[Ben Wood speaking] My name is Ben Wood and with Department of Public Health colleagues Jennica Allen and Jessica del Rosario. Our role is to help put the information that is being presented throughout these webinars into context and to support action in ways that will sustainably and effectively address the reasons why some populations have been disproportionately impacted by the pandemic. To do that we will do the following provide shared definitions and context setting for thinking about racism and its impact on health, encourage an emphasis on systems as a focus of intervention and which will include an introduction to the groundwater metaphor. We will provide an overview of the importance of examining the mental frames we each take into our work and then we then we'll end with a call to action which will include an over overview of a few tools that you can use and then concrete steps and actions you can take with your partners to put the CCIS data to work.
[Ben Wood speaking] So to kick us off with shared definitions and understandings as we provide some context to the powerful data you will see throughout the webinar series, we wanted to start by being clear about what racism is. We are using David Wellman's definition of racism, first published in 1977 in the book, Portraits of White Racism which succinctly is defined as a ‘system of advantage based on race’. This definition centers thediscussion of racism and its impacts on health, more on institutions, policies, and social systems than on individual acts of prejudice. It causes us to focus on how we are supporting the racial status quo through the defense both explicitly or implicitly of the practices of institutions’ policies and social systems.
[Ben Wood speaking] Similarly, we want to be clear about what racial justice is and isn't. It is not about increasing diversity, we are not solely trying to increase the types of people who participate in any given activity. It is not about equality, we are not striving to be all the same. What we are striving for in racial justice practice is equity. Equity means that there is fairness in systems and that we are actively seeking justice. One simple way to remember and distinguish between these concepts is to talk about mixing it up versus fixing it up. Diversity is about mixing it up, quite literally, racial justice is about fixing it up, actually taking action to address the impacts of racism on systems and people.
[Ben Wood speaking] Similarly, we always want to be clear about the difference between disparity and inequity. Classic examples being differences in birth weight. Male babies at birth tending to weigh more than female babies at birth. This is a disparity. It's a difference. But babies born to black women are more likely to have babies with lower birth weights than babies born to white women. This holds true while factoring in educational attainment. Babies born to college educated black women are still more likely to have a lower birth weight than babies born to white women who dropped out of high school. This is an unfair and unjust difference and is an inequity.
[Jennica Allen speaking] So I'm going to talk a little bit about the levels of racism and here you can see that we have the micro level and the macro level and on the micro level
we have internalized, in this upper left box. And really internalized is about how we take in messages of white superiority and for me as a person of color, this often shows up in the form of self-doubt. So if I get the job. If I get invited into leadership spaces, I think, oh they're really taking a chance on me. And Ben can give us an example of how internalized might show up for white folks.
[Ben Wood speaking] Thanks Jennica. There are many ways that internalized white ways of being and doing show up for myself. But onecommon one is, and especially in the context of racial justice practice, is this sort of notion of expecting to be taught, looking to people of color for direction, education, coaching, basically what to think and how to act and what to do and what not to do. Rather than putting in the work for myself.
[Jennica Allen speaking] Thank you Ben. So, the next levelis interpersonal and really this is how those internalized messages start to manifest outwardly onto other people. And we like to say this is the stuff that makes the news, right. But really, we want to maintain our focus on the macro level, so at the institutional level, we are thinking about the institutions themselves and the policies and practices that guide them and sort of define the way that they've been built. So, education as an institution, banking, housing, all of those are institutions. And structural is really how those institutions interact and then impact people's lives. So, we want to maintain our focus on the macro level and on the next slide you'll see some key takeaways that tell us about why.
