Building the Transdisciplinary Resistance Collective for Research and Policy: Implications for Dismantling Structural Racism as a Determinant of Health Inequity

Abstract

Structural racism is a multilevel system of ideologies, institutions, and processes that have created and reified racial/ethnic inequities. As a system, it works in concert across institutions to propagate racial injustice. Thus, efforts to address structural racism and its implications for health inequity require transdisciplinary collaboration. In this article, we begin by describing the process through which we have leveraged our discipline-specific training -- spanning education, epidemiology, social work, sociology, and urban planning -- to co-construct a transdisciplinary analysis of the determinants of racial health inequity. Specifically, we introduce the underlying theories that guide our framework development and demonstrate the application of our integrated framework through a case example. We conclude with potential research and policy implications.

Introduction

Structural racism is a multilevel system of ideologies, institutions, and processes that have created and reified racial/ethnic inequities.1 As a system, it works in concert across institutions that govern our society to build a concentration of wealth among White communities, facilitate systematic divestment from communities of color, and shape racially patterned distributions of opportunities, all of which are established determinants of health and well-being.2–5 Because the influence of racism on racial/ethnic health inequities is multilevel and multifactorial, transdisciplinary collaborations are necessary to disrupt both its legacies and contemporary manifestations.

This article aims to facilitate and encourage future transdisciplinary collaboration to dismantle structural racism and disrupt its role in shaping health inequity. We distinguish between interdisciplinary collaboration, whereby diverse disciplines are brought to the table to address an issue often using a single theoretical approach,6 and transdisciplinary collaboration, which requires the development of a shared language, integration of multiple theories, and shared frameworks to advance the research enterprise and inform sustainable and comprehensive intervention. This distinction is an important one, as the latter allows us to ensure: 1) we are using common definitions for terms that may have multiple, conflicting meanings across disciplines; 2) we are able to situate independent, discipline-specific research agendas in an integrated framework, thus permitting those projects to be informed by a cohesive knowledge base; and 3) we are best positioned to anticipate and adjust for unintended consequences.

In this article, we present the results of our own transdisciplinary collaboration. Through this collaboration, we leveraged our discipline-specific training to co-construct a transdisciplinary framework that allows for a more comprehensive analysis of the structural determinants of racial health inequity. We discuss our transdisciplinary collaboration, summarize the theories guiding the development of our integrated framework, describe the framework, and conclude with potential research and policy implications for its application.

Methods

Transdisciplinary Resistance Collective for Research and Policy

The formation of the Transdisciplinary Resistance Collective for Research and Policy (TRCRP) was facilitated by our participation in the Health Policy Research Scholars (HPRS) program, a national leadership program supported by the Robert Wood Johnson Foundation (RWJF) that aims to build a “Culture of Health.”7 A Culture of Health is one that leverages cross-sector collaborative research and practice in striving to ensure that all individuals within a diverse society have the opportunity to lead healthful lives.7 To build toward a Culture of Health, HPRS is strategic in providing resources and facilitating opportunities for learning, mentorship, and transdisciplinary collaboration among scholars from populations traditionally underrepresented in doctoral programs. In doing so, the program serves to enhance existing research, leadership, and policy capacity, while encouraging transdisciplinary work. Thus, our shared status as Health Policy Research Scholars provided an opportunity for us to forge transdisciplinary collaborations and develop an action-oriented research agenda to advance a Culture of Health.

Furthermore, our lived experiences as women of color and our disciplinary training inform our positionality within the Collective. We bring unique perspectives to understand how societal ideologies operating across different systems influence racial health inequities. We also bring to this work our scholarship and practice experiences, which span teaching and education, clinical social work, sociology, urban planning, epidemiology, and state-level policy development. Ultimately, we aim to leverage these perspectives, scholarship and practice experiences to not only document and explain, but to implement sustainable policy solutions aimed at disrupting these processes.

Lastly, our collective is a form of resistance to structural norms that perpetuate dominant hierarchies and sustain inequities, including processes that exist within institutions of higher education.8 For example, while the authorship hierarchy in academia awards individual achievement and encourages siloed research approaches, we note how this practice is at odds with the transdisciplinary collaboration required to disrupt racial health inequity that transcends individual disciplines and requires transdisciplinary solutions. To acknowledge the importance of rethinking authorship practices to reflect and encourage the integrated nature of transdisciplinary work, we chose to publish under the name, Transdisciplinary Resistance Collective for Research and Policy.

