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EDITOR’S NOTE: Today’s feature story is an edited version of a keynote address Dr. Flojaune G. Cofer gave at Next City’s Vanguard Conference in Sacramento, California, on Tuesday, October 1, 2019.
First, let’s talk a little bit about backstory. I think storytelling is a really important part of why we do this. Now I’m a big nerd, so there will be pop-culture references sprinkled throughout. For those of you who have seen Star Wars, this will have some Easter eggs for you. Maybe some ways that you’ve never thought about Anakin [Skywalker]’s life. For those of you who have never seen Star Wars … first of all, what’s wrong with your life? Second of all, your homework is to watch it. I recommend starting with episodes four and five; skip one, it’s just trash and does nothing for the story. Then watch two, three, and then go back and watch six.
All you need to know if you haven’t seen Star Wars is that there’s a kid named Anakin Skywalker who grows up to be the primary villain, named Darth Vader, in the first three movies that came out. And if you know that, you’ll be able to follow right along. So let’s think about Anakin’s conception. He is born a slave, and there is no mention whatsoever of his father. We can kind of imagine what the ties might be since he is born a slave. In his childhood, he remains a slave, and then he is taken from his mother to be trained as a Jedi at about age 10. As a result, he experiences abandonment, heightened arousal and a significant fear of loss. That’s important because sometimes when we’re intervening to try and protect someone, there still is separation, there is still that trauma that exists when somebody enters foster care because their [birth] parents can’t take care of them, or whatever the case may be.
Up to this point, Anakin’s life has mostly been risk factors. But because of that separation, he actually does develop a trusted adult relationship with Obi-Wan Kenobi and gets a Jedi education, which we know is associated with better outcomes in the future than he would have had remaining in slavery. And unless you’ve attended the Kanye School of Hard Knocks, I hope I don’t have to explain to you that freedom from slavery is a good thing, and it’s definitely not a choice.
But, at the same time, in his adolescence, he is exposed to violence via the Clone Wars and he remains separated from his family. So that’s an ongoing trigger for him. And his adulthood looks a lot like what we might expect for somebody who has more risk factors and protective factors. He has an unplanned twin pregnancy (spoiler alert: it’s Luke and Leia), he lacks trust, he has corrupting influences in Sith Lord Darth Sidious, he has domestic violence in his marriage to Padme, he’s severely burned, the Death Star explodes, there’s ongoing war around him, and he prematurely dies.
And that is not often how we think about Darth Vader’s life. What I find most interesting about how the story is told is that we meet him in episode four of his life and so we spend the better part of 30 years wondering, how did this guy get to be so bad? And what was his early life like? Finally, we get to go back and hear the story. And that’s often what happens to us in real life. You meet people in episode 4 of their lives and you have no context for their own backstory, and we just say, “What is wrong with this person?” Instead, we need to be curious and find out what their story is.
But the part of Darth Vader’s story that is interesting to me is that he prematurely dies. Now I know there are some nerds out there who want to call B.S. on my fandom, who are saying, “That guy didn’t look so sick; he looked like he lived a long life.” But if you go by the text that scrolled by at the beginning of each film … that guy is only supposed to be 45. So I just want to let you know that if I look like that at 45, check on me. Because I’m not OK.
Dr. Flojaune G. Cofer, Ph.D., MPH
The truth is that this even bears out in science. That if we experience significant stressors throughout our lives, our telomeres are shortened every time we go through cell replication and we actually age faster than our biological age. I don’t think George Lucas intended this, but I’m using it for my example because it works. He experienced premature aging because of all the things that happened in his life. And so when we think about inequities and health equity, in particular, is what’s happening in people’s lives and in the lives of the people before them that has led us to this place. So health equity essentially is what we think about when we see differences in outcomes. These outcomes result from injustices. It is our responsibility to address what has happened that makes people like Darth Vader only live to be 45 instead of the long lives they should have had in front of them.
People like Darth Vader are tempted by the dark side instead of being able to stay in the light. There’s a concept called Life Force Theory that talks about how there’s a very narrow path to success — but many, many opportunities for you to fall off that path and not be able to live a life with prosperity and well-being. If we believe health is a human right, if we think health is something that we all deserve, then that path cannot be narrow. It has to be wide.