[Jennica Allen speaking] So we want to make sure that we're leading with race and racism explicitly but not exclusively. So, we understand that people have multiple identities, and we want to honor and acknowledge all of those identities and maintain an intersectional focus at each of those. So again, turning back to why we want to keep this structural, is we want to keep the analysis structural. It is not helpful for the movement to think about and focus on who is a racist because using David Wellman's definition of racism. Racism really is a system that does not require racists in order to function. So, we want to make sure that our analysis remains structural and we're thinking about the interaction of systems and their impact on people's lives. Here we have bolded Don't Personalized Critiques of Systems because it's really important. The idea behind this is we can understand and identify the failures in those systems that we talked about. In the education system, in the public health system, without personalizing those particular critiques. So, I love public health. I will always work in public health. And I can both love public health and understand its history of perpetrating harm against communities of color. The analysis itself is the tool. So often when we do presentations on things like this, we often get the question. Well, okay that's great I believe it. Now what is the thing, give me the next step, how do I get to anti-racism, how do I get to racial justice. And we want to offer that when we present information like this, this is an invitation, this is an opportunity to start to shift your thinking and when you startto over and over flex the muscle of using this analysis and using this systems framing that in and of itself is the tool. Racial justice work is not work done for people of color. So, in the concept of linked liberation, I enter into racial justice work as a black woman for me. Ben enters into racial justice work as a white man for him, right. He does not do this work on behalf of me, and this is not about improving things for one group or another. Really, it is about linked liberation and getting there together. And tied to that is the idea that systems that are failing communities of color are actually failing all of us. So really racism isn't working for anyone. Everyone is harmed by the suppressive system and that is the key takeaway that we want to make sure people are understanding as related to the rest of them. Next slide.
[Jennica Allen speaking] All right, here we have threedistinct periods in our history and some key characteristics of each. We have Chattel Slavery first, which is the active slave trade in North America as we know it from Jamestown to the Emancipation Proclamation in 1865. In this period the health system was characterized by the slave health deficit and drastically disparate treatment within the health system andof course vastly different outcomes from there. Following the Emancipation Proclamation, we entered a 100-year period of legal segregation, which many of us know as Jim Crow rule. During this period, we saw an uptick in junk science. Perhaps you're familiar with the skull size studies published to support the racial hierarchy that was starting to take hold. And finally, we have the period from 1965 through today, which is characterized by structural racism. We are still seeing the effects of the prior two periods now, which I think we can all agree on. But what we really want to point out here is that those first two periods, with that arrow, represent 87% of our history. So next time someone says, “oh that was so long ago” or “all of that is over” or even the next time you find yourself thinking it, we ask you to pause and reconsider. 87% is a super majority by any count. So of course, the legacy holds. Next slide.
[Jennica Allen speaking] So different systems havedeveloped different terminology but the racial inequity that we're talking about shows up everywhere. So in health we call it health disparities. In education, we refer to the achievement gap. In economic development, we refer to historically underutilized businesses. And at their core we believe that all of these terms fundamentally describe the same phenomenon. So, we think that to address the phenomenon in any of them weneed to ask why it is showing up in all of them. We want to keep asking the question, what causes the racial inequity? And we want to consider the possibility that racial inequity in one system contributes to racial inequity in another. Or even that the same dynamic that causes the achievement gap also causes disproportionate minority contact. So, we can fairly easily draw the connections here. As an example, studies indicate that children disciplined in school are more likely to be referred to the Juvenile Justice System. They're also more likely to withdraw from school. Withdrawal from school, we know, can lead to low-wage jobs, which is directly connected to limited health care access and therefore health disparities. So, when we see that we have disproportionality in school discipline, that impacts juvenile justice, employment, and ultimately health. So, the problem really is that we're not using the same language to describe the same thing. And more importantly we don't have an accurate understanding of the problem because we are all looking at just one piece of it. Next slide.
[Jennica Allen speaking] So this is one example, of a pathway, that Ben will explain further in a minute and the original version of this is from the Boston Public Health Commission and we think it's a great visual. So often race, and racism, are defined as Social Determinants of Health, but this image depicts the Social Determinants of Health in the middle and asks us to consider the impact of racism and then other oppressions because wewant to lead with race and racism explicitly, but not exclusively, you remember, have on the Social Determinants of Health. And how that in turn creates the health outcomes that we see more acutely. And I will turn it over to Ben.
