Introduction
For some time now, public health advocates have been aware of the influence of non-medical factors, such as health knowledge and behaviors, on the quality and longevity of people’s lives. This attention has expanded “upstream” to an interest in the health effects of household conditions such as economic stability and the built environment. More recently, the field has grappled with the role of systems and structures in creating poor health outcomes.Reference Braveman, Egerter and Williams1 The need to shift interventions ever further upstream has become urgent in light of the COVID-19 pandemic and recent public protests against structural racism and other forms of subordination.
In this moment of crisis, there are also the seeds of transformation: “Health justice” has become an essential organizing, analytic, and policy framework. The health justice framework connects public health research on the social and political determinants of health with the recognition that justice-focused social movements are key drivers of structural change.Reference Tobin-Tyler and Teitelbaum2 The call to link policymakers and professionals with social movements has already transformed other fields by means of such “[x] justice” movements.Reference Harris3 For example, in the early 1990s the mainstream environmental movement, which had largely been focused on conservation, was challenged by advocates representing city dwellers, communities of color, Indigenous communities, working-class people, and others who called for “environmental justice.”Reference Cole and Foster4 Soon afterward, proponents of “reproductive justice” challenged reproductive rights advocates to recognize the impact of structural racism on reproductive health and freedom.Reference Ross and Solinger5
Today, the public health field is similarly being called to help dismantle the pervasive structural inequality that pervades our society. This call invites public health practitioners to recognize that, if we are to have health-promoting institutions and systems, building them will require the creativity, insights, and energies of justice-oriented social movements. The health justice framework is one potent result of this call.
Justice is a health issue and vice versa. The more unequal a society is, the worse its health outcomes are.Reference Wilkinson and Pickett6 And the unjust health disparities that have persisted despite many years of public health efforts can be traced to long histories of social subordination.Reference Harris and Pamukcu7 Embracing health justice, however, also raises new questions. For example, if — as many governments and organizations have recently declared — racism is a public health crisis,Reference Mendez8 where might solutions lie?
The key to leading longer and healthier lives lies in shifting from a profit-driven economy reliant on diminishing natural resources to one that supports the resilience of people and the systems that sustain them — without the costs of this shift falling on the most vulnerable.
We suggest that the “Just Transition” (also referred to as JT) framework is a powerful and timely way to understand and address the health disparities created by racism and other forms of structural subordination. JT, a “movement of movements,” links advocacy around environment, health, reproduction, climate, and other pressing problems of inequality around the same root causes: a racialized political-economic system that demands ever-growing profits from a finite planet and its people.
The term “just transition” was first coined by labor advocates concerned with the plight of workers at risk of being left jobless and impoverished by deindustrialization.Reference Eisenberg9 More recently, the term has been embraced by climate justice activists focused on the need to transition away from fossil fuel dependence, given the imminent threat that greenhouse gases pose to life on Earth.10
In the climate justice context, Just Transition is a vision with a simple but transformational premise. The key to leading longer and healthier lives lies in shifting from a profit-driven economy reliant on diminishing natural resources to one that supports the resilience of people and the systems that sustain them — without the costs of this shift falling on the most vulnerable.
JT advocates fight for a rapid transition from a fossil-fuel based economy to an economy based on renewable, less ecologically destabilizing resources. The JT framework treats the transition process as far more than a technical and political problem. To accomplish a just transition requires rethinking the institutions, processes, and systems that currently create and sustain political, economic, and social inequalities. The JT mission is, therefore, not reform but transformation.Reference Farrell11
In this essay, we argue that as the public health field moves upstream to address the “cause of causes” for unjust health disparities, the JT framework offers new possibilities for partnership and collective action. In Part I, we introduce the framework’s history and tenets by applying a JT lens to a public health issue. In Part II, we suggest some policy implications of the JT framework for public health advocates.
