Unmasking the Hidden Narratives
Many a slip in budget work across the globe has drawn on experiences in a number of countries, setting out a step-by-step process for analyzing a government’s budget to assess its compliance with human rights obligations. While the focus may be on right to food-related issues, the process described is readily adaptable to work on other rights, including water and sanitation. By drawing on more recent experiences of budget work, this approach provides a more in-depth and developed approach to human rights budget analysis.
Dignity Counts, a collaborative effort by Fundar-Centro de Análisis e Investigación, the International Budget Project (IBP), and the International Human Rights Internship Program (IHRIP), uses a real-life case study to explore how budget analysis can be used to assess a government’s compliance with its human rights obligations and arrive at specific, concrete recommendations related to budgeting and expenditures that could improve the human rights situation. Although focused on the right to health in Mexico, the analysis is applicable to other human rights, such as water and sanitation, and to other national contexts.
The Banyan Tree Paradox considers why issues where culture features prominently often provide particularly difficult challenges for human rights activists. Ripple in Still Water is a digest of information and experiences relevant to local and national-level economic, social, and cultural rights activism, including strategies and tools for addressing water and sanitation issues through a human rights lens.
Structural Inequities and the Social Determinants of Health
Health inequity arises from social, economic, environmental, and structural disparities that contribute to intergroup differences in health outcomes. The root causes of health inequity include the intrapersonal, interpersonal, institutional, and systemic mechanisms that organize the differential distribution of power and resources across lines of race, gender, class, and other dimensions of identity.
Structural inequities, such as racism, sexism, and classism, are the personal, interpersonal, institutional, and systemic drivers that make social identities salient to the fair distribution of health opportunities and outcomes. Policies that foster inequities at all levels are critical drivers of structural inequities, which in turn shape the social determinants of health – the conditions in which people live, work, and play.
For example, the effect of racial biases in policies and practices (structural inequities) is the “sorting” of people into resource-rich or resource-poor neighborhoods and schools largely based on race and socioeconomic status. Because the quality of neighborhoods and schools significantly shapes life trajectory and health, race- and class-differentiated access to clean, safe, resource-rich environments is an important factor in producing health inequity.
Structural inequities affect individuals “from womb to tomb.” African American women are more likely to give birth to low-birthweight infants, and their newborns experience higher infant death rates – not due to biological differences, but likely from the chronic stress associated with being treated differently by society. In elementary school, there are persistent differences across racial and ethnic divisions in rates of discipline and reading attainment, not attributable to differences in intelligence.
Structural inequities also create differences in the ability to participate in policy and political decision-making, and even in the fundamental right to vote. Implicit biases create differential health care service offerings and delivery, affecting the effectiveness of care provided, including a lack of cultural competence.
Determinants of Health and Equity
Whether with race, ethnicity, gender or other markers of human difference, the prevailing American narrative often draws a sharp line between the country’s “past” and its “present,” asserting progress toward equity, diversity, or inclusion. However, perceptions are not always aligned with the persistence of disparities.
Historically, inequities continue to ramify into the present, and conditions that enable disparities often reproduce themselves. Racism, an umbrella concept encompassing mechanisms at the intrapersonal, interpersonal, institutional, and systemic levels, plays an important role in structuring socioeconomic disparities.
Three major mechanisms by which systemic racism influences health equity are discrimination (including implicit bias), segregation, and historical trauma. Discrimination, both overt and inadvertent, has deleterious effects on physical and mental health, with chronic exposure to seemingly minor “everyday racism” contributing to stress-related conditions.
Implicit biases, whereby individuals hold racial biases of which they are not aware, can lead health care providers to treat patients differently based on race or ethnicity, contributing to disparities in care. Residential segregation, perpetuated by discriminatory housing and mortgage practices, concentrates poverty, poor housing conditions, and social disorder in certain neighborhoods, limiting economic opportunity and increasing exposure to environmental hazards.
The unequal allocation of power and resources, manifesting in unequal social, economic, and environmental conditions, is a more fundamental root cause of health inequity. The social determinants of health – education, income and wealth, employment, health systems and services, housing, the physical environment, transportation, the social environment, and public safety – are the terrain on which structural inequities produce health inequities.
Addressing the Terrain of Health Inequities
Education, as both a process and an outcome, demonstrates a positive correlation with health status indicators. Educational attainment is associated with lower mortality, fewer chronic diseases, and healthier behaviors. However, disparities in educational achievement persist across racial and ethnic groups, contributing to intergenerational transmission of advantage and disadvantage.
Income and wealth, as predictors of a number of health outcomes, are unequally distributed, with rising income inequality and wealth gaps between the top and bottom. Concentrated poverty disproportionately affects racial and ethnic minorities across the social determinants of health, from education to housing.
Employment, a key source of income, health insurance, and other benefits, demonstrates disparities in unemployment rates, wages, and occupational status across racial and ethnic lines. Psychosocial, physical, and resource-related aspects of work can all shape health outcomes.
Despite progress expanding access to health care, systematic differences persist in utilization and quality of care for racial and ethnic minorities, the poor, and other marginalized groups. Addressing social determinants through community partnerships and multi-sectoral approaches is crucial for improving population health and reducing disparities.
Housing conditions, neighborhood features, and affordability all impact health, with physical hazards, segregation, and displacement contributing to disparities. The physical environment, including parks, food venues, and climate change, shapes community health, with inequitable distribution of environmental assets and burdens.
Transportation networks, services, and infrastructure play a multifaceted role, facilitating mobility and access to opportunities, while also producing pollution and safety hazards disproportionately affecting low-income and minority populations. The social environment, reflecting social networks, cohesion, and norms, can buffer against or exacerbate health challenges.
Public safety and violence are significant social determinants, with low-income communities and communities of color disproportionately affected. Structural racism manifests in the criminal justice system’s role in mass incarceration of racial and ethnic minorities, contributing to the breakdown of educational, economic, and social opportunities in these communities.
Toward Community-driven Solutions
Health inequities are the result of more than individual choice or random occurrence. They stem from the historic and ongoing interplay of inequitable structures, policies, and norms that shape lives across the social determinants of health. Improving the science of population health interventions, place-based approaches, and strategies to improve health equity will require interdisciplinary training models and community-academic partnerships.
Communities around the country are recognizing their power as agents of change, taking action to address the root causes of health inequities. From addressing structural racism in policing to building community wealth, these place-based initiatives demonstrate the potential for collective action to create more equitable, healthier environments. By understanding the cultural dimensions underlying water-related human rights violations, advocates can forge powerful, community-driven solutions that unlock the human right to water and sanitation for all.
The Joint Action for Water blog is committed to amplifying these community stories and equipping readers with the knowledge and strategies to advance water justice. We invite you to join us in this rippling movement for change.
