Social Justice in Healthcare - View from the Deep-South, USA


Published: 10 October 2018

This short podcast about social justice reflects a session that was presented at the 2018 International Rural Nursing Conference held in Nashville, Tennessee USA.

Dr Pamela Payne Foster from the University of Alabama initially defines social justice and then proceeds to talk about health disparities that affect various racial-ethnic groups.

Dr Foster particularly focuses on the work she has conducted in relation to HIV AIDs. She describes how she engaged religious communities to embrace this condition as a social justice issue rather than a stigmatised disease, which resulted in greater community acceptance and treatment for this underserved population.

TedX Tuscaloosa Talk given April 11, 2015

Audio Transcript

Hello, this is Dr Pamela Payne Foster, and I am doing a follow-up podcast from a presentation I did recently in Nashville Tennessee at the International Rural Nurses Association meeting.

I am currently a professor starting 8/16/18 at the University of Alabama School of Medicine, Tuscaloosa campus. I’m also Deputy Director of the Institute of Rural Health Research here at the campus.

So, my work has mainly been working in some of the rural African American communities here in Alabama. My father is a native of rural Alabama, most of you have heard of a town called Selma. Selma Alabama is his birthplace, so I have just been proud to work in communities like Selma and others in the rural south - Alabama.

So, what I'm going to do is just give some highlights of some of what I talked about, really to help spur the conversation around these issues. One thing I did was I started out with some definitions to really bring us into the mindset of how we can really frame social justice in our work with health disparities.

So, many of us know the definition of health disparities as comparing two populations and looking at the differences in their health outcomes, usually in the context here in the United States we look at racial-ethnic groups like African Americans or Latinas and we compare them to the standard, larger group like the Caucasian here in the United States.

Now, that's not always the case. For example, usually the minority groups have poorer health outcomes than the Caucasian majority group but in a place like South Africa, where native Africans might be the larger population, they might have worse health outcomes.

So, that's our definition with health disparities - really comparing the health outcomes with two different populations on something like race or ethnicity. That's what I call sort of a two-dimensional definition, and I'd like to shift now to what I call a three-dimensional definition, which gives us a little bit more information about the differences between different groups, and this is what we call health inequities.

So, more of a three-dimensional definition because it really incorporates the differences we see between the two groups but really trying to understand what is the root cause or what are the underlying causes that cause the differences between the two groups.

Certainly, the underlying causes like generational poverty or history, certainly when I look at some differences between blacks and whites here in the US I always have to go back to the history of the transatlantic slave trade and slavery in these places. Even though it happened 200 years ago, it still has repercussions down the line generationally.

Same thing for colonisation even in a country like Australia where you have natives there. Why is their health outcome different, perhaps to those colonisers who came? Of course, that history of colonisation brings with it oppression, which leads to poverty... so all of these things are issues and really what we talk about with these health equalities is social issues.

So, it makes it very difficult for those of us who are trained as physicians or healthcare providers like nurses, Nurse Practitioners. We are trained to really look at the sciences of the body and deal with a given diagnosis by giving treatment, yet sometimes we miss that underlying cause of disease or poor health outcomes that we see. So that's really the premise of the work I've been doing to try to get a little deeper into why we have to begin as healthcare providers to think in a different way.

Now, I'll give one example that I use in my own research, but also let me just go, now, to talk about how we can overcome some of these barriers.

One is with training. As I said, most of us are not comfortable dealing with social health issues because of our training: we haven't been trained that way, of course. We have colleagues who have been trained that way - there are people who have been trained in medical anthropology, social workers, there are other disciplines, psychology, other social sciences we really should begin to partner with in order to solve some of these health inequality issues. So, that's one way.

Or, as a clinician we can go back and get another degree. I worked in the area of bioethics before - my last boss when I worked at the National Centre for Bioethics at Tuskegee University, most of you have heard of the Tuskegee syphilis studies, they have a national bioethics centre there that focus on underserved communities. Minority communities like African Americans, Latinos - but my boss was a retired cardiologist who went back to school to get a PhD degree in philosophy and that's how he got into the area of bioethics.

So, thinking about even combining degrees for training or combining training programs to really get the kind of product we want. It's interesting, I'm a preventive medicine public health physician so I have public health training as a part of my residency training. I got a Master's of Public Health - I think the idea of training around population health rather than patient centred, to really think about people who are trained as population scientists as well as patient scientists, is great.

So that's one way, another way would be partnering with a social scientist, which I think is always a good way to deal with these very complex issues.

So, back to my example of HIV AIDS. I work in this area - I came to it actually because in this country HIV AIDS was mainly found in gay, white males in large metropolitan cities, and over the decades, 30 years later the epidemic is largely African American - both male and female - and not only in large cities but in small rural areas and in small communities and particularly has shifted from the east and west coast of the United States to now the South, the Deep South where I am now in Alabama.

So, the question was, why? And, as I began to look at the issue and look at the data there was a question of whether or not there was more stigma around HIV. So that our prevention efforts were not as much advocacy around HIV, particularly around rural areas, and particularly as I began to do some research with the nursing league, we found that people living with HIV AIDS said that where they felt most stigmatised was the church, and as we know culturally in the South it's very religious in that area of the country and that might actually be a barrier to effectively dealing with HIV AIDS in that part of the country.