[Ben Wood speaking] Thank you, next slide and thank you Jennica for that great overview and to further support everybody's understanding of and ability to communicate these concepts, we want to introduce the groundwater metaphor. This is a concept created over time by many racial justice practitioners but coalesced into a document and training program by the Racial Equity Institute. We want to introduce this concept using the
somewhat complicated graphic shown here and which is adapted from work developed by the Bay Area Regional Health Inequities Initiative and which we at DPH like to call the Health Inequity Pathway. The graphic is designed toaccomplish two primary functions, first is that the downstream health outcomes on the right side of the graphic are the result of a complicated pathway of upstream factors on the left side of the graphic that shape the social and physical environments in which people live and which greatly impact our health. The second is that there is a difference and a need to intervene at the multiple levels of the pathway, upstream to downstream. We are not going to spend time explaining the whole pathway in more detail than that but rather provide an enhancement to it which incorporates the following concept. Which is that if we accept that racism is embedded in all the systems that provide opportunity or create disadvantage then we want to proceed to a place where we are impacting that structural racial arrangement in ways that will both focus on systems and eventually be deeper than on any single system. The groundwater metaphor is a simple but powerful tool to help us move to that place. And it goes something like this, if you see a sick fish in a lake, the natural urge is to focus on that one fish to figure out what's going on with it. If you take one step back and look at the lake as a whole, and you see half of the fish sick,you start to ask questions about the lake itself. But if you take the next level view and see half of the fish sick in many different lakes you have to ask what is it that that is common across all of them. In the environmental context, it quite literally can be the groundwater. When we're talking about health inequities the commonality is that racism is pervading each and every lake, causing the fish to be sick. So how can it be that educators create racial differences in the classroom? How can it be that healthcare providers contribute to racial differences in clinical settings? How can it be that courts create racial differences, without some common cause across those systems? The problem becomes, when we focus on fixing fish or only cleaning up one lake at a time, all we end up doing is putting those fixed fish back in the toxic water. Or we end up filtering a lake that gets quickly re-contaminated again. The groundwater metaphor is based on three observations. That racial inequity looks the same across systems, that's what Jennica was presenting and describing; importantly that socioeconomic differences do not explain racial inequity; and that inequities are caused by systems regardless of people's culture or behavior. So, a few additional grounding ideas the groundwater concept helps to drive home that we hope you consider, and think about in context of the information you will see in the CCIS findings include the following. Proponents of equity seldom consider multiple systems simultaneously, and we consider that to be a problem, if you fix one system for one population inequities will continue to emerge over time. It is likely impossible to solve for educational attainment differences between blacks and whites without also solving for the wealth gap, without solving for criminal justice inequities, etc. Also, as the CCIS findings make abundantly clear, communities and people of color are hurting, and we need to both fix the immediate harm that is beingcaused while simultaneously focusing on the long-term, multi-stem solutions that are the real reasons why people are hurting. And finally, the burden of change needs to be on the system and not the people who are failing to succeed in them. If we had one thing to say at the end of the day, this would probably be it. I'm going to pass it back to Jennica to talk a little bit about mental frames as an additional and critical ingredient to supporting the understanding and interpretation of the CCIS findings.
[Jennica Allen speaking] Thank you Ben so we are going to talk a little bit about understanding frames and on the next slide we have just the definition that we like to use here. “Frames are mental structures, that shape the way we see the world. As a result, they shape the goals we seek, the plans we make, the way we act, and what counts as a good or bad outcome of our actions…frames shape our social policies and the institutions we form to carry out policies.” And that is from George Lakoff. And on the next slide we're going to talk a little bit about dominant frames.
[Jennica Allen speaking] So dominant frames are ideas attitudes and beliefs that are shared across society by the majority of people. They evoke certain standards values and morals that are reinforced and continued throughout society and across time. Dominant frames are things everybodyknows, right, and are often not questioned. They're embedded in the general consciousness. So, one of the examples that we like to highlight is bootstrap theory. The American dream, and those sort of work hard and succeed ideas, and they feel probably the most relevant for today's presentation. They are commonly held, but as we see in the next slide, go to that one, thank you.
[Jennica Allen speaking] It really is a little bit more like this, right? Where we have two folks saying, “Don't depend on others to help you learn to stand on your own two feet.” And one of them says, “Who said that?” And they point to the person who said it, who's actually being carried. So, the bootstrap theory again and American dream are things that are embedded in our general consciousness. And when we start to unpack for the framing of those, we have a little bit of a better idea of how that looks. Next slide.
