All Things Equal

Don Operario, PhD, Grace Crum Rollins Professor and Chair of Behavioral, Social, and Health Education Sciences, places much of his focus on the synergistic epidemics of HIV, substance abuse disorders, and mental health within LGBTQ+ populations.

“The issue of health equity arises just by the definition and the framing of these issues. While they are present across the board, they are disproportionately concentrated in minoritized communities. So, to improve equity, we need to be even more assertively focused on targeting resources, attention, and our science toward understanding what the factors are that create and cause these issues to be so highly and disproportionately concentrated in these unique minoritized communities.”

A slew of proposed and passed legislation that impacts transgender people has already had significant influence on public health, according to Operario. Promises to revoke current policies that protect gender-affirming care presents additional wide-ranging health concerns. When she was California’s attorney general, Vice President Kamala Harris opposed Proposition 8—an amendment to ban same-sex marriages—and as a senator, she backed the federal Equality Act, which bans discrimination against those identifying as LGBTQ+ in employment, housing, and other situations. As governor, Tim Walz has signed bills banning conversion therapy and protecting gender-affirming care. 

Research has shown that trans youth and gender diverse adolescents are more likely to attempt suicide than cis-gender peers. There is evidence to support the idea that just knowing legislation that could impact the transgender community is being considered—even if it has not been passed in a state where one lives—can have negative mental health impacts.

“This is going to damage the health of trans people, especially youth, but also family members of people who are trans or who don't locate themselves within the gender binary,” says Operario. “What's already happening, I think in spaces where restrictions on trans health are being rolled out, is migration of individuals to places where there is more access to trans-inclusive health. That migration comes at great costs. It's separating people, especially young people from their families and from their communities of support and communities of care. It's leading them to enter into new, often urban spaces that don't necessarily have immediate places for these people, especially young people, to work, to live, to grow healthy supportive networks.”

Some in the research community have referred to this forced relocation for medical care as the “trans tax,” which refers to the costs and uncertainties trans people often go through in order to access gender-affirming care. These costs can include housing and job instability, safety concerns, discrimination, and affordability of medical care in their new living environment.

One of the realities of modern American life is that there is disproportionate minority confinement with rates highest among Black men.

“The first impact of the epidemic of mass incarceration on the election is that many potential voters are taken out simply by the fact that they have had involvement in the criminal legal system,” says Anne C. Spaulding, MD, associate professor of epidemiology. “So there's disenfranchisement of multiple potential voters. One of the issues with incarceration is that it hides people and keeps them out of sight.”

Harris has positioned herself both as “smart on crime” and as a “progressive prosecutor” through her two memoirs as her career trajectory shifted from prosecutor to presidential candidate. While her stance on the criminal legal system had not been released at time of this article’s printing, in her time as a former prosecutor, she put those committing serious crimes behind bars and helped remediate nonviolent offenders. She has both supported police and called for police reform.

Pledges by the Trump campaign to take more people off the streets and to funnel more illegal immigrants and drug offenders into prisons also amplifies existing community health problems and health disparities.

“Those who are incarcerated tend to have an overabundance of infectious diseases,” says Spaulding. “This is both because of the fact that people with less access to health care may be those who are disproportionately confined, but also that active incarceration promotes transmission of infectious diseases.” Spaulding’s research team saw this particularly pronounced through wastewater surveillance during the COVID-19 pandemic, and have also seen evidence of it with mpox.

Other infectious diseases that can be of particular concern in confinement settings include tuberculosis, HIV, and flu. Spaulding has long been a proponent for opt-out HIV testing in jails as an effective way to help people know their status and start receiving treatment, which not only has an individual benefit but a community-wide one as well (since those housed in jails are eventually released back into the community).

Those with severe mental illness or uncontrolled mental illness are also largely represented in jails and prisons. In areas where there are insufficient resources in the community for those without insurance to access mental health care, many conditions go untreated, and individuals may be more likely to self-medicate with substances and be picked up by law enforcement.

“I think jail and prison health is a good measure of how much society cares for members of its community,” says Spaulding. “We are talking about those people who live at the margins without power, money, or political pull. It has been said, ‘If you want to judge a society, you look at how it treats those who are incarcerated.’ Jail and prison health needs to be an issue across political parties. It's in our self-interest and in the interest of the well-being of friends and family that we watch how we treat those who are incarcerated.”

Like many GOP candidates before him, Trump has repeatedly emphasized his desire to dismantle the U.S. Department of Education and place the matter of education within the states. While the likelihood of this occurring is small, the public health implications of disrupting the educational infrastructure could be substantial to American youth, especially those in lower-income or racially marginalized groups. It could also impact the country’s jails and prisons.

Chandra L. Ford, PhD, professor of behavioral, social, and health education sciences, notes that reductions to education support, if they were to go into place, could further compound the school-to-prison pipeline.

“As we disinvest in education, there's a corresponding increase in investments in the prison industrial complex, which moves students who are now considered ‘bad’ kids into the school-to-prison pipeline,” says Ford.