I. Introduction to Just Transition: A Public Health Example
The JT framework identifies deep flaws in our political-economic system as a root cause of injustice, and one of the most glaring flaws is the role of race in allocating resources. As so many justice movements have charged, racism does not only harm the oppressed; it can be a barrier to everyone’s wellbeing and shared prosperity. Heather McGhee memorably writes that racism is why we “can’t have nice things” — like reliable roads, a robust social safety net, and dignified jobs.Reference McGhee12 Building systems to exclude some people from these resources means that everyone suffers.
Indeed, racism — specifically, anti-Black racism — explains a lot about our nation’s inconsistent commitment to the public infrastructure on which our collective health depends. From public education to clean water, racism in the United States has historically led many citizens and policymakers to believe that public goods should only flow to the “deserving,” and that Black and brown people do not qualify.Reference Alesina, Glaeser and Sacerdote13
An example comes from one of the most basic public health interventions, sanitation. By many measures, sanitation is an early public health success story. Yet unjust disparities persist, with communities across the country suffering from what Catherine Coleman Flowers calls “America’s dirty secret:” Many families, especially the rural poor, lack an affordable and hygienic way to access clean water or dispose of their toilet waste.Reference Flowers14 Flowers makes clear that this fundamental public health problem is not caused by individual ignorance or even household poverty. Rather, she follows the chain of causation upstream to a political economy structured by centuries of anti-Black racism.
Flowers’ home state of Alabama provides an illustration. Following the Civil War and Reconstruction, Alabama white supremacists organized the passage of a new state constitution to destroy its budding multi-racial democracy. Still in force today, the Alabama constitution of 1901 is one of the longest constitutions in the world (with 977 amendments) and was deliberately designed to disenfranchise Black and poor white people. Still today, as the New York Times has noted, the constitution has many features that “creat[e] solid constituencies against change.”Reference Robertson15 The constitution requires amendments for even local public health interventions like mosquito control and litter enforcement. It contains a tax code that is among the most regressive in the nation. And it “puts enormous power in the hands of the Legislature.”16
Though originally motivated by anti-Black racism, the Alabama constitution has successfully locked many of its present-day residents into poverty, no matter what their race. For example, with a permanent cap on taxes built into their state constitution, rural cities and counties are forced to rely on fines and fees — which disproportionately burden the poor — to pay for basic public goods such as schools, transit, health care, and sanitation.17 And, unfortunately, Alabama is not an anomaly. The southern states that once were the stronghold of slavery, today feature some of the worst living conditions and attendant health outcomes in the United States.18
The example of toilet waste thus illustrates that seemingly straightforward public health issues may be anything but. Given the workings of a biased political economy, no technical fix or public awareness campaign would be sufficient to ensure that all families in the US receive access to the human right of basic sanitation. Going even further upstream reveals that a racialized political economy prevents us from living in communities where health, belonging, and shared prosperity is the norm.
Without a political commitment to the common good, the market determines who has access to the determinants of health. And as we have observed from the early days of the pandemic, such a system places everyone at risk.Reference Harris and Pamukcu19 The health justice lens asks us to broaden our focus from health disparities to the pernicious legacy of anti-Black racism in the United States. A Just Transition lens asks us to pull the focus still further.
Continuing with the example of sanitation, climate scientists anticipate not only rising temperatures in the future, but also increasing cycles of deep drought punctuated by sudden intense rains. The flooding caused by such extreme weather events may well overwhelm even presently-existing sewage systems and further contaminate local water sources, leading to public health threats such as cholera and other water-borne diseases.Reference Howard20 In order to adequately address these health risks, it is not enough to simply bring infrastructure in poor and Black communities up to existing standards. We must redesign public health-related infrastructure for a new, increasingly inhospitable future — and do so in a way that redresses longstanding inequities, addresses the new threats to everyone’s life and health, and prevents further damage to our fragile ecosystems.
