Abstract
Since the onset of the COVID-19 pandemic, the shortcomings and neglected weaknesses of public health systems have risen to the surface, emphasizing the need for new approaches to designing and delivering public health training. Higher education institutions have a critical role in advocating for societal change and sufficiently prepare the next generations of public health. Therefore, this commentary shares the unique voices of current and recently completed graduate students from public health programs across the United States in identifying areas of improvement, so that proactive steps toward refining the current landscape of public health education and training may be taken. We speak upon the inaction and accountability of public health academic spaces in dismantling the various forms of systemic oppression, such as racism, colonialism, and epistemic injustice, while encouraging prospective and current graduate colleagues to be mindful and curious to re-imagine the role of such pedagogies of public health to reduce the progressing health inequities.
Keywords
Public health education and training has endured rapid change over the years accompanied by many challenges that have shaped current public health paradigms, practices, and policies. Following the stilted response to the COVID-19 pandemic, we have yet to witness justice in racially motivated attacks against unarmed Black Americans (McCoy, 2020) and Asian Americans (Gover et al., 2020), the abrogation of sexual and reproductive rights (Hubler, 2022), and the institutional inaction on firearm control (Duchesne et al., 2022). Academic institutions of public health are expected to abide their training approaches by national standards and priorities of the Council on Education for Public Health (CEPH, 2021), while also striving to curate a diverse student collective. In lieu of the outdated aspects of current public health education (i.e., obsolete content in courses, structure of courses, pedagogical methods of teaching) (Meredith et al., 2022), institutions of public health have a responsibility to provide the foundation for students—undergraduate and graduate alike to give them the tools needed to be catalysts for structural level and health equity change (Krieger, 2020). Our intentions are not meant to discredit the efforts of institutions of public health but rather suggest possible alternatives approaches that programs can consider grounding their curriculum in principles of health equity. This review critiques current health equity pedagogy practiced and upheld by academic public health institutions through the unpacking of differences in epistemological thinking and authoritative ways of knowing in public health, re-framing social determinants through racial capitalism to understand structural inequalities and discuss considerations for environmental racial justice within biosecurity curriculums in public health.
Re-Imagining the Pedagogy of Health Equity
With the increased velocity and volume of unjust murders of unarmed Black Americans, among others, Ahmaud Arbery, Breonna Taylor, and George Floyd (Buchanan et al., 2020) joint with the influx of anti-Asian hate crimes related to the COVID-19 pandemic (Findling et al., 2022), the large public outcry denouncing state-sanctioned anti-Black and anti-Asian violence supports an urgent reform of social justice and anti-racism work. Yet, as students, we are not witnessing nor experiencing the space to reflect and critically evaluate these real-world events within most academic learning environments. These institutions advertise a curriculum with health equity principles and practice, especially following the declaration of racism as a public health crisis (Paine et al., 2021). However, the CEPH accreditation domains are only stated in a few of the public health competencies (Council on Education for Public Health, 2021). Institutions and programs must center Black and Brown communities through practical and intellectual support, rather than relying on the validation from statements or offices of diversity and inclusion or solely relying on the “resilience” of these communities to withstand oppression (Ramirez-Valles et al., 2023). Much of the takeaways from academic public health programs are dominantly on the proficiencies of the “social determinants of health” (SDoH) framing and dismissal of the historical and structural underpinnings of racism and White supremacy that create the SDoH (Chandler et al., 2022). For instance, progress in addressing the Black maternal mortality disparities in the United States is limited when relying on the SDoH lens (Crear-Perry et al., 2021). Institutional racism that shapes unlivable conditions for diverse birthing people (e.g., unpaid maternal leave, lack of health insurance coverage, respectful and culturally appropriate care) (Crear-Perry et al., 2021) may be more accurately viewed through interlocking systems of domination (Collins et al., 2021). In addition to shifting the conversations toward deeper power asymmetries, institutions can flourish by centering students and faculty of color who encompass the irreplaceable and unteachable lived experiences to compliment alternative and critical ways of troubling systems in efforts to promote health equity (Goodman et al., 2022; Ramirez-Valles et al., 2023). In brief, institutions can support meaningful collaboration beyond the ivory tower where non-academic communities are recognized, compensated, and invested in as expert contributors of knowledge (Hinckson et al., 2017). Progress toward health equity will never accommodate the academic expectations that value productivity over impact (Lett et al., 2022). Thus, institutions of public health should remain reflexive of and held accountable when “health equity tourism,” which occurs when scholars lack the experience and ethical commitment to engage in health equity scholarship, opportunistically enter these spaces for a temporary period and the potential return in incentivized resources, surfaces (Lett et al., 2022). Health equity work cannot be mastered through veneer lectures, transactional short-term internships, or a certificate of completion, which is the polluted messaging some institutions are sending to their students and carrying with them beyond the program (Braveman, 2014; Lett et al., 2022).
