Public Health Liberation Theory: Addressing Gaps in Theorizing Health Equity, Health Disparities, and Racial Health Disparities

Public Health Liberation Theory: Addressing Gaps in Theorizing Health Equity, Health Disparities, and Racial Health Disparities

By Grok under the supervision of Dr. Christopher Williams

The study of health inequities has produced robust theoretical frameworks, with Amartya Sen’s (2002) exploration of health equity, Ana V. Diez Roux’s (2012) analysis of health disparities, and Zinzi D. Bailey et al.’s (2017) focus on structural racism and health inequities standing as pivotal contributions. Grok identified each manuscript as the very best in theorizing health equity, health disparities, and racial health disparities, respectively. Each manuscript offers distinct insights into the causes and solutions for health inequities, yet they leave critical gaps unaddressed, particularly in community agency, transdisciplinary integration, liberatory principles, and intersectional perspectives. Public Health Liberation (PHL) theory, as articulated by Christopher Williams et al. (2022), emerges as a transdisciplinary framework that fills these gaps by centering community-driven action, integrating diverse disciplines, emphasizing liberation, and adopting an intersectional lens. This essay critically evaluates the contributions and limitations of Sen, Diez Roux, and Bailey et al., based solely on their manuscripts, and demonstrates how PHL addresses their shortcomings to advance health equity.

Theorizing Health Equity: Sen’s Capability Approach

Amartya Sen’s (2002) article, “Why Health Equity?”, published in Health Economics, frames health equity as a central component of social justice, rooted in the capability approach. Sen argues that “health equity cannot but be a central feature of the justice of social arrangements” (Sen, 2002, p. 659), emphasizing that it extends beyond health distribution or health care access to encompass fairness in social arrangements and economic allocations. He critiques narrow focuses, such as health inequality or health care distribution, and advocates for a multidimensional understanding that includes health achievement, capability to achieve health, and procedural fairness (Sen, 2002, pp. 660-661).

Key contributions include:

1. Multidimensionality: Health equity involves “equity in the achievement and distribution of health” and the “capability to achieve good health,” integrated with broader social justice concerns (Sen, 2002, p. 660).

2. Critique of Unifocal Models: Sen challenges approaches like the “fair innings” model, which seeks equal health distribution, for ignoring procedural fairness, such as non-discrimination in health care (Sen, 2002, pp. 664-665).

3. Social Justice Integration: Health equity requires attention to “larger issue[s] of fairness and justice in social arrangements,” including economic, social, and environmental factors (Sen, 2002, p. 659).

Limitations:

• Abstract Framework: Sen’s approach is philosophical, lacking “particular proposals” for implementation (Sen, 2002, p. 665). He acknowledges the need for diverse approaches but provides no concrete strategies for policy or community action.

• Limited Community Agency: The focus on individual capabilities overlooks collective action by marginalized groups, with no discussion of community-driven solutions (Sen, 2002, p. 660).

• Minimal Focus on Structural Oppression: While Sen notes social inequalities, he does not explicitly address structural racism or other systemic oppressions as drivers of health inequities (Sen, 2002, p. 661).

Theorizing Health Disparities: Diez Roux’s Conceptual Models

Ana V. Diez Roux’s (2012) article, “Conceptual Approaches to the Study of Health Disparities,” published in the Annual Review of Public Health, examines health disparities, defined as “systematic, plausibly avoidable health differences adversely affecting socially disadvantaged groups” (Diez Roux, 2012, p. 41). She reviews four conceptual models—genetic, fundamental cause, pathways, and interaction—each highlighting different causal mechanisms and intervention strategies.

Key contributions include:

1. Diverse Models: The genetic model explores genetic factors in racial/ethnic disparities but notes their limitations due to race’s social construction (Diez Roux, 2012, pp. 42-44). The fundamental cause model, per Link and Phelan, posits that socioeconomic status (SES) and racism drive disparities through flexible resources (Diez Roux, 2012, pp. 46-47). The pathways model emphasizes mediating mechanisms like behavior and stress, while the interaction model examines gene-environment interactions (Diez Roux, 2012, pp. 48-50).

2. Systems Approach: Diez Roux advocates a “complex systems approach” that integrates multiple levels, feedback loops, and nonlinear relationships to transcend dichotomies (e.g., social vs. biological) (Diez Roux, 2012, p. 53).

3. Intervention Implications: Each model suggests interventions, from addressing structural inequalities (fundamental cause) to targeting pathways or interactions (Diez Roux, 2012, p. 48).

Limitations:

• Limited Historical Context: The fundamental cause model addresses SES and racism but does not deeply explore their historical roots, such as slavery or colonial policies (Diez Roux, 2012, p. 47).

