Tag Archives: Power

Addressing Race & Power to Advance Health Equity: An Infographic

As HIP works with more community partners and public health departments to advance health equity, we’re looking for new ways to talk with folks about what we mean by equity.

This Equity Infographic contains user-friendly, visual content to share with organizations or individuals who may be less familiar with the term.

Content in the infographic is from HIP Co-Director Jonathan Heller’s article, “If we want to advance equity in public health practice, we must address race and power.” The infographic was designed by UC Berkeley School of Public Health Center for Health Leadership consultants Billy Luong, Briana Levin, and Carlos Cerda using Paper by FiftyThree.

We Thought it was Good, but not THIS Good: Community Participation in HIA

When we started this evaluation of how the field of HIA is doing at encouraging community participation in HIA, we have to admit, we had low expectations. But the results are in, and they are much more encouraging then we thought they might be.

At HIP, we have focused on community participation as a key way to reach international HIA goals of democracy and equity. We strive in our work to authentically and intentionally encourage community members who are impacted by public decisions to be involved in the HIA process. But, to be honest, we didn’t know for sure if community participation would lead to greater democracy and equity, or how strong the connection would be. So we set out to study it.

How do you measure how much a community participated in an HIA? How do you measure how that participation impacted democracy and equity? We started by diving into the literature and looking for resources to help us figure that out. First, we found the International Association of Public Participation’s Spectrum of Participation, and we adapted it to be more specific to HIA.

Table 1_ spectrum comm parti

Then, we had long discussions about what the ultimate outcome of democracy might be, on an individual and collective level, and we decided it was captured best by the concept of civic agency. We defined civic agency as: a community’s ability to organize and undertake collective action in its own self-interest. We measured civic agency by creating survey questions that lined up with the ways civic agency was discussed in the literature. We asked questions about community members taking action, increasing contact with decision makers, strengthening skills to influence future decisions, and if community voices about the HIA topic were heard.

Once we had our questions ready, we sent out our survey to HIA team members and to the community members that participated in their HIAs. We got nearly 100 respondents (63 HIA team members and 30 community members), representing 47 HIAs across the US. We followed this up with an in-depth study of four HIAs that we followed from beginning to end, to better understand the context of our findings and see if there was anything we missed.

Turns out, the field is doing a better job at incorporating community participation in HIAs than we thought. Most respondents reported that the level of community participation in their HIA fell in the middle of the spectrum, at the “involve” level. Perhaps even more encouraging, community members ranked their HIAs as higher in community participation than HIA practitioners did.

Figure 1. Level of Community Participation as reported by HIA team members (N = 59) and community members (N = 28).

Figure 1

Another finding that was stronger than we expected – no one feels like the community participation has a negative impact on the success of their HIA. In fact, a whopping 84% said they thought it had a positive impact.

Figure 2. Impact of Community Participation on the Success of the HIA

Figure 2

In fact, further analysis showed that HIAs that had higher levels of community participation had better odds of successfully impacting the HIA decision point (this is how we defined success). In other words – it’s not just having the community participate that improves the success of an HIA, it’s having the community participate at high levels of participation.

Finally, HIAs are doing a good job at supporting democracy through civic agency. With responses ranging from 63% to 85%, the majority of respondents reported that each measure of civic agency was achieved through the community participation in their HIA. This is great news. While we always suspected this would be the case – it makes intuitive sense that involving people more in the decision-making process that impacts their lives increases democracy – it is very encouraging to see this documented.

Figure 3. Civic agency outcomes (N = 88)

Figure 3

So overall, this study was able to contribute to the field of HIA by helping to define levels of community participation and impact on democracy through civic agency. We were able to show that the field of HIA is already doing a decent job of community participation in HIA, and community participation is contributing to civic agency and to the success of HIAs. Higher levels of participation led to even more successful HIAs.

But there’s still room for improvement. Less than one-third of the respondents indicated that community participation in their HIA was at one of the top two levels on the spectrum – where the most benefit comes. The findings from this study give us even more reason to keep striving for these higher levels of participation. We thought this was true, and now we know it is. Good news, indeed.

Check out our full report for more information on recommendations to enhance community participation in HIAs.

