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Looking Up the River: The Impact of Race & Ethnicity on Health

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A presentation for the Oklahoma Health Equity Campaign on racial health inequity in Oklahoma, including history, causes, and policy recommendations.

A presentation for the Oklahoma Health Equity Campaign on racial health inequity in Oklahoma, including history, causes, and policy recommendations.

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  • Let’s start with the title of this presentation[River allegory]I think too often in the helping professions (including non-profits, social services, health providers, etc) we get caught up in fixing the visible symptoms of the problem. It’s understandable: they’re easier to identify, quantify, and address. But I would like to suggest today that we need to spend at least part of our time identifying and eliminating the root causes of the health inequities we’re trying to address. This is harder to do for several reasons:Our educational system hasn’t done a great job of fully conveying our history, especially the uglier bits, so we have little context to understand why things are the way they areWe’re not generally taught as a culture to think systemically: this is woven into our American mythology, when we learn about rugged individualism and personal choice, bootstraps and self-reliance. All these social narratives frame the way that we see the world, and shape how we solve social problems. It’s challenging to unscript from these frames and look at things in a different way.Finally, it can be uncomfortable, even painful, to examine our collective experience this way. On some level, we know that it’s easier to look at disparities and disadvantage as the problem of POC, and ignore the privilege and advantage that benefits the majority (in the case of race, white people, but privilege exists across identities). We’re ill equipped to discuss these issues and too often these conversations lead to feelings of guilt, shame, betrayal — all completely understandable, but also completely unproductive and inadequate in bringing about genuine solutions. So today I invite and challenge you to leave the scripts and turn off the autopilot when it comes to race.We have so effectively stigmatized bias and racism as a society — swung the pendulum of acceptance so far in the opposite direction — that we’ve cut ourselves off at the knees when it comes to dealing with the actual impact of race. We brag about being colorblind, claim that those who speak about race are the true racists, dismiss any attempts to address racial disparities as political correctness. Meanwhile, our communities become increasingly segregated, tensions continue to rise, and we keep talking past one another. Study after study shoes that this approach isn’t helpful.
  • I’ve been asked to do this in 45 minutes, so please bear with me as I go through a lot of material very quickly. The good news is that I will post this presentation and additional resources to my blog, which you can find at www.TulsasJourney.org. I’ll send that link to Marisa to distribute to the list as well, so for now, feel free to absorb the information with the peace of mind that I’ll be in your hands later.I would also as that you take notes on questions as they arise so hopefully we can address them all at the end. Also, please be mindful that if there are things that challenge you today, it’s probably because I’m going against the script we’ve all been taught. That’s okay: discomfort is where learning happens. One of the ways we’re taught to consider challenging issues is through a didactic lens — either/or thinking rather than both/and thinking — if something in this presentation gets you into that mindset, I encourage you to examine what it is that got you into that mode: that’s a growing edge to work on when you leave today.
  • We’ve all heard these stats, right? Nationally and within our state, people of color face dramatic health inequities from cradle to grave.
  • I want to point out that while we’re talking about race today, it’s important to remember that the intersections of identity are vital to understanding this complex challenge. That is to say, that adding age, class, gender and gender identity, sexual orientation, national origin, physical ability, and other identities into the mix exacerbates existing inequities several times over. Take a transgender woman of color — she has several identities that are underserved or abused by our health systems, and framing her identity along racial lines alone tells only part of her story.
  • You can see in these statistics that women of color experience racial bias and gender bias, as a result of being often invisible to the health care system.
  • In Oklahoma, as we know, the major health indicators tell a similar, if not worse, story. These charts demonstrate how white people, though in the majority, experience lower than average rates of infant mortality, AIDS deaths,….
  • …poverty, reliance on Medicaid, and lack of insurance than people of color
  • Viewed together, you’ll notice how POC consistently experience poorer than average health than their white counterparts (second column) or the statewide average (first column)I’ll post a detailed fact sheet on my blog with this presentation with many more local statistics.