In building the JT framework, climate justice advocates embraced several of the key tenets of the environmental justice movement. One of these is the recognition that economics, equity, and ecology are intertwined, and that policymaking must be attentive to their reciprocal effects.Reference Pellow21 A second tenet is an emphasis on social justice as a guide for policymaking. Like the labor organizers before them, and like health justice advocates today, climate justice advocates place frontline communities at the center of policy design and enforcement.Reference Agyeman22 Without this intervention, the burdens of environmental degradation — including both the burdens of climate chaos and the burdens of decarbonization — will fall disproportionately on populations with a long history of economic exploitation and political disenfranchisement.
Fortunately, the spread of environmental justice, climate justice, and now Just Transition advocacy has produced policy innovations attentive to these tenets. For example, countries in the global South have developed policy designs for “climate reparations.” Reference Burkett23 At the domestic level, states and even local governments are taking action in the absence of strong federal leadership. California lawmakers, for example, aided by environmental justice advocates, passed innovative legislation that funnels a significant portion of revenues from the state’s greenhouse gas “cap and trade” program back into disadvantaged and low-income communities.Reference Kaswan, Atapattu, Gonzalez and Sec24 At the municipal and regional levels, California JT advocates are working to create “green zones”25 in which neighborhoods heavily impacted by pollution — most often populated by low-income people and people of color — refocus land-use planning on the need for pollution-reduction solutions and increased investments that will transform these communities into healthier, more prosperous places to live.
II. Linking Health Justice with Just Transition Organizing and Advocacy
As we have seen, the health justice and Just Transition frameworks share several features. Both invite advocates to go upstream to address the root causes of unjust disparities. Colette Pichon-Battle argues that “Climate change is not the problem; climate change is the most horrible symptom of an economic system that has been built for a few to extract every precious value out of this planet and its people.”26 Similarly, the inequitable distribution of the social determinants of health is symptomatic of a racialized economic system that treats the goods and resources essential to healthy lives as “private,” to the detriment of all — and a political system that too often shies away from problems of structural inequality.Reference Trounstine, Rahman and Gilman27
The health justice and JT frameworks also share commitments to intersectionality (the recognition that systems of oppression are interlinked); to acknowledging the limits of the law to accomplish transformative change; and to a focus on the basic public goods and services essential to healthy life on earth.28 And they embrace a vision of justice that is multidimensional, including distributive justice (equitable distribution of the benefits and burdens of public policy); participatory justice (as the familiar phrase goes, “Nothing about us without us”); and corrective justice (acknowledging and repairing past harms).Reference Natarajan, Atapattu, Gonzalez and Seck29
The Just Transition framework goes beyond health justice, however, in at least one important sense. JT moves even further upstream, calling for a fundamental redesign of political and economic institutions. For example, the advocates who gathered in Washington, DC for the first People of Color Environmental Leadership Summit in 1989 called for ending the production of toxic substances in the first place — not just making the distribution of toxic waste geographically “equal.”30 Today’s JT advocates embrace this call to transform economic production itself, rather than just seeking equal distribution of the existing system’s benefits and burdens.
JT advocates point out that capitalism as we know it is committed to endless economic growth, which is inconsistent with a finite planet.31 Rather than our extractive economy in which racial capitalism has flourished, JT advocates envision a “regenerative” economy that will be resilient in a time of climate chaos.32 Looking backward to histories of subordination and forward to more democratic futures, JT advocates embrace the values of health justice, and place them in a broader context.
Here are some of the lessons we believe the JT framework can impart to public health advocates as they move further upstream, into health justice and beyond:
Transform Rather than Tweak
The JT framework envisions two major avenues for action: “stop the bad” and “build the new.”33 The field of public health is often encouraged to focus on stopping the bad, whether the bad looks like sugary drinks, inhabitable housing, or the rapid spread of COVID. But there is a powerful opportunity at hand to ask, What would it look like to build the new? What is the shared vision of health justice, and how can the field use that to rally more collaborators? Harnessing the “design imagination”Reference Escobar34 of communities and policymakers can transform everyone’s sense of what is possible and focus us on expanding the universe of health-promoting resources rather than simply restricting present harms.
