Zinzi Bailey can still recall watching TV in her college dorm at Princeton University and seeing the anguish on the faces of people in New Orleans as they realized just how much they lost in Hurricane Katrina.
The Jamaican immigrant also noticed who was hurting the most.
They were brown faces, similar to hers. And she knew there were some underlying factors that caused this group of people to fare so much worse than others.
“I watched the rhetoric around who was classified as a ‘looter,’ and who was struggling to live,” said Bailey, a research assistant professor in the Division of Medical Oncology at Sylvester Comprehensive Cancer Center at the Miller School of Medicine. “It was a very visible complexion of suffering. Things like housing, and access to transportation . . . you could see all the points of inequity and failure within our system. But it took a disaster for us to comprehend all the components involved.”
That was when Bailey started to realize the pervasive role of racism in the United States—beyond her own personal experiences.
Since then, she has researched the influence of racist practices like slavery, redlining, employment discrimination, and mass incarceration on the Black population of the United States and the world. She wrote about the impacts of cancer, maternal morbidity, opioids, tobacco use, and even neighborhoods on the health of minorities. And she investigated the causes of these disparities by talking to people and tracing the barriers that put them at a disadvantage.
Today, Bailey is a leading voice at the forefront of a national conversation about structural racism, and medicine’s role in it. In December, she was the lead author of a commentary in the New England Journal of Medicine (NEJM) outlining the major implications of structural racism that influence health care for minority populations. And in February, she was a key voice on an article in another major medical journal, The Lancet, chronicling the devastating effects of the Trump administration’s health and social policies.
“Racism is not an isolated ideological event, it’s a system or culture of inequity. So, it’s important that we are able to recognize that in ourselves and our institutions,” said Bailey, who joined the University in 2017 after working as the founding director of research and evaluation for the New York City Department of Health and Mental Hygiene. “The more that we are able to recognize our history, the more we can learn from it.”
In the NEJM article, Bailey, along with co-authors Dr. Mary Bassett, and Justin Feldman, described structural racism as not just privately held beliefs, but a mindset embedded into our laws, rules, and government, as well as in the United States’ economy, culture, and society. They pointed to residential segregation, the criminal justice system, and unequal medical treatment as the main outlets where structural racism continues to perpetuate these disparities among minorities. Recently, this fueled the uneven realities of the COVID-19 pandemic, they wrote. And they called on the health care community to help undo these trends.
In particular, the trio urged health care professionals to support more research about how racism affects health outcomes, rather than disregarding its relevance. And they pressed medical and nursing schools to include training about racist practices of the past, so that future patients receive more compassionate care. They also called on medical schools to accept more Black students and hire more Black faculty members.
“Change will require policies that restructure the chances for a healthy life for people of color,” they pointed out. “Our fields have much to regret, and we have much still to offer to right our historical wrongs.”
The NEJM piece was a more accessible version of a longer article published three years earlier in The Lancet, while Bailey was working in New York. That’s where she got to know Bassett, who was New York City’s commissioner of health at the time and also co-authored both articles with her. Bassett now leads the FXB Center for Health and Human Rights at Harvard University, but the two still collaborate often.
The insights offered in both articles caught the attention of many health care professionals, including Erin Kobetz, the University’s vice provost for research and scholarship, who recruited Bailey to work with her at the Sylvester Comprehensive Cancer Center. Since 2017, the two have collaborated to investigate issues of health inequity in cancer patients and even created a web platform called Scan360, which allows users to understand the influence of their background on potential cancer outcomes. Kobetz said a major asset of Bailey’s scholarship is her ability to statistically demonstrate how racism has impacted the health of minority populations, particularly Black people and women.
“Her work on structural racism is critically important and fills a necessary gap in understanding how systemic inequity can directly condition worse health outcomes,” said Kobetz, who is also the associate director of population science and cancer disparities at Sylvester. “Perhaps because she was able to offer evidence in such a high-impact medical journal, it could force more attention to the notion that achieving health equity necessitates attention to racism on multiple levels of influence.”
Primed for a future in health care
Born in Jamaica, Bailey immigrated to the United States with her parents when she was 3 years old and grew up in the South Miami-Dade neighborhood now known as Palmetto Bay. From listening to the work experiences of her dad, a water quality engineer, and mom, a longtime nurse at Jackson Health System, Bailey said the difference in care offered to people of color drove her desire to go into public health.