The Transdisciplinary Collaboration

During a 2019 RWJF Annual Leadership Institute activity, we became aware that while situated in different disciplines, our work centered around a common core issue: structural racism. As we explored this more deeply, we uncovered how our conceptualizations of structural racism varied with the theories and literature we invoked from our respective disciplines. Thus, to authentically be in conversation with one another required that we develop a shared definition of and understanding around structural racism.

In developing this shared definition, it became evident that through this collaborative space we had a unique opportunity to integrate our discipline-specific knowledge, approaches, and methods into a transdisciplinary framework aimed at understanding and addressing the myriad consequences of structural racism. We met regularly over 12 months via an online, remote video conferencing platform. We began by exploring the discipline-specific theories relevant to our respective research and practice. Even as we acknowledged each of the disciplines in which we are trained and the complexity of our technical discourse, we undertook the task of developing a shared language to build a transdisciplinary framework. In doing so, we laid groundwork to holistically understand and address the ideologies that drive policies, practice, and resource allocation resulting in racial inequity.

Guiding Theories

To develop the framework both precisely and parsimoniously, we identified several discipline-specific theories that guide our work toward health equity. As has been noted previously, “frameworks provide a metatheoretical language that can be used to compare theories.”9 The framework allows us to discuss and decipher the overlapping concepts that are central to the analysis of racial inequities across our disciplines. This, in turn, allows transdisciplinary researchers to have a common language and theoretical grounding, relevant to specific research questions and agendas.9 Next, we briefly discuss five discipline-specific theories that primarily guide our work. Key elements of the guiding theories are shown in Table 1.

Table 1. Five theoretical frames guiding the development of the Transformative Racial Equity Framework.

Theory	Key elements of the theory
Racial-state theory	Race is integral to physical, ideological, and philosophical development of the modern nation-state9
Racialized organization theory	Challenges the conception of race-neutral organizational landscapes; Connects racial schemas with material resources; Legitimizes the limited agency of structurally marginalized, racial groups10
Critical race theory (CRT)	Permanence of racism; Critique of liberalism; Intersectionality; Whiteness as property; Counter-storytelling16,20
Phenomenological variant of ecological systems theory (PVEST)	Environment, proximal and distal, support development; Racialized context influences development12,15
Resistance theory	Individuals are not acted upon by structures but negotiate and struggle with structures to create meaning from these interactions18-19

Racial State Theory

At the distal level, racial state theory contextualizes multifactorial racial processes by establishing the centrality of race in the historical formation of the modern nation-state. It holds that European global exploration increased exposure to diverse populations and were accompanied by perceived threats of the “unknown” resulting in a crisis of fear and anxiety.10 This crisis produced racial hierarchies that led to the “ordering of the state” in an effort to control this perceived racial threat.10 Thus, the modern nation-state functions to maintain (White, heteronormative, patriarchal) homogeneity, by institutionalizing and operationalizing racial threat through oppression, erasure, surveillance, and restriction - racializing every aspect of society.

Racialized Organization Theory

Moving from the distal to the proximal, racial organization theory bridges the “macro-policies of the racial-state and the micro-politics of racial interaction.”11 Racist policies within institutions are manifested at the granular level to perpetuate and maintain a racist-ordering state. In turn, societal ideologies, institutional policies, and individuals that operate within are transformed by the organizations. However, it is important to note the degree to which individuals assimilate to the expectations of a racist ordering in the allocation of power and resources, is variable.

Phenomenological Variant of Ecological Systems Theory (PVEST)

At the interpersonal-level, PVEST is an ecological systems theory that interrogates the intersection of identity development and environmental context by examining the unique burdens and risks often confronting people of color.12–14 Specifically, PVEST builds on ecological human development theory15 to examine how young people make meaning in larger contexts through the interpretation and explication of feedback from the environment, with particular attention to individual differences by race, class, skin color, gender, and maturation.16 PVEST provides an understanding of how structurally marginalized racial groups, such as Black adolescents, interpret, understand, and react to discrimination, microaggressions, stereotypes, and other race-based forms of expression.

Critical Race Theory (CRT)

Critical Race Theory offers an academic lens to approach race and racism while engaging in candid discourse around racial equity. CRT originated in legal studies and was introduced to education17 and public health18 as a race-equity methodology and praxis that acknowledge race as a social construct and makes visible the complex and coordinated ways in which racism permeates societal institutions with consequences for distributions of health and well-being. CRT also operates on a personal level providing an understanding of how individuals engage and perpetuate racist ideologies and offers a counter-narrative that centers historically and contemporarily marginalized voices, ie, the most affected by, but not included in the governance that directly impacts their lives. When historically marginalized people of color resist racialized and inequitable structures, they are met with a language of colorblind racism, neutrality, and gradual change.

