Introduction
Education is a critical component of health justice.Reference González1 Health justice is an emerging framework that seeks to leverage law and policy in furtherance of health equity.Reference Tobin-Tyler and Teitelbaum2 Health equity is achieved when “everyone has a fair and just opportunity to be healthy”3 and “everyone can attain their full potential for health and well-being.”4 Health justice, in turn, focuses on eliminating health disparities and establishing fair treatment for those who have been historically or currently marginalized.Reference Cannon5 The word “justice” goes beyond a traditional vision of health equity to center the role of law and policy in causing and exacerbating health disparities — and also their potential to promote equity.6 Health justice requires more than an exploration of the connections between education and health; it requires scholars, researchers, advocates, and policymakers to explore how and why education drives health disparities.7 It necessitates an examination of how structural racism and other barriers impact minoritized communities,8 followed by action through law and policy reform and meaningful enforcement of existing laws to facilitate health equity.Reference Cannon9 Critical perspectives, such as Critical Race Theory (CRT) and Dis/ability Critical Race Studies (DisCrit), provide approaches that advance this vision of the educational system as an important vehicle for health justice.
Health justice recognizes that only a small fraction of our health is driven by the care we receive at the doctor’s office, while approximately 80% of our health is actually delineated by the social, structural, and political determinants of health, which are the conditions in which people live, eat, work, play, age — and learn.Reference Magnan10 Health justice highlights that systemic and institutional barriers, including racism in both the provision of health care and in the social determinants of health, such as racism in education, lead to compromised health outcomes.Reference Yearby11 Health justice seeks to promote health equity by identifying and eliminating such barriers.
To advance the movement towards education as health justice, we posit that critical perspectives should be used to deepen and broaden the understanding of the interconnections between health and education across a range of educational inequities. This article applies approaches from critical theories to a health justice examination of educational inequities and argues that they should be deployed to strengthen scholarship, research, advocacy, and policy-making to promote justice and equity in education and health.
Thalia González, Alexis Etow, and Cesar De La Vega have argued that health justice should be expanded to be inclusive of education, highlighting the “co-influential” linkages between education and health.Reference González, Etow and De La Vega12 They urge that problems such as school policing and exclusionary school discipline necessitate legal and policy interventions to eliminate long-standing disparities that harm the health of students of color and students with disabilities.Reference González13 To advance the movement towards education as health justice, we posit that critical perspectives should be used to deepen and broaden the understanding of the interconnections between health and education across a range of educational inequities. This article applies approaches from critical theories to a health justice examination of educational inequities and argues that they should be deployed to strengthen scholarship, research, advocacy, and policy-making to promote justice and equity in education and health.
I. Education as a Critical Social Determinant of Health
While “public health has been largely underemphasized in [education] reform efforts” and the connections between education and health have also been largely “overlooked by the health law community,”14 a wide body of research shows the impacts of education on health and well-being.15 Those with more years of schooling are more likely to have better job opportunities, higher income, greater access to health care, healthier behaviors, better physical and mental health, less disability, and a longer lifespan.Reference Olshansky16 In particular, Americans with college degrees on average earn significantly more per year than those who do not complete high school.17 The lowest earners are Americans who do not complete high school, more than half of whom are unemployed.18 Lower educational attainment is associated with increased risk of teen pregnancy, poverty, maternal mortality, and incarceration.Reference Penman-Aguilar19
High quality K-12 education is necessary for young people to succeed in obtaining higher levels of education, with their related health benefits. During primary and secondary education, children learn academic, social, and executive functioning skills, including skills in meeting behavioral expectations, which are essential for admission and success in higher education.Reference Brown20
Further, as highlighted by school closures caused by the COVID-19 pandemic, schools are important sources of wellbeing as spaces for social and emotional development, building relationships and community, obtaining food and limited health care, and engaging in physical exercise.Reference Colao21 Schools can be a haven from violence, abuse, or neglect.22 Schools have also promoted healthy lifestyles, health literacy, the ability to cope with stress, and management of chronic diseases.23
