A Research Agenda for Racial Equity: Applications of the Ferguson Commission Report to Public Health

Abstract

The Ferguson Commission was an independent body of 16 commissioners in operation from November 2014 to December 2015 and appointed by Missouri governor Jay Nixon to examine the root causes underlying the death of Michael Brown Jr.

Its report, “Forward Through Ferguson: A Path Toward Racial Equity,” raises many issues on racial equity that public health is well suited to address, such as trends in police use of force, the health implications of the school-based discipline gap, and the health benefits of a coordinated housing strategy.

Public health can also learn from the principles the commission adopted, including being unflinching in the questions asked and conclusions drawn, applying a racial equity lens to public health work, and moving beyond programmatic solutions to policy solutions.

“Public health should be a way of doing justice, a way of asserting the value and priority of all human life.”

—Dan Beauchamp¹

These words echoed in our minds during our work with the Ferguson Commission. They reminded us that the core of public health, including epidemiology, biostatistics, and health education, is critical to confronting health disparities. Public health has an established history of combating the disparities that stem from social injustice, particularly by working within the civil rights legal framework for countering racial inequity. The recent report of the Ferguson Commission, “Forward Through Ferguson: A Path Toward Racial Equity,” indicates racial inequities that remain and the unique set of tools public health can use to address them.

The Ferguson Commission, an independent body of 16 commissioners (see the box on the next page) in operation from November 2014 to December 2015, was appointed by Missouri governor Jay Nixon to provide an unflinching report outlining recommendations to address the underlying issues that contributed to the death of Michael Brown Jr, who was shot and killed by police officer Darren Wilson on August 9, 2014. Although the events that led to the formation of the commission are unique to the St. Louis, Missouri, community, the conditions of racial disparity and inequity that the commission were charged with addressing are not.

Ferguson Commission Commissioners: St. Louis, MO, 2014–2015

Commissioner	Position and Affiliation
Reverend Starsky Wilson (co-chair)	President and chief executive officer, Deaconess Foundation; pastor, Saint John’s Church (the Beloved Community), St. Louis
Rich McClure (co-chair)	Member, St. Louis Regional Board of Teach for America; emeritus member and former president, Civic Progress
Sergeant Kevin Ahlbrand	Detective sergeant, St. Louis Metropolitan Police Department; deputy commander, Major Case Squad of Greater St. Louis; president, Missouri Fraternal Order of Police
Rasheen Aldridge Jr	Director, Young Activists United STL
Reverend Traci Devon Blackmon	Pastor, Christ the King United Church of Christ; coordinator, Healthy Mind, Body, Spirit, BJC HealthCare
T. R. Carr Jr, PhD	Retired professor and former chair, Department of Public Administration and Policy Analysis, Southern Illinois University, Edwardsville; former mayor, City of Hazelwood
Gabriel E. Gore, JD	Partner, Dowd Bennett, LLP
Becky James-Hatter	President and chief executive officer, Big Brothers Big Sisters of Eastern Missouri
Daniel Isom, PhD	Professor of policing and the community, University of Missouri, St. Louis; retired chief of police, St. Louis Metropolitan Police Department
Bethany Johnson-Javois (ex officio commissioner)	Chief executive officer, St. Louis Integrated Health Network
Scott Negwer	President, Negwer Materials
Brittany N. Packnett	Activist; executive director, Teach for America, St. Louis
Felicia Pulliam, JD	Development director, FOCUS St. Louis
Patrick Sly	Executive vice president, Emerson
Grayling Tobias (active December 1 through April 13)	Retired superintendent, Hazelwood School District
Bryon M. Watson	Retired sergeant, St. Louis County Police Department; officer, St. Louis Community College Campus Police
Rose A. Windmiller	Associate vice chancellor, Government and Community Relations, Washington University, St. Louis

The commission heard consistent reports of systemic disparities from hundreds of community members, local and national leaders, and scholars through their donation of more than 3000 hours (Figure 1). It heard about how Black children in area schools were seven times more likely to be suspended²; how Black drivers were 3.5 times more likely to be pulled over and searched³; how, in predominantly Black municipalities, it was not unusual for there to be more warrants issued for arrest for unpaid fines than there were residents⁴; and how all these inequities and others fed a life expectancy gap of nearly two decades between the wealthy, White parts of town and the poor, Black neighborhoods.⁵

FIGURE 1—

Overview of the Ferguson Commission’s work: St. Louis, MO, 2014–2015

^aSee http://forwardthroughferguson.org.