Re-Imagining Epistemic Injustice in Global Health
Global health has been considered as “an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide” (Koplan et al., 2009). However, global health is still upheld by its colonial and imperial underpinnings, centralized by those who are deemed as “more” credible knowers and producers of knowledge (Bhakuni & Abimbola, 2021). Members of historically marginalized groups, such as scholars from countries in the global south, frequently experience less opportunities and more barriers that prevent them from fully engaging in social and practical sensemaking than scholars based in the global north (Zoller & Kline, 2008). Academic institutions of public health have the opportunity to work toward health equity through decolonial efforts and disrupt epistemological asymmetries within its scholarship. This may be done by critiquing current epistemological regimes, such as authoritative positivist methods in academic empiricism (Brown, 2015; Park et al., 2020). Institutions may benefit from reconsidering non-westernized methodologies in comparison to “gold standard” models (e.g., p-values, health indexes) to address certain health problems. For example, incorporating transdisciplinary frameworks, such as critical race theory and qualitative methodologies (Butler et al., 2018; Ford & Airhihenbuwa, 2018; Wigginton et al., 2018), may welcome contextual lived experiences of communities whereas statistical regressions may fail to capture. These hierarchies can be challenged within course curricula (i.e., what topics and readings are taught in class, who authors these required readings and lecture formats). Epistemic injustice such as this can operate at an individual level (Fricker, 2007, pp. 11–14), but can reflect deeper systemic implications that may dilute the accurate interpretation of knowledge, determine who is deemed a “credible” knower, and control which projects should or should not receive funding and resources (Bhakuni & Abimbola, 2021; Koum Besson, 2022). This is important for critique because one’s academic position (e.g., institution status, mentors, access to resources) greatly shapes the opportunities a scholar has to produce knowledge and gain credibility, but also what is not only deemed worthy of material, often financial investment but also what unpublished or unfunded projects are deemed unfit for recognition. Thus, careful examination of prioritized investments in knowledge, within and beyond the classroom, and how opportunities are distributed is necessary to decentralize ways of promoting and practicing health equity (Koum Besson, 2022).
Re-Imagining Racial Capitalism as a Determinant of Health
The COVID-19 pandemic’s disproportionate effect on disadvantaged populations extends beyond the physical and mental health impacts, but attributable to racial capitalism (Perry et al., 2021). Racial capitalism, developed by theorists, one of which is Cedric Robinson, asserts that “the development, organization, and expansion of capitalist society pursued essentially racial directions” (Robinson et al., 2020). In other words, instability caused by the pandemic and subsequent economic uncertainty worsened existing inequalities that were already present in our society. For instance, Black and Latinx communities, as well as Indigenous Nations comprise of double the COVID-19 infections, hospitalizations, and mortality compared with White patients (Centers for Disease Control and Prevention [CDC], 2022). Due to historical and contemporary forms of structural racism and segregation in the United States, these communities are overly represented in frontline occupations that often do not provide adequate health insurance and with no options for remote work (Hawkins, 2020). Interestingly, despite higher exposures of COVID-19 infection among physicians compared with the general public, such as frontline workers, they have similar infection rates (Roberts et al., 2020). Reflective of the Inverse Hazard Law by Krieger et al. (2008), in which hazards inversely happen through the distribution of power and resources, interventions solely focused around improving income, such as the one-time stimulus payments do not impart lasting change upon what communities of color were experiencing since the COVID-19 pandemic (Garon et al., 2020). The reality of COVID-19 infections concentrating among low-wage and frontline workers is not inherent because of their racial and ethnic identities, but instead is discoursed through structural racism. For example, instead of operating at an individual-level framing (e.g., income, class, socioeconomic position) (Weida et al., 2020), students can benefit from structural inquiry on how these social determinants and patterns of health inequity are reflected through racism (racial capitalism producing material inequities in communities of color) (Ford & Airhihenbuwa, 2018; McClure et al., 2020). While the evaluation on structural racism in public health pedagogy is limited, there is an opportunity to start having critical conversations to work toward solutions grounded in health equity but also abolition (Flores & Greenwood, 2023). In order for radical change to happen, public health cannot afford to perch for neutrality where these conversations end once the class ends, but to equip its scholars to dismantle these large systems of oppression.
