Art, Anti-Racism and Health Equity: “Don’t Ask Me Why, Ask Me How!”

Abstract

Objective

One of the fundamental challenges in research on, and the practice of, anti-racism is helping people open their minds to new possibilities and new ways of thinking.

Design

This commentary illustrates how art can help people unlearn misinformation and narrow ways of thinking while enhancing flexibility that allows people to think creatively about efforts to eliminate or mitigate the health effects of racism.

Results

Historically, art has been a critical foundation of the history of protest and struggle to achieve equity in the United States and across the globe. Whether music, poems, paintings or other forms of creative expression, art has been at the core of efforts to express emotion, communicate difficult concepts, spur action and change what seems impossible. Art has been particularly important in illustrating and helping to facilitate how people understand what racism is, how it feels to experience privilege or oppression and exploring the implications of policies and practices that affect health indirectly or directly. Yet, art remains underutilized in anti-racism education, training and organizing efforts within public health. This commentary includes several arts-based examples to illustrate how art can facilitate insights, observations and strategies to address racism and achieve health equity.

Conclusion

Art can be an important tool to facilitate moving past intellectual arguments that seek to explain, justify and excuse racism. Art may be particularly important in efforts to illuminate how racism operates in organizational or institutional contexts and to communicate hope, resilience, and strength amid what seems impossible.

Introduction

“…You wouldn’t ask why the rose that grew from the concrete had damaged petals. On the contrary, we would all celebrate its tenacity. We would all love its will to reach the sun. Well, we are the rose - this is the concrete - and these are my damaged petals. Don’t ask me why, thank God…, ask me how! Hahahaha…Tupac Shakur (2000), The Rose that Grew from Concrete1

How do we eliminate racism and achieve health equity? For some in public health, neither eliminating racism nor achieving health equity are realistic goals. In this commentary, we argue that using art and the arts in the context of anti-racism initiatives is one promising strategy that can be used to disrupt old ways of thinking, inspire new insights, inform new strategies and motivate individuals and communities to work together to create and sustain conditions that promote equal health and well-being outcomes for all. The goal of this commentary is not to contribute to the literature that offers strategies for using art to manage chronic disease, adapt to difficult life circumstances, or more effectively survive stressful situations. Rather, we seek to call public health professionals to dream, create, and think of audacious ideas that will help us devise strategies to achieve health equity and maintain equity once achieved.

This is not a call exclusively for those who are the targets of oppression to yet again devise strategies to not only help themselves but help those who benefit from the inequalities in our society. As we have seen recently in books like Dying of Whiteness,2 those who benefit from the racial hierarchy in our society act and vote against their policies that would help them if they think it would also benefit others that they do not feel are worthy of assistance. This call is for White allies to devise strategies to educate, mobilize and address their White counterparts while the various groups who have not historically benefitted from the US racial hierarchy devise strategies to adapt to, work around, dismantle and rebuild structures that are more equitable and fair for themselves and for the rest of society.

Background

As long as there has been racism, colonization and White supremacy,3-9 there have been efforts to eliminate, dismantle and transform these systems of oppression and pursue health equity.10-12 More than 120 years ago, DuBois argued that, “We must endeavor to eliminate, so far as possible, the problem elements that make a difference in health among people.”13, p148 Despite this charge and a long history of activism and social change, the science of how to help bring shared vision, goals and progressive change has been understudied and underutilized, particularly in the context of public health.

In public health, considerable attention, resources and effort have been dedicated to documenting and measuring the health effects of racism, discrimination and other social determinants of health.14 However, many have critiqued the recent decades of research on health disparities and health equity for focusing too much on documenting disparities, and identifying determinants of disparities without equal attention and resources being dedicated to addressing and eliminating health disparities.12,15

How do we apply what we know about patterns and determinants of health to practices, programs, and policies to eliminate disparities and sustain equity once achieved? A decade ago, Syme16 noted that considerable research has focused on problems of the individual and the risk factors they experience rather than the societal forces that are the root causes of the problem. While we have seen a considerable increase in research on and attention to social determinants of health and fundamental causes, few public health professionals are trained to create policies or interventions that address social, economic or other factors that shape population health and perpetuate health disparities. The question of how we envision new practices, policies, strategies, and solutions remains elusive. We need other ways to imagine and devise the world and what seems possible in it; strategies that may help us achieve the elusive goal of achieving health equity.