These disparities plague communities across the nation, and because of their impact on health are public health issues. Thus, the ongoing work of implementing the 189 calls to action contained in the commission’s report (the box on page 1929) is, in part, the work of public health. The World Health Organization, the Centers for Disease Control and Prevention, and individual health-focused government agencies have advanced health equity frameworks acknowledging this.⁶ However, despite the well-established link between social justice and population health, a great deal of attention remains focused on individual behavior change and clinical health services and delivery and not the underlying infrastructure that feeds disparities.

Focuses of the Ferguson Commission Calls to Action by Area: “Forward Through Ferguson: A Path Toward Racial Equity,” St. Louis, MO, 2014–2015

Justice for All	Opportunity to Thrive	Youths at the Center
Police reform	Access to affordable health care	Supporting the whole child
● Use of force	Financial empowerment	● Addressing hunger
● Training	● Increase in minimum wage	● Schools as centers of health
● Civilian review	● Elimination of predatory lending	● Reforming school discipline
● Response to demonstrations	● Universal child and family development accounts	Education infrastructure reform
Court reform	● Financial empowerment sites	● Investing in early childhood education
● Sentencing reform	Job training and creation	● Supporting education innovation
● Constitutional rights	Access to affordable and quality housing	● Fixing school accreditation
● Conflict of interest	Building equitable transportation infrastructure
Consolidation
● Consequences of court fragmentation
● Consequences of police fragmentation
	Racial equity

We examine the superseding theme of racial equity and its applications to public health. We introduce the commission’s three signature priority areas for framing public health calls to action and research questions. We also discuss commission principles that are applicable to public health.

RACIAL EQUITY

Racial equity was a theme that overlaid the three other signature priority areas of the report. Having a region where outcomes are no longer predicted by race requires dismantling structural racism. Structural racism refers to systemic factors that create, maintain, and perpetuate racial inequity across institutions. A recent commentary published in the Journal highlights the myriad ways racism affects health and the imperative for the field to help root out racism.⁷

Specifically, the piece calls attention to the importance of seeing racism as structural and not merely a group of isolated incidents. This point aligns with the commission’s decision to make racial equity a goal reflected in outcomes rather than focusing narrowly on the death of Michael Brown Jr. Examining upstream determinants across multiple social identities is essential for effecting change, which is something public health has underscored by developing policies such as Healthy People 2020 and by calling for an intersectional frame that connects issues of equity across domains.^8,9

ENGAGING PUBLIC HEALTH WITH CALLS TO ACTION

“If you live in a safe suburb, and you’ve got a good job, and you’ve got health insurance, and you never worry about your kids’ schools, and you don’t wonder if you might get pulled over because of the color of your skin, then maybe the status quo is working just fine for you. But for thousands of St. Louisans, the status quo is killing them.”

—Forward Through Ferguson¹⁰

Justice for All

The events in Ferguson, Missouri, highlighted deep and persistent inequities in law enforcement practices. For example, in 2013 in Ferguson, as elsewhere, Black drivers were far more likely to be stopped while driving and searched or arrested during that stop than were White drivers.³ The US Department of Justice recently used the civil rights legal framework to foreground the illegality of unevenly enforcing laws on the basis of race and to enter into a consent decree with the municipality of Ferguson.¹¹ Public health scholars can help provide the data needed to use that framework to address remaining injustices in the practice of law enforcement.

Question: What are the trends in police use of force?