So part of what I want to talk about is how to spot the pattern. And when we start talking about health inequities, it reflects injustice. Not genetics. Not choice. Injustice. And that’s important for us to keep in mind because if we don’t tell the full story of how some of the patterns emerged that we see now if you only take a snapshot, we will come to faulty conclusions. And then the way in which we address the issues doesn’t get to root causes and the heart of why this happened in the first place.
I’m going to talk a little bit about the history of race, but I want to make sure that we remember that this is not to be experienced the same for everybody within a racial category, but depending on your ability, your associated amount of status, your gender identity and sexual orientation that you may be experiencing this differently. And so I want to keep that in the back of our mind. What happens to the even more vulnerable people within a community. Before we go any further, for those of you who love to argue with people on the internet, and I know you’re out there. One of the things that I see often happens is that somebody will say something is racist. And then people who argue about what racism is, but nobody ever shows up with some definitions.
We need to think about what racism actually is in order to combat it. And so there are just several types of racism. And the first is personally mediated racism. I sometimes call it Disney racism, because it’s the type of racism that even the three-year-old can point out because it’s very easy to see when people are being treated differently because of who they are.
But then there’s internalized racism and that’s when we begin to believe the negative things that have been said about people like us. And so the fact that you can get a stress response because of that and you’re internalizing those outward ideas about your identity.
Then there’s cultural racism; that’s where the identities of certain groups are privileged over others. The best example of cultural racism is the fact that depending on how you count, there are only five to 12 countries on the whole planet that were never colonized by Western Europe. So most of the world’s populations see white skin, light hair and light eyes as a beauty norm. Even though most of the world’s population does not look like that. And that’s because when you’re talking about cultural racism, there is a social and economic benefit to looking like people in power. And so because of colonization, that is why we have colorism in the world over.
“If I look like that at 45, check on me. Because I'm not OK.”
But there is a subset of racism, which is anti-blackness. And I always like to shout out Asians for Black Lives, because they really were intentional about doing this work. And some of the things that they did were really critical in entering into the race-conscious space. But it’s deeper than racism, and it’s the fact that privileges are not equitably distributed, both in terms of the way that colorism works, but also the way that proximity to whiteness can work. And so there can be bias against black people even within communities of color. And it’s important that we call that out as a subset of cultural racism.
But lastly, we get to the mother lode. Because the type of racism that I think is most important, and that I’m trying to spend my life’s work addressing, is institutional racism. That’s where we have all these policies and practices in place that don’t require racial animus, that don’t require individual people to not like other people or to not invite them over for your holiday dinners or any of those things. It’s where we have policies and practices in place that will perpetuate themselves until we put a stop to it. And putting a stop to it is not just rescinding the policies, it’s actually putting in place things to address the effect that those policies have had.
So. I’m going to tell you the story of marijuana because I think it’s an important one that’s often not known. So what is currently known as the Drug Enforcement Agency (or DEA) used to be the Federal Bureau of Narcotics and it was run by a man named Harry Anslinger for the first 32 years it was in place. And Harry Anslinger had some really interesting — and by “interesting,” I mean “absolutely terrible” — ideas about human beings. And he was able to, because of his position, actually put those into policy. And one of those ideas was to criminalize marijuana significantly because of the following. (This is a quote):
“There are 100,000 total marijuana smokers in the U.S., and most are Negroes, Hispanics, Filipinos and entertainers. Their Satanic music, jazz and swing result from marijuana usage. This marijuana causes white women to seek sexual relations with Negroes, entertainers and any others… Reefer makes darkies think they’re as good as white men.”
And that, my friends, is a policy platform that has existed for the last 80 years. Thank you for coming to my TED talk.
So what happens while he is head of the bureau is that in 1944 the New York Academy of Medicine came out with a report that said marijuana doesn’t cause violence and doesn’t promote insanity, and doesn’t lead to addiction. He dismissed this. And then in the early 1950s he passed what was called the Boggs Act and the Daniel Act and that created mandatory minimum sentences of two to 10 years for marijuana. And then the Daniel Act multiplied those by up to eight times. So you could get 80 years for possession of marijuana because of these policies. And then we layered additional policies on top of that with the Controlled Substances Act.