Conversely, children can experience discrimination, exclusion, fear, or violence in schools due to the school-to-prison pipeline; school brutality, which is the unwarranted, excessive, and often traumatic use of force by state officials upon children at school;Reference Tuchinda24 inequitable investment of resources; and other systemic and institutional problems.Reference Schafer25 These problems, which disproportionately impact children of color, children living in low-income households, and children with disabilities, often manifest racism, ableism, and inadequate understanding of trauma and adversity.Reference Benson and Fiarman26 They compromise students’ educational experiences and well-being.27
These problems also increase the risk of high school suspension, expulsion, poor attendance or grades, arrest, detention, and incarceration, all of which are significant barriers to completing high school and entering college.Reference Amselem28 Students who are suspended are at significantly increased risk of being suspended again and dropping out.29 Receiving more severe or lengthy exclusionary discipline decreases the likelihood of graduation from high school.30 Further, any form of exclusionary discipline increases the risk of experiencing criminal victimization and incarceration, each of which harms health independently.Reference González and Kaeser31 In these ways, inequities in education result in compromised health outcomes during and after childhood.32
The health justice framework compels us to understand that educational inequities harm the health of children, especially children from historically and currently marginalized communities, during both childhood and adulthood. As González, Etow, and De La Vega observe, “[a]pplying and expanding health justice to be inclusive of education, and more specifically, [exclusionary] discipline and policing, is a critical first step in dismantling a pathway of negative individual and community health and well-being.”33
This article argues that critical perspectives enhance the ability of policymakers, advocates, and scholars to identify and eliminate educational inequities across a range of educational domains through enforcement and reform of law and policy. Critical perspectives help elucidate connections between educational inequities and health inequities and strengthen arguments about the urgent need to address those inequities. By deploying approaches from critical perspectives such as CRT and DisCrit, health justice can powerfully inform and reinforce educational reform efforts.
II. Critical Perspectives in Understanding the Role of Education in Health Inequity
Notwithstanding recent political efforts to distort and denigrate CRT by, for instance, banning it from public schools in some states,34 CRT can help to deepen health justice’s exploration of how and why educational inequities drive health disparities.Reference González and Joki35 Insights from this exploration enhance the analysis and reform of educational law and policy in order to achieve educational and health equity. CRT can also help society avoid the “critical mistake” of lacking an “antiracist public-health response to practices, policies, and systems of racism in schools that maintain [W]hite supremacy.”36
CRT is the practice of interrogating the role of law in protecting and perpetuating racial hierarchy and is one of a number of critical theories exploring inequity.Reference Bridges37 Several CRT approaches can facilitate and strengthen our understanding of education as health justice and can be used beyond education to explore law’s impact on health equity, deepening the health justice framework. CRT and practice must serve as tools for protecting the lives, liberty, and dignity — including the health and well-being — of communities of color “because those are what are literally at stake” in the pursuit of health justice.Reference Gupta38
A. Counternarrative: Storytelling to Understand Education as Health Injustice
Scholars, researchers, and advocates of health justice and educational reform, along with policymakers, can deepen their impact in leveraging law in pursuit of health and educational equity through counternarrative storytelling, an important principle of CRT and DisCrit. Many scholars and researchers focus on theory and data, but the health justice framework can also benefit from stories, which CRT posits “are powerful means for destroying mindset — the bundle of presuppositions, received wisdoms, and shared understandings against a background of which legal and political discourse takes place.”Reference Delgado39 Dominant discourse is born of “comforting” stories that engender complacency, facilitate the view that the current state of health and health inequity in our country is inevitable and natural, and serve as a barrier to progress.40 Counternarratives can disrupt that complacency41 and engage the conscience.Reference Locke42 When scholars, researchers, and advocates bring forward and amplify counternarratives, such stories can help policymakers understand why the status quo is unacceptable and what impactful reform would entail, in both the educational and health justice spheres. What follows is an example of counternarrative in furtherance of education as health justice.
It was 10 AM on a Wednesday. Her friends were in school, but twelve-year-old Jasmine43 was sitting in a juvenile detention facility. The day before, she threw her textbook to the ground, hitting the foot of another student. The school resource officer arrested Jasmine and she was sent to juvenile detention overnight. The principal told Jasmine’s mother that she was expelled. He informed her that Jasmine had violated too many school rules, was insubordinate, and had not shown she could be a productive member of the school community. After continuing to get into trouble frequently and consistently receiving mediocre grades over the next several years, Jasmine dropped out of school in tenth grade.