Lean into the Partnership Possibilities of Upstream Advocacy
Elsewhere, we have urged public health advocates to see civil rights lawyers and social justice changemakers as allies in addressing structural subordination.35 Similarly, public health advocates who engage with the JT framework may find important allies in justice movement organizing.
Take, for example, the Indigenous “land back” initiative within the JT policy space. Indigenous peoples seek to reclaim control over their traditional land bases, not only as a matter of reparative justice, but also in service of ecological resilience. Under rubrics such as “traditional ecological knowledge,” Indigenous advocates are innovating new forms of cooperative governance and regulation to create more sustainable regimes of food production and water protection.Reference Whyte36 Many Indigenous traditions, moreover, link healthy food, lands, and water to human mental, emotional, and spiritual health as well as their physical health.Reference See37 Such connections have inspired “healing justice” initiatives that place health at the center of organizing for Native and non-Native communities alike.38 In contrast, the public health field is only just beginning to explore approaches like “cultural healing,”39 and can seek insights and partnership from initiatives such as these.
Indeed, JT-inspired partnerships are likely to be transdisciplinary and potentially transformative. Environmental health researchers have long worked hand in hand with environmental justice advocates, sharing knowledge and combining strengths to make positive change. An example is the recent water crisis in Flint, Michigan, in which researchers and clinicians worked together with residents to uncover the truth about Flint’s contaminated water and to craft meaningful solutions.Reference Hanna-Attisha40
Leverage Good Governance to Expand Civic Participation and the Public Good
The JT movement could also catalyze partnership between the fields of public health and political economy. In particular, JT advocates who promote innovative governance practices are working to increase community voice and control in key political and economic institutions, including worker cooperatives, participatory budgeting, and community energy systems.41 This work dovetails well with recent research on the health benefits of individual and collective self-determination.42
Governance fundamentally determines how we steward and allocate the goods and services necessary for human life. Law and political economy scholars are exploring the social and political implications of providing access to such goods, including housing, solely through the market.Reference Rahman43 JT advocates, similarly, propose that primary public goods should be governed according to democratic rather than market principles. The Red, Black, and Green New Deal, for instance, identifies access to potable water as a human right rather than treating water as a commodity.44 Globally, the international movement La Via Campesina, representing peasant farmers, links the struggle for food sovereignty to the need to develop climate resilience in farming practices.45 Material needs such as clean water and adequate food are the basic building blocks of public health. The JT framework can bring public health advocates into this fast-moving interdisciplinary conversation.
Seek Justice Movements as Partners — and Checks
As we have written elsewhere, examples abound of abuses that occur when social biases are expressed through the force of law and the pretense of promoting health.46 In recent history, we have seen forced sterilizations in Puerto Rico, as well as a punitive and racialized “crack baby” scare.47 Even today, anti-trans bills proliferate across the country under the guise of protecting children — despite public health practitioners decrying the significant harms of such legislation.Reference Barbee, Deal and Gonzales48
One of the lessons of both the health justice and the JT frameworks is that the powerful tools of law must be counterbalanced with full awareness of their potential to hurt as well as help subordinated people. For public health advocates, embracing this lesson means recognizing the vital role of justice-oriented social movements in addressing health disparities — and being open to both solutions and critiques from these groups. When justice movements act as accountability partners to elites, policy is more likely to center marginalized communities and reject the punitive urges of moral panics.
Moreover, justice movements have the capacity to shift what is politically possible, as movements like Black Lives Matter have recently demonstrated. Many of the most sweeping progressive transformations in our history, from the abolition of slavery, to the acceptance of women in the workplace, to education for people with disabilities, to the growing acceptance of gender diversity, have been kindled by non-elites. Ordinary people have worked together around kitchen tables, in the streets, and these days on social media, proposing ideas and actions that were first deemed outlandish, radical, and “unrealistic,” only to later be viewed as common sense. The field of public health, like so many other disciplines, is indebted to those who make what the late John Lewis called “good trouble.”