Harry Anslinger, commissioner of the Federal Bureau of Narcotics from 1930 to 1962. (Credit: Penn State Special Collections)
Then Nixon gets in office in 1971 and says this is public enemy #1, and that we have to start the War on Drugs. But shortly thereafter, the Shafer Commission says, you know, we think decriminalizing marijuana is a good idea. Nixon said, “No, thank you.” The DEA acknowledged that decriminalization was worth considering during the Carter administration. Carter said, “No, thank you.” And next thing you know, the most urgent problem that we are facing is that all these are political positions we’ve taken based on what we believe about marijuana, and not actually what we know from science or academia. And that resulted, once Reagan was in office in the 1980s, in a series of bills that are passed such as the current Crime Control Act, and the Anti-Drug Abuse Act, and also their amendments. And all of those things came along to just make it much more on criminals to be able to have access to or to sell drugs.
So what was the impact of all this? Well as we know, community trauma. We incarcerated people, we separated families. It compromised people’s immigration status, it compromised their child custody, it compromised employment, it compromised housing, and also access to social services. And what we also saw was that there was a racial component to this. No surprise given the reason that we criminalized drugs in the first place. So in California. What we found is that the differences in rates in terms of those convicted of misdemeanors or felonies is entirely attributable to racial bias in law enforcement. And when I say law enforcement, I mean arrest as well as prosecution. Not somewhat, not a little bit, not 25% attributable. But entirely attributable to racial bias in law enforcement.
Why is that? Because you know, what’s more American than apple pie? Drugs. Universally, across the board, we all like our drugs. And we like them about the same across many of our demographic areas, including race. And so we weren’t looking at this from the perspective of, who was using drugs. But we were looking at this as, how could we criminalize who was using drugs?
So how was it possible to criminalize in this way? Redlining. Redlining was the official practice of the Federal Housing Authority from 1934 to 1968 whereby they drew lines around the map and literally said, this is where black people, or people who were of lower social status were able to live. And that was the practice until 51 years ago. And if the system where you, if a certain number of people showed up in the neighborhood, it could go from an A neighborhood to a B neighborhood, or from a B neighborhood to a C neighborhood, or from a C Neighborhood to a D neighborhood very quickly. Because the Federal Housing Authority was very clear about who they want it to live where, and why. And so we think about our timeline in terms of when Anslinger was over the DEA and how all this played out.
And we see that redlining covers a pretty substantial portion of the start of the war on drugs. So we told people where they could live, and we criminalized behavior that we thought was unique to them. And then we were able to pretty easily go in and search for people in the neighborhoods we relegated them to, to be able to enforce these policies. Right? So you see how policy layers on top of policy. So what’s the legacy of redlining? Well, we did away with this practice 51 years ago, so how are we doing? Not that great. Despite the fact that we focus a lot on gentrification, two-thirds of those redlined areas are still inhabited mostly by Blacks and Latinos and three quarters still struggling economically to this day. And 91% of those “A” areas, those “greenlined” areas remain middle to upper income, and 85% are still mostly white.
(Graphics Courtesy Dr. Flojaune G. Cofer)
Why is that? Well, if you buy in a place where your house is worth more, then as the price of that house goes up, you build equity in the house. And then when you sell it, you’re able to buy another house in a similar neighborhood. And so there was a difference in wealth accumulation even for the people who were able to buy in redlined areas, whereby the time that these policies went away, we didn’t have the ability to be able to buy in other neighborhoods. This is the impact of institutional racism. Because to this day, we have, not many blocks away from here, we have places where these kinds of land deeds are still in place even though they’re not enforceable, but they were when certain people bought their houses.
That is the tale of two cities. Because of redlining we decided we didn’t want to support businesses in certain neighborhoods. And so that created food deserts. What we see is that if you live in certain communities, we know that there’s a link between the local food environment and obesity and diabetes and hypertension because of the food that is available in those communities. And that kind of walk into the red line in terms of what people invested in certain communities. And so we still see those food deserts to this day.
