Learning what defines equity and why it matters is essential to creating an environment that puts equity front and center. The following excerpt from IHI’s Improving Health Equity: Make Health Equity a Strategic Priority guide describes how some organizations are trying to better understand their communities to build will to address inequities.
Making health equity a strategic priority requires building will and increasing awareness about equity in your organization. Staff must understand what equity is and why it matters. Patient stories and equity data help build will, as does helping staff understand how equity relates to their organization’s mission and their daily work. Increasing awareness is a necessary step for building will and must be coupled with efforts to improve health equity.
Understand Your Current and Historical Context for Inequities
Health care organizations’ interventions and activities have the capacity to perpetuate, worsen, or ameliorate inequities. Health system leaders have a responsibility to understand, acknowledge, and openly communicate to their staff and community the role that the health system has played in perpetuating inequities and the broader historical context of how the inequities came to be. It can be difficult for individuals to admit that their organization has contributed to structural racism (i.e., a system of advantage based on race) through their policies, practices, procedures, and norms. However, an understanding of the root causes of racism in our organizations and communities provides the best opportunity to find solutions that can address the key drivers of inequities.
Described below are specific changes that health care organizations participating in the Pursuing Equity initiative tested to better understand and discuss their current and historical context for inequities.
- Visually map the community to elucidate inequities.
Pursuing Equity organizations found that visuals and maps are useful tools to build will to improve health equity.
Examples of changes tested:
- Rush University Medical Center (RUMC) is the largest employer in West Side Chicago, Illinois. Economic deprivation (including unemployment), poverty, lack of housing, and food deserts are the byproduct of decades of structural barriers in Chicago’s West Side. As a result of these factors, life expectancy in the West Side’s West Garfield Park neighborhood is 69 years, while life expectancy in the Chicago Loop area (about six miles away) is 85 years. As part of their efforts to build will for improving health equity among staff and community members, RUMC developed a graphic (see Figure 2) to depict life expectancy in different Chicago neighborhoods and to illustrate the effect of decades of inequity.
Figure 2. Life Expectancy (in Years) at Birth in Chicago by Neighborhood
- To better understand the history of Boston, Massachusetts, and surrounding neighborhoods, Brigham and Women’s Hospital Department of Medicine and Southern Jamaica Plain Health Center reviewed the Boston Residential Security Map of 1938 (see Figure 3). The Home Owners Loan Corporation created a City Survey Program in the 1930s, which examined the risk levels for real estate investment in cities across the United States, including Boston. The maps used four color-coded categories to indicate each neighborhood’s risk level, with red being the most hazardous and riskiest for lenders. This became known as “redlining”: the process of financial divestment in communities that were primarily people of color, while simultaneously investing in communities that were white and wealthy. Redlining also impacted predominantly white immigrant populations, yet those groups often deserted their communities, perpetuating racial divisions in devalued areas. The effects of these racist policies are still felt in Boston and all other major US cities today.
Brigham and Women’s Hospital Department of Medicine and Southern Jamaica Plain Health Center, both located in one of these historically “redlined” Boston-area neighborhoods, know that access to transportation, health care, food, housing, and education all effect a person’s health. These organizations are thus working to deepen their partnership with key organizations and leaders in these communities as part of their anchor organizational strategy.
Figure 3. Boston Residential Security Map of 1938
- Invite key community members and organizers who can to talk with the health care workforce about the community’s history, to deepen providers’ understanding of the context in which health care is provided.
To build will for improving equity, it is important for leaders and staff to understand the history of the communities in which their health system is located and the organization’s interactions with the community from an equity perspective.
Examples of changes tested:
- Boston’s Southern Jamaica Plain Health Center (SJPHC) invites elders and senior organizers from their community to staff meetings to provide historical context. Many SJPHC staff also have historical knowledge of Jamaica Plain and the surrounding communities. SJPHC Directors of Racial Justice and Equity provide training on using different types of narrative to discuss the historical, cultural, and institutional patterns that have perpetuated race-based advantage. SJPHC uses the Storytelling Project Curriculum as a framework to discuss racism with staff, focused on four types of stories and how to go beyond the stock stories narrative:
- Stock stories: Public, mainstream stories told by the dominant group and documented
- Concealed stories: Not public, hidden from the dominant group, and circulated by marginalized groups
- Resistance stories: Current and historical stories challenging stock stories and describing how racism has been resisted
- Counter stories: New stories that build on resistance stories and are constructed to disrupt the status quo and deliberately challenge stock stories
SJPHC Directors of Racial Justice and Equity lead the group through a dialogue about the four types of stories and how they present in both the community and the health system. SJPHC discusses how certain stories can perpetuate racism in their community and how other stories have the power to promote racial justice. SJPJC Directors, elders, and senior organizers emphasize the evolution of structural racism over decades and do not personalize the critique of the health system.
To learn more about the other essential elements of equity, download the free Improving Health Equity: Make Health Equity a Strategic Priority guide.
Editor’s note: Sessions about Equity and Leadership are part of IHI’s National Forum this December.
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