Applying counternarrative, the same story can be told very differently, centering the perspectives of Jasmine and her mother and providing context that enables their story to engage the conscience: Jasmine is a Black girl who attended Title I schools that served primarily Black children from low-income families. When Jasmine was in elementary school, she struggled to learn to read. When she was nine years old, her mother sent an email to the school principal stating that she suspected Jasmine had a learning disability and asked that Jasmine be tested, but the school never provided any assistance. The school leadership was overwhelmed with a small budget and concern that directing additional resources to one child meant depriving other children of assistance. Her mother had heard that evaluations of children for possible learning disabilities cost thousands of dollars, and the family could not afford that. Jasmine grew more frustrated and sometimes she avoided doing assignments that were too difficult, prompting her to receive mediocre grades and school detention.
In sixth grade, her father was murdered. Jasmine frequently felt anxious, sad, and overwhelmed. Even though school staff knew what happened and knew that Jasmine was struggling with grief and trauma, they never referred her for counseling or an evaluation. She often had trouble focusing and following instructions. Teachers labeled her as insubordinate and frequently referred her to the school resource officer, who wore a uniform and often threatened to have her arrested if she didn’t “grow up.” Jasmine was intimidated by and did not trust the officer. The day she threw her textbook to the floor, she had been in tears over a difficult quiz with instructions that she had trouble understanding. She didn’t mean for the book to hit anyone and the other student was not injured.
Jasmine’s school did not give her or her family information in writing about her expulsion, the option to contest the expulsion, or any assistance staying on track for graduation. When she was ultimately psychologically evaluated through the juvenile justice system, she received diagnoses of dyslexia and post-traumatic stress disorder (PTSD). No one shared these diagnoses with her educators, however. In tenth grade, overwhelmed by the difficulties of school, Jasmine dropped out. Afterwards, she had trouble finding and keeping a job with a decent wage and health insurance, and she was unable to escape poverty. She had several chronic health conditions, such as asthma and diabetes, and she struggled to meet her mental and physical health needs.
The first version of Jasmine’s story is one that has been told again and again, a story that centers adult frustrations with children who fail to meet expectations and facilitates complacency about the numbers44 of school dropouts and those entering the school-to-prison pipeline.45 Health justice demands a shift to a counternarrative to uncover the ways in which education and the laws that shape it serve as a health injustice in the United States. The use of counternarrative as a tool to make these connections will help scholars, researchers, advocates, and policymakers provide compelling evidence and identify important solutions to advance the intertwined goals of health justice and educational equity.
The injustice of Jasmine’s education harmed her health during and after childhood. In other words, the educational injustice that she endured was also a health injustice. Counternarrative storytelling allows the health justice framework to “center in the margins” or ensure that the perspectives of historically and currently marginalized groups are “the central axis around which discourse … evolves.”46 Storytelling through counternarratives like Jasmine’s can also facilitate the change that is necessary for health justice; it can “lead the way to new environments … Telling stories invests text with feeling, gives voice to those who were taught to hide their emotions. Hearing stories invites hearers to participate, challenging their assumptions, jarring their complacency, lifting their spirits, lowering their defenses.”47
B. Race Consciousness and Intersectionality: Interrogating Education as Health Injustice
Race consciousness is a core component of CRT. It involves digging beneath the surface of information to develop deeper understandings of concepts, relationships, and personal biases, especially as ignoring the role of racism in American society through “color blindness” has allowed racism to endure.Reference Peller48 The field of medicine is beginning to demonstrate understanding that racial differences in health are not biological and that race in fact is a social construct, with institutional racism in healthcare and in the social and political determinants serving as drivers of health disparities.49 Health justice requires the growth and deepening of race consciousness, which is essential to fighting structural racism to advance health equity, and “education policies and practices must be interrogated through a race-conscious framework.”50
A central principle of race consciousness is the concept of ordinariness, or the recognition that racism is integral to our society, rather than aberrational.Reference Delgado and Stefanic51 Research shows that people from racially minoritized groups are chronically exposed to diverse forms of everyday racism,52 which directly harm health by causing stress that impacts the body in many ways.Reference Geronimus53 Health justice must involve ongoing explorations of the ways laws and policies — and their operationalization — are mired in structural racism and function as everyday determinants of health inequity.54