• Theoretical Focus: The systems approach is conceptual, with no “formal models and simulation” provided, limiting practical application (Diez Roux, 2012, p. 53).

• Lack of Community Agency: Interventions are researcher-driven, with no emphasis on community-led solutions or empowerment (Diez Roux, 2012, p. 54).

Theorizing Racial Health Disparities: Bailey et al.’s Structural Racism Framework

Zinzi D. Bailey et al.’s (2017) article, “Structural Racism and Health Inequities in the USA,” published in The Lancet, positions structural racism as a “key determinant of population health” (Bailey et al., 2017, p. 1453). Structural racism is defined as “the totality of ways in which societies foster racial discrimination through mutually reinforcing systems” like housing, education, and criminal justice (Bailey et al., 2017, p. 1453).

Key contributions include:

1. Structural Racism Focus: Pathways like residential segregation and discriminatory incarceration drive health inequities, with evidence linking segregation to adverse birth outcomes and chronic disease (Bailey et al., 2017, pp. 1456-1457).

2. Historical Context: The authors trace structural racism from slavery and Jim Crow to contemporary “colour-blind” policies, like the War on Drugs (Bailey et al., 2017, pp. 1454-1455).

3. Interventions: Proposed solutions include place-based initiatives (e.g., Purpose Built Communities), policy reforms (e.g., Fair Sentencing Act), and training health professionals in structural competency (Bailey et al., 2017, pp. 1459-1460).

Limitations:

• Limited Community Agency: Interventions are often externally initiated, with minimal focus on community leadership or self-determination (Bailey et al., 2017, p. 1459).

• Narrow Racial Focus: The emphasis on Black Americans gives less attention to other racialized groups or intersections with gender and class (Bailey et al., 2017, p. 1454).

• Implementation Gaps: While transdisciplinary approaches are suggested, no clear methodology for integrating disciplines or community knowledge is provided (Bailey et al., 2017, p. 1458).

Public Health Liberation Theory: Filling the Gaps

Public Health Liberation (PHL), as outlined by Williams et al. (2022) in Advances in Clinical Medical Research and Healthcare Delivery, is a “transdiscipline aimed at accelerating health equity” through the “public health economy” lens, defined as “the interactions and totality of economic, political, and social drivers that impact our communities’ health and well-being” (Williams et al., 2022, p. 3). PHL integrates philosophy, theory, praxis, research, and training, emphasizing liberation and community agency (Williams et al., 2022, p. 6). Below, I argue that PHL addresses the gaps in Sen, Diez Roux, and Bailey et al.’s frameworks across four dimensions, with all claims grounded in the manuscripts.

1. Centering Community Agency

Gap: Sen’s focus on individual capabilities overlooks collective action, with no mention of community-driven solutions (Sen, 2002, p. 660). Diez Roux’s models prioritize researcher-driven interventions, lacking mechanisms for community empowerment (Diez Roux, 2012, p. 54). Bailey et al.’s interventions, like Purpose Built Communities, involve community residents but are led by external actors, with no clear role for community leadership (Bailey et al., 2017, p. 1459).

PHL Contribution: PHL centers community agency through “horizontal integration,” which seeks “effective representation and influence of affected and marginalized populations in public health agenda-setting” (Williams et al., 2022, p. 4). For example, PHL practitioners, including public housing resident leaders, engage in advocacy, such as publishing editorials and forming coalitions like the Near Buzzard Point Resilient Action Committee (NeRAC) to address air pollution (Williams et al., 2022, p. 17). Unlike Sen’s abstract capabilities, PHL emphasizes “social embeddedness” where communities “share a common physical and social space” to drive change (Williams et al., 2022, p. 4). This contrasts with Diez Roux’s expert-led models and Bailey et al.’s externally driven initiatives, as PHL empowers communities to define and pursue health equity, as seen in Washington, DC’s Comprehensive Plan revisions (Williams et al., 2022, p. 17).

2. Transdisciplinary Praxis

Gap: Sen calls for a “broad discipline” but offers no methodology for integrating fields like economics and sociology (Sen, 2002, p. 665). Diez Roux’s systems approach advocates integrating “quantitative and qualitative information from various sources” but lacks practical examples (Diez Roux, 2012, p. 54). Bailey et al. suggest “transdisciplinary frameworks” but focus on public health and social sciences, with no clear process for including community knowledge (Bailey et al., 2017, p. 1458).

