What strategies are used to help develop public health?
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For the residents of Coal Run Road, part of a small neighborhood in an unincorporated area of Zanesville, Ohio, running water in their homes is still a relatively new phenomenon.1 Throughout the almost 50 years before they received public water access in 2004, residents “used wells, hauled water, had water delivered to
their homes, and even collected rainwater and melted snow” for basic uses, such as “drinking, cooking, and bathing.”2(p463) Pollution from abandoned coal mines had rendered the groundwater unsafe, sometimes turning it blood
red.1,2(p463) Residents said they spent more money to purchase clean drinking water, in some instances up to 10 times more, than it would have cost to pay for public water.3(¶3,¶99) And
although they lived in a county where lack of access to running water was not uncommon,4 they went to these extraordinary lengths despite being surrounded by an extensive network of waterlines some of which stopped a mere 50 yards from their homes (Figure
1).1,5,6 Map of Water Line Extensions in Muskingum County, Ohioa
aFrom A. M. Parnell, Cedar Grove Institute for Sustainable Communities, August 6, 2008. This figure is available in color online (www.JPHMP.com). This almost entirely Black neighborhood—one of the few in Muskingum County—experienced clear racial
disparities in access to water.2(pp463-469) Some families might be driving to the nearby water treatment plant to purchase drinking water or waiting to reuse their dishwater while observing, at the very same moment, residents of the predominantly White part of the area run their lawn sprinklers and fill their swimming
pools.1,6,7 There was no law explicitly denying residents access to water on account of race, but the waterlines stopped where the Coal Run neighborhood began
(Figure 2).4–7 Some residents asserted that over the years, they had suffered various medical conditions caused by “their consumption of water and/or lack of potable water.”8 Map of Water Line Extensions in Muskingum County With GIS
Layersa aFrom A. M. Parnell, Cedar Grove Institute for Sustainable Communities, August 6, 2008. This figure is available in color online (www.JPHMP.com). For decades, Coal Run residents
regularly made public and private pleas with officials at the city, county, and township agencies that administered water and other municipal services. Although some individuals attempted to help them, their requests were consistently ignored, disregarded, or abandoned.2(pp464-469) Public officials relied upon the opacity and complexity of the governing water laws to absolve their respective
agencies of responsibility for addressing the neighborhood's needs.2(pp464-477) In 2001, one family said that when it raised its concerns with the County Commission Board, a commissioner responded that they “would not see water unless President Bush dropped a spiral bomb in their neighborhood and it hit good water[,]” and that “their great-grandchildren would be lucky to see
water.”1 Another family in the community stated that when they contacted the health department about obtaining water services, they were told “to dig a well.”2(pp469,475) Coal Run residents were able to access plumbed water after they retained counsel and filed a complaint in 2002 with the Ohio Civil Rights
Commission.3 They alleged a “pattern and practice of [racial] discrimination” that violated federal fair housing laws.2(p469) Shortly after filing the complaint, the governor's office convened various public officials to discuss the matter and the County subsequently executed a plan to transmit water to the
neighborhood.2(p469) It took a little more than a year to accomplish what had been a source of friction for almost a half century. Residents thereafter initiated a civil lawsuit for
damages.6,13 A federal jury returned a verdict in 2008 that found the city and county were liable for “racial discrimination [that] resulted in predominantly African American town residents being denied public water service.”9 As it turned out, the solution for
the community was not to construct another well but rather to transform a discriminatory practice by running public water lines into the community. We highlight the Coal Run story not to single out one community or one injustice or one set of public officials but rather to offer a narrative frame for the intersections of public health, law, and structural and systemic inequities. It is, among other things, an example of structural “racism and its many manifestations,” which
our society has had to confront in stark relief with the “the death[s] of George Floyd and countless others; the COVID-19 pandemic and its disproportionate impact on communities of color, and the [assaults and killings of] members of the Asian community.”10 These blunt examples contrast with the Coal Run story, which represents the often ambiguous and even hidden nature of inequity and racism that can be embedded in laws and legal
practices.11–14 Coal Run also underlines the intersectional forces likely entangled with the discrimination the community experienced: limited income, rurality, byzantine systems governing property and land ownership, the persistent effects of environmental degradation, complex and confusing public institutional practices, and circumscribed community voice, to name a
