Our recent webinar on structural racism and health equity set a record. While HealthBegins’ monthly webinars typically attract several hundred registrants, this one drew nearly 800.

Not only did hundreds of health professionals come to this discussion, but they vigorously engaged, with questions on how to acknowledge the health effects of racial injustice in the exam room, how to make an impact in the community, and how to convince others to care.

This show of passion tells us that health professionals are hungry for actionable information on this critical, neglected issue. We need more conversations, more mutual support, more usable tools.

HealthBegins is committed to catalyzing this movement by creating spaces for conversation, modeling methods, and sharing materials and resources. We see a critical opportunity where the work of Diversity and Inclusion meets the work of Social Determinants of Health and the practice of Upstream Quality Improvement.

To begin, here is a top-level summary of key lessons learned in our webinar, from the inspiring work of webinar guests from the Southern Jamaica Plain Health Center in Boston and AcademyHealth. Let this be the first of many resources that we and you, our community, share.

WEBINAR INTRODUCTION

Rishi Manchanda, MD, MPH, HealthBegins Founder & President

• Key questions for the webinar:
  • How is SDH and DI work done differently when it’s based in a framework that addresses structural racism and equity?
  • Where are healthcare institutions getting stuck when it comes to advancing and aligning SDH and DI efforts?
  • What are concrete ideas or innovations to get unstuck?
• Context: Current conversations on value, population health, and advancing the quadruple aim can all be grounded in efforts to combat structural racism and advance health equity and justice.
• Problem statement: “Despite growing interest in understanding how social factors drive poor health outcomes, many… remain reluctant to identify racism as a root cause of racial health inequities.” —Bailey et al., 2017, the Lancet
• Definition of racism: One current limitation to advancing racial equity through SDH and DI work is the lack of shared understanding of the different forms of racism. During the webinar, we defined the following forms of racism:
  • Structural racism: “The totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. These patterns and practices in turn reinforce discriminatory beliefs, values, and distribution of resources.” —Bailey et al.
  • Institutional racism refers specifically to discriminatory policies and practices carried out… [within and between individual] state or non-state institutions on the basis of racialized group membership. (Nancy Krieger, 2014)
  • Individual or interpersonal racism is prejudgment, bias, or discrimination based on race by an individual.

• There are many opportunities to weave SDH and DI work together and do better at aligning them to advance structural equity and racial justice. These include:
  • Get on your QI committee: If you are involved in SDH, DI, and/or policy/advocacy work, get involved in your hospital’s or clinic’s Quality Improvement committee or other committees related to strategic priorities (finance, governance, employee recruitment, etc.). Propose the adoption of a racial equity framework.
  • Start a conversation: In your own institution, you may have colleagues who are involved in separate SDH, DI, policy/advocacy, and/or QI initiatives. Invite colleagues from each of the areas of work into a discussion, using some of the resources below and examples provided by panelists. Feel to use or adapt the key questions for this webinar to guide your own conversation to find ways to get “unstuck.”

ADDRESSING STRUCTURAL RACISM IN HEALTHCARE PRACTICE:
THE SOUTHERN JAMAICA PLAIN HEALTH CENTER

Tom Kieffer, MPH, Executive Director

• It’s essential to apply a racial equity framework in addressing Social Determinants of Health (SDoH).
• Example problem: A patient misses an appointment because of transportation.
  • A traditional framework says: The patient is needy, the patient needs to be fixed.
  • Traditional solution: Temporary downstream solution, like a taxi or Lyft voucher, or application to Medicaid for transportation benefit.
  • A racial justice framework says: The patient is not the problem, the system is the problem. (For illustration, consider historical redlining in Boston, which overlaps with today’s transportation-poor neighborhoods. These zones of historical redlining and poor modern transportation also overlap with current high rates of disease such as diabetes.)
• Data collection: A group of Boston-area community health centers surveyed patients on transit. Findings: People of color take the bus more often and miss their appointments more often because of that. But the transportation system overall isn’t working well for any group.
• Solution to the example above: How does the Southern Jamaica Plain Health Center address the transportation problem with a racial justice framework?
  • Build an alliance with the patient. Express to the patient that we know the transportation system is not adequate and not fair.
  • Find a temporary solution. Taxi or Lyft voucher, van rides, application to Medicaid for transportation benefit.
  • Offer patient a link to community-based efforts to improve transportation, if that’s right for them.
  • Advocate for policy change. In partnership with local organizations run by the people most impacted, and using data we have gathered on the impact of transportation on our patient care.
• Now, broaden and deepen the effort. Solely addressing SDH and DI is not the answer to racial equity; these are elements of a strategy to address structural racism and advance racial equity. Other elements include:
  • Understand the history of our country, how racist policies created structural inequities, and how those have shaped healthcare.
  • Learn about how structural racism shows up in our own community and organization.
  • Adopt a common definition of racism in our organization, and embrace the role that white people and people of color have in addressing it.
  • Choose ways to address structural racism in our hiring, training, policies, programs, and content.
  • Build a diverse and inclusive organization.
  • Address SDH and DI in the framework of racial equity.
• Overcoming emotional resistance from staff who feel accused of being “racist” or who don’t believe this is the work of healthcare:
  • It’s important to us that people understand that the racial inequities we are addressing are structural. We don’t want people to personalize the critique of systems. We try to share our definition of racism and establish this structural framework, then present the data within that framework. We’re always explicit about racism, but establishing the framework helps insure that people don’t feel like you’re calling them racist. Then the data is about the systems that are creating bad outcomes for our patients of color. We’re calling people in to help us work on this problem and fix the systems, not calling them out as racist.