Foster a Shared Understanding of our Racialized Past and Present
The US is distinctive among other wealthy nations for its fragile social safety net, a failing closely tied to our national history of racism. Yet, as we’ve noted elsewhere, today many Americans hold misleading, partial, or downright incorrect understandings of this history and of present-day structural racism. Elsewhere we have discussed how this absence of a shared infrastructure of facts — including a recognition of structural racism — threatens our health, our social fabric, and our democratic values.49
In recent years, recognition of this need to recover and acknowledge the past has led to innovative collaborative projects in legacy media,Reference Hannah-Jones, Roper, Silverman and Silverstein50 in academia,Reference Wilder51 and in communities.52 Contrary to the fear that remembering the past will be “divisive,” such projects can bring people together. A sense of the common good is the foundation for transformative policymaking. It requires a shared understanding of history that includes the experiences of people of color and is honest about the role of white supremacy in shaping modern-day institutions and systems.
Find the Opportunities Within Crises and the Connections Between Them
We have argued elsewhere that moments of crisis represent “wet cement” moments, in which a suddenly shifting political situation makes possible new social transformation and policy initiatives.53 When the crisis passes, the change in systems and structures will often be difficult to undo. We collectively faced overlapping crises in 2020, for example, with the onset of the COVID-19 pandemic and global protests against racial violence.
2023 presents us with more such moments. Today the Russian invasion of Ukraine represents a pressing example, bringing to the world’s attention the unique vulnerability of women and children in times of political chaos, as well as the new chaos spawned by war and migration. Migration is often conceptualized as a purely political and social issue, yet migration — and how nations respond — is also a public health issue.54 Stateless, homeless people and refugees, lacking access to proper health care, are not only themselves vulnerable to old and new infectious disease, but may become reservoirs for new pandemics. The worldwide humanitarian catastrophe unfolding in Eastern Europe and beyond invites climate justice advocates and public health advocates into conversation about the health consequences of “climate migration.”Reference Gonzalez55
Conclusion
Examining political and economic institutions through the lens of health is a worthy and potentially transformative enterprise. From the JT side, as advocates endeavor to reimagine market and state governance for a just and sustainable world, an understanding of the health implications of institutional design will be invaluable.
The alliance we propose between public health and Just Transition advocates may challenge public health practitioners even more than the call for health justice. As we have noted elsewhere, public health approaches have traditionally favored incremental, reformist work and universalist, individualist policies.56 In contrast, JT advocates are partial to “non-reformist reforms” that have the capacity to alter fundamental practices and assumptions within politics and economics.57
The JT framework is explicitly committed to institutional transformation at a fundamental level. Even while it places the interests of subordinated communities at the center, the JT framework also returns us to the universalist impulse that motivates the field of public health: the commitment to building a world in which all humans have an equal capacity to flourish.
Health justice and Just Transition are complementary, indeed overlapping, frameworks that promote a healthier, more sustainable, and more just world. Law and policy spaces are fertile sites for collaboration between these movements. As public health moves upstream, we urge the field to embrace alliances not only at the micro and meso levels, but also at the macro level. We close by offering the words of the Climate Justice Alliance, a movement of movements on behalf of Just Transition: “Transition is inevitable. Justice is not.” 58 Let’s get to work.
Note
The authors have no conflicts of interest to disclose. The authors wish to thank Lindsay Wiley, Ruqaiijah Yearby, Brietta Clark, and Seema Mohapatra for their excellent work as guest editors and field leaders. The authors also gratefully acknowledge Christine Cordero, Co-Director of the Asian Pacific Environmental Network, for so capably serving as commentator in an earlier presentation of this work. Last, thank you to each author in this special issue, all of whom have informed this article.
