The Infrastructure Bill—Investing in Environmental Justice & Health Equity

From the air people breathe to the pipes they drink from, both the natural and built environment help define society’s health. One’s ZIP code is a significant determinant of life expectancy, yet the environmental resources for a healthy life are far from equitably distributed, with racial and ethnic minorities disproportionately facing toxic conditions.^1,2 The United States’ recent focus on infrastructure, from passage of the Infrastructure Investment and Jobs Act (IIJA) to efforts to break up the Build Back Better bill, has led to a whole-of-government approach to forge the America of tomorrow. However, this transition faces the challenge of simultaneously undoing present systems of oppression and building an equitable framework for the future. Despite recent policy initiatives to support the environmental health of vulnerable communities, current efforts are limited in scope and require a revised framework with explicit focus on health equity and environmental justice. Health care professionals are uniquely positioned to enact this framework and protect the environmental health of vulnerable communities.

Louisiana’s “Cancer Alley,” a region populated by majority Black communities with some of the most polluted air in the country, reflects of a long history of environmental racism in the United States. For 50 years, the city of New Orleans sent its industrial waste to this region to be incinerated and sprayed the ground with now-banned pesticides. In the 1980s, the city built low-income housing developments on top of this toxic landfill and encouraged Black residents to relocate there. The region now has cancer rates 50 times the national average.^3,4 This disregard for Black lives is mirrored in 20th century redlining practices that pushed Black Americans out of suburban communities and into urban housing projects, and in interstate highway projects that uprooted and divided Black communities.^5,6 These historical atrocities have been amplified by the COVID-19 pandemic, with the residential segregation and racist housing policies translating into higher rates of infection and mortality today. Black Americans are twice as likely to be exposed to air pollution than white Americans, and such exposure is as a risk magnifier for the most severe COVID-19 health outcomes.⁷ Environmental racism is especially pernicious because it precludes already disadvantaged communities from opportunities to build healthier futures.

While policies of harm, displacement, and segregation have institutionalized racial inequities in the United States, public policy also represents one of the most powerful tools in society’s arsenal to achieve health equity. For instance, the historic $1.2 trillion IIJA will make powerful strides in environmental health and racial justice with a focus on environmental remediation to clean up industrial waste sites, water infrastructure to protect against crises like that in Flint, and weatherization assistance for low-income households to support energy efficiency.⁸ While these provisions are encouraging, they are undermined by the IIJA’s primary investment in fossil fuel infrastructure—with almost three times more money for highways, roads, and bridges than public transit—that will likely continue to harm disadvantaged communities.⁹ With state transportation departments managing much of the money with few restrictions, the federal government’s efforts to protect against environmental harm and racial health disparities may be thwarted by business continuing as usual (e.g., building new highways and ignoring the resultant air pollution).

Figure 1. Fundamentals for policymakers to prioritize health equity and environmental justice on the infrastructure bill and beyond.

As such, when designing new infrastructure legislation, a whole-of-government approach for deracinating health inequities and environmental racism is critical (Figure 1). Communities must be at the forefront of these efforts with a bidirectional model of engagement; the present unidirectional approach leaves little opportunity for shared learning, thereby undermining the validity of stakeholders’ lived experiences. Meaningful community-based engagement requires consistency and patience to foster true collaboration and build trust. Focused investments are similarly necessary to improve health outcomes in marginalized communities, such as through remediating poor air and water quality and building pedestrian and bicycle infrastructure. Social determinants must be at the vanguard of environmental justice policy to begin tackling the harmful legacies of racism.

The Biden Administration’s Justice40 Initiative provides one structure for transformative environmental justice policy by requiring that at least 40% of all benefits from federal energy and climate investments are delivered to disadvantaged communities.¹⁰ With 21 priority areas ranging from the Superfund Remedial Program to the Low Income Home Energy Assistance Program (LIHEAP), Justice40 seeks to mobilize resources from all aspects of the federal government, including the Environmental Protection Agency, the National Science Foundation, and most executive departments. This comprehensive response emphasizes the intersectionality of environmental justice in that it is as much a health issue as it is one of urban development, homeland security, commerce, and more.

The Justice40 framework is also critical because it recognizes that, given the unequal distribution of societal resources, a rising tide does not lift all boats. As such, there is a need to center conversations on the needs of the few versus the needs of the many (Figure 2). Although the federal government is inherently distanced from local contexts, it can provide criteria for discretionary grants to ensure direct engagement with marginalized communities. Furthermore, the federal government can require impact assessments to optimize for both short- and long-term health outcomes of infrastructural investments. Although not all states conduct environmental impact assessments themselves, the National Environmental Policy Act (NEPA) requires all federal agencies to assess the environmental impact of “major federal action significantly affecting the quality of the human environment.”¹¹ NEPA also provides a mandate for interdisciplinary analyses, such as ones that integrate environmental, health, and equity-based impact assessments. Policymakers must focus their attention on the most vulnerable and underrepresented to ensure health equity is not simply a lens to don when convenient but a foundation for all their work. With a consistent whole-of-government basis of equity, a productive path forward can be paved for historically disadvantaged communities.

Figure 2. Focusing on the needs of the many versus the needs of the few. Taken with permission from Interaction Institute for Social Change | Artist: Angus Maguire.

Successful implementation of this framework will require health care professionals to lead policy discussions because all infrastructure is health infrastructure.¹² Indeed, infrastructure policy acts on various social determinants operating upstream of poor health outcomes, from the neighborhood and built environment to the social and community context. Given that nonmedical factors account for 60-70% of modifiable contributors to population health, health care professionals have a responsibility to go beyond traditional medical care by investigating the systems of racism sickening their patients and advocating for policies that propel health equity forward.¹³ This responsibility can include testifying at city council hearings on the beneficial (or adverse) health impacts of infrastructure proposals, working with professional organizations to promote healthier community design, and other public-facing responsibilities that reflect the larger physician-population relationship.¹⁴

Bearing direct witness to the deadly impacts of environmental racism, whether in the form of asthma, obesity, or other chronic conditions, health care professionals are also especially poised to help politicians focus on environmental health, lending their trust, expertise, and authority to the cause. In Cancer Alley, for example, local physicians have spearheaded campaigns against petrochemical industry expansion and have played an important role in the fight for racial equity.¹⁵ Undoubtedly, health care workers must partner with public health professionals on this environmental justice advocacy, but we call attention to health care professionals in particular because they typically operate on the individual level but have the capacity to make population-level change as well.¹⁴ With environmental racism and health inequities silencing the poor and disadvantaged, health care workers have a responsibility to lend their voices to ensure policy is crafted with justice at its heart.

The connections between infrastructure and health are robust, from the benefits of green spaces, physical activity, and clean air to the consequences of water pollution, community severance, and environmental contamination. Recent efforts to revitalize the Build Back Better bill and pass it in parts underline the national focus on infrastructure and rebuilding America. The present moment is a once-in-a-generation opportunity to begin abolishing long-standing pillars of environmental racism, or conversely perpetuate these histories of displacement and segregation. For public health stakeholders, the goal of all policy should be harm reduction and health promotion with specific focus on justice and equity; infrastructure is simply one vehicle to preserve and protect the environmental health of vulnerable communities.

References

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About the Authors