After earning a bachelor’s degree in public policy from Princeton, Bailey moved to New York to work for an organization called Public Health Solutions, where she was able to see the conditions of low-income communities of color living in Bushwick, a Brooklyn neighborhood. Facing gentrification and rising housing prices, she saw firsthand how residents were fighting structural barriers to their health, like poor housing conditions and environmental hazards in order to maintain the well-being of their families.
Soon, Bailey wanted to learn more and enrolled in a master’s-degree program in public health focused on global epidemiology at Emory University. While she took classes in the Atlanta area, Bailey worked as a research assistant at the U.S. Centers for Disease Control and Prevention and helped compile epidemiology information for the Division of HIV/AIDS Prevention, Viral Hepatitis, STD, and Tuberculosis Prevention, particularly related to the U.S. implementation of pre-exposure prophylaxis in preparation for forthcoming trial results.
A shift in perspective
She went on to earn her Doctor of Science at Harvard’s T.H. Chan School of Public Health, where Bailey studied the influence of structural racism on the criminal justice system, and explored such issues as why Black males are imprisoned more than white males, and Black females nearly twice as much as white females. She continues to study the criminal justice system and collaborates with sociology assistant professor Kathryn Nowotny to explore how prisons often amplify health inequities.
Yet during her time at Harvard, Bailey also noticed a gaping hole in much of the public health data available in the U.S. At the time, two of the most commonly used databases for health information both excluded information from people in institutions. This meant people in jails, prisons, and nursing homes were completely left out of national health surveys, and Bailey knew that people imprisoned were disproportionately Black.
“If we are only interviewing people who are not institutionalized, we get distorted pictures if we have a distorted level of incarceration across different populations,” she said. “But a lot of people, most epidemiologists, were not thinking about that when they were looking at the data. I saw this as our blind spot. So, that’s what got me more interested in the topic of structural racism.”
As her interest in public health grew, Bailey often mentally compared her experiences visiting family in Jamaica to her life in the U.S.. Then, once she traveled to places like Brazil and South Africa to study health care, she could not ignore a common thread she observed: the jobs that people could get, along with the homes and neighborhoods where they lived and how often they were entangled in the criminal justice system, was often defined by the color of their skin.
In 2015, Bailey became the founding director of research and evaluation in New York City’s health department. The experience gave her a chance to work with Bassett, who planned to explore why some city residents had the best health in the nation, while others had the worst.
“At the time, it was the first foray into investing in and acknowledging structural racism at the New York City Health Department,” Bailey said. “Part of [Bassett’s] mission was making sure we were recognizing the role that racism plays in our everyday lives, and part of that was looking at the data we produce and questioning what data we have, what data do we not have, and what we are asking or not asking.”
She learned how neighborhoods that the city did not invest in historically, such as the South Bronx, had some of the poorest health outcomes, which were exacerbated by COVID-19 last spring. This prompted her to do a case study last year on the Bronx, describing the historical precedents to the borough’s pandemic crisis.
But while in New York, Bailey also saw how health departments could help reverse the harmful trends perpetuated by structural racism. According to Bailey, Bassett led a charge for reinvesting in neighborhoods where residents have some of the worst health, like the Bronx, parts of Brooklyn, and East and Central Harlem. Under her leadership, staffers repurposed unused municipal buildings as neighborhood health centers, where community organizations could offer health services, maternal care, and nutrition classes at a low cost. Bailey hopes these examples will allow those in public health to recognize what works. In the meantime, she realizes that listening to concerns of local patients, and offering scientific information at their comfort level, is one of the best ways to improve health outcomes.
Bailey is now trying to impart this in her own community in Miami, where vaccine hesitancy is readily apparent. She has regularly contributed to a neighborhood church group about the importance of getting a COVID-19 vaccine, and she recently convinced her mother, and several of her friends, but she knows how critical it is to get more people protected.
“We can identify COVID-19 or develop a vaccine. But until we understand the people affected, how our interactions have played out thus far, and the gaps in public health care, we will never get to the places we want to be,” Bailey noted. “There’s a lot more listening we need to be doing. And we need to be engaging with people in honest, transparent ways to allow us to build community relationships, so that people will trust the medical information they are getting.”