Our Politics are Killing Us

Today’s blog post is written by Dr. Rajiv Bhatia, a physician, health scientist, Principal of The Civic Engine, and co-founder of HIP. The post was first published on December 18, 2015 by Medium

Doctors train to find the diseases behind the symptoms and signs. But, social diseases, like poverty, are usually hidden behind the ones that afflict our bodies. It’s something that medicine doesn’t often talk about it. And, our politics is what keeps these social diseases alive. Read more… 

Report-back from National Public Health and Criminal Justice Convening

On November 9, Human Impact Partners and the Vera Institute of Justice co-convened over 40 criminal justice advocates and public health practitioners from around the country at a groundbreaking, first of its kind convening. The event grew out of the idea that health and justice system leaders’ work in the pursuit of health equity, public safety, and social justice could be magnified by a powerful partnership across the fields of public health and criminal justice to advance these collective goals.

ConveningGroupPictureAn advisory committee – with leaders from JustLeadershipUSA, The Sentencing Project, Ford Foundation, WISDOM, and Drug Policy Alliance – helped HIP and Vera envision what the gathering could accomplish, and ultimately proposed a bold and audacious goal: to develop an alternative vision for a justice system that works to improve population health and wellbeing at every step and to develop an agenda for collaborative work to achieve that vision.

The convening was envisioned as a space to build relationships between people working at the intersection of public health and criminal justice and had an ambitious agenda. We began with participants recounting the modern history of mass incarceration and its disproportionate effects on communities of color. Participants spent time describing how they using a public health approach to issues such as drug policy and drug use, sentencing, over-incarceration, victims’ services, and reentry. Over and over, the group kept coming back to the significance of the current political moment and recognized that the progress we’re witnessing today was due to the committed efforts of community organizers – many of whom were formerly incarcerated and some of whom were in the room – who kept a constant spotlight on the injustices of the criminal justice system over many decades.

The group then turned to a discussion of their vision for an alternative justice system, and principles that should ground that vision. It was a robust dialogue, with participants highlighting the need to make a broad statement about our societal obligation for health and safety and that both the criminal justice and public health systems need to be transformed to focus on creating the social, economic, and political conditions necessary for all to thrive. This includes making the criminal justice system the choice of last resort for addressing social problems, and instead, upholding and supporting communities to overcome those challenges. The group agreed on the need to explicitly name race and racism as a root cause of poor health and over incarceration, and that the vision should be framed as a call to action. At the end, the group came to agreement on points of unity for the vision and clarity about who the vision was for. It was quite an accomplishment!!

Finally, the last part of the day focused on identifying a set of joint goals to move the vision forward. It was another rich conversation with many ideas of how the group could collaborate. The group was able to come to consensus on a set of research, communications, policy, and community building goals to advance together. Working groups are kicking off their efforts in the New Year, and we anticipate convening again in 2016.

We continue to be inspired by the energy and commitment of convening participants. A deep thanks to them for working hard and giving each other the benefit of the doubt as they explored what it means to be in relationship with one another. A special thanks to Mari Ryono – our fearless facilitator – as well as Ford Foundation for hosting the event and Open Philanthropy for funding it.

This work is part of HIP’s Health Instead of Punishment Program, which grew out of our recently adopted Strategic Plan. Contact us if you’re interested in learning more!

Was “Race Together” Wrong?

Starbucks’ short-lived “Race Together” campaign, in which baristas wrote the phrase on coffee cups, generated lots of conversations – and lots of controversy.

Was it a good idea, but poorly implemented? Did it succeed, however slightly, in nudging the nation to talk about racism? Or was it a marketing move that prompted more talk about Starbucks than racism, and was not grounded in a plan for more significant action?

Whatever you think, it’s an opportunity to reflect and learn. Public health practitioners wrestle continually with this question: Should we talk about racism? If so, how?

In an open letter, Race Forward offers smart ideas on what we can learn from Starbucks’ campaign in the movement for racial justice. Their thoughts, as well as recent conversation with the Public Health and Equity Cohort that HIP has blogged about here, prompted some of my own thoughts, illustrated with examples gathered from public health colleagues.

  • Keep the dialogue – it’s how we reach hearts and minds and come to understand our role in serving the public.

Health departments and agencies nationwide are hosting public screenings and conversations around the Raising of America documentary, about how improving the social and economic conditions that shape childhood and childcare can create a safer, healthier, and more equitable future for our nation. The Kansas City, Mo., screening and conversation brought together multiple health departments, an organization that advocates for racial and economic equality, educators, legislators, clergy, and the public. The conversation ended with more than 90 people committing to take action.

