Jessica Kang, a senior research scientist at the Center for Social Inclusion (CSI), and Rebekah Gowler, the director of health equity capacity development at the Center for Health Equity in the New York City Department of Health and Mental Hygiene (health department), discussed how the health department under the leadership of Commissioner Mary Bassett is transforming culture and practices to promote racial equity through its own work, as well as through its networks and partnerships.
The Center for Health Equity was established at the health department in 2014, Gowler said, and its purpose is to strengthen and amplify the health department’s work to eliminate health inequities and to ensure that all residents of New York City have equitable access to the resources and opportunities they need to reach their full health potential.
1 This chapter is the rapporteur’s synopsis of the presentation made by Jessica Kang, a senior research scientist at the Center for Social Inclusion, and Rebekah Gowler, the director of health equity capacity development at the Center for Health Equity in the New York City Department of Health and Mental Hygiene, and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.
The center takes four different key approaches to health equity:
- Focus on building and strengthening partnerships with other city agencies and community advocates in order to advance policy and systems change across the city.
- Work to make injustice visible through the use of data and storytelling and promoting critical research.
- Invest in key neighborhoods through place-based initiatives that the center manages in East and Central Harlem, the South Bronx, and North and Central Brooklyn.
- Support internal reform across the agency, with the aim of building the health department’s capacity to advance racial equity and social justice in all of its programs’ policies and practices.
All of the center’s work rests on a set of core values: racial and social justice, community power, accountability, diversity and inclusion, and data- and community-informed practice.
CSI is a national nonprofit organization whose mission is to catalyze local communities, government, and other public and private institutions to dismantle structural racial inequity, Kang said. CSI does this through five different types of strategies: policy development and evaluation, organizational change strategies, partnerships in coalitions, communication strategies, and leadership development.
For the past 5 years CSI has conducted research, including the use of focus groups, interviews, and testing, to answer such questions as: How can people talk about race to effectively change policies? and, How can people talk about race more explicitly? What CSI has found is that the first consideration is the dominant racial narratives. Similar to what FrameWorks researchers have found (see Sweetland’s discussion in Chapter 5), some people believe that the context of race today in the United States is post-racial. A version of this narrative is that there are people of color in positions of power, and a black man is president. Some people may even say that now some whites are discriminated against, Kang said. Now, more than ever, there are organizations, there are movements, such as Black Lives Matter, that have pushed the topic of race and racism into the forefront, particularly in terms of policing.
The work of CSI, Kang said, is informed by an understanding of what is called “dog whistle racism.” It combines implicit bias, which is defined by the Kirwan Institute for the Study of Race and Ethnicity as attitudes and stereotypes that affect our understanding, actions, and decisions (Kirwan Institute for the Study of Race and Ethnicity, 2014), with the current understanding of symbolic racism, in which there is a use of images, code words, and metaphors that implicitly signal race (Sears and Henry, 2003). Dog whistle racism—or the race wedge, as it is also called—is the combination of implicit bias and symbolic racism, and it involves the use of symbols or words. There is no need to mention race at all in order to trigger unconscious racism and push people toward policies that support and facilitate inequity.
Working from research done by Eduardo Bonilla-Silva involving white Americans born between 1940 and 1980 (Bonilla-Silva, 2013), CSI found that there are four dominant race frames, Kang said. These frames are (1) racism and inequality are things of the past, (2) disparities are caused by culture/behavior, (3) disparities are inevitable and/or natural, and (4) programs helping people of color are unfair to whites.
Affirm, Counter, Transform
CSI’s research-informed approach to counteracting dominant race frames is focused on speaking inclusively about race in a way that can move people on policy, Kang said. CSI developed a model based on research called ACT, which stands for affirm, counter, transform. CSI uses this model to train people on how to communicate about race in a way that can move people toward better outcomes. “Affirm” means to start with the heart and engage the audience with emotional appeals and explain how people are in this together. “Counter” means to explain the problem and take on race directly. “Transform” involves reframing winners and losers, and it ends with a message that binds the heart and a transformative solution that people want to support.