Re-Imagining Biosecurity and Biosafety Education
Biosecurity was originally framed around issues of national security of terrorism (Renault et al., 2021). However, recent events, such as the COVID-19 pandemic, revealed that these pathogens are not bound by international borders and are not immune to exacerbating historical developments in structural racism. While adequate biosecurity and disaster preparedness training is lacking, public health programs can unite biosecurity and biosafety education (BBE) with concepts of structural racism into their curriculum, either as part of existing courses (e.g., epidemiology, global health, environmental health) or, ideally, as independent BBE course. In addition to dissecting case studies and designing solutions to prevent disease outbreak, these programs may benefit from focusing on alternative interventions that address structural barriers and facilitators of community trust and adherence to biosafety policies (Emery et al., 2022). Prioritizing an environmental racial justice lens jointly with BBE can encourage more upstream framing pass White normativity and hyper positivist standards of biosecurity intervention. For instance, instead of relying on descriptive methods that only identify health disparities, such as COVID-19 infections among Black and Brown communities, there is a need to shift our methods more upstream to address why disparities continue to exist in certain communities (Gee & Payne-Sturges, 2004). A BBE curriculum is necessary to equip scholars with the expertise to not only confront invasive infectious diseases but also remain reflexive of communities already oppressed and often forgotten during these emergencies, due to existing systems and vulnerable to exposure to environmental pollutants and infections (e.g., COVID-19) (Washington, 2020). Jointly, there is an opportunity for more robust training in the dynamic relationship between health, humans, animals, and environments—called One Health, and racial justice (Washington, 2020). Although One Health is well established (Ruckert et al., 2020), it is only taught in certain public health courses, such as epidemiology and environmental health (Linder et al., 2020), and need to consider the implications of structural racism. While these are appropriate spaces for dedicated One Health training, an adapted curriculum with One Health and environmental racial justice can be designed to reach students across disciplines, especially program tracks that rarely require exposure to these concepts to have the fundamentals to health equity framing (Morgan et al., 2022), thus underscoring the need for structural One Health and biosecurity training across sectors to approach such challenges through holistic and cross-disciplinary actions that start addressing these mutually reinforcing pathways of health inequity.
Conclusion
Institutions of public health play an important role apart from the larger movement to advance health equity. These institutions continue to fall short in addressing racial and ethnic inequities, requiring a re-evaluation of institutional pedagogy of public health through their in-class learning spaces and external bureaucratic processes of academic scholarship. Indigenous, Black, and Brown students and faculty are important experts in predominantly white spaces that claim to do health equity work and the capitalist environment that dictate our ways of knowing and producing knowledge. However, this is not to say that the labor should fall on students and faculty of color to lead these initiatives nor should be the opportunity to tokenize their “presence,” but rather for institutions to ground themselves as learners and co-collaborate in re-designing multidisciplinary solutions for health equity pedagogy and research. Furthermore, we invite scholars and institutional leaders of public health to critique current paradigms of how public health and health equity are being taught in academic spaces. As current and future trailblazers of health equity, we need to be brave in challenging and re-imagining the current apparatus of public health education and comfort of familiar routines of outdated training, while doing so together.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
