Social Justice, Health, and Human Rights Education: Challenges and Opportunities in Schools of Public Health

Social justice lies at the heart of public health. It is central to its mission and is frequently described as public health's core value. The social circumstances in which we are born, live, and work play a greater role in longevity and overall health in the United States than genes, health insurance, and access to health services.¹

While a core value of public health is social justice, current events often force public health practitioners and faculty to focus on emerging issues such as emergency responsiveness. For example, natural as well as human-caused disasters have required immediate response from frontline responders such as fire and police departments as well as public health professionals, as witnessed in the past decade with Hurricanes Rita and Katrina and the terrorist attacks on 9/11. Acknowledging that response to current events is critically important, faculty at the University of Arizona (UA), along with a cadre of socially conscious students, explored the means to keep discussions of social justice alive and more deeply embed the theme of social justice into the existing public health curriculum.

Discussion regarding the inclusion of a more focused social justice dialogue was initiated in 2004, when 69 students from underserved communities began to be accepted as fellows into the master of public health (MPH) program at the Mel & Enid Zuckerman College of Public Health (MEZCOPH) at UA or the Mexican American Studies program with funding from the National Center on Minority Health and Health Disparities Project EXPORT Center at the National Institutes of Health. These Project EXPORT fellows had experienced firsthand the consequences of social injustice. For example, many of these students were the first generation in their families to attend college. Several fellows were born and raised on tribal reservations, where their family members experienced high unemployment rates, few educational opportunities, and a number of social pathologies, including higher rates of alcoholism. The problems experienced by Latino fellows were similar. However, they began to develop a deeper appreciation of the health effects of social injustice during discussions with fellow students and through their fellowship experiences working in underserved communities. Faculty and students began working together to encourage dialogue on issues of social justice in public health, to identify training strategies, and to institutionalize those strategies within the college.

To initiate discussions, students and faculty first approached the definition and operationalization of social justice. For the purposes of public health education, it was determined that social justice was, at its heart, a value—a belief in the value and dignity of all people who should be accorded equitable access to health-care knowledge and resources. The Principles of the Ethical Practice of Public Health, devised by the Public Health Leadership Society, states that:

Humans have a right to the resources necessary for health. The Public Health Code of Ethics affirms Article 25 of the Universal Declaration of Human Rights, which states in part that “everyone has the right to a standard of living adequate for the health and well-being of himself and his family.”²

This statement echoes the definition provided by Gostin and Powers, who wrote that social justice involves “the fair disbursement of common advantages and the sharing of common burdens” and “captures the twin moral impulses that animate public health: to advance human well-being by improving health and to do so particularly by focusing on the needs of the most disadvantaged.”³

Students were surprised to find that within the core competencies of the Association of Schools of Public Health, it is only with the professionalism competency that any reference is made to social justice. Professionalism is described as, “The ability to demonstrate ethical choices, values, and professional practices implicit in public health decisions; consider the effect of choices on community stewardship, equity, social justice, and accountability; and commit to personal and institutional development.” Competency number nine under professionalism states that upon graduation, it is increasingly important that a student with an MPH be able to “… embrace a definition of public health that captures the unique characteristics of the field (e.g., population-focused, community-oriented, prevention-motivated, and rooted in social justice) and how these contribute to professional practice.”⁴

To ensure that this value is operationalized, students and faculty agreed that all students must have the skills or competencies needed to effectively address issues of social justice. A review of the curriculum within MPH programs, however, revealed that there is often a lack of formal coursework focused solely on social justice. In a cross-sectional survey of deans of accredited schools of medicine and public health in the U.S. and Puerto Rico, conducted by Cotter et al., the deans acknowledged that there was a clear relationship between health and social injustices and recognized the important role that social justice plays in health practice. Formal coursework in social justice, however, was absent in most of the surveyed institutions.⁵

In the initial discussions on how social justice could be incorporated into the MPH curriculum, and what competencies were necessary to help promote successful practice, students felt that discussions of social justice should be incorporated into all classes. Additionally, skills around community asset building and addressing disparities needed to be acquired. In other words, while it was important to identify and address negatives (e.g., health disparities), equal attention should be paid to identifying and working with community assets such as cultural richness, individual and historic resilience, and the strengths and resources that families bring to the table. By focusing solely on issues of access, quality, and ability to pay, schools of public health may not acknowledge or teach students how to successfully address the complex cultural, economic, and social issues that underlie the social inequalities that result in poor health, particularly among the most vulnerable populations.