The Counted project of the UK-based newspaper the Guardian began when journalists could find no reliable prevalence and incidence data on police shootings in the United States. To an epidemiologist, such numbers are the bedrock of investigating and responding to a public health issue. The US government, however, maintains no comprehensive record of the number of people killed by law enforcement. Some describe the current voluntary program for police department reporting of “justifiable homicides” as “arguably less valuable than having no system as all.”¹² In 2013 the Federal Bureau of Investigation database counted 461 justifiable homicides at the hands of police.¹³ Crowdsourced counts found an additional 300.¹² When The Counted project began in 2015, it identified more than 400 instances of fatal use of force by police in the first half of the year alone.¹²

The Federal Bureau of Investigation has plans to replace its current system with a better one by 2017. Public health professionals, with their experience building surveillance systems, should help design that system and ensure that it provides real-time data at the local level. When it is launched, they should apply the science of epidemiology to understand trends in incidence and prevalence, which can help develop interventions and policies that keep citizens and officers safe. The Centers for Disease Control and Prevention and local health departments should be key partners in the tracking of outcomes associated with police violence, perhaps by making deaths stemming from police use of force a reportable condition.¹⁴ That work should begin now with the data that the Guardian has uncovered as well as data from the Centers for Disease Control and Prevention’s National Violent Death Reporting System, which is well under way, although it falls short of delivering prompt, comprehensive, and community-level data.¹⁵

To some, this issue might not seem like the purview of public health. However, several community members testified to the commission that lack of trust in law enforcement kept them from feeling safe in their own neighborhoods, from accessing opportunities, and ultimately from thriving. When procedural justice is perceived as being lacking, trust in police diminishes, and collective efficacy and neighborhood health suffer.¹⁶ Recognizing this, the American Public Health Association adopted the “impact of police violence on public health” as one of its policy statements in 1998.¹⁷ It remains as pressing an issue today as it was then.

Youth at the Center

The commission’s focus on youths was driven by the unique vulnerability of this group and the enhanced potential for long-term, transformational change when a child is provided a healthy and nurturing environment. The discipline gap is one impediment to providing all children such an environment.

Question: What are the public health implications of the school-based discipline gap, and what can be done to narrow that gap?

Extreme disparities exist in the application of disciplinary procedures, with students from historically disadvantaged racial, ethnic, and gender subgroups disproportionately affected, a phenomenon known as the “discipline gap.” The discipline gap is particularly large in Missouri among elementary school–aged children: 14.3% of Black students were suspended in 2011–2012 compared with 1.8% of White students.²

Higher suspension rates are closely tied to poor academic performance and higher dropout and delinquency rates, and they have tremendous future economic costs for suspended students and society as a whole.² A cycle begins when a child is suspended, especially in the early grades, leading to the “school to prison pipeline,” wherein students who are removed from their classrooms become far more likely to interact with the juvenile and adult criminal justice systems.² Well into adulthood, having a criminal record severely undermines their ability to access and utilize health care services, procure a job, and, ultimately, maintain their own health and contribute to the health of their household.¹⁸

The link between education and health and the scale of the discipline gap makes it an issue of public health, and work focusing on the health equity aspects of education is already proceeding. However, relatively little is known of the health outcomes of the discipline gap, including the health behavior outcomes, which likely go on to affect lifetime health. Public health can apply the disciplines of epidemiology and behavioral health to better understand why the discipline gap exists and its outcomes and to continue the work of using the civil rights framework to battle educational injustices.

Opportunity to Thrive

The inequities within and across various systems, including those of education, health care, and transportation, were most evident in the commission’s work in the area of Opportunity to Thrive. In public health, we know of these environmental conditions as social determinants of health. Housing is one such determinant that affects a range of health, functioning, and quality of life outcomes and risks.

Question: What would a more coordinated housing strategy look like, and what health benefits might it offer?