Resistance Theory

While the framework presents oppressive processes, we also acknowledge resistance to these normalized patterns often expressed in individual or collective forms of protests for change. Transformational resistance is defined as a critique of oppression and a desire for social justice.19 It is the notion that people of color react to, and demand change within, oppressive structures in ways that do not conform, nor perpetuate social reproduction of oppression. For example, schools as autonomous political, cultural, and ideologically reproductive spaces, often serve as sites of resistance, manifesting oppositional behavior to dominant societal ideologies and values.20

In our independent scholarship, these theories help us to situate our research in the broader literature, illuminate specific relationships between the variables under study, and help us to interpret our findings. In bridging across them, however, we noted complementary ways in which they illuminate the subtleties of how racism, a unifying element of the theories, operates in society and our daily experiences, and how Whiteness, as a system, evolves and reproduces itself over time. Thus, our resulting transdisciplinary framework illustrates the permanence of racism, as a structured system, that interacts with institutions and organizations, both shaping and being reshaped by them, which in turn, systematically maintains, justifies, and perpetuates racialized hierarchies from the macro-level to the interpersonal-level contributing to racial inequities.11,19,21,22 Areas where specific theories provided important nuance included the application of PVEST at the individual-level to understand individual agency and developmental trajectories13 as well as Resistance Theory to highlight the non-linear relationships between organizations and individuals, whereby individuals are not simply acted upon by more macro-levels, but also implement transformative alternatives to resist the imposition of harmful structures. Next, we illustrate this multi-theoretical, integrated framework.

The Transformative Racial Equity Framework (TREF)

In developing this framework, we discussed theories relevant to our individual disciplines and how our understandings transverse different research contexts. We draw on these theories to conceptualize how racism is institutionalized in nested ecological and bi-directional systems that individuals navigate from the institutional to the interpersonal. Taken together, they were critical in building our Transformative Racial Equity Framework (TREF; Figure 1).23 As an extension of the ecological system framework,14 the framework is designed to help researchers understand how health inequity is embedded in multiple layers of society, including ideology, institutions, organizations, and individuals. However, unique from the ecological system framework, racism and resistance inform ideologies and have a bi-directional relationship with each of the layers. We acknowledge the agency of individuals to influence organizations, institutions, and ideologies. TREF allows us to see not only racialized health inequities but to also acknowledge that people are resisting structural oppression. We introduce the TREF as a conceptual tool to illuminate and dismantle structural racism that can guide future research, including question development, data collection and analysis, interpretation of findings, and dissemination.

Figure 1. Transformative Racial Equity Framework.

Example: Applying TREF to COVID-19

To briefly illustrate how transdisciplinary collaboration, and the TREF specifically, may facilitate a more comprehensive analysis of health inequity, we apply them to examine emerging data around the unequal burden of the coronavirus 2019 (COVID-19) pandemic. COVID-19 is a highly infectious, potentially fatal, acute respiratory infection affecting many countries globally.24 By April 2020, even with minimal data reported, the Centers for Disease Control and Prevention confirmed a disproportionate burden of illness and death among Black people in their analysis of data from hospitalized, lab-confirmed cases.25 Media coverage of the mortality data for which race/ethnicity had been reported found that while Black people comprise 21% of the total population, they account for 42% of COVID-19 deaths.26 As media outlets, policy makers, clinicians, and researchers, among others, begin to develop explanations for this disproportionate burden of mortality among Black communities, these narratives will have critical implications for intervention that will shape the course of the pandemic. As such, using a transdisciplinary approach adjusts for unintended consequences and makes visible the interconnectedness of structural determinants of health inequities.

Using critical race theory, the outer layer of the TREF encompasses the societal ideologies that undergird why racialized health inequities exist and are exacerbated during a viral outbreak. This serves to deconstruct character flaw models that suggest that Black people, in particular, engage in deviant behaviors (eg, alcohol consumption, tobacco, or other substance use), thus increasing their risk of contracting and dying from COVID-19. Concerningly, such narratives have already begun to emerge across various outlets, including the media, which may have implications for public support around effective policy solutions.27 They are also reflected in suggestions made by the United States Surgeon General, Jerome Adams, to tell “big momma” and “pop pop” to avoid drug use. These narratives perpetuate false logics that Black communities should bear the personal responsibility of survival, rather than the institutions that disenfranchised their health access, effectively absolving societal institutions perpetuating racialized ideologies.28