Gowler said that the health department has learned the importance of using effective and strategic communication to advance racial equity. They found the ACT framework developed by CSI to be essential to internal reform and public advocacy. She added that the health department also found it useful for appealing to shared values; talking explicitly about race, racism, and racial justice; countering dominant race frames; and offering practical solutions and action steps for people to be able to move and advance work that hopefully will continue to mobilize and garner additional support in the public health field and beyond in order to advance racial equity and social justice across cities.
In February 2014, Bassett, the newly appointed New York City Health Commissioner, introduced herself to all agency staff in an e-mail in which she described her priorities for the agency. In that e-mail she called health inequities unfair, unnecessary, and avoidable. New York City, Gowler said, is one of the most unequal and most segregated cities in the United States, so it is unsurprising that there are also health inequities. This communication set the stage for an ongoing cultural shift at the health department involving agency leadership and staff engaging in more open and honest conversations about inequities in terms of what they are, what is at their root, and what can be done to address them.
In 2015, Bassett published a perspective piece in the New England Journal of Medicine titled “#BlackLivesMatter: A Challenge to the Medical and Public Health Communities.” In this piece, Gowler said, Bassett addressed her call to action against racism directly to the medical and public health communities and health professionals. Bassett identified key actions that practitioners of the field could take to advance racial equity: critical research, internal reform, and public advocacy.
Gowler explained that taking action through critical research involves professionals conducting critical studies that examine racism alone and at the intersection of other systems of inequity that harm health. Critical research is intended to spur conversations about systemic health, responsibility, and accountability for poor health outcomes. Critical research can also provide tools that are used in the public health and medical fields for community advocates and policy makers to make changes in their own communities.
The health department looked for opportunities to use its data and information to advance critical research, Gowler said. The department relaunched its Community Health Profiles with the purpose of increasing its utility for advocacy and decision making across the city.2 The Community Health Profiles are newly aligned with the 59 community districts, which are the local level of government in New York City. The Community Heath Profiles include not only health outcomes, but also data on new neighborhood level measures that were not previously provided, such as air quality, school absenteeism, and housing. The profiles
2 See https://www1.nyc.gov/site/doh/data/data-publications/profiles.page (accessed June 22, 2016).
also provide disaggregated data by place, making it possible to make comparisons across communities and also with the citywide data, as well as providing more robust demographic data for each of the communities.
Internal reform, Gowler said, should include looking for inequities in institutions, systems, infrastructures, policies, and practices and identifying ways that change can be implemented. Bassett called for internal reform in the health department with the goal of strengthening and aligning internal institutional practices with the department’s mission and goals to advance health equity externally. Without attention to the reform of the health department’s own policies and practices, Bassett was concerned that its actions might make unintended contributions to the inequities that it sought to eliminate. Internal reform is focused on building the capacity of the agency to advance racial equity and social justice in all things that it does. To do this, the health department’s work is being supported by CSI and the Government Alliance on Race and Equity (GARE).3
Developed by CSI and GARE, the National Best Practice Framework has three components, Gowler said. The first component is normalizing conversations about race, racism, and racial justice within an organization. The second component is operationalizing racial equity by providing staff and leadership with the tools that they need to make conscious choices that will advance equity. The third component is organizing staff and partnering with others to mobilize and engage people to get the critical feedback and support they need to grow and continuously advance the work through an iterative and cyclical process.
Coupled with this framework, Gowler said, is a set of six core strategies developed by CSI and GARE for jurisdictions and public agencies to support their internal reform process. These are:
- First, operate with urgency and build collective will. Strong leadership combined with strategic and effective communication is important.
- Second, build and use a shared analysis across the agency. This strategy involves staff training to build a common language and shared understanding for how to build the strategies and activities necessary to create and advance their own equity lens.
