Spatial Justice and Implications for US Health Care

The recognition that where people live matters to their health has deep roots, highlighted in the works of Hippocrates, W. E. B. Du Bois, and in contemporary research on environmental and place-based factors that shape health.^1,2 Although health systems have come to accept their role in helping change community conditions in support of health, their complex institutional, financial, and sociopolitical considerations can prevent positive change or lead to more harm. We suggest that the concept of spatial justice must be incorporated in health system actions to improve population health.

Spatial justice³ refers to the relationship between people and places as mediated by historical and current values, assumptions, beliefs, policies, investments, and practices. The National Academies of Sciences, Engineering, and Medicine Roundtable on Population Health Improvement recently hosted a workshop on spatial justice as a driver of health in the context of societal emergencies, including pandemics and climate change. Participants—planners, architects, social scientists, community organizers, residents, policy makers, and others—examined how space is organized, used, allocated, owned, and who is or is not included in decisions about design, building, and use of spaces.

We use insights from the event to distill the following 5 principles to promote spatial justice:

1. Recognizing and making visible histories of displacement, rupture, and dispossession, including serial forced displacement, theft of land, and internment.

2. Showing how policies and practice can perpetrate and reinforce, but also mitigate and interrupt, systemic harms (eg, through restorative justice practices linked with the natural world).

3. Avoiding the conventional wisdom, narratives, and easy solutions (for example, urban renewal seemed like a solution for the ills of cities, but it layered displacement and gentrification on the legacy of disinvestment).

4. Embracing and sustaining over the long-term effective, high-level, and systemic solutions co-designed, co-created, and co-managed with communities and people who live here.

5. Seeking interdisciplinary and cross-sector collaboration, as well as joint advocacy for inclusion and representation in professional pipelines and community leadership.

What does this mean for health systems? Health systems face the urgency of the current crises of the pandemic and climate change effects on health, the ongoing deep inequities in health, and addressing racial justice. The concept of spatial justice should inform health system actions.

First, hospitals and health systems must recognize and unearth their own history, place in the local landscape, and contribution to spatial injustice. Population-level health outcomes must be linked to the physical history of the places where persistent inequities exist, from land acknowledgments that connect to the original stewards of a place and explicitly link to work being done to further justice and equity, to visualizing climate crises through time-lapse maps that provide historical and demographic context and inform action. Some universities, academic health centers, and health systems are grappling with their own institutions’ legacy of displacement, segregation, and other kinds of racial violence and are exploring mitigating and restorative strategies, such as medical reparations, which are efforts to provide restitution for exploitation and harms committed in the name of medicine or science.

Second, health systems should examine how their own policies may reinforce or remediate legacies of segregation in geography and in care.⁴ Often, we fail to acknowledge there are valid sources of knowledge⁵ outside our own disciplinary boundaries and cultural traditions, and the importance of the people and communities that possess them being involved in and leading healing. One cannot layer new solutions on systems implicitly or explicitly designed to produce inequities. As health systems make decisions about their physical footprint and access to the care they provide, as well as partner with financial institutions, the social sector, philanthropy, and others on community development, they must acknowledge what needs to be undesigned and redesigned. Agreements that may look good on paper but do not tackle legacies of injustice perpetuate harm.

The community health needs assessment process required for all tax-exempt hospitals provides one opportunity to authentically engage with and listen to community residents and organizations,⁶ but such processes require sustained long-term relationships and trust. Also, having an approach that acknowledges that community members bring their own knowledge and expertise is key. The meaning people attribute to places can transform our understanding of land, for example, from a mere patch of dirt with real estate value to a sacred place. This is illustrated by the ancient Hawaiian practice of ho’oponopono, in which healing the land is an integral part of reconciliation (such as in a community-based juvenile justice program for indigenous youth) and of healing physically, mentally, and spiritually.

Third, health systems should make investments for the long term and with accountability to the community, including being intentional about where they deliver care, lowering barriers to access, and how they invest in the locales where they operate both through their community benefit efforts and other economic investments. Some hospitals have been taking actions consistent with being an anchor institution—making decisions about financial, procurement, hiring, real estate, and other matters with the community and inclusion in mind. For example, one hospital system has partnered with others to form a land trust to support and preserve affordable housing.

A long-term mindset includes preparedness and building resilience for evolving threats to community health and well-being. Hurricanes, wildfires, and other climate-related disasters hold lessons not only for making health systems more resilient,⁷ but for the larger role they play in mitigating climate change as purchasers and users of renewable energy,⁸ as designers and builders of physical structures, and as members of communities who must think of themselves as bound together with their local neighborhoods and responsible for improving their shared well-being and resilience. Lessons from the Accountable Communities for Health movement, partially supported by Centers for Medicare & Medicaid Services through its Accountable Health Communities model, include consistent focus on racial justice in an accountability framework that brings community residents to the decision-making table. Efforts to be accountable to and partner with communities require acknowledgment of the intentional and unintentional policies that benefitted certain groups over others and then expanding the circle of accountability to include populations previously left out of decision-making and excluded from benefitting directly from the allocation of resources.

In addition, health systems must cross boundaries and partner to advocate for change to advance social and racial justice. Disciplinary boundaries often limit our understanding of the world. Cross-sector work and multidisciplinary collaborations make our understanding of the world approximate reality—expanding our perspective by incorporating the perspectives of others. This is especially true of cross-discipline collaboration to advocate for racial justice and inclusion in science, technology, engineering, and mathematics professions and in medicine.⁹ Health sector efforts to improve spatial justice require partnering with planners, architects, historians, attorneys, and other disciplines, but diverse disciplines are insufficient. The Association of American Medical Colleges recently launched a Center for Health Justice which is intended to “reach beyond medical care and change structures and systems to improve the political, economic, and social factors that drive health inequities” and includes a growing multidisciplinary partnership to help further that goal.

Zip codes may matter more than genetic codes in determining population health outcomes. What we do with this recognition also matters. For health systems, this recognition must lead to acknowledging the past and co-creating with communities and other partners the solutions that integrate a spatial justice ethos in the design and use of their physical campuses, their work on community development, their environmental footprint, and all their actions that relate to places and spaces.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Baciu AB et al. JAMA Health Forum.

Corresponding Author: Kirsten Bibbins-Domingo, MD, PhD, MAS, University of California, San Francisco, PO Box 1364, San Francisco, CA 94143 (kirsten.bibbins-domingo@ucsf.edu).

Conflict of Interest Disclosures: Drs Baciu, Rodríguez, and Bibbins-Domingo reported being members of the National Academies of Science, Engineering, and Medicine (NASEM) Roundtable on Population Health Improvement. Dr Baciu reported being a senior program officer in the Division of Health and Medicine at NASEM.