  • So, how did we get here? It’s easy to look at the data and make assumptions based on the received narrative I spoke about a few minutes ago: if as Americans we believe that your life is a sum of your own personal choices and those choices alone, it’s a rational conclusion to say that people of color exercise bad judgment, make poor choices, and therefore reap what they sow. And of course, health status is caused by complex interaction of many factors, including individual behavior. However, recognizing the importance of individual behavior in health status does not at all minimize the need to focus on systemic influences such as poverty and racism. Focusing on behavior alone limits our understanding of history, context, and systemic causes. It also limits our ability to see people as fully human and capable of making rational decisions — we often apply our own worldview to other people’s experiences, which can lead to paternalistic thinking and diagnoses. When we become more aware of people’s historical context, we begin to see that the choices they make are completely logical given their experiences, and we can become much more effective in our work. **Before I go any further, I want to say that while I have aggregated this information myself, I have relied heavily on the work of experts in the field of race and health, specifically on Vernellia Randall, whose excellent book Dying While Black informed much of this presentation. **Let’s take a few minutes and examine the history of health in the U.S.
  • Again, we are often distracted from an honest discussion around race by discussions on socieoeconomic class. And indeed, race is a strong determinant of social class —In the US, race is a major determinate of social class because of how our economic systems were designed and laws were established regarding wealth acquisitionBut more importantly, when controlling for economic status, racial inequities persist
  • Race still matters because it is part of our collective consciousness, it permeates how we see and understand our environment. Most of the time, when someone says racism, they’re talking about what I call “old school” racism — lynch mobs and white hoods. Now, we know that that form still exists — in fact, for a lot of reasons, it’s on the rise since 2001 — but that’s not the form that is most prevalent in 2010. Instead, racism has become more obscure, less easy to identify (though no less harmful) — because it has become codified in how our institutions operate. This is what we call institutional racism.What makes this form most insidious is that it doesn’t need bad intent to operate. That is to say, because racism is in the DNA of our institutions (because, after all, all our modern social systems originated during a period of white supremacy), it has it’s own inertia. So it’s much more challenging to identify a culprit because there often isn’t one: rather, it works quietly in the background of our society, and is often invisible to everyone but those it impact.Consider this example:May not be intentional, but it mattersCoded messages So you can see how we can get wrapped up in the idea of intent and miss the point entirely: focusing on intent abdicates accountability, it allows unintentional discrimination to go unchecked, because it’s easy to say that because the institution didn’t intend to discriminate, it’s not responsible for discriminatory outcomes. One of the central tenets of social justice is that privilege renders invisible the impact of our actions, which makes intent less important. Example: even if an office doesn't intend to be inaccessible to people with limited mobility, they may still not have wheelchair ramps. Intent doesn't matter when outcome demonstrates discrimination.
  • So, what does this all have to do with health care? Well, I submit that along the continuum of health care (before seeking care, attempting to access care, and treatment), institutional racism is always present. In some ways, this may seem overwhelming. I hope that by the end of this presentation, you’ll instead feel inspired because once a problem is clearly diagnosed, the solutions become easier to identify and implement. We don’t have to do it all right now, but we do need to recognize where our current strategies are falling short because of an inaccurate assessment of the problem.
  • Toxins studies have concluded that race more than poverty, land values, or home ownership is a predictor as to the location of hazardous facilitiesRace is independent of class in the distribution of air pollution, contaminated fish consumption, location of municipal landfills and incinerators, abandoned toxic waste dumps, cleanup of superfund sites, lead poisoning in children, and asthmaAfrican Americans are disproportionately represented in jobs with the highest environmental hazards, such as fast food and pesticide-intensive farm labor, rubber making, coke production, battery manufacturing, lead plating and smelting, and industrial launderingThe blood lead levels in urban African-American children under the age of five significantly exceed the levels found in white children of the same age living in the same cities. This disparity persisted across income levels.
