Using Head and Heart to See and Address Structural Inequalities
Step onto the grounds of a plantation in the South. Read the stories, feel the place, and you’ll begin to understand how the lives of enslaved people and their ancestors were affected for generations far beyond emancipation. This is the quintessential history of racial hierarchy and racism in the United States—institutionalized and codified as the law of the land.
Plantations may be defunct, but oppressive and inequitable systems live on. Today we know this as structural inequality: the privilege and inequality that is embedded into our systems, institutions and communities because of the way they were created and are maintained.
A group of fellows from Clinical Scholars, a national leadership development program supported by the Robert Wood Johnson Foundation, recently embarked on an exploration of structural inequalities, one of several special experiences offered to fellows each year. They began as I described above, with a visit to Stagville Plantation in Durham, North Carolina, to ground themselves in the history and lived experience of enslaved people. That was an emotional, powerful and eye-opening experience that sparked deep conversation, and left many people reflecting on how so many details of this painful history have been left out of school curricula and our national narrative.
During the multi-day discussion and training that followed, one especially powerful experience was a “photovoice” project to illustrate fellows’ own stories of structural inequalities in their communities. Through these stories and images we learned about acts of resistance to honor ancestors lost on the Trail of Tears; about the fear and activism of a person married to an undocumented immigrant and living in constant fear for their safety; and how structural inequalities manifest themselves in many communities—our own communities—in many ways. Fellows left this experience with powerful insights on race in America that they are applying in their work and lives.
We will repeat and expand this training around the country—for Clinical Scholars and anyone else who wants to attend—and will post updates at ccphealth.org. Meanwhile here are some questions social workers and other clinicians, community organizations and many others can consider as part of your ongoing journey to create equity and build a Culture of Health.
How is structural inequality being manifested in the situations I am in?
Many clinicians are becoming more aware of the social determinants of health, which are those factors such as access to social and economic opportunities, conditions in the places where people live, and access to healthy options. Those factors affect people’s ability to get to office visits, follow their clinicians’ advice and take care of themselves. Beyond awareness, we need to be very intentional about seeing how our society and institutions create and sustain those factors. Ask, “Why is it that in spite of the quality of care I seek to provide to my patients, they still don’t have good outcomes?” For example, one Clinical Scholars team in Chicago is addressing the challenge of “pharmacy deserts,” a swath of a major U.S. city without access to a pharmacy, and the impact living in those areas has on patients who need to take prescriptions.
How has my discipline, field or institution contributed to structural inequality?
Early research in obstetrics and gynecology in the United States used enslaved women for experimentation. Forced sterilization and other gynecological procedures were used as a tool of oppression. People of color have been denied access to care, to education, and to banking and home ownership. Medical institutions and corporations have purchased land and displaced people. These experiences shape the way our systems continue to function and it’s important that we come to terms with this history. I’m excited about the way academic institutions are beginning to take a close look at themselves and their history with racism, including how they benefited from the slave trade. With your team, explore how people perceive your institution or organization and the history behind that. Are you open and accepting? Do people feel safe coming to you?
How do we dismantle it?
What can you and your team do to address structural inequality? Sometimes it can be hard for clinicians to step back from individual interventions and look at the institutional and systemic issues that affect their patients and their community. But if you ask “what about our clinic/community is making it hard for you to do what you need for your health?” you’ll likely find a place to start. Even a single step like working with the city to keep a bus running later along the route to your clinic can have a significant impact.
How can we engage in partnerships to address the issues of structural inequality?
You don’t have to do this alone, and in fact you’ll likely be more successful if you work in partnership with others. There’s a partnership at the core of the work I’m describing here, one between myself and Giselle Corbie Smith, Co-Director of the Clinical Scholars Program. We’ve known each other for 17 years and have had the opportunity to co-lead projects, submit grants together and much more. Partners can strengthen our work and can help us see things we take for granted or that have become invisible from our own personal context and worldview. Who can you work with in the community, from nonprofits and schools to faith leaders and elected officials, to find and address problems and build new, equitable systems?
It is no small feat to dismantle systems, practices and habits that have become ingrained over generations. But the more your heart and mind are open to seeing the barriers and inequities, the closer we come to solutions together.
Submitted By: Al Richmond, Executive Director, Community-Campus Partnerships for Health