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Reparations as a Public Health Priority — A Strategy for Ending Black–White Health Disparities

There has not been a single year since the founding of the United States when Black people in this country have not been sicker and died younger than White people. A growing consensus highlights a structural basis for these preventable disparities — structural racism — clarifying the need for a structural solution. Black reparations are one such solution and, we believe, a long-overdue approach to persistent Black–White health disparities in the United States.

Though the racial gap in life expectancy has narrowed, Black Americans continue to die 4 years earlier, on average, than White Americans. The divides on other U.S. mortality measures are starker: Black mothers are three times as likely as White mothers to die from pregnancy-related causes1; Black infants are more than twice as likely as White infants to die in their first year, according to the Centers for Disease Control and Prevention (CDC); and the rate of premature death (before 75 years of age) is 30% higher among Black Americans than among White Americans.

These racial inequities have been the focus of attention from the medical and public health communities in recent years. The National Institute for Minority Health and Health Disparities, for example, began as a program within the National Institutes of Health (NIH) Office of the Director in 1990, and through a succession of legislative iterations become an Institute of the NIH in 2010. Its mission, in part, is “to reduce and encourage elimination of health disparities.” The CDC has, since 2011, issued Health Disparities and Inequalities Reports and Strategies for Reducing Health Disparities, highlighting public health approaches. Private foundations such as the Robert Wood Johnson Foundation have adopted health disparities reduction as a core goal, and a generation of scholars has worked assiduously on this challenge for several decades.

An important advance is that addressing Black–White health gaps is no longer at the margins of academic or health concerns. But though this attention has brought some tangible gains, progress has been strikingly limited. Despite improvements, life expectancy remains stubbornly tied to whether a person is born Black or White. Black–White health gaps continue to characterize American health and, at the current pace of effort and investment, will continue to do so for decades to come.

Perhaps the most important insight into why these gaps persist comes from work that focuses our thinking about fundamental causes of health.2 This work shows that forces that shape our societal structures — including power, money, and access to resources — inevitably become embodied in health and will continue to shape health patterns unless they are addressed. This understanding clarifies that the Black–White health gap is inseparable from the enormous gap in resources between Blacks and Whites in the United States. Black Americans earn 65 cents for every dollar earned by White Americans. Even more dramatically, the average Black family has about $10 in assets for every $100 accrued by the average White family. In 2015, for example, the Federal Reserve Bank of Boston found a truly staggering racial gap in wealth in Boston: household assets averaged $8 for Black families and about $247,500 for White families. And power, money, and access to resources — good housing, better education, fair wages, safe work places, clean air, drinkable water, and healthier food — translate into good health.

The radical implication of this link is that what really needs fixing is access to resources. We suggest that one means for fixing it is Black reparations for slavery. Reparations would target the underlying causes of Black–White health gaps. Efforts to provide better health care, to provide more medicine, and to tackle the greater disease burden in a population that lacks access to essential resources for health are bound to fall short — they may be necessary, but they will never be sufficient. If the medical and public health communities understood both this inadequacy and the central role that Black reparations could play in narrowing health gaps, they might feel compelled to engage with the question of Black reparations.

We believe that there are three pathways through which reparations could reduce health disparities. First, they would go some way toward expanding the extremely limited resources available to many Black Americans. Insofar as the relationship between resources and health is inarguable, there is no way to close a health gap without also addressing a resource gap. In the short term, reparations would give many Black Americans the means to obtain health-producing resources such as better neighborhoods, better schools, and access to cleaner air.

Second, reparations would help reduce the stress felt by many Black Americans, which is undoubtedly associated with poor health. Psychological strain has been clearly linked to poor health,3 and reparation funds that alleviated some of this strain could help improve the health of Black Americans.

Third, we would expect the ultimate effect of Black reparations to be intergenerational. Health is produced over the life course and across generations, and any effort in the present to level the wealth playing field could reset the potential wealth and assets — and consequent health — of future generations. Thus, any reparations provided today would be an investment in the future and in reducing disparities that have been intractable for generations.

A growing literature makes the moral, historical, legal, and economic arguments for Black reparations.4 However, such advocacy has rarely considered the health advantage that reparations would offer.5 Black reparations could be implemented in various ways, ranging from cash transfers to the creation of investment vehicles, and we need research to elucidate the most effective forms. It seems likely that no single approach will be sufficient to counterbalance the centuries-long deprivation that continues to harm the health of Black Americans today. But at the core, reparations would be an acknowledgment of the harms of slavery, a restitution of resources that have long been denied to people affected by slavery over generations, and would bring some closure to profound injustices that the country has long shamefully neglected.

Black reparations have been highly controversial, a proposition generally seen as politically untenable. Though supported by most Black Americans, reparations are opposed by a majority of Americans overall. Yet the tide is turning. Democratic presidential candidates discussed — and several supported — reparations during the 2019 primary debates. In 2019, Congress held its first hearings on a reparations bill in more than a decade. Then the murder of George Floyd unleashed unprecedented global rejection of the human cost of the U.S. racial hierarchy. These developments create an extraordinary opportunity to clarify that a fundamental driver of Black–White health gaps is a difference in resources that is structural in origin, owing to many obstacles to Black advancement. We cannot ameliorate long-standing Black–White health inequities without addressing the structural forces that pattern them.

Black reparations would not solve racism — structural racism permeates all we do and bars Black Americans from equitable access to housing, occupational opportunities, and safe neighborhoods, to name but a few determinants of health. But reparations would represent a monumental break with the past.

At the 1963 March on Washington, Martin Luther King, Jr., proclaimed that “In a sense we’ve come to our nation’s capital to cash a check.” He explained: “America has given the Negro people a bad check, a check which has come back marked ‘insufficient funds.’” From this, his famous “I Have a Dream” speech, we remember King’s words about the content of our characters. But his remarks on the obligation to repair has often been overlooked. It is left to those of us in medicine and public health to argue that now is the time to act, because equity is not simply about repair in cash or in kind. Addressing the Black–White wealth gap through reparations is about saving lives. By bringing attention to the health benefits of addressing this gap, we can help shift a national conversation about reparations that often becomes mired in blame and accusation to one that centers the critical importance of health.

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