  • 25% of African-Americans have no source of health coverage (independent of class)the number of uninsured African-Americans is increasingracial barriers to employment are one explanation for the significant difference in insurance coverageAfrican-American is more likely to be in a lower paying job which does not provide employer-based health insurancehigher percentage of African-American families with only one adultlocating adequate health care facilities within the Black communityFacilities serving African American communities are relocating to white neighborhoodsPrivatization of hospitals Lack of early access to health care increases health problems over timeassuring competent health care workforce in black communitiesWithout physicians and providers in their communities, African-Americans are likely to delay seeking health careAfrican-Americans are seriously under-represented in every health care professionsThis lack of African-American voice leads to increased ignorance on the part of European-Americans regarding issues pertaining to African-American healthThis lack of African-American representation in health care is traceable to slavery, racism and segregationTrustSyphilis testinginvoluntary sterilizationForced institutionalization
  • assuring the cultural competence of the health care workforceAssumptions of the middle- class, middle-aged, European American system:the system focuses on individual autonomy rather than family involvementassumes a basic trust in the health care system instead of distrustrelies on a western European American concept of communicationsIt is built on a western European concept of wellness, illness and health careOne barrier to culturally competent care is the physicians' own negative perceptions about African Americans. Because they have differing needs and problems in accessing care, physicians may see African Americans as less compliant and more difficult to care for.Through reparations culturally competent care can be assure by requiring: health professional schools to train providers from a diverse backgroundall physicians to have a rotation during their internship and externship the focus on providing culturally competent careproviders to take continuing educational units in cultural competencyhealth care facilities and managed care organizations to complete and submit on regular basis a cultural competency assessment to a regulatory agency health care be provided in accordance with realities of the needs of the various "classes" of the Black community.increasing the knowledge about health and health of black persons and translating it into effective clinical practiceThe health condition of African Americans will continue to suffer until they are included in all types of health research. The information from that research has to be translated into clinical practice without becoming just another stereotype.Racial inequality persists despite laws against racial discrimination, in significant part because of the inadequacy of Title VI. As long as the law requires a conscious discriminatory purpose for disparate treatment liability, individual discrimination claims cannot address the issue of unconscious prejudice.Our legal system has had particular difficulty addressing issues of "unthinking discrimination", that is discrimination that results from acting on biases and stereotypes. Office of Civil Right's ("OCR") Title VI enforcement effort has produced little consistent data for evaluating Title VI compliancethere has been "little uniformity in how different states handle Title VI requirements, little guidance, little analysis of the information collected by this process, no research and developmentTitle VI lacks specific definitions of prohibited discrimination and acceptable remedial actionOCR has relied on individual complaints as a means of enforcement which is particularly troubling where most discrimination and even harm is hidden from the individualOur health care system presents several additional problemsPeople of color will be totally unaware that the provider or institution has discriminated against thembecause of the very specialized knowledge required in medical care, individuals may be totally unaware that they have been injured by the providerOur health care system, through managed care, has actually built in incentives which encourage "unconscious" discrimination
  • Notice how the language of race is noticeably absent. I don’t think this is an accident — but I also don’t think it’s intentional. How is that possible? I think it’s because we’ve thwarted our own ability to talk about race in honest ways. We’re afraid that talking about race makes us racist, that we should instead be colorblind, so we couch things in terms of “cultural competency” — which is entirely about understanding “the other”. In fact, the very word “culture” is loaded: how many people consider white to be a race, or think about whiteness as a culture? We don’t think of the standard training we receive as cultural competency in service white people, but that’s precisely what it is. So what happens is that we focus externally rather than internally. We think of spaces as racialized only when POC enter them — instead of realizing that whiteness is a racial construct as well, one which we rarely examine, but that has as much cultural baggage as any other racial identity.
  • Because that identity is normalized — because we see whiteness as standard or neutral (think of “flesh colored” or “nude” bandaids, “normal hair” shampoo,
  • a focus on education and prevention through targeted servicesdiabetescardiovascular diseasematernal and infant mortalityHIV/AIDScanceroral healthmental healthdrug, alcohol and tobacco addictionasthma violence (including domestic violence).the provision of a liveable wage for all persons and familiesPoverty effects housing choice, job choice, food and educationThe San Francisco Department of Public Health reported livable wages diminish mortality rates, decrease unnecessary hospitalization of the poor, eliminate some costs associated with caring for the homeless, and saved lives
  • Through reparations culturally competent care can be assure by requiring: health professional schools to train providers from a diverse backgroundall physicians to have a rotation during their internship and externship the focus on providing culturally competent careproviders to take continuing educational units in cultural competencyhealth care facilities and managed care organizations to complete and submit on regular basis a cultural competency assessment to a regulatory agency health care be provided in accordance with realities of the needs of the various "classes" of the Black community.
  • As the United States Commission on Civil Rights foundThere is substantial evidence that discrimination in health care delivery, financing and research continues to exist. Such evidence suggests that Federal laws designed to address inequality in health care have not been adequately enforced by federal agencies. . . [Such failure has] . . . resulted in a failure to remove the historical barriers to access to quality health care for women and minorities, which, in turn has perpetuated these barriers.
  • As the United States Commission on Civil Rights foundThere is substantial evidence that discrimination in health care delivery, financing and research continues to exist. Such evidence suggests that Federal laws designed to address inequality in health care have not been adequately enforced by federal agencies. . . [Such failure has] . . . resulted in a failure to remove the historical barriers to access to quality health care for women and minorities, which, in turn has perpetuated these barriers.

Looking Up the River: The Impact of Race & Ethnicity on Health Presentation Transcript