Like unshakeable pillars, the principles of diversity, equity and inclusion have long ensured the stability and integrity of public health in America.
In recent years, however, those fundamental principles have come under attack in courts and legislatures. Now, public health leaders are concerned the assault could have devastating consequences for the health of communities and individuals by exacerbating existing health inequities and interfering with the work of public health departments to foster healthy and safe environments for all.
In some states, particularly in the South, conservative leaders have grown increasingly critical of DEI initiatives, claiming they are unconstitutional and that they can create division rather than unity. Their discontent has played out in a spate of anti-DEI legislation that poses significant challenges to public health efforts aimed at achieving health equity and improving health outcomes for all.
Diversity, equity and inclusion are vital, not just “accessories or nice-to-haves,” said Lauren Smith, MD, MPH, vice president of strategic portfolios at the Robert Wood Johnson Foundation. “It is in our nation’s best interest to embrace health equity and stay strong, as short-sighted or potentially misguided efforts attempt to unravel the gains we have made so far,” Smith told The Nation’s Health.
According to a recent NBC News analysis, more than 30 states have introduced bills banning or limiting DEI initiatives during their current legislative sessions. For public health, such legislation is part of a broader trend aimed at limiting the influence of DEI principles in public health initiatives and education, experts say.
Among the more notable setbacks, Florida Gov. Ron DeSantis in 2022 signed the Individual Freedom Act, sometimes referred to as the “Stop Woke Act,” which restricts the ability to discuss and address systemic racism and other social determinants of health. The law faces ongoing legal challenges.
Last year, in a move that sent shockwaves across the public health landscape, Tennessee Gov. Bill Lee rejected nearly $9 million in federal funding for HIV prevention programs. While Tennessee leaders said they wanted to instead use state funds to do work their own way, the decision came after the governor criticized access to inclusive health care for people who are transgender.
In interviews with The Nation’s Health, public health workers in conservative-led states who have dedicated their lives to advancing the principles of DEI said that rejecting inclusivity widens the lines separating blue and red states and makes it harder to carry out crucial public health activities. In fact, many public health workers in states with conservative leadership will not even talk about DEI issues publicly for fear of losing their jobs, Oni Blackstock, MD, MHS, told The Nation’s Health.
“There’s a lot of fear in the current climate,” said Blackstock, a primary care and HIV physician and the founder of Health Justice, a racial and health equity consulting practice. “We’ve seen this happen with the anti-DEI work in higher education too, where people have been targeted for continuing to try to work around some of the legislation that exists.”
In some states, public health workers are forbidden to use certain language related to health equity and are forced to hunt for replacement words, Blackstock said, adding that the art of “saying it without actually saying it” has become a common practice when filling out grant applications and creating targeted messages.
“They’re looking for workarounds,” said Blackstock, who formerly worked on HIV/AIDS at the New York City Department of Health and Mental Hygiene. “Instead of using the term ‘health equity,’ they’ll focus on rural populations. There might be a higher proportion of white residents in rural areas, but Black, Latinx and Indigenous folks fall into this category too.”
Despite challenging political environments and pushback against DEI, public health professionals remain steadfast to advancing health equity and uplifting DEI as a core tenet, said Hassanatu Blake, PhD, MPH, MBA, director of health equity and social justice at the National Association of County and City Health Officials.
“Today, there is a lot of evidence of employee burnout, leading to health workers leaving the health sector altogether, to funding cuts, illustrating how daunting working on inequities can be,” Blake told The Nation’s Health.
Politically-charged attacks against equity threaten health.
Photo by Designer491, courtesy iStockphoto
Public health professionals impacted by the politicization of DEI are persevering through tough times by working with nontraditional partners who are able to do things that they themselves are no longer able to do. That includes collaborating with community- and faith-based organizations, businesses and other sectors to mobilize against health inequities through equity-based programs and policies.
NACCHO’s online “Roots of Health Inequity” series can be an especially helpful resource for workers in jurisdictions where work around DEI has ground to a halt. Staff can do individual or group learning using the NACCHO resource, regardless of formal barriers, Blake said.
Beyond undermining crucial programs and jeopardizing funding, anti-DEI propaganda will also have severe consequences on quality of life, said Rex Archer, MD, MPH, director and professor of population and public health at Kansas City University.
“A primary reason that the U.S. has fallen behind 45 other nations in life expectancy — and is expected to drop to 64th by 2040 — is because we have an increasing number of residents who have been historically economically and socially marginalized, and continue to be made vulnerable,” said Archer, who led Missouri’s Kansas City Health Department for more than two decades.
DEI programs are essential for reversing this downward trend, “not just for those who are aware of their vulnerability, but also the majority of the middle class whether in urban, suburban or rural regions, need protections from economic structural injustices that DEI programs bring to light,” Archer told The Nation’s Health.
Meanwhile, DEI is top of mind for public health professional Nicole Taylor, MPH, who has been delving into the topic for her graduate school research at Campbell University.
“We’re all moving in the same direction, we all want the same thing,” said Taylor, a former program manager in HIV/AIDS prevention and disease intervention at Austin-Travis County Health Department in Austin, Texas. “Whether you’re 55 or 15, whether you’re a newborn or facing palliative care in hospice, we all want, at those moments, to be able to attain the highest level of health,” Taylor told The Nation’s Health.
In either camp, the common goal should be for everyone to be able to attain the highest level of health, said Taylor, noting that the topic has sparked some spirited discussions with her colleagues.
“What are we advancing?” she said. “Is it hearing that racism and systemic racism is finally acknowledged? Is that the end game? Or from where we sit, is the highest level of health for everyone the end game?”
For more, visit www.rootsofhealthinequity.org.
This article was corrected post-publication.
- Copyright The Nation’s Health, American Public Health Association