[Jennica Allen speaking] So here we have an old but reallyI think powerful example. And the idea here, this is from August of 2005. We have at the top an image of a young black man and the Associated Press writes, “A young man walks through chest deep floodwater after looting a grocery store in New Orleans on Tuesday August 30th, 2005. Flood waters continued to rise in New Orleans after Hurricane Katrina did extensive of damage.” At the bottom we have two folks who racialize white in the AFP writes, “Two residents wade through chest deep water after finding bread and soda from a local grocery store after Hurricane Katrina came through the area in New Orleans, Louisiana.” So, the idea here and we've gone ahead and circled it for folks. So, you can see where at the top they've written looting and at the bottom they've written finding and who gets to be residents and what does that mean. So, the idea here is really just to convey how passive it can be and often is, right? So, it's unlikely that anyone wrote their blurb intending to be harmful, intending to be racist and share harmful language, but as old as this is the concept still stands possibly even more now. So, we scroll and we scroll and we take in what is presented to us, but the idea here is that everything presented to us is framed. And a critical tool in this work
is identifying the frame and thinking through the context.
[Jennica Allen speaking] So here we have a powerful quotethat we think is important in this time particularly and it is from Sonia Renee Taylor and it says, “We will not go back to normal. Normal never was. Our pre-corona existence was not normal other than we normalized greed, inequity, exhaustion, depletion, extraction, disconnection, confusion, rage, hoarding, hate, and lack. We should not long to return, my friends. We are being given the opportunity to stitch a new garment. One that fits all of humanity and nature.” And on the next slide we're going to start to talk a little bit about data to action, right? So, you're going to hear a lot of data presented and we're going to talk a little bit more about some the racial justice framing that I just started to speak about and provide you with a call to action.
[Jennica Allen speaking] So on the next slide, we have a really helpful tool. So this is something that we will see more of in a minute but wewanted to introduce it because we think that the questions are incredibly useful. So as you listen to the data presentations, and as you continue in this work, we want you to ask these questions. When presented with the information shared, ask what the problem is? Ask who's causing it? What would fix it? And we'll walk through an example on the next slide.
[Jennica Allen speaking] So this is a really strong example that we like to use often because it feels pretty accessible, particularly to public health audiences, and folks who have long done their work in this field. So the idea behind the framing tool, the reframing tool, is that we ask these questions that you see on the side, on the left here, the five questions. What's the problem? What's the cause? And tied up with that, is who and what's responsible? What's the solution? What action is needed? And what values are highlighted? So then we take a look at the traditional approach. And then we take a look at the racial justice approach, and we think about high rates of diabetes. Again this is a sort of ready-made example, that serves the audience well, usually in terms of understanding the concept. We traditionally think of the problem as high rates of diabetes. And we traditionally think of the cause of that problem is poor nutrition, lack of exercise, overweight and obesity rates. So then, who and what's responsible for all of those things become the individuals, mainly the diabetic individuals. And then the solution here would be to improve nutrition and increase physical activity. And the action needed then would be nutrition education classes, exercise classes, those sorts of things. And the values we see highlighted in this particular approach are individualism, personal responsibility, personal choice, individual freedom. When we start to think about the racial justice approach to this, we have to, we are obligated to come up with a more nuanced understanding of the problem. So instead of just the high rates, right? And for the purposes of this exercise, we're talking about type two. But when instead of just the high rates of diabetes, we should be thinking about the persistent racial inequities in diabetes rates. The cause of those are food deserts; income inequity; racial redlining, and transit and zoning for green space in communities of color, in particular, disinvestment in communities of color; and residential segregation. So now instead of the folks with diabetes being responsible for the cause, we have businesses, we have policy makers. The solution then becomes food security in all communities. Economic investment in low-income communities, communities of color. Accessible and affordable healthy foods in all communities, particularly communities of color. The action needed, and the way we like to separate solution from action is, solution is what would fix it, and action is what are the steps to get to that place. So, the action needed here in the racial Justice approach is food access policies that target roots of inequities, economic policies that invest in communities of color in partnerships across sectors and with community residents. So now the values highlighted are equity, justice, fairness, and shared responsibility, as opposed to the largely individual focused values we saw in the traditional approach. And we want to be clear that when we talk about the framing here you very well may see your work in the left and side of the reframing tool and that's okay. That is great public health work that is really important that we don't let downstream failures go, right? We absolutely want to be working at every point along the stream that you heardBen talk about. The idea really is that we're starting to shift our thinking and if we have a better more nuanced understanding of the problem, then we will also start to see better more nuanced understandings of solutions and the action steps that we need to get there. And I will turn it over to Ben for the next slide.
