Reclaiming a Social Justice Framework for Public Health: Dialogue as a Vehicle for Change Doak Bloss Ingham County Health Dept. May 7, 2013

Distinguishing Disparity from Inequity

Health Disparity A disproportionate difference in health between groups of people. Health Inequity Differences in population health status and mortality rates that are systemic, patterned, unfair, unjust, and actionable, as opposed to random or caused by those who become ill.* Distinguishing Disparity from Inequity (By itself, disparity does not address the chain of events that produces it.) *Margaret Whitehead

What Does a Social Justice Framework for Public Health Look Like? Primary Prevention The prevention of diseases and conditions before their biological onset. Conventional Interpretation Preventing Environmental Exposures Improving Resistance To Disease Education to Reduce Risky Behaviors e.g. Food & Water Safety… … Immunizations… …Smoking cessation Social Justice Interpretation Attending to theSocial Determinants of Health Confronting Root Causes Explicitly

Social Determinants of Health The economic and social conditions that influence the health of individuals, communities, and jurisdictions as a whole. They include, but are not limited to: Safe Affordable Housing Social Connection & Safety Quality Education Job Security Living Wage Access to Transporta- tion Availability of Food Dennis Raphael, Social Determinants of Health; Toronto: Scholars Press, 2004 What Does a Social Justice Framework for Public Health Look Like?

Safe Affordable Housing Social Connection & Safety Quality Education Job Security Living Wage Access to Transporta- tion Availability of Food However, If we reduce disparities at the level of Social Determinants of health, will we be reducing health inequity?

Root Causes Power and Wealth Imbalance LABOR MARKETS GLOBALIZATION & DEREGULATION HOUSING POLICY EDUCATION SYSTEMS TAX POLICY Social Determinants of Health Disparity in the Distribution of Disease, Illness, and Wellbeing Institutional Racism Class Oppression Gender Discrimination and Exploitation SOCIAL NETWORKS SOCIAL SAFETY NET Safe Affordable Housing Social Connection & Safety Quality Education Job Security Living Wage Transportation Availability of Food Psychosocial Stress / Unhealthy Behaviors Adapted from R. Hofrichter, Tackling Health Inequities Through Public Health Practice.

Changing the Questions Instead of only asking: Why do people smoke? Perhaps we should also ask: What social conditions and economic policies predispose people to the stress that encourages smoking?

Changing the Questions Instead of only asking: Who lacks health care coverage and why? Perhaps we should also ask: What policy changes would redistribute health care resources more equitably in our community?

Changing the Questions Instead of only asking: How can we create more green space, bike paths, and farmers markets in vulnerable neighborhoods? Perhaps we should also ask: What policies and practices by government and commerce discourage access to transportation, recreational resources, and nutritious food in neighborhoods where health is poorest?

The Workshops 40 Workshops 800 – 825 participants Public health staff, community members, other service providers

Evolution of the Workshop 2005: Internal Social Justice Dialogue Project 2000: Community Voices 2008: Social Justice Facilitator Training 2009: Four-Day HESJ Workshops Strategic goal: to provide participants with language and conceptual frameworks that REVEAL rather than disguise modern forms of oppression and their impact on health.

CONVERSATION about Race, Class, Gender, etc. DEBATE about Oppression, Privilege, and the role of Public Health TRAINING in Cultural Competency, Diversity, etc. One way to explain what we mean by dialogue is to compare to what it is not. It is NOT… The Workshop is Dialogue-Based

Dialogue as the Vehicle for Change Dialogue is different from CONVERSATION ConversationDialogue Casual, undirected exploration Marginalizes difference Consensus approach Vigorous and directed exploration Welcomes difference Collective approach Derived from William Issacs, Taking Flight: Dialogue, collective Thinking, and Organizational Learning

Dialogue as the Vehicle for Change Dialogue is different from DEBATE DebateDialogue Highlights competing factions Best solution Emphasis on persuading Highlights commonality of purpose Multiple, complementary solutions Emphasis on listening

Dialogue as the Vehicle for Change Dialogue is different from TRAINING TrainingDialogue Unilateral exchange of information Embraces what is known Teaches new solutions Mutual exchange of information Embraces what is not known Discovers new solutions

Workshop Structure / Content Core Concepts of Health Equity (Finding a Common Vocabulary) Exploring Unearned Privilege Day 1Day 2 Seeing the Health Consequences of Privilege and Oppression Creating Health Equity Day 3Day 4 Two-week Interval between Days 2 and 3

The Workshop is Dialogue-Based Dialogue Triggers are generally of Three Types: The Lived Experience of Participants Constructs that Enable Dialogue on Oppression & Privilege Analysis & Application To Real-Life Scenarios Whats in a Name? I Remember Privilege Walk Where is Your Power? Target & Non-Target Identities 4 Levels of Oppression and Change Modern vs. Traditional Forms Unnatural Causes Case Study Scenarios Challenging Conversations