CRT also emphasizes that race intersects with other identities, such as gender and disability, and each of these identities can be grounds for marginalization. Intersectionality recognizes that a person may experience multiple marginalizations, such as racism, sexism, and ableism, and the distinct experiences of a multiply marginalized person, including their health, cannot be fully understood and addressed by looking at and treating each form of marginalization separately.Reference Crenshaw55 Of particular relevance to Jasmine’s story is Dis/ability Critical Race Studies, or DisCrit, which posits that “disabled persons of color are embodiments of intersectionality.”56 In order to develop a complete understanding of ableism and of racism, health justice should build on DisCrit to analyze health inequities experienced by people of color with disabilities.57 Along with CRT and DisCrit, Critical Race Feminism, QueerCrit, LatCrit, TribalCrit, and other critical perspectives58 can enhance and deepen the exploration of education law and other forms of law as drivers of health equity, an exploration that is central to health justice.
DisCrit scholars have argued in particular for interrogation of “the ways in which race, racism, dis/ability, and ableism are built into the interactions, procedures, and institutions of education, which affect students of color with dis/abilities in a qualitatively different way than [W]hite students with dis/abilities.”Reference Annamma, Connor and Ferri59 While education is “key to lifting people out of poverty and reducing socioeconomic and political inequalities,”60 education is far from equitable. Students from low-income families, racially minoritized students, and students with disabilities — and those experiencing intersectionality through multiple forms of subordination — generally receive the least benefits from education and disproportionally experience harms from school-inflicted trauma and the school-to-prison pipeline.Reference Okilwa, Khalilfa and Briscoe61
i. disproportionate academic attainment
During the last forty years, on average, White students persistently and significantly scored higher on standardized tests in math and reading than Black and LatinxReference Mora, Perez and Vargas62 students, though the gap between average scores of each group is slowly narrowing.63 For indigenous students, these disparities are particularly stark. Native American fourth-graders on average have both the lowest reading and math scores in the nation.Reference Cai64 Standardized tests have long been criticized as being racially biased.Reference Stewart and Haynes65
Similarly, Black, Latinx, and Native American students experience significantly higher rates of high school dropout than White students.66 And students with disabilities have significantly lower graduation rates than their peers.67 The lowest graduation rates are experienced by students of color with disabilities.68 DisCrit helps to explain that students at the intersection of multiple minoritized identities (e.g., Black students with disabilities) experience the least benefits from education due to the unique experiences they encounter as a result of their intersecting identities and due to experiencing multiple forms and levels of oppression.Reference Fenning and Johnson69
Research shows that non-completion of high school increases the risk of poor health and premature death.70 The corresponding average incomes of Black, Latinx, and indigenous Americans are consistently significantly below that of White Americans.71 And the average income of Americans with a disability is significantly below that of Americans without a disability, even though Congress intended that the Individuals with Disabilities Education Act (IDEA) would ensure that children with disabilities had “equality of opportunity, full participation, independent living, and economic self-sufficiency.”72
CRT asserts that racism is embedded in ordinary American social structures and functions to keep minorities in subordinate positions. The “ordinariness” of racism73 helps to explain why Black children persistently experience fewer benefits from education. Studies of implicit bias among educators and police officers support such theories empirically and illuminate themes of bias in regular interactions with students, including themes of White fear and suspicion of Black people; perceptions of Black children being older than they are; and beliefs in the intrinsic guilt and inferiority of Black children.Reference Lewis and Diamond74
ii. disproportionate discipline
The implicit biases of educators and law enforcement officers not only lower expectations for the academic attainment of children of color and children with disabilities, they manifest in disproportionate school discipline and student referrals to the juvenile and criminal justice systems. González, Etow, and De Le Vega center school discipline and policing as important issues of health justice because they are public health crises for which legal and policy interventions are critical to an antiracist health equity agenda.75
