Centering Margins: Advancing Health Equity by Confronting System Failures and Uplifting Positive Deviance

Health equity cannot be achieved without a deliberate focus on those living at the margins—those experiencing the worst health and life outcomes. From a critical epidemiological lens, centering the margins exposes system failures while also uncovering opportunities for transformative change through positive deviance. The individuals and communities who defy the odds, despite overwhelming barriers, illuminate pathways for addressing inequities.

A Case Study: Allentown, Pennsylvania

Allentown, the third-largest city in Pennsylvania and a minority-majority city where over 76% of residents are people of color, demonstrates what is possible when equity is prioritized. Through the work of Promise Neighborhoods of the Lehigh Valley (PNLV), we have achieved remarkable results in decreasing violence and improving outcomes for those at the margins.

Decreasing Youth Violence and Homicides

PNLV’s data-driven, community-centered approach has produced extraordinary results:

• Youth violence has been reduced to zero for the past two years.
• Total homicides in Allentown experienced a 78% reduction.

These outcomes reflect a steadfast commitment to addressing the root causes of violence, such as lack of opportunity, systemic inequities, and community disinvestment.

Zero Recidivism in Reentry Programming

PNLV’s Reentry Programming has achieved a 0% recidivism rate, demonstrating the power of community-based solutions. At the heart of this success is the Tri-Sector Reentry Round Table Breakfast, a groundbreaking initiative that brings together individuals, families, caseworkers, and organizations to:

1. Present cases and seek tailored support.
2. Collaboratively develop solutions.
3. Build cross-sector networks of resources around those who need it most.

This model not only provides practical resources but fosters a sense of belonging and agency for participants, ensuring their successful reintegration into the community.

Scaling Grassroots Solutions

PNLV’s journey exemplifies the transformative power of investing in grassroots solutions. What began as an organization with a budget of a few hundred thousand dollars has grown into a multi-million-dollar organization with the support of local, state, federal, and national funders and donors.

This growth underscores the critical need to deeply invest in hyper-local models led by the very people being served. These models hold immense power to change lives, families, and communities by building trust, fostering ownership, and centering solutions around those most impacted.

Systemic Inequities in Black Health Outcomes

Whether viewed through a Social Determinants of Health framework or the Vital Conditions lens, Black Americans continue to face significant disparities. The data speaks volumes:

• Black Americans have a shorter life expectancy than White Americans by approximately 3.5 years.
• Maternal mortality rates for Black women are nearly three times higher than those for White women.
• Black men are disproportionately affected by gun violence and mass incarceration.

These disparities underscore the necessity of addressing the systemic factors that create and perpetuate inequities.

Gun Violence and Mass Incarceration: A Public Health and Human Rights Crisis

When examining Black health equity, gun violence and mass incarceration cannot be sidelined. These are not just social justice issues; they are public health crises deeply impacting health and life outcomes.

Gun Violence

Gun violence disproportionately affects Black communities:

• Black Americans are 10 times more likely to die by homicide involving a firearm than White Americans.
• Gun violence is the leading cause of death for Black males aged 15-34.

The U.S. Surgeon General has declared gun violence a public health crisis. In Allentown, the reduction in homicides showcases the effectiveness of community-led solutions, including credible messenger programs, violence interruption strategies, and cross-sector collaborations.

Mass Incarceration

Mass incarceration is a healthcare crisis and a human rights issue:

• Black Americans are incarcerated at nearly five times the rate of White Americans.
• Formerly incarcerated individuals face heightened risks of chronic illnesses, mental health issues, and premature death.
• The economic cost of mass incarceration exceeds $80 billion annually, with unquantifiable human costs in broken families and community trauma.

PNLV’s reentry programming addresses these systemic failures by providing holistic support, breaking cycles of recidivism, and fostering sustainable reintegration.

The Social Determinants of Black Death

When considering the unique factors impacting Black Americans, I’ve coined the term “Social Determinants of Black Death” to highlight the drivers of mortality within our communities. These include:

1. Gun violence
2. Heart disease
3. Diabetes
4. Maternal mortality
5. Mass incarceration

Each of these factors is exacerbated by systemic racism, economic disinvestment, and inequities in healthcare access. These are not just statistics; they are lived realities for millions of Black Americans.

Positive Deviance: A Blueprint for Change

Amidst these challenges, there are outliers—individuals and communities who thrive despite the odds. This concept, known as positive deviance, offers a powerful framework for addressing health inequities. By studying what these individuals and communities are doing differently, we can identify scalable solutions. For example:

• PNLV’s tri-sector partnerships have fostered collaboration across government, nonprofit, and corporate sectors, demonstrating the power of community engagement.
• Allentown’s reduction in violence and recidivism showcases the impact of centering individuals and families in solution-building.

Positive deviance reminds us that those at the margins often hold the clearest demonstrations of what works—and what needs to change.

Call to Action: Centering Margins in Health Equity

As public health researchers, practitioners, and educators, it is our responsibility to center the realities of gun violence and mass incarceration when addressing Black health equity. These cornerstone issues are not just public health crises; they are reflections of systemic failures that demand urgent action.

To achieve health equity, we must:

1. Engage communities to honor the voices and experiences of those most impacted.
2. Advocate for policy change to dismantle structures perpetuating inequity.
3. Build cross-sector collaborations that prioritize individuals and families at the margins.
4. Invest deeply in grassroots organizations that drive hyper-local solutions and empower communities to lead their own change.

Health equity begins and ends with the margins. When we center the most vulnerable, we create systems that uplift everyone. Let us work toward a future where Black lives are not just valued, but where Black health and well-being are prioritized and protected.

Allentown’s success is a testament to what’s possible when we build solutions that honor and uplift the margins. By interrogating, disrupting, and innovating, we can create lasting change—for individuals, families, and entire communities. Because the cost of doing nothing is too great to bear.