few.2,6,* As our society engages in a contemporary public reckoning over racism and other inequities, we invoke the Coal Run story to emphasize this embedded and less overt aspect of law. We seek to underscore how innumerable communities can be disproportionately harmed by the
inequitable application of laws, policies, and practices.11–14 For example, residents of Coal Run finally got running water in 2004, but diverse communities around the country, including economically vulnerable areas elsewhere in Appalachia,15 small towns such as Sandbranch, Texas,16 cities such as Flint,
Michigan,17,18 and tribal jurisdictions such as the Navajo Nation,19 continue to face comparable lack of access due to deficiencies in the creation, implementation, or enforcement of laws and policies. We also tell the Coal Run story to highlight how law can be central to resolving structural and
systemic inequities. The community was able to get running water by utilizing an important feature of our legal system: antidiscrimination law. Indeed, many of the mechanisms that can help transform inequities are to be found in law.11–13 In this vein, the stories of Coal Run and others discussed here raise an important question for public health departments and
practitioners: what is the role of public health in addressing those unfair or unjust structural and systemic conditions that are rooted in laws and policies? In the case of Coal Run, delivery of safe drinking water through chlorination, treatment, and regulation of public supplies was one of the great public health achievements in the 20th century20; it did not benefit from these advancements because of a complex confluence of legal and social
factors. But we can imagine a scenario in which public health had a central role to play in addressing the neighborhood's needs—in gathering information about the problem, informing the public about it, and convening relevant actors to seek accountability. Invoking the recently revised 10 Essential Public Health Services framework, which identify “public health activities that all communities should undertake,” we assert that public health practitioners have a substantial role to play in
mitigating the effects of structural and systemic inequities, in part, by incorporating law into their efforts.21 For this article, we define law as constitutions, treaties, statutes, regulations, case law, judicial opinions, executive orders, ordinances, and policies that have a binding effect as well as the mechanisms for executing, implementing, and enforcing them.22 This article
outlines a potential pathway for state, tribal, local, and territorial public health departments that builds law into efforts to achieve equity in health outcomes and to mitigate the effects of structural and systemic inequities, such as racism. We first discuss the increased emphasis on equity in public health practice as well as the challenges that public health departments may encounter in pursuing equity-focused initiatives. We subsequently discuss the 4 elements of a pathway for
incorporating law into equity initiatives, which we hope can inform public health practitioners' strategic efforts on these topics. First, law can be understood as a key social determinant of health that can help refine how public health practitioners, and the communities they serve, understand equity. Second, law can be studied. The examination, assessment, and surveillance of law's functions as a social determinant can expand and strengthen the evidence base for achieving equity by helping
public health practitioners and the communities and populations they serve to trace when, why, and how certain structural and systemic conditions give rise to health inequities. Third, law can be centralized in public health efforts to translate and disseminate information and data about the root causes of inequities. Fourth, law can be a springboard for collaboration among
public health departments, the communities and populations they serve, and policy makers to expand the range of potential strategies for advancing equity (Figure 3). A Pathway for Public Health Practice to Leverage Law in Advancing Equity. This figure is available in color online
(www.JPHMP.com). Public health departments and practitioners are increasingly reimagining their roles as drivers of efforts to center equity in health outcomes—by gathering data and exploring interventions to help address the
inequitable conditions experienced by members of communities such as Coal Run and elsewhere.21 Indeed, these efforts are centralized by today's guidance for public health practice, including the updated 10 Essential Public Health Services.21 As public health practitioners pursue research and programmatic initiatives that emphasize addressing the social
determinants,23 they face the challenge of actualizing large-scale transformation of conditions that spring from systems of inequality, originate largely outside of the traditional public health domain, find voice in law and policy making, and, as a senior policy planner in the field characterized it, are dependent on the development and application of “political capital” (S. Lofton, JD, MPH, oral communications, June-November