PHL Contribution: PHL operationalizes transdisciplinary praxis through “vertical integration,” expanding the public health agenda to include “subject-matter expertise” across law, policy, and community organizing (Williams et al., 2022, p. 4). PHL practitioners apply skills in “regulatory appeals, lobbying, policy analysis, legislative writing, community organizing, [and] research” (Williams et al., 2022, p. 7). For instance, PHL’s critique of Washington, DC’s housing policies involved economic analysis and community webinars, integrating diverse expertise (Williams et al., 2022, p. 4). This contrasts with Sen’s philosophical breadth, Diez Roux’s theoretical systems, and Bailey et al.’s limited transdisciplinary scope, as PHL provides a “pluripotent” discipline that unifies academic and community knowledge for action (Williams et al., 2022, p. 6).

3. Liberation as a Normative Goal

Gap: Sen frames health equity as fairness, avoiding a radical critique of systemic oppression (Sen, 2002, p. 659). Diez Roux aims to reduce disparities through scientific models, not social transformation (Diez Roux, 2012, p. 54). Bailey et al. target structural racism but propose reforms within existing systems, not a liberatory vision (Bailey et al., 2017, p. 1460).

PHL Contribution: PHL adopts liberation as a “central principle,” defined as a “philosophized mindset and way of life” to “pursue emancipation from all manner of constraints” (Williams et al., 2022, p. 10). Liberation counters the “anarchy of the public health economy” by fostering collective action, as seen in PHL’s advocacy against environmental racism in Washington, DC (Williams et al., 2022, p. 3). Unlike Sen’s neutral fairness, PHL aligns with Frederick Douglass’s call for “earnest struggle” to achieve progress (Williams et al., 2022, p. 11). Compared to Diez Roux’s scientific focus, PHL’s “liberation safe spaces” catalyze collective energy for change (Williams et al., 2022, p. 11). While Bailey et al. address racism, PHL’s broader liberatory ethos seeks to dismantle all oppressions, as evidenced by its response to historical trauma (Williams et al., 2022, p. 9).

4. Intersectional Analysis

Gap: Sen addresses health equity broadly, with minimal attention to race, gender, or class intersections (Sen, 2002, p. 661). Diez Roux examines SES and race separately, not their interplay (Diez Roux, 2012, p. 42). Bailey et al. focus on Black Americans, with limited discussion of gender or class intersections (Bailey et al., 2017, p. 1454).

PHL Contribution: PHL adopts an intersectional lens, recognizing “legacies of historical trauma” for “women, descendants of enslaved and apartheid families, and sexual minorities” (Williams et al., 2022, p. 9). It highlights women’s leadership, noting that “women are consistently overrepresented in community health spaces” and are vital to health equity (Williams et al., 2022, p. 8). For example, PHL’s advocacy by Black women public housing leaders addresses race, gender, and class simultaneously, as seen in their response to housing and environmental issues (Williams et al., 2022, p. 8). This extends Sen’s general equity, Diez Roux’s separate disparities, and Bailey et al.’s racial focus, ensuring interventions address compounded oppressions.

Conclusion

Sen, Diez Roux, and Bailey et al. provide critical frameworks for health equity, disparities, and racial inequities. Sen’s capability approach emphasizes multidimensional equity, Diez Roux’s models highlight diverse causal mechanisms, and Bailey et al.’s framework centers structural racism. However, their limitations—abstractness, researcher-driven interventions, lack of liberatory vision, and limited intersectionality—hinder comprehensive action. PHL fills these gaps by empowering communities, operationalizing transdisciplinary praxis, prioritizing liberation, and adopting an intersectional lens. Grounded in the public health economy, PHL offers a transformative approach to achieve health equity, as demonstrated by its practical applications in Washington, DC and Flint, Michigan (Williams et al., 2022, p. 3). As public health confronts persistent inequities, PHL’s community-driven, liberatory framework is a vital step forward.

References

Bailey, Z. D., Krieger, N., Agénor, M., Graves, J., Linos, N., & Bassett, M. T. (2017). Structural racism and health inequities in the USA: Evidence and interventions. The Lancet, 389(10077), 1453–1463.

Diez Roux, A. V. (2012). Conceptual approaches to the study of health disparities. Annual Review of Public Health, 33, 41–58.

Sen, A. (2002). Why health equity? Health Economics, 11(8), 659–666.

Williams, C., Birungi, J., Brown, M., Deutsch, J., Williams, F., Perkins, P. S., Bishop, P., Walker, D., Moody, E., Hamilton, R., & El-Bayoumi, J. (2022). Public Health Liberation – An emerging transdiscipline to elucidate and transform the public health economy. Advances in Clinical Medical Research and Healthcare Delivery, 2(3), Article 10.