Reclaiming a Social Justice Framework for Public Health: Dialogue as a Vehicle for Change

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

2. Distinguishing Disparity from Inequity

3. Distinguishing Disparity from Inequity Health Disparity A disproportionate difference in health between groups of people. (By itself, disparity does not address the chain of events that produces it.) 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.* *Margaret Whitehead

4. 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 the “Social Determinants of Health” Confronting “Root Causes” Explicitly

5. What Does a Social Justice Framework for Public Health Look Like? 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 Quality Education Job Security Social Connection & Safety Living Wage Access to Transporta- tion Availability of Food Dennis Raphael,Social Determinants of Health; Toronto: Scholars Press, 2004

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

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

8. 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?

9. 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?

10. Changing the Questions Instead of only asking: How can we create more green space, bike paths, and farmer’s 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?

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

12. Evolution of the Workshop 2000: Community Voices 2005: Internal Social Justice Dialogue Project 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.

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

14. Dialogue as the Vehicle for Change Dialogue is different from CONVERSATION Derived from William Issacs, “Taking Flight: Dialogue, collective Thinking, and Organizational Learning”

15. Dialogue as the Vehicle for Change Dialogue is different from DEBATE

16. Dialogue as the Vehicle for Change Dialogue is different from TRAINING

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

18. 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 What’s 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

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

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

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

22. Decision to examine and challenge one’s own beliefs and assumptions Respectfully challenging others’ assumptions, actions, beliefs The Personal / Interpersonal Pathway (Dialogic) Recognizing opportunities to model one’s own work for others Personal Interpersonal Institutional Cultural

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

24. The Organizing Pathway Personal Interpersonal Illuminating inequity for those with the power to change policies and practice Building power In the public arena to advance new norms that challenge inequity Recognizing one’s own power to challenge or change policies and practices Organized action to challenge and change inequitable policy and practice Institutional Cultural Messages that reverse prevailing oppressive norms Modeling policies and practices that promote equity.

25. Decision to examine and challenge one’s own beliefs and assumptions Respectfully challenging others’ assumptions, actions, beliefs The Cultural Pathway Personal Interpersonal Establishing policies and practices that promote equity while respecting individuals’ personal resistance Messages that promote challenging dialogue Institutional Cultural Messages that challenge inequitable policy and practice Messages that encourage self- examination of assumptions, actions, beliefs Messages that reverse prevailing oppressive norms

26. “Trying on” Ideas about Power Power the ability to get what you want “Power Over” (coercive power) “Powerless” 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. Self-Interest what you want, based on your values & experience “Selfless” “Selfish”

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

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

29. 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 decisions—be mindful of their impact on social justice.” Departmental Changes, 2009 - 2013 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

30. Doak Bloss Health Equity and Social Justice Coordinator dbloss@ingham.org