Competencies would thus involve developing skills in many areas, including skills for facilitating the creation and sustainability of community coalitions, for building collaborations between universities and community-based organizations, for strengthening interrelationships within families and between organizations, and for engaging in the fundamentals of advocacy.^6–9 By developing human potential and creating strong and supportive physical and social environments through collaborative efforts, communities are better able to prolong and multiply public health efforts, and gather the resources necessary to collectively solve current and future problems.¹⁰

While these discussions were enlightening, they directly influenced only the cadre of faculty and students. Thus, strategies were developed and initiated to expand these discussions into the college and the university. These strategies included raising issues of social justice in a broad range of classes and “brown bags” (i.e., discussion and dialogue over lunch), providing additional learning opportunities though research and service-learning projects, encouraging involvement in the development of courses that address social justice topics, and launching an annual social justice conference.

STRATEGIES FOR TEACHING AND INSTITUTIONALIZING SOCIAL JUSTICE IN A COLLEGE OF PUBLIC HEALTH

Class discussion

No official discussion guides were developed to assist students in raising social justice issues in their coursework. However, the wide range of activities provided them with an opportunity to identify questions that were relevant for many discussions even in courses (e.g., Introduction to Biostatistics and Epidemiology) that did not generally touch on social justice issues. They also discussed ways of incorporating social justice topics in term papers.

Brown bags

Students were actively involved in planning brown bag presentations and discussions. Many of these brown bags were developed to provide or enhance skills for effectively working in communities. These brown bags included presentations on interventions that were designed to address issues of health disparities and social injustice, and trainings in a wide number of areas including developing questionnaires, conducting qualitative research, interviewing, reporting, and grant writing.

Service learning in community coalitions

EXPORT fellows were assigned to work with community coalitions as part of their participation in service learning. These opportunities, which included attending coalition meetings, participating in community activities, and working with the coalition to conduct surveys, also helped students develop new insights into working with and in underserved communities and the short- and long-term effects of social injustice.

Social Justice Symposium

It was at this time that students initiated the development and implementation of a university-wide symposium on social justice, the planning of which provided them with an opportunity to identify the primary issues that needed to be discussed, find resources to address those issues, and provide a forum in which social justice education and awareness could be formally discussed. The first student-planned Social Justice Symposium, held in April 2007, was entitled, “Social Justice in Health: How Social Justice and Human Rights Affect Communities of the Southwest.” The stated objectives of this symposium were not only to raise awareness and expand consciousness about the centrality of social justice within public health, but also to clarify assumptions and exchange critical analysis about how social injustice impacts health outcomes.¹¹ Additional aims were to provide clear evidence of how multisector partnerships can effectively address health disparities in communities of the Southwest and to engage students and faculty in a discourse on the relationship between social equality and public health.

Students encouraged speakers from different departments within the university and from community-based programs to share their research and participate in the dialogue. Each speaker identified human rights and social justice (or lack thereof) as causal factors leading to a wide range of health disparities and inequalities in the Southwest and proposed possible solutions, all of which included developing community-campus and interdisciplinary partnerships. They also addressed how the strengths of communities could be tapped to build solutions.

The highlight of the first Social Justice Symposium was a keynote address by Dr. Victor W. Sidel, Distinguished University Professor of Social Medicine at Montefiore Medical Center, Albert Einstein College of Medicine in New York, New York. Sidel is a leading international scholar and advocate of human rights in health. The following year, Dr. Alejandro Toledo, the 46th president of the Republic of Peru, was the keynote speaker.¹² Toledo was a particularly effective speaker, as he learned about social injustices firsthand. He was born to a family living in extreme poverty in a small, remote village in the Peruvian Andes. As one of 16 children, Toledo began at 6 years of age to work on the streets of Lima, shining shoes and selling newspapers and lottery tickets to help his family. A fortuitous opportunity made it possible for him to attend several of the most prestigious academic centers of the world, and that access to education paved the way for him to become the first Peruvian president of indigenous descent and an influential leader in Latin America.