As with the rest of the nation, St. Louis faces an affordable housing crisis.¹⁹ Between 2000 and 2013, the number of affordable units available per 100 families earning less than 30% of the area median income fell from 27.7 to 20.8.²⁰ The lack of stable housing is a primary driver of poor health outcomes for lower-income people.²¹

As a result, a changing network of resources has been established, including public housing; tenant-based rental assistance, primarily Housing Choice vouchers; and state and federal housing tax credits, primarily the low-income housing tax credit. The national low-income housing tax credit program is the largest rental housing production program in history. Across Missouri, low-income housing tax credit–funded units now constitute one third of all subsidized units.²² At the same time, traditional public housing has dropped to less than one in eight (12%) of subsidized units in the state, down from one in five (21%) in 1996.²³ With the population in need of affordable housing continuing to grow and shift to the suburbs, as many as two thirds of poor families are not benefitting, leaving them facing untenable housing costs.¹⁹ Such housing resources also tend to promote both racial/ethnic segregation and economic segregation, which carry negative public health effects.²⁴

These changes in the St. Louis region echo similar dynamics nationwide. In the face of these forces, communities need responsive and comprehensive housing strategies. Public health has begun to identify housing strategies that show promise from a health equity perspective. Public health scholars can continue to help apply a health equity lens to proposed housing policies and interventions.

COMMISSION PRINCIPLES FOR PUBLIC HEALTH

The engagement opportunities we have laid out are not exhaustive. The commission’s report contains nearly 200 calls to action that cast into sharp relief a set of deeply interconnected and complex issues that propagate racial disparity and poor health in our communities. And the research questions are not the only type of guidance we as public health professionals can derive from the work of the commission. We can also glean from it the principles the commission used that are applicable to our work in public health.

Be Unflinching

“Unflinching” was intentionally in the charter issued by Governor Jay Nixon when he called the commission into being. The word became a touchstone of the commission’s work and inspired it to deliberately name the ways structural racism has affected the region; these include questionable school accreditation and transfer practices, seemingly biased investigations of police use of lethal force, and unjust municipal court practices.

In public health, we must be similarly unflinching and determined when asking uncomfortable questions, such as why racialized health disparities persist and how our institutions allow and even encourage those disparities. We must draw bold conclusions that do not shy away from holding the appropriate systems and institutions accountable.

Apply the Racial Equity Lens

One way of being unflinching is by intentionally applying the racial equity lens to all public health work. This framework involves assessing an initiative or issue by asking, “Whom does this benefit?” “Does this differentially affect racial and ethnic groups?” and “What is missing that will decrease or eliminate racial disparities?”

As public health scholars, we can use the work of the commission by deliberately asking these questions in our work. Although the field of public health has a history of casting light on the harms of inequity, the incisive exploration of who benefits from the status quo has been relatively lacking. We can also be mindful about language, ensuring that we are naming race and racism, defining our terms, and examining variables that underlie racial inequities in addition to mere racial differences.

Title VI of the Civil Rights Act of 1964, which prohibits discrimination on the basis of race, color, or national origin in any program or activity that receives federal funds, provides a powerful legal framework within which to ask these questions and pursue action in the case of answers that suggest discrimination.

Advocate Policy in Addition to Programs

“When the goal is social equity, programs are important but policies are for the long term.” These words were written by commission cochair Reverend Starsky Wilson in an editorial for Governing magazine.²⁵ He goes on to observe, “Ultimately, programs can’t eliminate the systemic injustices that any group faces. They can help people manage the effects of these injustices, but they don’t overcome or cure them.”²⁵ As public health scholars, we understand the importance of primary intervention and upstream solutions.

The social determinants framework for addressing health disparities favors systematic and policy-based interventions over programmatic ones.⁶ Similarly, the civil rights framework provides legal grounds for holding our policies to high standards of equity. Moving forward, public health can continue to support the intersectoral work of advocating equity by helping partners in other sectors use these frameworks to advance equitable policy.

CONCLUSIONS

The Ferguson Commission’s recommendations were not novel: similar calls have been made by kindred bodies time and again.¹ But the present context provides a timely opportunity to use the commission’s report as a platform to advance the work of racial equity in Missouri and nationally. Although the current turmoil reveals a flawed set of systems and institutions, it also catalyzes disciplines to engage in the cross-sectoral work that will be necessary to foment progress.

The #blacklivesmatter movement and the impact it is having on political discourse are proof that this work is in progress. Public health can make unique contributions to this work through its ability to advocate racial equity through health equity across sectors.