2020).24,25 It is now well established that health outcomes are influenced by the conditions of the environments in which people are born, grow, live, work, play, and age.26–28 These social determinants of health are the structural, economic, cultural, and political factors
that order relationships, assign social status to members of different populations, distribute money and power, and build or disrupt communities.28 They largely exist outside of any one person's control and “are mostly responsible for health inequities.”26 Social determinants are established and maintained by institutional structures that systematically distribute resources and power in ways that cause
certain populations to experience deeply entrenched disadvantage, and as in Coal Run, over generations.28 Typically, this disadvantage is traced to sociopolitical constructs—many of which intersect and reinforce each other—such as race and ethnicity, sex and gender, disability, socioeconomic status and societal class, or
geography.27,29 Structural racism is a social determinant of health.30 It has been defined as the “macrolevel systems, social forces, institutions, ideologies, and processes that interact with one another to generate and reinforce
inequities among racial and ethnic groups.”31(p116) Because it goes beyond the values, beliefs, or actions of any single person, even in the absence of interpersonal racism, structural racism provides that racial inequities likely would
persist.14,29 It is an elemental, if not foundational, factor in the entrenchment of structural and systemic inequities in the United States that saps the potential of our entire society.29,30,32 Recognizing these structural and systemic factors that impact health, researchers and practitioners increasingly emphasize the achievement of health equity33 and more recently equity without the
health modifier.21 Equity is an ethical concept that seeks to confront and redress structural and systemic disadvantages while articulating a principle that all people's lives should be treated with value, regardless of race, gender, disability, or other markers of social position.34 Equity is also a practical concept that requires “focused and
ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.”34(p416) While public health practitioners note a growing awareness of and facility with the social determinants of health and equity, they may struggle in their efforts to formulate a strategic approach to
addressing them.35–36 Indeed, some have reported many challenges: gathering data that pinpoint with sufficient precision the relationship between structural and systemic conditions and health outcomes37; developing and disseminating narratives that translate these data to build support among policy
makers and the public for advancing equity as a public health priority36,38; and formulating and pursuing policies aimed at confronting these structural and systemic conditions, which can require working with institutions and actors outside of the “traditional” public health
domain.34,35 Law is frequently an unacknowledged or missing determinant of health, despite having implications for most, if not all, of the conditions that contribute to health
outcomes.39,40 Law establishes and underpins the authority of not only public health agencies but also the institutions, practices, norms, and rules that govern life in our society.41 Law and its implementation and enforcement may be understood as critical drivers of the structural and systemic
conditions that influence health,11,30–32 and it can be at the center of efforts to achieve equity.40,† To emphasize this point, we provide a few examples of how law is a powerful undercurrent of the social determinants of health,
as described in Healthy People 2030.42 This select list begins to show how law and its implementation and enforcement are foundational and integral to the development of conditions that shape people's material circumstances and day-to-day lives. And while public health has recognized the importance of law for advancing public health
policy,21,46 the systematic examination and application of laws and their potential influence on population-level health outcomes are still developing.42 By conceiving of law as a social determinant of health, public health and legal practitioners can examine how many health problems
may be rooted in structural conditions created by law and its application.39 This effort tracks with existing obligations within public health practice to conduct assessments that “investigate, diagnose, and address health hazards and root causes.”21 For example, if Coal Run were confronting its water troubles today, the health department might have viewed the recently updated 10 Essential Public Health
Services, which centers equity.21 It might have solicited the community's input as well as the perspectives of other relevant actors, such as the Civil Rights Commission, and assessed the laws and policies governing the area's water administration with an eye toward their health effects. It might even have examined whether those laws were being applied equitably by conducting a geographic information system (GIS) mapping study similar to the ones that
