Racial Health Care Disparities: How Do We Move Forward?

I have been practicing Pediatric Hematology in Minnesota for 20 years. For the bulk of that time I’ve had the distinct honor and privilege of caring for children with sickle cell disease. Sickle cell disease is one the most common inherited genetic disorders, and is the most common abnormality detected on nationwide Newborn Screening tests. There are 100,000 Americans living with sickle cell disease. It is a disease that affects the red blood cell and has multiple complications including severe pain, stroke, lung disease, infections, and early death (http://scinfo.org/). Although sickle cell disease is a global issue that affects people of all races, in the United States patients are predominantly black.

As a white man, trained by mostly white faculty and white mentors, I never really gave this much thought. Physicians strive to provide quality health care to all of our patients and families and race shouldn’t be an issue, right? Well, then I stumbled into a workshop on White Privilege given by Heather Hackman at the Rainbow Families Conference in 2008. Only then did I begin to consider how my identity as a white male physician might affect the health care delivery to my patients of color. This consideration was long overdue and since that moment, I have been on a journey to better understand racial health care disparities and, with Heather, develop an action plan to address this inequity.

While many factors affect health care equity, disparities based on race that target communities of color are consistently reported in the management of many diseases. For example, blacks receive a lower standard of care than whites when being treated for breast cancer, orthopedic problems, cardiovascular disease, pain, and end-of-life care. According to the 2009 National Healthcare Disparities Report produced by the Agency for Healthcare Research and Quality, many of these discrepancies are not decreasing. Blacks receive worse care than whites for half of the core measures studied, and only about 20 percent of measures of disparities in quality of care improved over the study period of 2000–2007. Being uninsured was the single strongest predictor of quality of care. However, when correcting for uninsurance and socio-economic status, blacks still eceive worse care than whites (www.ahrq.gov/qual/qrdr09.htm). At the local level, a recent Wilder Foundation study reported similar results. Blacks and Native Americans in the Twin Cities have a significantly shorter life expectancy than whites, even after correcting for socio-economic status. (“The unequal distribution of health in the Twin Cities: a study commissioned by the Blue Cross and Blue Shield of Minnesota Foundation,” October 2010 available at www.bcbsmnfoundation.org/objects/Publications/F9790_web%20-%20Wilder%20full%20report.pdf)

Barriers to racial health care equity include the health care system (insurance, funding, white-domination in provision of care), the patient (poor health literacy, fear, mistrust), the community (awareness, advocacy), and we the providers (bias, attitudes, stereotypes, expectations). The combined magnitude of these factors can seem overwhelming, and yet there are points of entry for each of these major variables. As providers, I believe we have the greatest potential for changing racial disparities by working on our own biases. There is much published evidence that our behavior contributes to race/ethnicity disparities in care and that patients and providers perceive race as an issue in health care delivery. Heather and I recently published some of our work in this area (http://hackmanconsultinggroup.org/wp-content/uploads/Race-Matters.pdf). So, what can we do about provider attitudes and biases?

Stay tuned…..Heather and I have developed a training module for health care providers to address race, racism and whiteness and how these affect health care delivery. We hope to present data from our initial pilot training at the 7th Annual Sickle Cell Disease Research and Educational Symposium & Annual National Sickle Cell Disease Scientific Meeting April 14-17 in Miami (http://fscdr.org/).

Similar to Heather’s blog from January 13 Racial Justice Work: A Spiritual Imperative, I strongly believe that racial justice work is also a Health Care Imperative. In the words of Martin Luther King, Jr: “Of all forms of inequity, injustice in healthcare is the most shocking and inhumane.” National Convention of the Medical Committee for Human Rights, Chicago- 1966 (http://www.standupforhealthcare.org/blog/martin-luther-king-jr-a-civil-rights-icon-s-thoughts-on-health-care).

 

© 2013 Hackman Consulting Group – Do not reproduce part or all without permission.

