Juneteenth: Delayed Freedom, Delayed Justice – Delayed Screening, Treatment and Survival

June 16, 2023, by Guest Author - Melissa B. Davis, Ph.D., Director, Institute of Translational Genomic Medicine, Morehouse School of Medicine

An Asynchronous Act of Freedom

One of the most relevant events in United States history, which represents the enduring theme of ‘Freedom’ and ‘Liberty’ on which the US was founded, is the day when enslaved Africans were finally freed from slave labor. You may think that date would be synonymous with the signing of the Emancipation Proclamation (January 1, 1863), and it should be. But the fact that it is not, reflects how, for some, the realization of an ever so obscure and tenuous “Freedom and Liberty” in this great nation is always delayed. Juneteenth is the holiday that represents the actual timing in mid-June (recorded as June 19th, 1865), when two years after the official act, slaves in the southern US learned that they were free. The revelations took place in various ways and recounting of these events are centered on the deception that prolonged enslavement and delayed justice. It then took over a century for this moment to be conceived as a possible holiday, despite its exceptional significance to US history. The delayed justice against enslavement and other forms of oppression such as colonialism, the delayed acknowledgment of humanity, and the delayed reaction to the celebration of freedom represents a persistent theme that permeates social systems worldwide for people of African decent. Africans and Africa diaspora in every nation who were forced to labor and then finally emancipated continue to face the social constructs that marginalize their descendants to this day. Here, I discuss parallels of the history surrounding Juneteenth and how these and similar events of slavery and colonialism have contributed to the current and persistent state of cancer health disparities globally. From education to legal and even throughout our medical systems, delays in action toward human rights and justice against inhumanity have ultimately manifested as disparities in poor health outcomes.  

The Social Impact of Slavery and Racism

Historically, there has been a strong connection between health disparities and social justice globally. Health disparities among social classes have existed for as long as there has been surveillance of health (1; 2). The first epidemiological connection between systematic deprivation and mortality rates highlighted a clear social gradient in health outcomes in European social class groups in the 19th century (3). A significantly larger impact for health disparities experienced by people of African descent, due to the globalized transatlantic slave trade that occurred over centuries has been observed, and its effect continues throughout the African diaspora worldwide. For those celebrating Juneteenth, the US Black population, records of health disparities begin with the observations of W.E.B. Dubois on the “Health and Physique of the Negro American” (4) where he connected, the detrimental effects of poverty, discrimination, and segregation on the health outcomes and higher death rate of Black Americans compared to White Americans. His work was corroborated in the mid-1980's in the initial multi-volume Minority Health Report from the US Secretary of Health’s office (5). The recommendations from that report gave a cautious summary acknowledging that the consistent racial health disparities that have existed for generations since slavery are ultimately due to a complex interplay of social, structural, and biological factors that require serious attention and research. 

Similarly, research on cancer health disparities over the past two decades has led to a comprehensive list of survival risk factors related to social determinants that drive cancer inequities worldwide (6; 7). For instance, delays in access to care in the health system is often the difference between survival and death. A ‘Juneteenth’ event in the cancer care continuum, which would be a delay in diagnosis, a delay in treatment, a delay in monitoring recurrence cannot be a celebratory moment. Other modifiable risk factors driven by social determinants such as structural racism that are deeply embedded in the social structures of the lived experiences of patients can be observed worldwide (8; 9). Delays in achieving social justice, which includes dismantling systemic barriers and addressing inequalities in society, can impede efforts to reduce cancer health disparities globally. Therefore, advocating for policies that promote equitable access to healthcare for all populations must be prioritized. 
In addition to these social factors, biological determinants (10) have also contributed to the disparities of cancer outcomes, though our knowledge of these mechanisms has been delayed and hence our action. The wealth of genetic and cancer biology knowledge that exists has largely been derived from a homogenous European population and the delay in the inclusion of non-European population - African, Asian, Latin American, Pacific Islander – in our knowledgebase has delayed our progress in developing tailored therapeutics and diagnostics for all populations. Our intentional focus on African ancestry to give rigorous interrogation of potential missing aspects of genetic risks in people of African descent has led us to appreciate the complex interplay of both social and biological factors that drive population differences in tumor biology. We now have the ability to measure the translation of lived experiences of individuals onto the genetic response to their perceptions of these exposures known as epigenetic response (11). The impact social factors have on tumors is only now starting to come to light as we look at the diverse tumor phenotypes/subtypes of the people of African descent globally (12). 