produced the maps referenced earlier in this article.5 Such a study might have laid bare the denial of services to the Coal Run neighborhood. In addition, as one public health practitioner noted (T. Ingram, MPH, oral communication, November 4, 2020), the health department might have initiated a health impact assessment that examined how changes in the governing water laws could influence equity.47 One burgeoning approach to the examination of how laws and policies influence health outcomes is legal epidemiology, or the “the scientific study and deployment of law as a factor in the cause, distribution, and prevention of disease and injury in a
population.”48(p69) It applies public health surveillance methods, which involve the regular, systematic, and ongoing collection, assembly, analysis, interpretation, and dissemination of information about the health of the community,49 to law and policy. Legal epidemiology is transdisciplinary, drawing upon applied research methods as well as the
legal interpretation and policy analysis central to legal research and practice.41,50 Legal epidemiological assessments can be instructive for understanding “which laws facilitate, challenge or harm health,”48(p69) not
least because they can be directly tied to health outcomes data. Correspondingly, surveillance of laws and policies can help public health practitioners make stronger evidence-based connections between structural influences and inequitable health outcomes41,50; better understand the needs and challenges of the communities they serve, not least by
crafting studies with community input51,52; and support the voices and capacities of the communities and populations they serve by providing them with critical data.51,53 Legal
epidemiology can be deployed in response to a broad or narrow range of needs experienced by the populations that public health practitioners serve. The Coal Run matter preceded the development of legal epidemiology.41,50 But today, the health department serving Coal Run might have conducted an assessment of municipal and county laws over time to
consider why 32 000 of the county's 85 000 residents, most of whom were White, also lacked access to running water.4 They also might have compared the county's water laws with those of other counties in the region or state. Findings from such a study could have helped the department develop a strategic plan to promote the expansion of water services to other communities that faced gaps in access. Legal epidemiological researchers
can engage across agencies and communities to thoughtfully select topics, design studies, and build relationships to better understand local health inequities.53 Researchers and public health practitioners have already begun to strategically pursue legal epidemiological studies with a focus on equity. We discuss some of those efforts in the following text. Built environment has a significant influence on health
outcomes,11 and researchers have begun to explore the legal and policy infrastructures that shape how communities are conceived of, planned, and administered. “Complete Streets” laws and policies have garnered attention as a mechanism to promote equitable population movement and to improve health by supporting the safe and accessible physical activity of all
users.54,55 They are also connected to other structural mechanisms that can influence equity: land use and zoning laws, mass transit accessibility, and community design and investment.55 One legal epidemiology assessment identified 21 Complete Streets state laws across 18 jurisdictions, highlighting
their substantive commonalities and identifying policy challenges, such as implementation and evaluation.55 It further applied evaluation data to these findings, determining, for example, that Florida's 1984 state law “was associated with a 29-year decrease in pedestrian deaths” across the state.55(p631) Other recent legal
epidemiology research has examined a broad range of state laws concerning fair housing, predatory lending, voting rights, and minimum wage laws, among others that altogether implicate structural racism53; telehealth and broadband statutes and regulations56; and the nature, scope, and reach of Health in All Policies.57
Public health department practitioners have conducted legal epidemiology assessments on housing laws, namely, how states and localities protect housing access through inclusionary zoning58 and protect tenants and landlords through just cause and retaliatory eviction ordinances.59 These initiatives reflect efforts to trace the often convoluted or hidden sources of inequity that can be found in law. These studies, completed by public health department practitioners as well as academic researchers, show that legal epidemiology is not limited to academic or large research institutions. Its methods can help demystify law by transferring the rigorous examination of laws and policies from the exclusive domain of lawyers to public health and other practitioners who seek to advance equity.60 Future analyses might examine the following: The surveillance and analysis of law may give rise to a rich body of
evidence on the impact of structural and systemic conditions on health outcomes as well as identify potentially transformative legal and policy interventions in response to local issues and community-identified needs. Law and storytelling are intertwined. Law deals in history, conflict, and resolution.