Racial ideologies not only manifest in public narratives but are also embedded in institutional governance, presented as the second layer of the framework. Guided by racial state theory, we assert that, historically and systematically, governance materializes ideologies through policies and practices, which contribute to and perpetuate health inequities. For example, redlining and restrictive covenant policies, developed in racial-capitalistic-nation state ideology2 forced Black communities into segregated and abandoned communities. These policies, coupled with educational, economical, housing, and social policies, limit opportunities for Black communities to achieve a Culture of Health. Thus, early COVID-19 data revealing that Black communities are disproportionately impacted should be analyzed in the context of historical and existing policies rather than assumed behavioral norms.

Because governance regulates the distribution of organizational resources, we apply racialized organization theory to our next layer. Policies, rooted in ideologies that justify racialized disparities, determine which communities are displaced, how schools are funded, and the access to quality health care. Though the inequities in access to health care are known, COVID-19 illuminates the severity of the gap that persists. Even with improvements to the health care system, Black communities are more likely to continue to have inadequate access to high-quality health care services.

Individuals, the innermost layer of the framework, live, interact, and operate in the organizational context influenced by governance and societal ideologies. PVEST builds on this concept to understand the intricacies of these layers at the interpersonal level. For instance, the confluence of being less likely to have access to quality health care, education, environmental security, and political power3,29,30 dramatically increases the vulnerability of Black individuals to COVID-19. Additionally, because racialized ideologies and structural inequities impact one’s identity and development,13 making meaning in larger contexts during a public health crisis can have implications on individual health and wellbeing. As resistance theory holds though, Black communities are not only resisting these narratives, but organizing for policy-level interventions that re-imagine institutions in service of population health equity.

As illustrated here, the multidirectional, multifactorial processes that are uncovered through the application of the TREF can assist scholars in moving toward a Culture of Health. The critical nature of doing so is never more evident nor urgent than in the crisis of a pandemic; however, the need for this transdisciplinary work will persist beyond the pandemic’s grip.

Discussion

Our transdisciplinary, integrated framework offers several important avenues for researchers who are working to intervene on structural racism and its health consequences. Extant scholarship has documented how racism systematically operates at multiple levels, including societal, institutional, organizational, individual-levels and across sectors.11 Thus, productive transdisciplinary work must involve the integration of how racism influences the production of knowledge and methodologies used in health equity research. Therefore, we highly recommend that future research and practice use the TREF, a framework that acknowledges the racialized structural determinants of health inequities. In their application of the TREF, researchers can further integrate the knowledge from their respective disciplines, and mutually inform each other’s work while capturing complex causes and consequences of racial health inequities. Furthermore, the TREF allows for the operationalization of a common language to be used and understood by researchers across disciplines who have shared research agendas. Additionally, this framework enables transdisciplinary researchers to operate outside of their disciplines and avoid simply parsing the effects of racial health inequities. Finally, it is imperative that transdisciplinary collaborators continue to explore the conceptualization of these shared terms within the TREF for applications throughout their research process and beyond to ensure an ongoing common understanding.

The TREF also has important implications for policy development. As Health Policy Research Scholars, it is essential that our research efforts align with policy interventions that seek to dismantle structural racism. With this in mind, we foresee this framework as a tool to inform more comprehensive policy-making and as an aid to facilitate research and community-based partnerships working to address health inequities. The TREF adds value by requiring researchers to think about policy at multiple levels while actively incorporating cross-disciplinary perspectives. In doing so, it can help illuminate and stem the unintended consequences of policy decisions in domains other than those directly targeted for intervention.

Conclusion

Dismantling structural racism and disrupting its role in shaping health inequity requires a coordinated, transdisciplinary approach. In this article, we described our transdisciplinary collaboration, presented the TREF framework, and discussed its implications for research, policy, and practice using the current COVID-19 pandemic as a case example. Taken together, engaging an iterative, transdisciplinary collaboration and developing an integrated framework serves to disrupt the ways in which structural racism presents in research, practice, and policy. That is, while traditional research approaches encourage siloed inquiry, comprehensively understanding and informing interventions on racism as a structural determinant requires meaningfully collaborative efforts.31 As the Transdisciplinary Resistance Collective for Research and Policy, we endeavored to visualize and leverage the synergy present when disciplines truly collaborate to address the structural determinants of racial inequity. We recommend that scholars invested in moving toward a Culture of Health invest in transdisciplinary approaches.