Who They Were, A Structure Designed to Marginalize – And Where We Go From Here

The emancipation of enslaved Africans was the result of a persistent and sometimes treacherous plight for mere human rights, fought by a diverse allyship that even spawned civil wars, simply to acknowledge that an entire lineage of people should be considered human. But the act of granting them mere freedom would not be enough for them to truly have the human rights necessary to live in good health. For the years prior to emancipation, it was illegal for slaves to own property, receive education or compensation for labor, all while actively being denied an acknowledgment of citizenship by the highest courts with the US Supreme Court’s Dred Scott judgment (1857). The disregard that occurred from the governance structures towards denial of freedom at the time of emancipation, and the exploitation due to isolation for enslaved individuals in the southern states, are the core of the redlining and neighborhood deprivation that led to racial marginalization and structural racism that impact health outcomes of African Americans to this day. This began what we now define as the structural racism in the social determinants of health that characterize indices like “area deprivation” (13). After the abolition of slavery, Jim Crow laws enacted in the late 19th and early 20th centuries, and the practice of redlining systematically enforced racial segregation, denying African Americans access to education, housing, employment, and public services. Having a dearth of wealth left newly freed African Americans dependent on government programs that were designed for unequal distribution of resources and designed to marginalize an entire community of African diaspora.  
Similarly, the legacy of colonial policies and practices, such as land dispossession, forced labor, and economic exploitation, has created social and economic conditions that increase the risk of cancer in African populations and impact the metaphorical “war on cancer” along the lines of race, ethnicity, and socioeconomic status. Colonialism, through its continued exploitative and oppressive practices has disrupted indigenous healthcare systems, imposed colonial medical models without considering local contexts, and prioritized the interests of colonial powers over the health needs of local communities (14,15,16). The direct consequence of this delayed justice and continued devaluing of minoritized populations has long lasting implications on their social, emotional, and physical well-being leading to significant disparities in health outcomes including cancer. 

A Concerted Effort to Overcome

To meaningfully address cancer disparities globally, we must study historical determinants of health to identify root causes and dismantle the structural factors that continue to maintain and perpetuate the unequal distribution of health resources, opportunities, and outcomes (15; 17; 18). The history of African Americans in the United States is indeed marked by the creation of their own identities within a complex social construct. The institution of slavery sought to erase their individuality and heritage, treating them as a homogeneous group solely based on their African ancestry and categorized them based on their skin color. And this racial construct has been a persistent tool of marginalization that consistently perpetuates the daily struggle of the descendants of the intended beneficiaries of the Emancipation Proclamation, albeit delayed. African Americans continue to navigate and redefine their identities within a complex and diverse society drawing strength from their history, culture, and resilience in the face of ongoing challenges and systemic inequities while contributing to the nation’s rich tapestry of diversity and progress. 
It is a difficult existence at times, to identify as a member of a group that has been marginalized for over 400 years. You are compelled to be an activist at some point in your lifetime. But what if you don’t identify with those who are celebrating Juneteenth? When you see the images of people who lived during that period, what are the thoughts that come to mind? Does it seem like a fictional depiction of a foreign land or an unknown race? I see people who look like me. I see people who look exactly like my relatives, the people I’ve known my whole life. I see my uncles and cousins and my grandfather. My immediate feelings are “what were they feeling in the moment when this image was taken? What was the smell in that place, or what was the heat of the day like as they worked? And what was the reason for the picture to be taken?” I wonder, above all else, “How did they live? And were they OK?” To be the direct descendant of them, to be the great granddaughter of and carry the transgenerational epigenetic trauma from their daily lives is a heavy weight to carry. I often ponder what Juneteenth really means to my own family. Here’s what we can do on the day we have so long desired as a holiday. We should rest upon the 14th Amendment and the empowerment it brought to the ebb and flow of it all. We remember that after the 13th Amendment (Emancipation) came the 14th Amendment, that clearly stated African Americans are US Citizens, and WHY: They were BORN here! We may have had to meet with Dred Scott, the Great Nadir, and Jim Crow, but the resolution of citizenship, now makes this act of freedom a holiday, and with it a new dawn to create a dream manifest. Angela Davis aptly captures the global interest in Black struggles by emphasizing the “resilience and creativity exhibited by Black people throughout history. Despite the suffering endured, the power of song and artistic expression has served as a transcendent force, uplifting spirits, and serving as a testament to the indomitable human spirit.” We celebrate with resilience despite the hurt and suffering. Resilience permeates across all people of African descent. Post-colonial resilience is a complex and ongoing process. It requires the active participation and engagement of all stakeholders, including governments, civil society organizations, educational institutions, and individuals, to create a more just and inclusive world. In the global context, by decolonizing health systems, addressing structural inequalities, empowering local communities, and fostering global solidarity, we can work towards a more equitable and inclusive approach to global health that prioritizes the needs and aspirations of all citizens.

And this is why I have dedicated my career to the science of cancer disparities focusing on the people of African descent globally. Because there is more to the story of our people than the oppression and marginalization. There are mysteries in our ancestry that give unique character, distinct perspectives, and an underappreciated variation, even in our biological processes that harbors the key to our survival. We therefore remain dedicated to contributing our very best to reducing cancer health disparities among people of African descent globally. By prioritizing cancer research projects led by scientists of African descent who will bring unique perspectives, experiences, and cultural insights to their research, helping to uncover new approaches to prevention, diagnosis, and treatment. And for this reason, I am PROUD to be a descendant of the African diaspora, dispersed across the world. I will always be. 

Dr. Melissa B. Davis is an NCI grantee and the principal investigator of an R01 project titled:  The DARC side of Breast Cancer Disparities - African Ancestry and Cancer (R01CA259396).