[Ben Wood speaking] Thanks Jennica. And so here's just one additional tool, based on the
groundwater metaphor presented earlier that is similar and that you can use to self-assess your work, and help you place the activities or initiatives you are implementing, or considering to implement, based on the CCIS findings on a matrix by asking two questions. One, are you working upstream so are you addressing, for example, city or institutional policies. Are you working to change the actual physical environment in the community etc. or are you working more downstream to deliver a program or a service to people. And the second question, is your initiative or approach being used, work to fix the fish or are you actually trying to clean up the groundwater. So here's an example, Supplemental Nutrition Assistance Program or SNAP benefits. It's a critically important policy tool to increase the ability of low and lower income people to access food. It is absolutely an upstream policy solution, but it does little to change the reasons why the benefit is needed in the first place. It helps each individual fish tremendously, but it does not alter the groundwater and we place it accordingly in the upper left hand side of the matrix. DPH's Mass in Motion program, by way of contrast, is an example of an initiative that strives to have a groundwater approach. It does that by focusing on both process and outcomes. The Mass in Motion approach creates partnerships between municipal decision makers and residents who are most impacted by their decisions. It focuses on diagnosing the root causes of why health inequities exist and it focuses on policy and multi-systems change solutions that work to provide opportunity for people to lead healthy lives. Strategies that include examples such as changing zoning to counteract the causes of segregation or working to implement, or working to eliminate, sorry, food deserts through economic development. Ultimately our hope is that more and more actions can be found in the right-hand side of the matrix, working upstream to address the systems that create risk and harm and implemented in a way that recognizes the key concepts of the groundwater metaphor. We also want to support the practice of working downstream but doing that more individual work using a groundwater approach. So just a few questions that you can keep in the back of your head as you work to embed a groundwater approach, whether you're working on upstream or downstream activities, include questions such as the following. Can you identify the, can you identify the system that is at play? For example, how food is distributed regionally in any given geography, is a system. Can you identify where that system is failing to work for people? Can you identify whether your proposed solution is asking people to adjust to fit that system or are you requiring changes to the system itself? Basically asking where is the burden of change falling. Can you also name how systems are interacting the impact outcomes? For example, how economic opportunity and food access are interacting? What are you actually doing about those interactions. And finally how do you and other stakeholders and gatekeepers understand the role you play in dismantling the systems that create risk and harm. So, if all this seems a little bit overwhelming and you're not quite sure where to start we now wanted to give some words of encouragement and suggestion of how to think about what it is that you can influence. So I'm going to kick it back to Jennica. Next slide, please.
[Jennica Allen speaking] Thank you Ben. Yes so I think we really want to drive home this point because you will look at this you will look at the tools and you'll probably say, “Well that can't be tackled in a well or sick visit, if you're a provider and that can't be tackled with our budget if you head up a nonprofit CBO.” But we want you to be thinking about your sphere of influence and your sphere of concern. So for me I think, my, I am, my sphere of concern is very large, right? I am very concerned about maternal and child health outcomes. I am very concerned about public health, in the environment. I am very concerned about violence as a public health matter in emergency. And my sphere of influence however is a lot smaller than that. I can impact fewer things than I am concerned about but as soon as I am able to identify where my sphere of influence lies then I am well on my way to sort of starting to tackle this work and see my role in it. So my sphere of influence includes anyone whose ear I can get and who will listen and who will sort of partner with me in this work. So I that can be my supervisor and my sort of reporting structure that can be any of the community-based organizations or the hospitals that I might work with through my role. It might be any of the community members in my personal life when I interact with any community groups. And the idea is that we never want you to shrink your sphere of concern to meet your sphere of influence. We want you to identify your sphere of influence and really start to act and push and leverage there. And one of the important things, tying back to the framing piece here, is that within your own sphere of influence is really just how you read things and how you contextualize things and how you understand the frame. So even if it's just when you take in a news story really starting to think about the fact that context matters, right? So perhaps you are taking in the information, perhaps you're putting out the information. You might be sharing data, you might be sharing back things, information to your funders or to your community. And we want to be clear that context matters, so if you don't provide it, if you don't consider it, then you let folks run away with the narrative. So there the sphere of influence is probably broader than you think but once you can identify that the work is really already begun.