Beyond describing what equity is, we need help imagining the process by which we achieve this goal. Anti-racism is an educational and organizing framework that seeks to confront, ameliorate, eradicate racism and unearned privilege.17 Art offers an opportunity to facilitate the processes by which we refine our understanding of the determinants of health inequities and solutions to achieve health equity. We need creative ways to construct racism and efforts to resist or undo racism in a way that allows multilayered understandings and help people see the lived experiences of systems of racial oppression that often go unrecognized and unquestioned.18 Artistic expressions cross a range of mediums from museum exhibitions transfiguring symbols of systemic racism, podcasts using storytelling to counter dominant narratives, to works of fiction to help envision alternative futures. Because it facilitates the ability to sense feeling, ideas, and beliefs that are widespread in society, works of art are critical in generating emotional responses and deeper connections to experiences and others.19 This is the essence of anti-racism praxis.

What is Anti-Racism?

Anti-racism praxis seeks to achieve equity, social justice and peace and move toward a world where racism either is non-existent or its health effects are negligible.17 Anti-racist community organizing builds on the core components and principles of community organizing and infuses anti-racism as core values and beliefs. Anti-racism community organizing is based on two premises: a) racism is the defining form of oppression in the United States; and b) racism is the most critical and largest obstacle to social equity and community organizing for social change.20 Racism can be characterized as both a process and as an outcome. As a process, racism has been defined as “an organized system, rooted in an ideology of inferiority that categorizes, ranks, and differentially allocates societal resources to human population groups.”21, p76 As an outcome, racism has been described as the product or result of a persistent pattern of systematic inequality by race.22 Consequently, racism is an analytic tool to explain systems, patterns and outcomes that vary by population groups that are broader than the explicit decisions and practices of individuals, organizations or institutions. Beyond a series of isolated incidents or acts, racism is a deeply ingrained aspect of life that reflects norms and practices that are often perceived as ordinary, constant and chronic.10,11 Racism is a violent system of power that can be active and explicit, passive and implicit or somewhere in between.23 Racism pervades national cultures via institutional structures, as well as the ideological beliefs and everyday actions of people. While cultural narratives and media coverage often present it as reflecting aberrant views of a minority of people, racism is often aligned with the normative culture of particular eras, geographic contexts and locales.17

Why Art as Part of Anti-Racism Organizing?

According to Shapiro (2002),20 many anti-racism programs and initiatives seek to change awareness of cultural differences, personal healing, reducing prejudice, individual growth and transformation and increased activism. Despite the fact that successful interventions usually need to be targeted, context-specific interventions may focus on changing behavior rather than deeply held attitudes or beliefs.24 The problem is that even the most well-intentioned people bring with them beliefs, attitudes, and experiences that shape how they process and apply new information. According to reviews of anti-racism interventions,20,25,26 the objective of the majority of interventions is to heal, organize and empower those who are the targets of racism by helping them see how the world is shaped by systems, with traceable historical roots, that advantage some and disadvantage others. Few of these interventions have been rigorously evaluated, but from the first author’s experience using anti-racism principles and approaches in various settings, it is clear that often some may simply struggle to get past old ways of thinking and experiencing the world. We argue that art and the arts can facilitate processing of and connection to information that can be the foundation of efforts to pursue change consistent with the principles and goals of health equity.27 The goal of these efforts are not to pursue individual health promotion but to pursue the ideal of population health equity.

