasing access to the SDOH and reducing stress among Black Americans.

 The implementation of a reparations program is a vast, complex undertaking. There are several key practical considerations to take into account to ensure reparations produce their desired impact, and have adequate public support and political will to be enacted. As policymakers begin to translate this discourse into tangible policy, they will have to consider the following:

 

1. Reparations must provide long-term security that enables community investment. Reparations in the form of compensation ensure that restitution for economic harms (e.g., free labor and income inequality) are provided. However, these financial payments must be proportional to the gravity of the wrongdoing. Beyond financial payments, rehabilitation reparations include the delivery of medical care, psychological care, and social services (e.g., addressing health disparities and the SDOH). And, third, satisfaction reparations verify that there is complete public disclosure of the truth (e.g., K-12 schools teach the comprehensive and accurate truth about slavery and its current implications).
2. Transparency and accountability will be critical to ensure the equitable distribution of reparations. One way to significantly reduce the likelihood that a reparations policy is ineffective is to prioritize complete transparency and foster high community belonging and engagement. A diverse stakeholder group of Black people (i.e., rural and urban Black people) should be guiding the decision-making processes on the distribution of reparations.
3. To increase public support and political feasibility for reparations, funding options should minimize taxpayer burden. One strategy advises the federal government to use deficit spending to fund reparations. The government must ensure that any money used to finance reparations should not disadvantage the funding stream of other valuable programs (i.e., Head Start) and/or counteract the positive effects of reparations for Blacks. Alternative funding options to taxation will ensure that reparations do not infringe on the public’s liberties and access to health-promoting resources.

 In advocating for reparations policy measures, policymakers are likely to face two primary challenges. First, opponents argue that reparations are not worth the tremendous investment because social problems are insurmountable, too complex, and unfixable; thus, not worth solving. Despite numerous policy and programmatic efforts by various sectors (e.g., education, health, and housing), inequities persist, and thus—so goes the logic—how could reparations be the solution? Though addressing social inequality is a massive task, public health professionals are morally obligated to prevent disparities and work toward health equity, and no evidence has declared health disparities truly “unfixable.” 

Second, the American value of individualism contributes to a narrative that poor social and health standing is a result of an individual’s actions and that they have free will to make their life circumstances better (i.e., eat healthier). Therefore, reparations, like many social welfare programs, are likely to be viewed as a “handout” for the “undeserving,” and thus opposition would be considerable. This perspective neglects the historical injustices that have led to systems and institutions that intentionally deny resources from Black people. Withholding restorative action maintains the status quo and allows for the perpetuation of health inequities.

Reparations alone will not solve institutional racism. They must be accompanied by a systematic evaluation and revision of federal, state, and local policies that perpetuate structural racism, which can only be accomplished in parallel with a radical new understanding of U.S. history, and a shift in social values and beliefs toward Black people. But the notion that reparations are not a silver bullet should by no means be a deterrent—if our country is to move towards health equity for Black Americans, they are a critically important place to start.

 

Photo of graffiti in Washington DC by Daniel Lobo available through flickr