As part of race consciousness, CRT scholars advocate moving beyond the “colorblindness” that has allowed racism to flourish and has contributed to racial illiteracy.Reference Bonilla-Sillva76 A race-conscious examination of school discipline reveals that Black students are not misbehaving more frequently or with greater severity than White children.Reference Skiba77 However, Black students account for 45% of all of the school days lost due to suspension, even though they constitute only approximately 15% of the K-12 student population.Reference Whitaker78 Black students are disproportionately suspended for minor, non-violent infractions, such as dress code violations.Reference del Toro and Wang79 Further, studies uniformly show that Black students are at heightened risk of disciplinary exclusion if they also have a disability.80 Black students lose more days of instruction to suspension than Hawaiian/Pacific Islander students, Native-Americans students, and Latinx students (listed in decreasing order of average days lost to suspension), and each of these students of color on average lose more days to suspension than White students.Reference Losen and Martinez81 Unfortunately, students suspended or expelled are nearly three times more likely to be in contact with the juvenile delinquency system the following year, and suspension or expulsion dramatically increases the likelihood of dropping out of high school.Reference Fabelo82
Similarly, Black boys are 2.15 times more likely than White boys to be referred to law enforcement and 2.44 times more likely to be arrested at school.83 Black girls are 3.01 times more likely than White girls to be referred to law enforcement and 3.66 times more likely to be arrested at school.84 An arrest significantly diminishes the likelihood that a student will graduate from high school,85 which, as discussed above, has significant health impacts.
Even though IDEA contains provisions to protect children with disabilities from suspensions and expulsion, and Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA) (Section 504 and ADA together are hereinafter “Section 504”) prohibit discrimination against children with disabilities, students with disabilities are twice as likely to be suspended as their non-disabled peers.86 They are also significantly more likely to be arrested at school.87 As recognized in guidance recently issued by the U.S. Department of Education, many students with disabilities face discipline “because they are not receiving the support, services, interventions, strategies, and modifications to school or district policies that they need to manage their disability-based behavior.”88 Moreover, many students with intersectional identities, such as students of color with disabilities and particularly Black girls with disabilities, are excessively selected for discipline and policing.89
School brutality also disproportionately impacts Black students and students with disabilities.90 Nationally, Black children are 2.5 times more likely to be corporally punished at school than other children.Reference Font and Gershoff91 Black girls are 2.17 times more likely than White girls to be restrained at school, and Black boys are 1.58 times more likely than White boys to be restrained.92 In some states, such as Tennessee, students with disabilities are twice as likely as students without disabilities to be paddled at school.93 The disproportionate application of school brutality upon Black children and students with disabilities is health injustice because such brutality is an adversity that is often traumatic. In turn, trauma dramatically increases the risk that a child will be diagnosed with a disability, enter the school-to-prison pipeline, fail to graduate from high school, and experience mental and physical health problems.94
Intersectionality, a tenet of CRT and DisCrit, helps to explain why Black girls experience higher levels of arrest and restraint than both White children and Black boys and why Black students with disabilities experience higher levels of school discipline than Black students without disabilities.95 Black girls often uniquely experience the intersection of multiple oppressions of sexism, racism, and ableism.96 Adults tend to view Black girls as older than they are and thus less innocent and deserving of protection and support, a phenomenon known as “adultification.”97 Black girls are more likely to be disciplined for cis-gendered and misogynistic expectations of femininity.Reference Wun98 Consistent with implicit bias and historical stereotypes,Reference Blake, Butler, Smith and Losen99 school officials more frequently punish Black girls for “talking back,” being “unladylike,” and being “disrespectful” and “uncontrollable.”100 By disproportionately punishing Black girls, the education system “formally and informally reinforces racialized sexism.”Reference Coker and González101
DisCrit helps to explain that students at the intersection of multiple minoritized identities (e.g., Black students with disabilities) experience the highest levels of school discipline due to the unique experiences they encounter as a result of their intersecting identities and due to experiencing multiple forms and levels of oppression.102
iii. lack of trauma awareness
The lack of awareness of the impact of trauma upon health, disability, and school performance entrenches the disproportionate discipline and failure to support the special education needs and school attainment of multiply-marginalized children. Recent research reveals that most Americans have at least one potentially traumatic adverse experience during childhood (an adverse childhood experience (ACE)), such as the death of a parent, child abuse, or parental incarceration.103 Trauma can so significantly impact physical and mental health that it can create and exacerbate disabilities that impede learning and behavior at school, materially heighten the risk for a panoply of illnesses, and shorten lifespan.104 Trauma dramatically increases the risk that a child will be diagnosed with ADHD, act with impulsivity or in fight-flight-or-freeze mode and be expelled, enter the school-to-prison pipeline, and fail to graduate.105 Accordingly, trauma itself is a source of health injustice.