Juan Jaime De Zengotita, MD, Medical Director

• Beginnings: The center started its journey addressing structural racism more than 10 years ago by:
  • adopting a shared definition of racism, “a system of advantage based on race” (David Welman)
  • agreeing to be explicit about racism as well as other forms of discrimination
  • thinking of ourselves as an (aspiring) racial justice organization, with patients as partners
• Into the exam room: Initially the center trained all staff on a racial equity framework. Then a group of providers worked for two years on tools to apply this perspective in the exam room, to use it to build a better alliance with patients. One question they ask: “Many of our patients experience racism in healthcare. Are you willing to share some of your experiences with that?”
• Elements of the center’s racial justice program:
  • Youth programs on identity, racial reconciliation, and healing
  • Training on racism and health, offered to the community, public agencies, and organizations
  • Research on how we work in the exam room and elsewhere
  • Promoting equity in our larger organization (Brigham & Women’s Hospital, Partners Healthcare)
  • Policy work via the Government Alliance on Race and Equity, and on issues such as youth employment, sex education in schools, and transportation
  • Participation with Brigham & Women’s in “Pursuing Equity,” an IHI national learning collaborative to develop learning materials and best practices to share with other institutions

DIVERSITY & INCLUSION IN HEALTH SERVICES AND POLICY RESEARCH:
ACADEMYHEALTH

Margo Edmunds, PhD, Vice President for Evidence Generation and Translation

• Context: AcademyHealth is a membership organization, serving many in health services and policy research, with a mission to generate evidence and policy information to improve population health and the performance of health systems.
• Report available: “The Future of Diversity and Inclusion in Health Services and Policy Research,” 2015. This report identified steps AcademyHealth could take to lead the way on building diversity and inclusion in its own work and can be instructive for other organizations.
• Report’s recommendations:
  • Make a public commitment to diversity and inclusion
  • Communicate clearly about your commitment
  • Collect data and report out to hold your organization accountable
  • Identify best practices that are already out in the field
  • Build a more diverse pipeline
• Implicit bias is a current focus of AcademyHealth’s work, including its collaboration with HealthBegins. For example:
  • National Interoperability Collaborative, a Kresge-funded project through which AcademyHealth is working to address implicit bias in research questions on SDoH.
  • Internal awareness: AcademyHealth works to spot and stop implicit bias at its own events, such as promoting racial, ethnic, and gender diversity among invited speakers and program committees.
  • Promoting racial/ethnic and gender diversity and inclusion in organizational leadership:  AcademyHealth actively promotes opportunities for diverse researchers to present their work and participate in communities of practice focusing on social determinants, workforce, behavioral health, gender health, and many other topics.
• On making the case: Look for teachable moments and hook your messages to real-time events in the external environment. Be ready to communicate when something happens, such as the Starbucks diversity training. That’s when you can explore how systemic and structural racism are built into society, but show there are things individuals can do.

RESOURCES RECOMMENDED BY PANELISTS

The Boston Public Health Commission has been implementing an approach to structural racism in public health work and is a good connection for health departments.

2016 paper from IHI: “Achieving Health Equity: A Guide for Health Care Organizations”

Access to Public Spaces in America, a documentary film created by Stanley Nelson for Starbucks’ diversity training

Diversity.com, a recruiting website with lots of relevant materials

Government Alliance on Race and Equity, for intersectoral action with healthcare institutions as part of a broader action

Liberation in the Exam Room, a tool from IHI and the Southern Jamaica Plain Health Center

“The Future of Diversity and Inclusion in Health Services and Policy Research,” the 2015 report from AcademyHealth

Contracting for Racial Equity guide from GARE and the Haas Institute. Also see the example of HealthBegins’ own inclusion rider, as explained in this archived webinar.

RESOURCES RECOMMENDED BY PARTICIPANTS

Advancing Cultural Competence in the Public Health and Health Care Workforce, an online certificate program from the State University of New York at Albany

The Healthcare Equality Index, a tool from the Human Rights Campaign that evaluates healthcare facilities’ policies and practices related to the equity and inclusion of their LGBTQ patients, visitors, and employees

The Racial Equity Institute, a team of trainers and consultants who help healthcare leaders and organizations understand and address racism, curates a list of racial equity tools and resources.

“Why Addressing Unconscious Bias Can Make People Nervous,” an article from Health Communication Partners

Winners Take All: The Elite Charade of Changing the World, a book by Anand Giridharadas about how the global elite’s efforts to “change the world” preserve the status quo and obscure their role in causing the problems they later seek to solve.

The Inclusion Scorecard for Population Health, a tool from the healthcare training and consulting company Impact4Health

NEXT STEPS

Stay engaged.

We’ve created a page on our website to compile and share resources like those above. Please check in regularly for updates.

• Have you come across resources that have been useful to understand and address racial justice? Please share them here. We’ll include your suggestions on our resources page.

Want to get more involved in helping to build bridges between SDH, DI, and racial justice work? Contact us and let us know how you’d like to help.