We anchor our approach in Akbar’s three step process of critical self-education: deconstructionist, reconstructionist, and constructionist.28 We also add critical insights and information from Watts’ research on sociopolitical development,22,29 which builds on Freire’s work on critical consciousness.30,31 Sociopolitical development is a process of increasing knowledge, analytic skills, emotional faculties, and capacity to engage in behaviors that directly or indirectly seek to achieve change in social and political systems29 that lead to health equity. It is important to clarify from the beginning that our goal is not indoctrination; if we are not promoting freedom of thought and expression, then we are no better than the system of racism that we are analyzing. Having said that, our goal is to facilitate critical thought that leads to action.32 To do so, we believe that both beneficiaries of privilege and those targeted by oppression need to first critically analyze and commit to a process of self-awareness and self-actualization so that they do not perpetuate personally the trauma they seek to heal professionally. Table 1, Table 2 and Table 3 provide examples of art that is consistent with each of these three phases.

Table 1. Examples of art to move toward health equity. Descontructionist – facilitate unlearning .

Artist	Artistic Work	Goal of Work
Elizabeth Alexander, Kwame Akoto-Bamfo, Toni Morrison, Hank Willis Thomas and others	The National Memorial for Peace and Justice/ Lynching in America: Confronting the Legacy of Racial Terror	Educates people about the terror and trauma that sanctioned violence against African Americans created. Provides a space for truth-telling and reflection about racial terrorism. Public commemortation of atrocities in our history is a first step toward recovery and reconciliation.
D. Channsin Berry and Bill Duke	Dark Girls	A documentary about being a dark-skinned Black woman in America. The film delves into the concept of beauty from within and outside of the African American community, and biases about race.
Carson Ellis	Illustrated 20 unarmed African Americans from police database of police killings	Helped consumers experience the magnitude of racism and hard truths about being Black or White in America.
Writer: Herman Raucher, Director: Melvin Van Peebles	Watermelon Man, 1970. Movie. A Bennett-Mirell-Van Peebles Production	In this comedy, an extremely bigoted, White insurance salesman gets the surprise of his life when he wakes up and discovers that he now looks like a Black man. He soon finds that he is the victim of the same forms of racism and discrimination that he previously used against African Americans. As his wife (Estelle Parsons) leaves him and all attempts to explain and reverse the phenomenon fail, Jeff comes to accept and even profit from his new status.

Table 2. Examples of art to move toward health equity. Reconstructionist – devise new ways of learning.

Artist	Artistic Work	Goal of Work
Ava Duvernay	13th	A documentary examining the functionining of the US prison system.
Raul Rucker	Rewind: Adapted the design of Ku Klux Klan robes to incorporate fabrics like Kente cloth, camoflage, and spandex	Highlights how racism has changed over time and how it can become normalized in ways that faciltiate its power and influence.
Billie Gracy Lynn	“American Mask” three American flags sewn into KKK-style hoods	“It’s a deliberately provocative piece,” Lynn told CNN. “It’s a proposal. I’m asking a question. There’s no way to walk up to someone on the street and say, ‘Do you think people are concealing their bigotry and racism behind the flag, behind being patriotic?’ That’s the question and that’s what I find so disturbing.”
Derrick Bell	Faces at the Bottom of the Well: The Permanence of Racism, 1992. New York, NY: Basic Books	A series of allegories and historical examples to illustrate how racism is an integral and permanent part of American society. The stories highlight how African American efforts to achieve equity are doomed to fail as long as the majority of White Americans do not see their health and well-being threatened by the status quo.

Table 3. Examples of art to move toward health equity. Constructionist – develop new strategies to pursue equity.

Artist	Artistic Work	Goal of Work
Derrick Bell	Silent Covenants: Brown v Board of Education and the Unfulfilled Hopes for Racial Reform, 2004. New York, NY: Oxford University Press	Despite the success of the Brown v Board of Education Supreme Court decision in 1954, the ruling has more strongly enforced efforts to address separation by race than equality by race. The allegory plays out the alternative notion that they would maintain segregation by race but rigorously enforce and invest in making communities equal.
Sam Greenlee	The Spook Who Sat by the Door, 1969. Wayne State Detroit, MI: University Press (Book and movie)	The fictional story of Dan Freeman, the first Black Central Intelligence Agency officer, who uses what he learned in gathering intelligence, political subversion, and guerrilla warfare to train African American street gangs in urban areas to fight for equality.
Kasi Lemmons	Harriet, 2019	A biographical film about abolitionist Harriet Tubman. While there is considerable attention to her heroic efforts to liberate hundreds of slaves through the Underground Railroad, the movie also deals with diverse roles and perspectives that African American and White people had about racism, progress and what roles they needed to play.
Denzel Washington, director	The Great Debaters, 2007	Based on a true story, the movie plot revolves around the efforts of debate coach and the debate team at Wiley College, a historically Black college in Texas during the Great Depression. Grappling with issues of racism from day-to-day insults to lynchings, the characters represented different perspectives on how to achieve racial equity.