 

 

 

Understanding Resistance to Social Justice Trainings

One of the most consistent and challenging elements of training on social justice issues is the resistance that members of dominant groups put forth, particularly when talking about how systems of oppression work and the relationship of their privilege to those systems. And while there are ample sources of information that talk about how to respond to resistance (i.e. racial identity development models, Allan Johnson’s “Getting Off the Hook” from his book Privilege, Power and Difference or Elder and Irons research on “Distancing Behaviors”), in my introductory-level trainings I try to keep it simple and explain this resistance as being driven by three primary sources: Ignorance, Fear, and Privilege. I present them in this order because this tends to be the progression of their visibility in a training (a person’s lack of information often being more obviously visible than their blatant privilege), and it is a logical sequence when trying to support resistant people in their learning and growth.

 

Ignorance

The first layer of resistance, “Ignorance”, refers to a participant’s lack of accurate education and critical awareness with respect to the focus of the training. More specifically this ignorance is either about a participant’s lack of knowledge altogether, their misinformation and mis-education about the topic, or their lack of critical thinking skills when engaging with the topic. In the training itself, the first aspect merely requires time for accurate education and information to be shared, and as such the level of resistance here is comparatively low. An example of this comes from trainings I do on sexism and gender oppression. At some point we get to discussing issues of violence against women and sexual assault, and I pause to ask how many men in the audience will be thinking about the possibility of being sexually assaulted on their way back to the car (very few hands go up) versus how many women will be mindful of this (almost all hands go up). Invariably the men are surprised by this and come to realize that they don’t know as much as they thought they did about the lives of women in this society which lead to a palpable and positive shift in the learning energy of the room.

 

The next layer of resistance due to ignorance is more complicated in that it first involves the “un-doing” of the participant’s previous knowledge and then a educating of that participant from a social justice perspective. These folks tend to resist more because they are attached emotionally, politically, or intellectually to the misinformation they have been given. I encounter this pattern when I do racial equity trainings and have to undo many layers of mis-education white people have received with respect to race (see James Loewen’s Lies my Teacher Told Me) and then accurately educate them about the history and presence of racial issues throughout U.S. society. Easier said than done, of course, because participants have held their ideas their entire life and are often hard pressed to let them go. Nevertheless, after enough exposure to racial justice content these participants do begin to let go of their resistance.

 

The final level of resistance out of ignorance stems from a lack of experience with critical thinking which engenders a fair bit of push back because it is touching into the core processes by which people make sense of the world. Critical thinking involves accepting complexities and grappling with multiple perspectives, and for participants who have lived by seeing issues as “either-or” this is a significant challenge for them and they often strongly resist. Examples of this can be seen in trainings I do on the oppression of LBGTQI folks where many heterosexuals have been raised to simply believe that “gay is bad and that’s it”. In these situations, I use a three-part definition of critical thinking and slowly take participants through it using commonplace examples, building eventually to more complicated social issues, and finally to LBGTQI issues. This of course takes considerable time, patience, and repetition but it is essential in aiding these resistant participants in grasping the concept of critical thinking and thereby being ready for the remainder of the training.

 

The antidote for resistance out of ignorance in trainings is, of course, to have ample amounts of information at your fingertips in order to provide both resources and specific examples for folks who might be struggling with so much new information. As such, I never go into any educational moment regarding social justice content without ample information and resources to help move these folks along.

 