Presentations were also given on research addressing American Indian issues of social justice within Arizona and Northern Mexico, and farm worker health and human rights. Interdisciplinary/interdepartmental panel discussions on social justice issues in public health were also well attended. The evaluation revealed that participants overwhelmingly rated the symposium a success at deepening dialogue on social justice. Participants also strongly encouraged college leadership to institutionalize the event as an activity supported by the college, both financially and as a part of the college's mission. Both of these goals were accomplished, and the college now provides financial support for an annual symposium.

Development of courses and service-learning opportunities

Embedding the language of social justice into health policy discourse and public health courses is central to securing the conceptualization of human rights in public health. An additional result of efforts by EXPORT fellows to raise issues of social justice in public health curricula was the development of a new course focused on U.S.-Mexico border health, entitled U.S.-Mexico Border Health Policy. This course, which provides students with fieldwork and service-learning opportunities, focuses on working with underserved communities to (1) raise awareness of how the communities are affected by policies formulated and implemented by federal and state governments, and (2) promote strategies for engaging communities in policy development.

An existing health disparities course was expanded with considerable input from EXPORT fellows and offered to undergraduate public health students for the first time in spring 2011. The course begins by introducing students to contemporary issues in public health, race, economics, and social justice. These discussions provide them with the vocabulary and necessary narrative for communicating about issues of race and social inequality in public health. The course explores controversies about health disparities. For example, what empirical evidence exists that some communities have less access to health care, receive measurably inferior treatment, and have greater and more intensive experiences with sickness? In addition, the course examines the importance of, and methods for understanding and addressing, health disparities through changes in research strategies, policy decisions, and programs for prevention and treatment. Finally, the course explores the historic and present-day impact that social, political, and economic systems have on the well-being and health quality of underserved communities.

Students also learned about strategies that have been shown to increase efforts regarding addressing health disparities and social justice, such as (1) identifying community and individual strengths, (2) mobilizing communities,^13–15 (3) building coalitions,^16,17 (4) engaging in community-based participatory research (CBPR),^18–20 and (5) advocating at the community level.

A series of intensive service-learning courses, including courses provided by the Border Health Service Learning Institute (BHSLI), provide a unique opportunity for MEZCOPH to partner in the development and implementation of real-world experiences with U.S.-Mexico border communities. The BHSLI courses provide a venue for students and faculty to work directly with community partners in ways that both assist them in their everyday delivery of services to the community and strengthen ongoing CBPR in border communities. While issues of border health may not be as salient for other schools of public health, BHSLI could be replicated at other sites. Other service-learning courses at MEZCOPH focus on rural health, maternal and child health, and urban issues.²¹

DISCUSSION

This article has addressed a wide range of activities, both formal and informal, that were developed and conducted to teach MPH students about social justice and health. While we have argued that it is important to teach students about social justice, it is also important to evaluate the impact of that teaching on students' social justice awareness and understanding. We have tracked these students over time, assessing how they incorporate what they have learned into their current positions and into programs they plan and implement. Most students have reported continued or planned work in the areas of health disparities reduction and social justice issues after completing the fellowship program. As one example, a group of former EXPORT fellows introduced a position statement for consideration by the American Public Health Association (APHA) related to the deaths of migrants in the Arizona-Sonora migrant corridor. On November 10, 2009, the APHA Governing Council adopted a policy statement that was introduced by our students.²² In addition, former fellows also created a venue to further address these types of issues through the establishment of the Global Health Alliance, a student-run organization that aims to enhance students' knowledge of how public health functions in a global context.

CONCLUSIONS

We believe that our obligation as a school of public health is to continuously look beyond traditional methods used to address public health issues, as “the study of the behavioral determinants of risk behavior, using standard concepts and classical methods, may have reached their limit.”²³ Our intention is not to detract from the importance of traditional core public health courses and their content, but, rather, to discuss ways to expand student education and training to encompass other subjects—in this case, social justice—and other methodological approaches that are of significant importance.