Deconstructionist Phase

The deconstructionist phase is characterized by critical social analysis, or helping people to critically analyze and challenge their social world; not adapt to it.22,29,30 A key part of this analysis is understanding that the root causes of social and health inequities comprise a system of inequality that unfairly disadvantages some and unfairly advantages others.32,33 In the context of anti-racism approaches to health equity, a key goal is to help people “read the world” in such a way that they can recognize and “problematize” accepted explanations for the existence and persistence of health disparities.34-37 Frame viability describes the extent to which an explanation for a pattern of health is culturally and politically salient (eg, health disparities are primarily due to genetic or behavioral differences) and frame validity describes the extent to which an explanation is empirically true (eg, racial disparities are due to structural racism).38 Critical questioning, problematization, and coaching are key strategies to help distinguish between viable and valid frames.

Art and the arts can create opportunities for disrupting mental models and worldviews that can facilitate problematizing viable frames, unlearning misinformation and learning accurate information. In unlearning, the goal is not to help people forget, but it is to recognize that a current or old way of thinking is no longer effective or is incomplete (eg, there may be differences in gene expression or the prevalence of behavior but these are better explained by larger contextual forces than more downstream factors). A new model or paradigm is needed that can help reach the goal of achieving health equity, at least in part, because of the ways that people process new information.39 When people encounter new information, they attempt to fit them into their existing thinking.40 When the information is congruent with or fits these mental schemas, or ways of thinking, they are experienced as obvious and even helpful, but when information challenges or runs counter to their ways of thinking, people are likely to reject the new information – rather than challenge their existing schemas – if there is not a fit.

Reconstructionist Phase

Once people have developed the critical awareness of these issues, the reconstructionist phase will help people propose strategies to address the limitations and errors they identified in previous exercises. A primary focus of this phase of training will be to describe how a particular problem could be studied to be more congruent with the social, cultural, and historical experience of a particular racial or ethnic group. People will be charged with considering alternative perspectives from other fields that explore the issue from a different perspective and propose strategies to address the limitations or errors in the way a problem has been conceptualized, examined, or addressed. While this notion is not new,7,41 helping people see how racism is part of the fabric of our society is essential to dismantling it and eliminating its effects on health.

In the context of anti-racist education and organizing, beliefs about how to define racism and how to explain the existence and persistence of racial disparities in health can become especially sensitive and polarizing. The terms often used to most accurately describe root and social determinants of racial disparities in health (eg, racism) often trigger emotional reactions and psychological barriers to fully exploring these possibilities. The term racism and the label of racist are often loaded and polarizing because they have deeper meaning and implications for how people see themselves and those they love, admire and respect. Though some anti-racist organizing strategies seek to offer people new definitions of what racism, racist, and other terms mean to help people rethink these terms as descriptors of systems and their outcomes rather than individual beliefs, values and behaviors, some – regardless of race – cannot and do not move past their resistance to these foundations. This severely limits the potential impact and sustainability of anti-racist educational and organizing efforts.42,43