Fear

However, sometimes I encounter participants who actually do have a solid information base and yet still resist social justice content. In these cases the source of the resistance is almost always “Fear”. This second level of resistance has a few key organizing principles: fear of conflict, fear of making a mistake, and an overall fear of the issue being discussed because of its intensity in our society. I live in the Upper Midwest and there is a substantial level of conflict avoidance in this part of the country. As such, many white folks, for example, are reluctant to address issues of race, racism and whiteness because they do not want to create any conflict in their work or homes (not realizing that the mere existence of racial oppression is already a moment of conflict). Likewise, many men will not address issues of sexism or gender oppression when talking to women or trans folks because they are afraid to make a mistake. Unfortunately, this approach is read as tacit approval of sexism / gender oppression and ends up sending the opposite message that these men want to convey. Sometimes, however, the overall intensity of issues tends to keep members of the privileged group quiet. When discussing issues of class and economic access, for example, there is a sense that because these issues cut so deeply in our society they are just too difficult to bring up and are thus avoided. The antidote to these fears is to do the opposite of their inclination and take a risk by speaking up. No growth happens from a place of silence, and no change happens from the inaction brought about by the freezing effect of fear. As such, role play scenarios, moments of paired “practice”, case studies, mock debates, and “what would you do” inventories are important ways to help dominant group members see the absolute necessity of leaning into their fear, speaking up and taking action.

 

An additional dimension of fear to be considered with respect to dominant group resistant is the fear dominant group members have of backlash from their peers. As a university professor I often heard this from men as we discussed issues of sexism: they knew the joke being said or the comment being made was wrong and oppressive to women, but they were too scared of the “crap” they would get from their male peers if they spoke up so they stayed silent. In this case it was clearly not a matter of not knowing right from wrong, it was purely a moment of men policing other men around their collusion with sexism. To try and find an ally in the middle of these situations is a difficult task and this is where the practice options in the previous paragraph become critically important: if men who want to end sexism speak up before these situations arise and engage their male peers in less contentious instances, they will be more skilled and able speak up in these more difficult moments despite the threat of backlash. Once again the need for ongoing action and practice is a critical feature in reducing dominant group resistance because of fear.

 

Privilege

The core reason why members of dominant groups resist equity conversations, however, is connected to their “Privilege” and the benefits they receive via systems of oppression. Whether these responses range from “I’ve worked for everything I’ve got and have no privilege” to “I feel guilty and don’t know what to do” to “I did not even know I had privilege”, the benefits that men, whites, and professional middle class / owning class people (just to name a few) get are so substantial that it is the core reason these participants resist talking about issues of oppression.

 

I find that one of the many viable approaches in these moments is to a) get participants to understand and agree that systems of oppression exist, b) get them to understand and agree that within each system of oppression there is a group targeted and a group that benefits, and then c) remind these dominant group participants of their core values and how the mere existence of a system that oppresses some for the benefit of others is against who we say we are as a nation, who we want to be as a community, and who they want to be as people in this world. This last point is often connected to the context I am training in, so if I am working with teachers I remind them of their commitment to educate all children, if the audience is doctors and nurses I remind them that they took an oath to serve all people, if it is faculty at a law school I remind them of their commitment to truly fair adjudication in this country, if they are a religious organization I remind them that benefitting from systems of oppression and doing nothing about it fundamentally compromises their core spiritual beliefs (see last week’s blog). In these ways, we can lead resistant participants to a place of not only cognitive dissonance regarding their work in the world, but also a place of moral dissonance where they are urged to tap into their deeply held values and beliefs in the service of dropping their resistance and opening up to social justice content and action. In this way we help resistant participants see that the existence of privilege for some at the expense of others is a toxin to our entire society and will inevitably harm all of us – an injury to one is an injury to all. Sharing from my personal experience I stress to these resistant participants that acknowledging my white privilege, for example, is not about guilt or shame or being blamed for the ills of the world, but is instead a moment where I can recognize all that has transpired before me regarding race, racism and whiteness, and using that knowledge make a different choice – a choice for justice, a choice for my core values of compassion and equity and peace, a choice that cannot undo the past but that absolutely can help us all heal from its wounds and move forward as a more whole, more safe, more generous and loving society.

 

Resistance out of privilege is intense, sometimes angry, but underneath it is uncertainty on the part of these dominant group members – What kind of world will it be if I’m not on top? What will happen to me? How will I know how to be in this new world? The normativity of their lives as members of dominant groups makes the dismantling of privilege feel like the end of the world altogether. And this, again, is where the appeal to deep and profound aspects of the human condition can sometimes help these participants make the leap and learn how much better it feels to be on the right side of history, to be a sower of equity not enmity, and to be doing the hard and heavy work of healing that which has divided us for so long. Although it may sound like it, this is not Polyanna. This is about the deep truths of who we are as humans. We are a collective species, and we do need each other…not just “our” kind, all of humankind. And in the face of this deep connection we have to each other and to the needs of the human heart, privilege is anathema and a socially just world is the salve.