Four Levels of Oppression & Change Feelings, beliefs, values Personal Interpersonal Institutional Cultural Actions, behaviors, language Rules, policies, practices Collective ideas about what is normal, true, right, beautiful Adapted from Dr. Valerie Batts, Is Reconciliation Possible? Lessons from Combating Modern Racism

Four Levels of Oppression and Change Feelings, beliefs, values Personal Interpersonal Institutional Cultural Actions, behaviors, language Rules, policies, procedures Collective ideas about what is normal, true, right, beautiful Adapted from Dr. Valerie Batts, Is Reconciliation Possible? Lessons from Combating Modern Racism Early Work Workshops

Decision to examine and challenge ones own beliefs and assumptions Recognizing opportunities to model ones own work for others Respectfully challenging others assumptions, actions, beliefs Recognizing ones own power to challenge or change policies and practices Establishing policies and practices that promote equity while respecting individuals personal resistance Modeling policies and practices that promote equity. Messages that reverse prevailing oppressive norms Messages that promote challenging dialogue Building power In the public arena to advance new norms that challenge inequity Illuminating inequity for those with the power to change policies and practice Messages that challenge inequitable policy and practice Messages that encourage self- examination of assumptions, actions, beliefs Organized action to challenge and change inequitable policy and practice PersonalInterpersonal InstitutionalCultural Pathways to Change across Four Levels Organizational practice encourages challenging dialogue

Decision to examine and challenge ones own beliefs and assumptions Recognizing opportunities to model ones own work for others Respectfully challenging others assumptions, actions, beliefs PersonalInterpersonal InstitutionalCultural The Personal / Interpersonal Pathway (Dialogic)

Decision to examine and challenge ones own beliefs and assumptions Respectfully challenging others assumptions, actions, beliefs Recognizing ones own power to challenge or change policies and practices Establishing policies and practices that promote equity while respecting individuals personal resistance Illuminating inequity for those with the power to change policies and practice PersonalInterpersonal InstitutionalCultural The Interpersonal / Institutional Pathway Organizational practice encourages challenging dialogue

Modeling policies and practices that promote equity. Messages that reverse prevailing oppressive norms Building power In the public arena to advance new norms that challenge inequity Organized action to challenge and change inequitable policy and practice PersonalInterpersonal InstitutionalCultural The Organizing Pathway Recognizing ones own power to challenge or change policies and practices Illuminating inequity for those with the power to change policies and practice

Decision to examine and challenge ones own beliefs and assumptions Respectfully challenging others assumptions, actions, beliefs Establishing policies and practices that promote equity while respecting individuals personal resistance Messages that reverse prevailing oppressive norms Messages that promote challenging dialogue Messages that challenge inequitable policy and practice Messages that encourage self- examination of assumptions, actions, beliefs PersonalInterpersonal InstitutionalCultural The Cultural Pathway

Trying on Ideas about Power Powerless Power Over (coercive power) Power the ability to get what you want SelflessSelfish Self-Interest what you want, based on your values & experience Power is neither good nor bad. It is neutral. Power is not given by others. It is claimed or built (with others). Power is a product of relationship. Power is most effective when it is focused and channeled. Communities where people have strong relationships with one another are more powerful than communities where relationships are fragmented.

Pre/Post Questionnaire Findings Conceptual Questions ( I have a clear understanding of ): Health Disparity Health Inequity Social Justice How SJ relates to my work 44%84%31%68% 26%69%28%68% Awareness QuestionsSocial Determinants: Individual behaviors and lifestyle Access to quality medical care Things like access to affordable housing, transportation and an adequate living wage How well we give everyone the opportunity to achieve power and wealth regardless of race, class, gender and other forms of difference 71%33% 82%80% 87%91% 63%75% (The health of our community is determined by…)

Pre/Post Questionnaire Findings Awareness QuestionsOppression: Gender Class / SES Race 58%78% 80%85% 70%85% Comfortable Talking Questions: Gender Class / SES Race 68%78% 64%78% 62%61% (I am comfortable talking with others about discrimination or prejudice based on…) (In our community, people are discriminated against on the basis of their…)

Is Institutional Change Happening? Post workshop statements: Introspection: Notice my own thoughts and biases. Education: Point out inequality when I see it, without blaming or shaming. Voice: Speak up to those making oppressive remarks. Reform: Influence policy decisionsbe mindful of their impact on social justice. Departmental Changes, Funding & Hiring of Environmental Justice Coordinator Community Health Assessment based on SJ Framework New Health Officer appointed October 2011 Workshops for other departments, other disciplines Equity Action Circle conceived Alignment of Public Health and Community Organizing

Doak Bloss Health Equity and Social Justice Coordinator