Because anti-racism organizing is relational,42 it is important to connect with others if one genuinely struggles to relate to the experience of others or how others conceptualize and frame their experience and explain the historical processes and historical events that shape them. Anti-racist community organizing brings people together who are affected by a problem to increase their collective power so they can resolve the problem. Thus, listening, building human relationships, nurturing trust, respect and understanding17 are essential components of the process. Encouraging active sharing and participation of all people involved and the presumption that all have some level of expertise to bring to the penultimate goals are keys to this phase. Horizontal communication, rather than privileging some voices over others, also may be critical to model and encourage if the goal is to work across identities and experiences to create common strategies and goals.32 In this phase, one of the key goals is collective identification, or facilitating feelings of solidarity, collective efficacy and shared culture.32 Some of the components of collective efficacy can be an increase in positive regard for one’s social group and their membership in it, and embracing the goal of inspiring change, not simply for oneself, but for the betterment of the collective.32 Similarly, Williams44 argued that research is needed to help individuals envision and sympathize with the harsh realities of disadvantaged individuals and situations, and to enhance emotional identification with and build empathy and support for populations that experience disproportionately poor health outcomes.

Constructionist Phase

The final phase of this anti-racism organizing strategy is the constructionist phase. The goal of this phase is praxis, or the creation of ways of thinking for the purpose of action and the expectation that insights from action will help to refine how we think about the problem and potential solutions.32 As part of this process, the constructionist phase is a time to consolidate and summarize new information, lessons learned, insights, reflections, and plans and marry them with one’s own beliefs, ethics, values, knowledge, identity and skills. This phase also aims to promote political efficacy, or an increased confidence and motivation to act to pursue health equity.32 Feeling capable of action and that the action will be meaningful and impactful are essential precursors to action, but these also require hope and optimism.45 Hope and optimism are hard to create but often harder to sustain.45

For people to be motivated to get involved – and remain involved – in efforts to create change and help to mobilize others, often they must first feel the motivation to respond.46 Often that comes from the desire to “become free not simply from something, but for something” (italics in original).47,p166 Spirituality has been a fundamental source of motivation for the Civil Rights Movement and other efforts to create change that would lead to health equity. While not a necessary component of sociopolitical development, spirituality has been the foundation of hope and optimism and a tool to inoculate or at least temper discouragement, disillusionment and pessimism.22 In other work, spirituality was the foundation of men’s efforts to redefine notions of manhood for themselves and how they sought to have an impact on the world.48

Conclusion

As Derrick Bell wrote, “If we are to seek new goals for our struggles, we must first reassess the worth of the racial assumptions on which, without careful thought, we have presumed too much and relied on too long.”49,p14 One of the fundamental challenges of anti-racism organizing to achieve health equity is to increase individual and collective capacity to look at the world as if it could be otherwise.50 Because the problem of pursing health equity not simply one of science but of translating science into narratives, beliefs, practices and policies, we have to recognize that efforts to make a moral or social justice case for eliminating health disparities and achieving health equity have been largely ineffective.44 While the arts alone do not address the need for leadership or community organizing, the arts may help individuals and groups think more critically, connect more closely, and become and remain more confident in their ability to achieve health equity.

Anti-racism presumes, accepts and embraces different views as essential ingredients to facilitate new ways of thinking.51 The arts represent one of the few areas in our society where people can come together to share an experience even if they see the world in radically different ways.51 There is no strategy known to these authors to effectively engage and change those who are not at least open to new ideas and principles, and that art does not solve that problem. However, for those who are at least open to considering new ideas, concepts and strategies to achieve health equity, art may provide critical stimuli to facilitate critical reflection, unlearning, relearning and perhaps most important, connecting.

People who become activists or committed to key issues like health equity often do so around “gut issues,” or those that touch them personally in some way.46 Beyond making a career studying it, becoming involved in efforts to pursue health equity often involves people weighing potential consequences of their behavior, connecting their choices to their moral values, and considering their thoughts and feelings as well as the impact of their efforts on their social relationships, careers, safety and legacy.

One of the other advantages of art is that it can be experienced personally and privately, in a space where people may feel most safe, comfortable and open. The rise of streaming services and other digital platforms, the ubiquity of portable devices and the ability for people to take in what can be difficult information or face difficult strategic decisions of how to intervene can give people time to process and sit with information. This can be particularly important for some who need time and space to reflect or grapple with information and how it aligns with or challenges their deepest values and beliefs. Contact with art can be a space where people can be challenged in ways that make information that they have heard in other formats finally resonate with and galvanize them to see a world that is better than the one in which we live.52