 

So, while there are innumerable ways to address the deeper psychological, sociological, and physical complexities of why dominant group members resist training on social justice and equity issues, my experience has shown that framing resistance using these three levels gives introductory level participants a fairly accessible way to understand it and a visible course of action for confronting it. In my 20 years of teaching and training on this content, I have had countless (truly, countless) experiences with white people who resist racial equity work, men who resist gender equity work, and well resourced people who resist class equity work and have found that addressing this resistance on one or more of these three levels resonated with participants and created some space for them to (albeit slowly) release the grip on their resistance and more readily embrace the training.

© 2013 Hackman Consulting Group – Do not reproduce part or all without permission.

 

 

 

 

Racial Justice Work: A Spiritual Imperative

Over the course of the last few years, I have had the privilege of working with various communities of faith on racial equity issues and I usually title the training “Racial Justice: A Spiritual Imperative”. I do this for two reasons: First, the word “imperative” tends to stimulate curiosity among congregants and draws them to the training. And second, it is true. I explain it this way – in Karen Armstrong’s recent publication, Twelve Steps to a Compassionate Life, she states that every major world religion or system of faith has at its core love, compassion, and service to others. Importantly, the centrality of these issues is not limited to the monotheisms, or to the Eastern religions, but is evident in a wide range of examples within various systems of faith. Even “spiritual” (but patently not religious) organizations such as Alcoholics Anonymous have love and service at their core.

 

And so, if love, compassion and service are at the heart of many of the world’s systems of faith, then it stands to reason that the mere existence of something so hateful, so inhuman, and so toxic as racial oppression (or any form of oppression for that matter) is an affront, or even an impediment, to one actualizing their chosen spirituality. Conversely, and this is something that most congregants intuit, it is logical to presume that engaging in racial equity work draws one closer to the core principles of their faith or spiritual path. Putting all of this together, it does not seem too much of a stretch to assert that racial justice work is imperative to the lived experience of many of the world’s faith systems. And this is exactly the approach I take when training communities of faith on these issues, especially communities of faith that are predominantly white: I help congregants understand the ways racial oppression undermines their faith, and in turn how racial justice work feeds and strengthens it.

 

Once understood, many congregants are eager to get started and “jump right in”. However, there are two very important issues to be mindful of before a community of faith undertakes racial equity work. The first is the occasional notion in predominantly white congregations that, while this work is part of their spiritual path, they are really only engaged in it to help people of color – a paternalizing (sic) attitude that does more harm than good. In fact, when congregants understand that racial oppression is based on both the way systems of racism target communities of color and how systems of white privilege benefit white people, the white members realize that they are part and parcel to this system and begin to engage in it more honestly and effectively. As such, much of the work these predominantly white congregations need to do when embracing racial equity work as a spiritual imperative involves addressing both racism that targets people of color and an examination of their white privilege.

 

A second caution for predominantly white congregations when doing racial equity work as a spiritual imperative is that many in the U.S. (and perhaps other Western societies) tend to individualize systems of faith or religious philosophy, often with the result of distancing themselves from the suffering of their fellows. This results in a predominantly white congregation’s racial equity work having the feel of charity instead of real equity, thereby maintaining a certain privileged distance while trying to address racism. The solution is to reach deeply toward our common humanity and remember that there really is no separation between us – whether it be “whatsoever you do unto your fellows you do to me”, or the teachings of karma, or the notion of tikkun olam, or the pillar of hospitality, the base principles of many of the world’s systems of faith do not actually allow one to extricate themselves from their community of fellows. Thus, racial equity work is not about “charity” work for others, but personal work that deeply connects us to each other and to our essential humanity.