Stories were used by Greek orators as an early technique to practice law, and in many cultures, laws were passed from one generation to the next through storytelling.61 Indeed, it has been stated that “a lawyer's primary task is translating human stories into legal stories and retranslating legal story endings into solutions to human
problems.”62(p6) Law has used storytelling to describe the effects of oppressive rules61, and stories can “constitute discourses of hope, liberation, and justice.”63(p428) Public health practitioners can also be storytellers and can draw upon
the storytelling dimension of law in their efforts to educate the public and identify solutions.21 The Coal Run neighborhood offers a reminder that at the core of many developments in the law—statutes passed, regulations implemented, lawsuits adjudicated—are stories of individuals and communities. They may be working to improve their health while navigating forces that might often feel beyond them, such as implicit and explicit
bias, an unyielding status quo, or imbalances of power.1,2 Law, with its long historical arc and its direct impacts on communities, provides a rich repository of narratives that public health practitioners can use to educate policy makers and the public about equity36 and how people, communities, and
populations encounter the intersections of communities, government, and health. Significantly, this approach also comports with a key element of the 10 Essential Public Health Services: communicating effectively with the public to inform people about health, factors that influence it, and how to improve it.21 Narrating these intersections in meaningful ways can be a challenge. A recent study suggested that while senior-level
leaders in major urban public health departments indicate high levels of engagement with and support for efforts to advance equity, some note that the language of “equity” marks a superficial rhetorical shift away from emphasizing health disparities that lacks substantive or practical meaning.36 Law may serve as a communication tool for practitioners seeking to frame equity for audiences who might not be receptive because they perceive “equity” as
inaccessible or as a political or ideological construct. In other words, one approach to discussing equity would be to frame it through the lens of laws that have inequitable impacts—or their inverse. Alternatively, the same study suggested that health department leaders might perceive the term “equity” as overly academic and inaccessible to the very constituencies it is meant to
involve.25,36 This research also indicates that for some public health practitioners, the language of “health equity” hampers their work because it is “politically loaded” and risks meeting resistance in settings “that might not be automatically supportive” of a framing of disparities that invokes structural rather than individual causes for
them.36(p338),64 One potential corrective to these difficulties in framing is to tell concrete stories of people and communities (or creating spaces for them to tell those stories themselves). Law can be centered in storytelling because it establishes identifiable and traceable circumstances in which people must operate, make
decisions, and carry out their lives. Explaining how people and communities navigate laws and structural conditions that may impact their health does not require the use of convoluted or specialized language. Even in narrating the story of Coal Run, it is not necessary to refer to the social determinants of health or equity to demonstrate the extent to which racism, at worst, and willful neglect, at best, might have posed risks for the health of that community. The community's need for water,
their sustained efforts to address that need, the outcomes following a series of legal and policy interventions, all draw attention to the disparate conditions at their core. Moreover, the story of Coal Run draws clear attention to the need for a public intervention—the community could not have accessed public water without some governmental action. In
addition, law and policy can undergird creative and robust approaches to translating and disseminating information about the effect of structural inequities on health outcomes. By way of example, research examining the relationship between historical redlining and contemporary levels of asthma burden in several California cities identified a consistent pattern of significantly higher rates of emergency department visits due to an asthma-related event in historically redlined census
tracts.65,66 They concluded that “redlining policies that denied wealth generating opportunities in communities of color and undermined the physical environments of neighborhoods might have affected present-day asthma related outcomes across eight California
cities”65(pe28) By visualizing their findings in maps that contrast the geography of asthma-related visits with historical redlining maps,11,66 the researchers have begun to tell a story about how asthma outcomes might be
linked to a legal and policy regime, as discussed earlier, that contributed to the concentration of poverty and environmental hazards in some Black and Latino communities in California.43 Similar to the GIS maps developed for the Coal Run case, the maps in this study are a visual story that provides context linking asthma to a set of laws and policies that excluded those populations from the formal housing market, denied them access to credit, and
helped facilitate disinvestment and concentrate harsher living conditions within their communities.43,65,67 Cross-sector
collaborations and partnerships with community-based leaders and organizations68 as well as officials from social services and other public agencies, such as education, housing, law enforcement, and economic development agencies,69 have been identified as a critical component of public health practice.21 Public health departments and practitioners increasingly
seek to “cultivat[e] broadly defined collaborations,”69(pp 344-345) particularly in the effort to advance equity.21,46 In this vein, as practitioners have indicated (T. Ingram, MPH, oral communication, November 4, 2020; C. A. Jacob, MPH, oral
communication, October 30, 2020), public health departments can serve as partners and conveners to help develop policy solutions. These relationships can elevate the voices of populations that experience disadvantage and offer unique perspectives and solutions to issues that implicate inequity (T. Ingram, MPH, oral communication, November 4, 2020). Applying this lens to Coal Run, the health department not only might have investigated root causes to develop an evidence base
