What would it take for health promotion to take structural racism seriously?

On racism

Racism is a powerful and organized social system that permeates all aspects of cultural, economic and political life at local, national and global levels. Racism is an organized cultural and social system whereby the dominant racial group creates an order of human value, differentiates and categorizes people into ‘races’ and uses its power to define reality and allocate resources inequitably. Race is a social construct, it is imagined. It is through racism that meaning is attached to racial groups, through powerful ideologies, values, policies and practices. Ultimately, White supremacy and Whiteness overvalue ‘The Ways of White Folks’ (1) and devalue us all. Structural racism is sanctioned by states through action or inaction in public policy and by institutions – private, public and not-for-profit alike. Racism interacts with other systems and institutions, influencing those systems and in turn being influenced by them.

Far from accidental, racism is engrained into systems, policies and practices. At its heart, racism destroys souls and bodies consistently exposing Black, Indigenous and people of color (BIPOC) to conditions that are deleterious to health. Racial inequities manifest across national boundaries, within nations, at sub-regional and local levels. Inequities between countries continue to reflect the dominance and substantial power of White-dominant countries in comparison with those in the Global South, many of whom were colonized and continue to be maligned through imperial neoliberal policies. In settler states like Canada, the United States (US), Australia and New Zealand, Indigenous Peoples are exposed to ongoing racist colonial violence leading to unacceptable health and social inequities (2). In Toronto, Canada, people of colour represented 83% of COVID-19 cases even though they represent just over half of the city’s population (3). Residential segregation has been linked to poorer health for Afro-Brazilians (4). #sayhername, a US-based campaign, shines light on police violence levied on Black women and girls (5). Simply put, there is no shortage of evidence that racism is a pressing challenge that must be addressed now with clarity and conviction.

Disciplinary silences, exclusions and incomplete inclusions

Despite past calls (6 –9), the field of health promotion has yet to fully contend with the pervasiveness of racism, particularly its impact on the health of society and solutions to eliminate racism. Contemporary health promotion seems to assume that with a disciplinary grounding in equity and social justice, a focus on structural racism automatically ensues. In practice, however, health behaviourism and individualist and neoliberal approaches continue to dominate (6, 10 –15). In a recent review of 249 high-impact public health journals, only 14 journals had relevant articles and institutional racism was a core concept in only 16 articles (16). Even approaches with more structural orientations, like mainstream discourse on the social determinants of health, often fail to include a nuanced analysis of structural racism (that is, proposals for action that explicitly name and implicate racism as a fundamental determinant of health). Moreover, when theories (like intersectionality) with the expressed goal of liberation for Black and Indigenous women slowly travel into health promotion, the liberatory goals for Black and Brown peoples are sometimes decentred. To quote Patricia (17), ‘They are singing our song, but we don’t recognize it.’

In educational settings, the limited engagement of racialized faculty (18) contributes to the dearth of critical perspectives in health promotion. When racialized faculty are present, their naming of issues of racism and racial injustice are often seen as self-serving rather than as legitimate research agendas (18). This is mirrored in health promotion competencies that do not include skill and knowledge of racism and spills into the curriculum, impacting health promotion education. Programs are matriculating health promoters who lack understanding of racism as a legitimate health and social concern and who are ill-prepared to propose and develop health promotion actions that eliminate racism.

The way forward

If we accept that racism is a system, implicated in and by all other systems, we accept that we all have a role to play in our everyday health promotion activities. We then have to proactively invest in ensuring that sites of health promotion knowledge production, education and practice advance the interests and wellbeing of Black, Indigenous and racialized communities (8, 9). Health promotion has to ask, ‘What is our stake in upholding White supremacy and the ‘ways of White folks’? Are we prepared to continue to create and maintain systems and practices that harm and ultimately kill or are we ready to take racism seriously?’

An explicit focus on cultural, structural, institutional racism and Whiteness provides direction for health promotion education, research and practice. Health promoters in all spheres must develop a deep race consciousness that acknowledges the centrality of race and racism in everyday life (9, 19). This requires moving from colour-blind or race-neutral approaches to a view that racism’s contemporary manifestations are not arbitrary and mysterious, but systematic and knowable. Racial inequities then stop being seen as random but as the natural product of oppressive racist norms, values and actions. Doing so subverts the assumptions of everyday life which work to uphold and bolster White dominance and racial inequities (20). Anti-racist and critical race approaches must be embedded across health promotion competencies and curricula to contribute to training a new cadre of health promoters deeply implicated in addressing racism across the spectrum of the health promotion field.

At its core, health promotion has to critique and expand its disciplinary roots and practices. Disciplinary self-critique of health promotion actively examines the conventions of health promotion, those which take for granted truths and ways of working and the implications these have on societal understanding of race and racism and actions to eliminate racial injustices (9). Self-critiques expose how epistemic, cultural and structural racism is manifest through health promotion research, practice and policy, be it through silences, exclusions or erroneous inclusions. Disciplinary self-critique through a range of critical race approaches (8) provides a path for the development of transformative health promotion approaches with emancipatory potential for Black, Indigenous and people of colour. Health promotion must engage with theoretical and epistemic approaches that actively centre on the knowledges and perspectives of Black, Indigenous and other people of colour in national and global knowledge production activities. This must be coincident with critiques of Whiteness and its dominance in the production and use of knowledge in research and practice settings. As a researcher, what disciplinary traditions do you draw on, and have you engaged with the critiques from critical race scholars in those disciplines? Does your research examine how racism affects health-generating processes? Does this go beyond simply stating that race matters to underscoring how racism and racialization function to make race matter?

Health promotion practice must propose and implement policies and programs that invest in racialized communities and are divested from White supremacist systems. Actions rooted in decolonizing anti-racist praxis call for substantial investments in education, income and poverty reduction, employment, neighbourhoods and housing, climate and planetary health and other critical determinants of health for BIPOC (21, 22). Public policy-making, governance, politics, program development, implementation, evaluation and other mechanisms through which power and influence are wielded have to be transformed so that they no longer serve as tools through which racial inequities are reproduced, but instead are used as opportunities to envision and produce racially equitable societies.

Health promotion knowledge and action projects of all kinds cannot be neutral; they can either uphold the current norms of pervasive and widespread racialized inequities or they can actively challenge them. Health promotion has to contribute to two distinct but complementary agendas: understanding the impact and experiences of racism on health in its broadest sense, and developing the science and practice of anti-racism in health promotion (23). Health promotion must choose the path of challenging structural racism and the abysmal racial inequities it is designed to create, as a mere inclusion in racially oppressive systems will not suffice.