Schools can further traumatize students through expulsion, lengthy suspension, school brutality (which includes corporal punishment, seclusion, and restraint), and other harsh punishments, even though trauma can be the main reason for educational failure.106 A lack of understanding of trauma impairs the ability to recognize and support, rather than harshly punish, a child who is manifesting the effects of trauma through behavioral challenges.107 Schools can diminish the harms of trauma, however, by providing culturally responsive school-based mental health services and other supportive services such as restorative justice,Reference González, Etow and De La Vega108 as well as services and accommodations for trauma-related disabilities pursuant to IDEA and Section 504.109 They can improve educational performance and outcomes by creating emotionally and physically safe school environments for all students, as Jasmine required.110 They can also avoid traumatizing students by eliminating school brutality, referral to law enforcement, and harsh discipline, including expulsion and long-term suspension, both of which increase the likelihood of school dropout and associated health disparities.111
iv. decreased investment in the education of children of lower-income families
Critical analysis of the relationship between the income of students’ families and educational and health outcomes is also necessary for illuminating education as health injustice. Generally, students who live in low-income households have significantly worse educational attainment and outcomes than students who live in high-income households.Reference Ferguson, Bovaird and Mueller112 While racial disparities persist across socioeconomic groups, structural racism has also relegated a disproportionate share of people of color to lower income.113 And those who are both low-income and people of color face compounding health disparities as a result of intersecting marginality.Reference Chen, Martin and Matthews114
Increased spending on education improves student outcomes, including in test scores, educational attainment, and wages, especially for low-income students.Reference Jackson115 However, except in a few states, such as New Jersey and Ohio, school districts serving students in low-income households do not receive significantly more resources than districts that serve students in higher-income households.116 In fact, in 2015, twenty two states spent at least 5% less – and sometimes more than 25% less — on their highest-poverty school districts, rather than their lowest-poverty school districts.Reference Cookson and Darling-Hammond117 Further, school districts themselves often direct more money to schools serving students in the wealthiest households.118 The financing of public schools with revenue primarily from local property taxes also advantages students in the wealthiest communities, which are often majority-White due to our country’s history of segregation.Reference Semuels119 The overall result is that wealthier students and White students receive more funding for their education, and the academic outcomes reflect the differences in investment.Reference Taylor120
In contrast, school funding that would facilitate health justice would provide each school with enough funding “to provide qualified teachers, support staff, programs, services and other resources essential for all students to have a meaningful opportunity to achieve the state’s academic standards and graduate [from] high school prepared for … postsecondary education[ ] and the workforce.”Reference Farrie and Sciarra121 Essential resources also include “school-based restorative justice practice, social and emotional learning, trauma-informed approaches, and mental health supports and services,” which address ACES, improve school climate and connectedness, and promote physical and mental health.122 Improved funding for schools would increase investments in areas of high poverty to address the additional cost of meeting the above goals in these locations.123
v. critically viewing jasmine’s story
Race consciousness, including the principles of ordinariness and intersectionality, help to explain the why behind Jasmine’s exclusion from school and the resulting harmful impacts. These critical perspectives highlight that Jasmine was denied the opportunity to achieve academically, discriminated against as a Black girl with disabilities in her exclusion from school and deprivation of necessary special education services, and put into the school-to-prison pipeline because she experienced the intersection of multiple oppressions, including sexism, racism, and ableism.