So, I began to test an anti-stigma, a faith-based intervention, which was very effective but i used some of the curriculum developed by a civil rights organisation here in the United States, called the NAACP - National Association for the Advancement of Colour People - old civil rights organisation, they've retained the name - but what they began to do was say, ok we know HIV AIDS is a public health issue but in order for the church to embrace it maybe we need to think about a social justice issue.

And this was very attractive to black churches. We know historically particularly in the 50s and 60s at this time the black church was really paramount, it was really a leader in dealing with the civil rights movement. Of course, we know with Dr Martin Luther King was steeped in the church as a pastor and was president of the Southern leadership conference and so we know the church was really involved in that way, we frame this issue as a social justice issue and what we did was to really talk about the numbers being so disparate compared to the white population that we could compare to other social justice issues. So, for example, they looked at the black male population being 11% and the HIV diagnosis at 42% very disparate. Same thing for women - we make 12% of the female US population, but 64% of female HIV diagnosis, and really the one statistic they used to really bring this home was if black America were its own country, it would rank 16th in the world in the number of people with HIV, which is very very graphic.

What they did was compare HIV to other social justice issues, like the rate of new AIDS diagnosis, 75.6 per 100,000 black males compared to 9.1 per 100,000 white males.

Compare that to statistics like those living without healthcare coverage: 17% of blacks compared to 11% of whites, 36% of blacks in poverty compared to 14% of whites, and highschool male graduation rates only 47% from black males and 78% for white males.

But, the statistic for HIV is so much worse than those social justic issues but the one that really ranks in commanility with it is incarceration rates - which we know incarceration rates are extremely high in the United States compared to other Westernised or comparable countries, but the incarceration rate for 18 year olds or older is 1 in 15 in black men, which is extremely high, and they compared that to the HIV diagnosis rate over a lifetime 1 in 16 for black men will be diagnosed with HIV in his lifetime.

So that's startling. And they said that the church is really the right place for action for the church to be involved. There are 21,000 black churches in the US, quite a bit, and most African Americans in the US say religion is very important in our lives, in a poll 79% say that it's very important in their lives. And if we look at the fact there are 39 million blacks living in the US, 53% of them say they attend church regularly, that's a lot of people who have the power to end HIV AIDS, 20 million.

So im gonna end now with a quote that really brings home why we need to begin to look at we as healthcare providers being involved in social justice issues - and there are many, at the conference i talked about some that i think we probably need to be more involved in here in the US is gun control gun violence issues, we have a great opioid abuse problem right now, in the United States, which is another issue, incarceration as well as police brutality issues in the United States - many have heard of the Black Lives Matter movement, I think we have to be involved as well.

But I'll end on this quote from the Reverend Dr Martin Luther King Junior. He said during that time:

'We are now faced with the fact that tomorrow is today. We are confronted with the fierce urgency of now. In this unfolding conundrum of life and history, there is such a thing as being too late.'

So, i thank you very much for your attention, and I look forward to hearing from some of you.

Dr Pamela Payne Foster can be contacted at:

Community Medicine and Population Health; The Institute for Rural Health Research 
The University of Alabama


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Pamela Payne Foster View profile
Dr. Pamela Payne Foster is a Preventive Medicine/Public Health Physician who is a Professor in the Department of Community and Rural Medicine and Deputy Director (as of 08/16/18), Institute for Rural Health Research, at The University of Alabama, Tuscaloosa Regional Campus. Dr. Payne Foster received a bachelor’s degree in Chemistry Pre-Medicine from Xavier University of Louisiana and a master’s degree in Biomedical Sciences and the Doctor of Medicine degree from Meharry Medical College in Nashville, Tennessee. She also completed her Internal Medicine internship and Preventive Medicine/Public Health residency from the State University of Stony Brook where she also received her MPH from Columbia School of Public Health. Before coming to the University of Alabama, she has served on the faculty of a variety of institutions including Morehouse School of Medicine, George Washington University, SUNY Stony Brook, and the National Bioethics Center for Health Care and Research at Tuskegee University. In addition to her broad training experiences in population and public health and bioethics and preventive medicine, her research interests include health disparities with a specific interest in HIV/AIDS related stigma in rural faith based settings in the Deep South. She has been involved in medical education through a variety of roles: as former Co-Clerkship Director for the Community Rural Medicine Clerkship, as a former Learning Community Leader, as a faculty member in the Community Rural Medicine Ambulatory Acting Internship, as a frequent Special Topics and Co-Enrolled Elective Instructor. Her main teaching areas of interest have been health disparities, bioethics and medical ethics, and diversity and cultural competency issues in health care. For example, she teaches a Special Topics course entitled: Cultural Competency in Health Care and she recently taught a special co-learning course entitled: Health Cultural Competency in Latinos. Dr. Foster also serves on a variety of committees both within her college and across the University of Alabama campus including: Former Chair of the Medical School’s 50th Anniversary of the Integration of the University of Alabama, committee member of the Medical School’s Diversity Committee, Former University of Alabama Faculty Senator and Co-Chair of the Faculty Life Committee, and Past President of the Black Faculty and Staff Association (2016-18).