Homelessness has reached its highest level since 2007 and experienced a 12% increase between 2022 and 2023, due to several factors, the most significant of which is unaffordable housing. According to the U.S. Department of Housing and Urban Development’s 2023 Annual Homelessness Assessment Report to Congress, in 2023, 20 out of 10,000 people in the United States were homeless, or approximately 653,100 people. More than a quarter of people experiencing homelessness were over age 54, and 20% were between the ages of 55 to 64.  Half of all people experiencing homelessness were white, 37% were Black, and 28% identified as Hispanic or Latinx. Asian Americans faced the largest percent increase for a racial group experiencing homelessness with a 64% increase.

Health concerns related to exposure, disease spread, violence, rape, mental illness, sanitation, malnutrition, and hunger are all issues affecting this population, which can have community impacts as well.

In response to HUD’s report, the Biden-Harris administration announced the ALL INside initiative which aims to reduce unsheltered homelessness by 25% by 2025. The plan focuses on six areas with the largest homeless populations: the state of California, Chicago, Dallas, Los Angeles, metro Phoenix, and Seattle and includes collaborations among 19 federal agencies who are partnering to address homelessness through “housing and support, crisis response, and prevention.” In February 2024 the U.S. Department of Health and Human Services and Department of Housing and Urban Development announced the Housing and Services Partnership Accelerator to provide federal technical assistance to eight states working to address homelessness over a 12-month period.

Both Harris and Trump have promoted affordable housing as part of their economic platforms, with Harris citing a $25,000 subsidy for first-time home buyers and Trump vowing to reduce mortgage rates, offer tax incentives to promote home ownership, and cut regulations that contribute to increased housing costs.

Trump’s campaign has promised to remove people experiencing homelessness from public parks and city streets and then offer people the choice to either relocate to tent cities he plans on establishing (with doctors, psychiatrists, social workers, and drug rehabilitation specialists) or face arrest. He has also repeatedly mentioned his proposal to re-introduce mental institutions for those who suffer from severe mental illness and are living on America’s streets.

In late June 2024, in City of Grants Pass v. Johnson, the U.S. Supreme Court overturned a 2021 decision that said cities could not fine or arrest people for sleeping outside if there was nowhere else to go. This recent action sets the precedent for cities to pursue legislation making it illegal for people to sleep outside in public spaces.

There have been a substantial number of states and school districts that have passed measures that outlaw the teaching of critical race theory in classrooms, an intellectual movement that uses a set of analysis tools for explaining and understanding what institutional mechanisms are reinforcing inequities.

This is something that Ford, a critical race scholar, finds particularly damaging not only to future public health practitioners seeking a strong educational background, but to the integrity of public health research and the general public it is intended to serve.

“If researchers are not able to use critical race theory—to draw on the concepts, apply the methods, or invoke the term—it would force them to conduct their work using faulty approaches and present their findings in ways that obscure or distort the truth. It means that we will have to pretend that certain dynamics are not at play when, in fact, they are at play.”

She adds, “Critical race theorists have argued we're in a late stage of racial capitalism where the stakes feel high, and many folks feel squeezed out of the power structure. Despite unprecedented access to all kinds of potentially life-changing technology, the forms of racial capitalism, imperialism, and settler colonialism that are taking shape in the early 21st century have the potential to exacerbate disparities.”

The role of community health workers in providing early education, detection, and linkages to early services before they escalate is just as important as affordable and timely health care for those who are already sick and affordable and timely medications for those who need treatment.

“The whole continuum of preventative services is often not considered when we think of health policy,” says Operario. “I'd love for a new administration to be as mindful of preventive care and community public health as they are of investing in health care and the health services infrastructure.”

Rachel Waford, PhD, assistant professor of global health and licensed clinical psychologist, also sees community investment as a strong opportunity for politicians to improve health equity across a range of health indicators, including mental health.

 “It’s looking holistically at what the things people need to be healthy. We often think of health as medication and therapy, but we forget it takes many ingredients to be well. We can have the best clinic that we can possibly design. But if it's in the middle of a food desert, or if it is hard to get to, or if there's safety issues, then that amazing health care can really only go so far.”

Waford and Operario both point to the need for thoughtful urban planning that supports healthier food purchase spaces, safe walking areas, green spaces and trees, as well as interventions that can be embedded into the school curriculum (including mental health services).

Joanne A. McGriff, MD, assistant dean of diversity, equity, and inclusion, also notes that community health could be improved by greater investment in the public health workforce. Expensive housing, education costs, and low pay for public health workers have contributed to the shrinking public health workforce.

“Public health is consistently underfunded,” she says. “The public health education pipeline is something as an educator I’m concerned about and that is connected to resources. The low incomes for public health workers is a problem that impedes us from being able to send good people out to do the work they want to do in the communities that need it the most.”

She adds that health equity is not just an issue for a single race or socioeconomic group. It affects every American. “It isn’t just about one group of people over there. This is an issue of distribution that will at some point impact you as well. You are not separate from your neighbor.”

Story by Kelly Jordan
Designed by Linda Dobson
Illustration by John Jay Cabuay