Her exclusion reflects traditional expectations that a girl should be quiet and compliant and not show frustration or anger.Reference Gadzekpo124 Her expulsion, arrest, and detention were consistent with racist expectations that Black children are disobedient and insubordinate, the adultification of Black girls, and racist fears that Black children are dangerous.Reference Douglass and Smith125 Rather than receive special education services and accommodations as required by law, Jasmine was harmed by the ableist belief that children who reject school work cannot be productive at school and should be excluded.Reference Flavin126 The lack of financial investment in Jasmine’s Title I school contributed to school administrators’ reluctance to spend limited funds to evaluate and assist Jasmine in compliance with disability law when there were other students who were also struggling at school and were less disruptive than Jasmine. And the expulsion and referral to the juvenile justice system revealed a lack of understanding and empathy regarding the relationship between trauma, disability, and education.127
III. Using Praxis to Advance Action in Support of Education as Health Justice
Kimberlé Crenshaw, who coined the term CRT, notes that CRT is not a noun, but a verb, an evolving and malleable practice.Reference George128 Health justice should also be a “verb” and function as an aspirational and dynamic vision involving action in pursuit of health equity. Health justice necessitates action to both enforce existing laws currently under-enforced for marginalized communities and systemically reform law and policy in pursuit of health equity.129
The agenda for both forms of change must be driven by people from marginalized communities who continue to be harmed by laws and policies that facilitate health and educational disparities.130 Health justice must promote their leadership and advance their goals as those goals evolve. One of the ways that CRT evolves is through praxis,131 which is an iterative process by which the knowledge gained from theory, research, personal experiences, and practice inform one another.132 Just as the theoretical underpinnings of health justice must be put into practice, the developing theory and the research under its umbrella should be guided by the lived experiences, visions, goals, and ideas of people from marginalized communities,133 thereby making the health justice framework most relevant, useful, and impactful.Reference Benfer134
Informed by CRT and the concept of praxis, health justice can lead to the reformation and transformation, “through careful, strategic, thoughtful advocacy, [of] the very systems in place that are destroying our communities and maintaining the subordination of people of color,”135 both in the area of education law and policy and in many other areas of law. In regards to education, critical perspectives require a range of interrogations. For example, what changes are necessary for K-12 public education to deliver, rather than thwart, health justice? How can health justice be effectuated through support for the goals of affected community members? How can health justice ensure the enforcement of extant laws that are currently under-enforced for marginalized communities, as well as the reform (and abolition) of flawed laws and systems?
Understanding education reform as a health justice issue, informed by critical perspectives, changes the analysis of both health and educational inequity. Critical perspectives underscore how interconnected these inequities are, how dependent health is on education and how structural racism and ableism underly inequities in education that drive inequities in health. In other words, using approaches from CRT and DisCrit reveals and emphasizes how structural racism and ableism facilitate educational harms that contribute to health harms that then facilitate health inequity. These revolving and “co-influential”136 inter-connections necessitate bringing in the health equity expertise of community members and organizations, scholars, advocates, and policymakers to inform education reform.137 Conversely, they also necessitate bringing in those with educational equity expertise to inform health equity efforts, as health equity cannot be achieved without education reform.
Because education is such a powerful determinant of health, health equity will remain elusive if our education system continues to subordinate and marginalize minoritized students.138 The health effects of injustice in the educational system provide compelling evidence on which scholars, advocates, and policymakers can rely in support of education reform on two levels: through new laws and policies and through better enforcement of existing laws. Ultimately, using critical perspectives will deepen and broaden the connections between health and education justice and will drive a more impactful agenda by giving scholars, researchers, advocates, and policymakers solutions that will improve outcomes for marginalized individuals and communities and facilitate equity in both spheres.