So the impact is what I call expected disproportionality. If you were to tell this story regularly, what would you expect to see? Exactly what we see. Poor, underperforming schools. Why? Because how do we fund the schools in our neighborhoods? Property taxes. The story is not surprising that we do what we do, but if I were to break aliens to this planet, tell them to look around and tell me what’s going on in the U.S. They would come to some pretty terrible conclusions about who works hard and who doesn’t and who’s deserving and who isn’t.
These differences in equity have real life or death consequences. We see differences in life expectancy based on zip code and those differences have everything to do with layers that map on top of one another, what has happened, but what the story is that entire community. So I wonder about that, and think a little bit about Darth Vader’s life and think about all the things that happened to him. He has individual trauma, he has what we call adverse community experiences, things that happen at the community and institutional and societal level that started him out with risk factors. And then there’s also the impact of history, of what has happened in that galaxy far, far away… or maybe what has happened in the one right here, over the last 400 years. And those events have direct ties to what we see in terms of health outcomes. Outcomes that we typically would not think of as being related. You think of them in the short term: What did you eat? How much did you move? We don’t think about it in terms of all of the traumas and triggers and stressors that are independent of that that are layered on top of those additional risk factors at the individual level.
(Graphic Courtesy Dr. Flojaune G. Cofer)
So when we think about equity, what does equity look like? Equity means change. But we don’t just want to change our policies and our laws. We want to change possibilities. So then if we only change the law so that we’ve done away with what’s been done before. We’re getting into a place that’s more restorative in nature, where we’re changing the possibility for the future and also acknowledging the different things have happened in the past that should not have happened and that people are owed, or deserve some sort of restitution for what was taken from them. Part of that is reengineering power structures.
Of course, we can’t overcome our socialization and our history in one conference session. But what we can do is make sure that our best practices are institutionalized so that we avoid reinforcing bias. Because human beings are not so great at this bias thing. And so we need to be saved sometimes from ourselves. That means we have to design these practices intentionally.
The first thing is to take a look in the mirror. When you get on a plane they tell you to secure your own mask before helping others. And we can do this work anywhere we work, with anything we’re doing. Each institution comes with a history and has policies and practices.
So we need to look internally in our own organizations and say, who is leading our organization, and who is underrepresented or entirely absent from leadership? Are they being compensated appropriately? Because sometimes we want to say we’re doing equity work, but we’re not valuing the people.
The big thing is that there has to be space for new ideas. Because sometimes what we want to do is what Mattel did with Barbie, when Barbie wasn’t just white. They took a white Barbie, made her black, and put her on the shelf. And that’s sometimes what we want. We want our diversity to show up in a way that’s packaged. We don’t want people to come in and have different expectations, different norms, different ways of being and different ideas about how we do this work. And we often find ways to push those people out because it “wasn’t a good fit.”
Externally, when we’re doing work outside our organization, are we actually confronting structural barriers, rocking them, tearing them down? Or are we creating more in the way of obstacles for communities that we’re trying to serve? Are we partnering with community members, working with them for pay? Are we actually looking for people who have the right skills or are we looking for people who are like us? And if it’s the latter, that institution reinforces the biases and reinforces the way things have always been.
So coming full circle, the other thing we have to do when you start this work is to actually learn the story, right? Because communities are writing a story. When you start Harry Potter with Book 4, you have no idea what’s going on. Who are these people? You have to start at the beginning, to understand what’s happening in the community. This allows you to recognize and sometimes preempt concerns and fears and mistrust and misconceptions — all these things that can stand in the way of you actually achieving what you want. And in the process, we lead with compassion and not with stereotypes. We come up with better ideas because we understand what the issue was in the first place, instead of superimposing our external views on it.
Flojaune Griffin Cofer is an epidemiologist who serves as the Senior Director of Policy for Public Health Advocates. She oversees the state policy efforts and the All Children Thrive-CA local trauma policy initiative. Her professional interest is addressing emerging and persistent public health challenges through research and policy. Her work primarily focuses on metabolic disease prevention, restorative justice, and adverse childhood experiences (ACEs).