Why Public Health Should Be Concerned about Racism and Illiberation

By Christopher Williams, Public Health Liberation Founding Director

Illiberation is not a word that appears in a standard English dictionary. It is not an adoptive use of the word “illiberal,” meaning miserly, or relates to the phrase “illiberal democracy.” Illiberation in the context of Public Health Liberation is defined as a state of arrested human development arising from fear that expressing differing opinions to a set of rules, cultural beliefs, norms, practices or against forms of authority will incur unacceptable social or material costs that subvert self-interest. Although it can be extrapolated to other fields, it is discussed here to explain a source of health inequity reproduction within the public health economy. Illiberation is concerned with the diminished expression of self and of people to convey human suffering, to identify its determinants, and to petition for relief. Everyone within the public health economy, including educators, researchers, and health officers, are susceptible to illiberation, though we are most concerned about illiberation among vulnerable or oppressed communities. Illiberation can be broadly understood as obedience to the public health economy which itself is reproducing deep inequity. We previously discussed public health realism - centrality of material self-interests in public health - that would explain the errant paradigm.

Illiberative fear need not be a conscious decision because it can exist as part of an internalized, conditioned worldview about social hierarchy and mal-distributive power. Illiberation assumes that individuals are rational beings that instinctively or logically weigh the cost of saying or doing something that they know to be morally right against the cost of their self-interests. This concept likely sounds familiar such as the effect of group dynamics on individual action that contradict one’s moral beliefs, except that illiberation is rarely captured in the single studies on induced cognitive dissonance from one-time exposures. Illiberation is an internalized form of sustained oppression.

Structural determinism has been commonly conceptualized as an externalized social force that no one entity owns or should take responsibility for., except that this ontological position is false and misleading. Whether structural violence or racism, similar ideologies within public health necessarily involve human activity for sustainability. Structural determinism to include racism and the social determinants of health are damaging for all the reasons that public health has established and for reasons that it has not readily acknowledged. Structural determinism coerces self-regulation of liberation, causing self-imposed diminution and inaction. Public health disparities research has been primarily concerned with the extrinsic factors. Our contribution to the literature is to draw attention to the intrinsic factors resulting from systematic oppression. Both levels of factors work synergistically to reproduce health inequity. Yes, our current health paradigm deserves critical appraisal as a structural determinant of health.

Structural determinism is upheld through arbitrary rule-making, theory-building, ontological control, social conditioning, ownership over the modern means of production, reliance on capitalist gain, false claims of powerlessness among authorities, accepted permanence of harm, redistributive power over resources, and feigned ignorance as to the severity, immorality, and ways of undoing inequity. Structural determinism is intrinsically produced within major areas of the public health economy - funding agencies, institutions of higher learning, health centers, corporations, and government agencies. If deep and chronic racial health inequities persist despite considerable investment in health care and health research, then the public health economy must help explain and contribute to racial health disparities.

Illiberation first came to our attention when one of our Board members, Patricia Bishop, who is a public housing resident council president, educated us on the common anxiety among her residents that they were afraid to speak out because of fear of retribution against them by the Housing Authority. This was later confirmed by other leaders and directors. Residents wanted to complain about deteriorating living conditions from mold, rodents, lead, and other environmental hazards. They believed that they could be subjected to harassment, a citation, or even eviction. Although there is room for improvement in educating residents about legal protections that would make these fears unfounded, this social phenomenon is important to understand the intrinsic factors of racial inequity in health - what we call illiberation.

Broadly, there are two ways to disrupt the patterns and practices within the public health economy that perpetuate health inequity. First, it is for the system itself to change through antiracism praxis such that material benefits and self-interest are affected. As with the public housing example, this can result from stiff fines, greater oversight, legal action, or increased public funding for repairs that provide for racial equity in housing. It can also occur through liberation where residents, individually or collectively, recognize their own power and ownership of self-emancipation from living conditions - public health liberation theory. That might take the form of a protest, non-payment of rent, use of escrow accounts in lieu of paying the Housing Authority directly, engaging local media, legal action, lobbying their political representatives, testifying at housing authority meetings, or raising money for repairs. Illiberation is a state of being where no or limited alternatives of liberation are considered for fear of retribution or adverse consequences. Illiberation can be a conscious decision to remain silent or a conditioned state of mind and being. As we discuss, agents of structural violence or determinism employ many tools to encourage illiberation. Withholding information about legal, political, or social pathways to affect community health is common. Public Health Liberation founder, Christopher Williams, who is a current public health PhD student explains, “Academic public health is at least 15 years behind. There is simply no urgency in public health for drawing attention to and addressing deep racial health injustices unless it comes with considerable material benefits.”

Illiberation inhibits the ability to seek information because of its futility given a fear-driven desire not to act on that information. The importance of this crippling fear is that public health cannot rely on affected populations to vocalize their need for help for public health to act. Public health realism explains why public health has failed to meaningfully prioritize, much less address, the social determinants of health, leaving the advocacy community as the major driver of change. Illiberation is a reflection of internalized systematic oppression in which structural determinism both exacerbates the social determinants of health through racial violence and further psychological harm

We conclude by encouraging all individuals and organizations that take part in the public health economy to reject illiberation and embrace liberation as a theory, methodology, philosophy, and practice. Public Health Liberation will publish a primer this summer and encourage readers to explore being a member.