 

In the many trainings I have done for communities of faith, it has been deep and abiding faith that draws many predominantly white congregations to this work and buoys them as they do it – even though it can sometimes be intimidating, confusing or frightening. I witnessed this a few months ago while working with a group of Catholic teachers – the racial equity content was clearly challenging for this predominantly white group of teachers, but when I asked them to identify ways their Catholicism buttressed their racial equity work, it became immediately evident in their body language and what they shared that their faith was a source of courage and motivation to continue to lean in and learn about racism and white privilege. Let this be an example to all communities of faith engaging in racial justice work: this is not charity work, this is not only about supporting communities of color, it is about ending the dehumanizing impact of racism and white privilege on all of us so that who we aspire to be as people of faith lines up with who we actually are on a daily basis.

© 2013 Hackman Consulting Group – Do not reproduce part or all without permission.

Hope for the New Year

As one who consults on, writes on, trains on and focuses on social justice and equity issues on a daily basis, here’s what I hope for in 2013: that we learn to breathe. More specifically I hope that we can grow in our ability to just take a moment, slow down, and breathe deeply. Sounds simplistic, I know. My students used to quietly refer to this as “human relations hoo-ha mumbo jumbo”. But as I continue to develop training tools and ways to reach wider audiences, I am more often beginning each training, conference presentation, and even key note address with a “grounding in” that has us all breathing deeply and remembering to be here now. And while participants in a training or workshop may have different lives, struggles, and ways of viewing the world, underneath that is a common body of hopes and needs – we all want to be safe, we all want to feel loved, and we all want to contribute to our communities in some way. And I have found that if we pause to breathe deeply, slow down, and take the time to listen and connect with one another, we can see those common hopes reflected in each other and thereby better connect across that which divides us.

 

Lest you think this is hyperbole, Sylvia Boorstein suggests that breathing deeply does two critical things for us in times of difficulty: first, it relaxes the body. Just as the mind has an impact on the body (stress leads to tightness), so too can the body impact the mind. Thus, breathing deeply and slowing the body down relaxes and slows the mind down. And, it is from this space that we stand a better chance of listening and connecting. Second she suggests that deep attention to the breath stops “the story” for a minute and allows for the possibility of truly hearing someone else over the endless din of the old lines we have running in our heads. In this way, we are able to suspend our old beliefs long enough to see an issue from another point of view. Both of these are essential elements for successful social justice training and why I use them in every training I conduct.

 

In my trainings and workshops, I see how deeply afraid some folks are when confronted with issues of equity. But I can also see that underneath those fears and often-defensive responses lies the hope that somehow we really can all be okay and all get along. In every tradition, in every heart, in every home there is actually a desire to “get along”. And yet, despite the countless gains throughout U.S. history, our society still tends to lose its way in so far as various equity issues are concerned. But losing one’s way is not the same as having no way at all, and so in this the beginning of a new year for some (acknowledging that not everyone follows the same calendar) I am hoping that we can awaken the common hopes that lie within, breathe and allow them to rise, and in the process let them carry all of us back to what we know to be true – that we are all in this together and that at our best, we are creatures of community not isolation, of compassion not derision, and of love not hate. Many of the world’s best thinkers support this: Jeremy Rifkin, in his RSA Animate video, suggests that we are actually soft-wired for empathy, Karen Armstrong asserts through her  “Charter for Compassion” TED talk that we cannot possibly have peace in this world without it, and the Dalai Lama  continually teaches that love for one another is an essential aspect of a truly enlightened person. But empathy, compassion, and love take presence, and presence takes connection to the here and now, and connecting in this way is powerfully facilitated by breathing deeply and paying attention to the breath. And thus my hope for this year is that we all learn, myself included, to work toward connection, presence and compassion by taking the time to simply and more deeply b-r-e-a-t-h-e.

© 2013 Hackman Consulting Group – Do not reproduce part or all without permission.