Navigating the Storm: How to Apply Intersectionality to Public Health in Times of Crisis

“We are in the same storm, but not in the same boat.”

—Author unknown

The United States is facing a deadly confluence of health, economic, and racial crises. As of this writing, COVID-19 cases are approaching 9 million and more than 225 000 American lives have been lost to this disease. As a result of efforts to curb the spread of coronavirus through stay-at-home orders and business closures, more than 40 million Americans have lost their jobs. In the wake of increasingly visible extrajudicial killing of Black Americans at the hands of law enforcement—notably the death of George Floyd after a police officer knelt on his neck for nearly nine minutes on May 25, 2020—mass protests have erupted in more than 2000 cities across the country. Many of these protests have been met with a militarized response, including tear gas and rubber bullets, injuring protestors, reporters, and bystanders.

In the face of such crises, what does an intersectionality framework offer public health researchers and practitioners committed to creating and maintaining conditions in which all people can be healthy? Originally articulated by Black feminists and coined by Kimberlé Crenshaw,¹ intersectionality provides a critical framework for understanding interlocking systems of oppression. Intersectionality explicates how mutually constituted positions in racial, gender, sexual orientation, ability, and other social hierarchies interact with legal, political, economic, and other structures of power in ways that generate interdependent forms of privilege and disadvantage.² Incorporating an intersectional framework into public health provides essential context for the aforementioned crises and makes clear the link between the systemic conditions driving social unrest and the inequitable distribution of COVID-19 physical and financial harms. Without an intersectional approach, public health researchers often simply disaggregate outcomes by multiple identities, such as gender and race, to highlight differences between groups (i.e., disparities), and they fail to make explicit the unjust social–structural context at the root of these differences (i.e., inequities).

For example, Preventive Medicine published a survey of women in the general population of four US cities, documenting that Latina and Black women had eight and four times the odds, respectively, of experiencing physical police violence than White women had.³ Although documenting the excess exposure to police violence that Latina and Black women experience is important, the article never addressed the legacy of structural racism and sexism in the United States that could explain the differences they identified. Moreover, the authors called for “community centered solutions to police violence that strengthen police–citizen relations.”^3(p155) The proposed solution does not consider the historical role of slave patrols,⁴ present-day immigration enforcement activities of police, or the obvious power differentials between these women and armed agents of the state who act with qualified immunity. In short, simply describing disparities based on gender and race falls short of the tenets of intersectionality by failing to identify the power structures at the root of health inequities.

By contrast, many policy think tanks and community-based organizations have presented clear and sophisticated intersectional analyses of the economic, psychosocial, and physical toll of the COVID-19 pandemic on multiply marginalized communities. For example, the Center for Public Integrity published a recent report that describes the impact of COVID-19 on Latina women. They explained how their vulnerability is created by institutional barriers (e.g., xenophobia, racism, nativism, sexism), which limit many Latinas to the lowest paid service jobs that require close contact with people; provide little, if any, access to health insurance; and are most likely to be eliminated during economic downturns.⁵

At minimum, public health surveillance data should be able to demonstrate the disparate health outcomes linked to social inequities. However, state public health agencies have been slow to collect COVID-19 data on race and ethnicity. As of August 17, 2020, three states still did not report COVID-19 deaths by race, two states did not report confirmed cases by race, and only six states report testing data by race.⁶ Although the Centers for Disease Control and Prevention’s COVID-19 Web site presents the number of cases and deaths disaggregated by race and ethnicity as well as by sex, they do not present these data disaggregated by both race and sex, rendering basic information on the prevalence of COVID-19 cases and deaths among Latina and Black women invisible. Similarly, data on gender identity and sexual orientation are unavailable. Without these data, it is impossible to identify the inequities wrought by unjust systems of power.

Although the collection and reporting of disaggregated data to document inequities is a central role of public health, it is insufficient for an intersectional analysis. We must also conceptualize, document, and explicitly articulate why identified disparities exist. Failure to do so implies that the source of health inequities lies within the specific individuals or groups who bear their burden and suggests that poor health is an innate quality of certain groups rather than created and maintained by systemic oppression. This limited understanding of health inequities leads to the development of interventions that target so-called risk groups for behavior change, leaving untouched the power structures that increase risk for some and provide protection for others. A true intersectionality lens demands that we both understand health inequities associated with intersecting social positions and, most importantly, engage with the historical and present-day contexts of power at the root of these inequities.

We must be crystal clear that the social categories we assess are not simply demographics. Rather, they represent interdependent and differential access to power and privilege. Therefore, our data collection systems, research questions, analytic approaches, data interpretation, and intervention designs should lend themselves to addressing intersecting systems of oppression. As eloquently stated by Lokot and Avakyan:

An intersectional analysis places power at the center, analyzing not what makes people vulnerable but . . . conceptualizing how power hierarchies and systemic inequalities shape their life experiences.^7(p3)

As we look at the current storm from the vantage point of our vastly different boats, our ability to identify and mitigate this tempest will depend on our willingness to confront its source and use intersectional public health responses to drive lasting change. To do so, public health must consistently collect data that allow the identification of health inequities across multiple axes of oppression, conduct intersectional analyses that situate these inequities within the historical and current multidimensional power structures that shape them, and be led by the people most affected by intersecting oppressions in the development of interventions to address them.