for why the system of laws, policies, and practices governing the allocation of water to residents posed risks to their health21,46 but also might have convened community members and potential partners, such as local social services agencies, the Civil Rights Commission, or even sympathetic actors in the county or municipal water authorities, to
brainstorm and develop policy solutions.21 Such solutions might have included addressing gaps in the water administration laws, developing a broad-based plan for building new waterlines, or determining other avenues of redress, such as pursuing a legal claim.1–3 Law and legal epidemiology can be a mechanism to facilitate data gathering, community collaboration, and the creation of plans to address
health equity, establishing a basis from which public health practitioners can invite community-based entities, the traditional legal sector, and governmental bodies into the process of examining laws and policies and their impact on health. One example of health department efforts to facilitate collaboration among community actors with a focus on law is the Alameda County Health Services Agency's Legislative Council. It endeavors to evaluate legislative efforts and policy
development, proffer legislative proposals, and build partnerships to pursue “community-driven public health policies.”70,71 It demonstrates a commitment by the public health department to identify itself as a key source of guidance in policy
making.21,70 Importantly, it also reflects a public health effort to effectuate mechanisms for seeking accountability among public actors.21,70 As we discuss earlier, in the years since Coal Run residents initiated their civil rights complaint, public health departments and practitioners have expanded their mandate to include emphasizing the social determinants of health as well as identifying the elimination of disparities and the achievement of equity as key goals. For many public health practitioners, these ideas are familiar. The imperatives of
pinpointing the health implications of inequity-producing structural and systemic conditions such as racism and economic marginalization29,72 of crafting and communicating messages to engage the public and policy makers73 and of building cross-sector and community partnerships have been documented over
time.46 What might be underemphasized in public health is how to leverage law and its applications to meaningfully mitigate some of these challenges and to aid public health practitioners in their efforts. Law has always been a central mechanism for carrying out public health policy, but it can play a far more expansive role in pursuing and achieving equity. The time is ripe to transform our understanding and use of law to incorporate its strategies
and messaging into the practice of public health to support practitioners, health departments, and communities as they work to expand health and well-being.34,60 We make this assertion acknowledging the tremendous demands already imposed on public health departments, particularly as at the time of this writing, practitioners
are under strain to address the effects of a widespread global pandemic.74 To that end, we must acknowledge the dilemma that many public health departments face. On the one hand, as we have discussed throughout, many have begun to develop robust strategic and programmatic efforts to promote and pursue equity. On the other hand, many carry out these and other efforts with limited personnel and strained
budgets.74 We recognize that the opportunity for direct engagement between public health and law that we have outlined here is more likely achievable with capacity building for those who seek to undertake this demanding work. Finally, we acknowledge the importance of validating and testing this pathway. It is our intention to engage public health practitioners in the field and others to comment on its elements and to illuminate how
to best operationalize them. We outline 4 elements of this pathway that are both conceptual and actionable. 2. Kennedy v City of Zanesville, 505 F Supp 2d 456 (SD Ohio 2007). 3. Fourth Amended Complaint, Kennedy v City of
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Accessed August 16, 2021. *We acknowledge here that this article is neither exclusively centered on structural racism nor meant to address many other related topics. For example, the question of whether the discrimination affecting Coal Run residents was intentional and the nuances of antidiscrimination law are beyond the purview of this discussion. †Indeed, for some, the influence of law on health is so pervasive that “health justice,” rather than “health equity” may be a more precise term for framing the relationship between law and health inequity. Berman ML, Tobin-Tyler E, Parmet WE, The Role of Advocacy in Public Health Law, J. Law, Med. & Ethics. 2019;47(2_suppl):15–18. Keywords: equity; law; public health practice; structural racism What are the different strategies used to promote public health?Community strategies: Conduct community-wide campaigns; improve access to outdoor recreational facilities; participate in community coalitions or partnerships to address obesity; enhance access to places for physical activity combined with informational outreach activities; enhance community- or street-scale urban ...
What are the 4 ways to improve public health?Invest in public health infrastructure. Address the opioid and substance use epidemic. Mitigate climate change and invest in environmental justice. Reduce poverty and improve economic stability.
What is strategy in public health?This is when you protect people's health by doing various things such as; ensuring the safety and quality of food, water, air and the general environment, preventing the transmission of communicable diseases, and managing outbreaks and the other incidents which threaten the public health.
What are the 3 strategies for health?3 Basic Strategies
There are three basic health promotion strategies per Rural Health Information Hub: health communication; health education; policy, systems and environmental change. Health communication helps people better understand health needs, equipping them for important individual health decisions.
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