- Third, build internal capacity to create a focused and organized infrastructure within the organization that moves equity work forward.
- Fourth, develop and implement tools that can be used to operationalize the advancement of equity. Many people support the advancement of health equity across communities but are unsure how to do it.
- Fifth, partner with others. Partnering is not only outside the organization, but also inside. The health department for example, has more than 6,000 employees and 13 different divisions, so organizing staff internally is critical for the success of the effort to advance racial equity and social justice.
- Sixth, use data and metrics. There is a need to evaluate and track the progress and success of the internal reform efforts and also to ensure that the organization is tracking its racial equity goals and really measuring its success in reducing inequities in health outcomes across the city.
In Bassett’s article in the New England Journal of Medicine she identified public advocacy as a key strategy for health professionals to use in various forms, such as working with policy makers to direct policy change, writing editorials and opinion pieces, and sharing a new narrative and framework, Gowler said. Partnering with community advocates can be accomplished by offering the department’s expertise in supporting advocates’ work to address health inequity.
An example that Gowler provided of the health department’s own advocacy work was its participation in the New York City Coalition to Dismantle Racism in the Health System, which was convened by Doctors for America. This coalition of institutions and advocates includes members from area medical, public health, and social work schools; hospitals, health centers, and other service providers; unions; community-based organizations; and others.
Gowler connected the internal reform efforts of the health department to the concepts of equity, diversity, and inclusion, as Burke had discussed earlier (see Chapter 4). What they have found in the health department, Gowler said, is that encouraging equity requires focusing on diversity and inclusion within the department’s workforce and that equity is important to implementing internal reform. The chief diversity officer leads the effort to create a more diverse and inclusive workforce. The health department is making an effort, Gowler said, to implement reform efforts that will
link the workforce to the demographics of the city, which would mean a workforce that reflects the city. It will also mean maintaining awareness of how implicit bias and the persistence of dominant race frames are perpetuated. If the health department’s workforce does not reflect the diversity of the broader community and does not make an effort to challenge dominant race frames, then it could potentially be a place where, as Fullilove discussed (see Chapter 3), there is prevalent white privilege thinking, Gowler said.
Internal reform is really about transforming the way that the staff and the institution practice equity in all of the work that they do, which includes administrative services, hiring practices, procurement, and contracting, Gowler said. Organizational change takes a lot of time and patience, balanced by an impatience and persistence to continually move forward. Internally, there has been some pushback to see early outcomes in a short time frame, but this is a long process. Inequities have been created over centuries, so to expect them to be resolved in 5 years or less is unrealistic.
Talking explicitly about race, racism, and racial justice is not typically normalized in institutions, Gowler said. Within public health, many people are comfortable talking about social determinants—how environmental factors, housing, and education affect health—but people are not yet comfortable in really naming the systems that drive not only the determinants of health but the determinants of inequity, like racism. There is a need, Gowler said, to move the conversation in that direction through training, through the critical analysis of data, and through engaging with communities and residents of neighborhoods and cities to hear their experiences and move beyond the traditional quantitative data analysis by using more storytelling to connect to peoples’ hearts and minds.
During the discussion, Gowler suggested that there is a role for the federal government to use its national platform to amplify and support racial and health equity work happening at the local level in health departments and across communities in the United States.
Mary Kate Allee of the National Association of County and City Health Officials (NACCHO) said that she was looking forward to discussing with her federal partners how NACCHO can help health departments to do more and do better. Lydia Sermons, the communications director for the U.S. Department of Health and Human Services’ Office of Minority Health, emphasized that she and her staff want to be a part of the dialogue moving forward. As representatives of a federal agency,
they are positioned to have impact through their engagement with so many communities and partners across the nation. She added that they are thinking about how to reframe messages because of the demographic shifts across the nation and about the need to address a range of inequities that the nation is confronting.