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The Systems That Drive Health

Posted on June 30, 2020
Cardboard sign with the phrase "Racism is a public health emergency"

By Ana V. Diez Roux, MD, PhD, MPH

As challenging as these times are, one bright spot is the increasing recognition that health emerges from the social and economic systems in which we live. Refreshingly, this is not merely an academic exercise buried in the discussion sections of abstract papers on systems thinking (which I have contributed my share to…). Instead it is illustrated vividly by countless stories in the media, by discussions we are all having in our homes and communities (in person or virtual), and by protesters demanding racial justice in the streets.

When portrayed through the stories of individuals (the immigrant worker who loses her job but cannot qualify for sick leave or unemployment), through powerful data-driven description (rates of COVID-19 by race and class) and through the explanatory power of history (250 years of slavery, followed by legalized discrimination, followed by pervasive institutional racism as major drivers of the health of Black Americans) it is easy to see how health is inextricably linked to our society and the ways in which it is organized. It is hard to imagine a more striking illustration of the systemic causes of health (and health inequities) than what we are living through across the world today.

But illustrations and evidence are not enough. We also need the language, the words to describe what we mean plainly. This of course is not new. To cite just three examples, George Orwell knew this (“To write in plain, vigorous language one has to think fearlessly…”) , James Baldwin knew this (“We made the world we’re living in and we have to make it over.”) , and Martin Luther King Jr. knew this when he spoke of the “three evils” of racism, poverty and war. Today a new Poor People’s Campaign, which builds on the campaign King was launching shortly before his assassination, speaks of the interlocking systems of racism, poverty, environmental degradation, and the war economy as major sources of injustice in our world today. There could not be a better summary of the systems that drive population health.

More than 50 years ago, Jay Wright Forrester, an early proponent of system thinking in science and practice, stated that in a complex system, “causes are usually found not in prior events but in the structure and policies of the system.” We have long known in public health that many types of interventions can be useful to improve health: some will target individuals, some will create the contexts and the environments that reduce adverse health exposures and promote heathy behaviors, but still others, and these are the ones that are in the eye of the storm today, will require acting on the social and economic systems we live in.

There are many examples of targeted interventions that have been major life savers: vaccines, oral rehydration therapy, seat belts, and tobacco taxes and bans are just a few examples. There is much that can be done through sound public health interventions like these. But addressing the fundamental causes of the profound and pervasive health inequities that we see by social class and race in our societies requires a systemic approach: an approach that acts on the “structure and policies” of our society. This requires actions beyond the purview of public health agencies. Of course, the main reason to change these systems is fairness and justice, they need to be changed regardless of their health impact. But disease and death are the ways in which these systems become embodied, and thus inequities in health have been and continue to be today powerful motivators for social change.

There are many things we can do as a school of public health to make visible these links, to show how these systems operate and what their health implications are. We can identify and advocate for interventions and policies that address both proximal and upstream causes. We must also work within our own system, our school and our university to eliminate inequities, injustices and racism in all our activities and practices. Other things we must do as people, as communities, as citizens or immigrants of our countries and our world. Addressing the root causes, changing the balance of winners and losers in the systems we have, will be hard. A first step seeing the systems for what they are. Today the inequities demonstrated yet again by COVID-19 and the worldwide demands for an end to racial injustice are making these systems and their effects more visible than ever.