Jasmine’s story provides some insight into these solutions. Jasmine experienced significant educational injustice in her life — and harms to her health as a result of under-enforced laws and systems in need of reform and abolition. Evidence suggests that racial and ethnic minorities are misidentified as having certain disabilities, including over-identification of Black students as having intellectual disabilities and under-identification of Black students as having specific learning disabilities.139 When students are appropriately identified, special education can provide services critical to academic success.140
Accordingly, long before she was expelled, Jasmine’s school should have evaluated her for a disability, recognized and supported her struggle against the effects of trauma, and acted to avoid excluding her and discriminating against her as a Black girl with a suspected disability, pursuant to the IDEA, Section 504, and Title VI of the Civil Rights Act of 1964, and Title IX of the Education Acts of 1972.141 If Jasmine’s school had timely assessed her for possible disabilities,142 a comprehensive evaluation at public expense, as required by law, would have revealed her dyslexia and PTSD. The school should have then provided individualized special education services and accommodations, such as specialized instruction to improve her reading skills,143 as required by the IDEA and Section 504, rather than expulsion, lost instruction, and referral to the juvenile justice system.144 With such proper implementation of these laws, Jasmine could have received the accommodations, services, and resources necessary to support her academic attainment and her well-being.
Before expelling Jasmine, school administrators should have provided her with written notice about the exclusion and the opportunity to be heard through a hearing.145 They should have held a manifestation determination review to determine whether her behavior manifested a suspected disability, which would have prohibited her expulsion and required an individually tailored educational program.146
Instead of surveillance by a School Resource Officer and further traumatization through the school-to-prison pipeline, which should be abolished, Jasmine required trauma-responsive education, such as counseling services,147 help building relationships and experiencing a sense of belonging and acceptance at school,148 a functional behavioral assessment to determine the root causes of her behavioral challenges,149 and a behavioral intervention plan premised on positive supports.150 Jasmine’s Title I school should have received more intensive financial investment so that administrators did not feel pressure to ration resources for students, to the detriment of their educational attainment. These approaches operate on two levels, both of which are necessary for health justice: they represent the need for enforcement of extant laws that often go under-enforced for marginalized students, as well as the reformation and abolition of laws, policies, and systems mired in inequality.
Applying praxis, educators, school administrators, policymakers, and advocates should listen to the voices of the many youth and parents across the country, especially youth and parents of color, who have called for increased access to culturally responsive school-based mental health services and police-free schools.151 Lawyers should serve as resource allies to youth and communities that are disproportionately harmed by school policies, including by enforcing anti-discrimination and disability laws, identifying the research that empirically supports their goals, and assisting communities in advocating for policy reform.Reference Casper152 Youth should be recognized and supported as experts on what they need and as leaders of policy change. “[S]hifting power to affected communities is a critical component to beginning to remedy the harms of long-standing disinvestment, discrimination, and disenfranchisement in frontline communities.”153
We know the health toll of failure to complete high school, low educational attainment, lack of appropriate accommodations and supports for students with disabilities, trauma, and the disproportionate exclusionary discipline, school brutality, and arrest of minoritized students. Reforms in both the education and health spheres should be informed by critical perspectives and prioritize keeping all children in school, especially those whose disability or trauma manifests as alleged misbehavior, with a sense of safety, belonging, dignity, and the supports necessary for them to achieve academically and thrive. Such education invests greater resources in children living in low-income rather than high-income neighborhoods to address the significant unmet educational needs of children in low-income neighborhoods.Reference Catcliffe154 Such education avoids inflicting trauma, especially upon students of color, students with disabilities, and those with intersectional identities, through abolishing school exclusion, school brutality, and the school-to-prison pipeline.155 Such education ensures that schools have “counselors not cops” to demonstrate culturally responsive support for student mental health, rather than suspicion often rooted in bias, that students will commit crimes.156 Education as health justice also embraces the requirements and spirit of disability law and supports children who have been harmed by trauma. Strengthened by critical perspectives, education that advances health justice aims to ensure that children living in poverty, children with disabilities, and children from racially minoritized backgrounds are achieving academically, staying in school, and receiving a just opportunity to live long, healthy lives.
Note
The authors have no conflicts of interest to disclose.
Acknowledgements
The authors express their gratitude to Samantha Rudelich for her excellent research assistance and to Thalia González and the other participants of the Health Justice: Engaging Critical Perspectives in Health Law and Policy Initiative workshop at which Professor González commented on this article, and the JLME editorial and reviewer team, Janel George, and Marta Beresin, for their valuable feedback.
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