  • Productive dialogue, particularly between people with different levels of power, is often accompanied by discomfort. But done in a supportive setting, it can be valuable for moving forward.

Since 2005, the Ingham County, Mich., Health Department has hosted Health Equity / Social Justice Workshops that use facilitated dialogue to have structured, strategic conversations among the health workforce and with interested community members. The dialogue builds the capacity of participants to talk about differences like race, class, and gender and their impacts on community health, as well as strategies to engage other individuals on these issues.

  • Beyond dialogue are structural solutions that require commitment to a larger, coordinated, long-term strategic plan that involves staff across levels and community partners.

In 2006, the Alameda County, Calif., Public Health Department launched the Place Matters initiative to address the social factors that shape health. As described in Public Health Reports, three factors created a strong foundation for the initiative: senior leadership dedicated to ensuring strong government-community partnerships and to building employees’ skills in advancing health equity; identifying inequities at the neighborhood level; and a strategic plan to achieve health equity that included policy change.

That strong foundation has translated into action. Alameda County Place Matters staff have provided testimony locally to successfully protect tenant housing rights. They have provided findings from data collection and suggested policy solutions to federal agencies, including U.S. Housing and Urban Development and Health and Human Services. And they continue to partner with community organizations to identify policy solutions to persistent problems of landlord retaliation, displacement, and deportation, as well as a lack of affordable housing that force people to live in unsafe and unhealthy housing.

Like Starbucks, public health practitioners are advancing conversations about race – hopefully, in more comprehensive and strategic ways. One place where we agree with the Starbucks campaign is in being impatient. We can’t wait for change.

Organizing the Narrative for Health Equity: Minnesota Department of Health Leads with Race

Guest blog by Evan Bissell, Catherine Harrison and Susie Levy
UC Berkeley School of Public Health and Department of City & Regional Planning
For more information about the basis of this post, visit our web-based narrative.

Health agencies across the country are working to develop leadership in advancing health equity. These efforts often look to build power through developing partnerships through an inside-outside strategy.

In one such effort, last February the Minnesota Department of Health (MDH) released its Advancing Health Equity Report to the state legislature. The report was striking in its explicit analysis of structural racism – the normalization of an array of dynamics, historical, cultural, institutional, and interpersonal, that routinely advantage white people while producing cumulative and chronic adverse outcomes for people of color. The report says:

“Race is not the only factor in structural inequities, but is a significant one. Even when outcomes related to other factors such as income, gender, sexual orientation, and geography are analyzed by race/ethnicity, greater inequities are evident for American Indians, African Americans, and persons of Hispanic/Latino and Asian descent. A concerted effort to specifically address the issues of structural racism and to develop the language and tools to uncover and change the structures shaped by racism will be invaluable for addressing other structure-based inequities.”

According to the report, “Health is something we create as a society and as communities, not something an individual can purchase or produce alone.” It recommends an array of actions that focus on many sectors of governance and the structure of the Department of Health itself. The report received prominent news coverage and its analysis has been used by community groups fighting for minimum wage, workers rights, and other issues. But the story of MDH leading with race did not start with the release of the report.

Image credit: Evan Bissell
Image credit: Evan Bissell

For many years the Department and community partners have worked to reframe the narrative of what creates health for Minnesotans, but have faced political pushback when working to address the social determinants of health. For MDH to address issues like housing, education, transportation, and incarceration, it needed to build relationships externally, across agencies and with community partners. The Healthy MN Partnership, a collaboration between the Health Department and community members and organizations, was formed and has proved influential in shifting the narrative of health. By challenging MDH to shift its view from measuring sickness to ensuring healthy living conditions, the broader lens of social determinants of health was adopted.

Image credit: Evan Bissell, adapted from MDH image
Image credit: Evan Bissell, adapted from MDH image
Image credit: Evan Bissell, adapted from MDH image
Image credit: Evan Bissell, adapted from MDH image

This shift didn’t happen in a vacuum. The theory of change guiding this work is grounded in a community-organizing perspective, which moves beyond the connection between health and living conditions, and recognizes that the capacity to act is critical to impact health.

According to MDH, the capacity to act – another way of saying power – is built through organizing people, narrative and resources in the following ways:

  • People: Develop accountable relationships and partnerships that align interests and directly impact decision-makers.
  • Narrative: Build public understanding and public will to support action that reflects health equity.
  • Resources: Shift the way resources, processes and systems are structured to advance health equity.

To learn more, see our web-based narrative, from which the infographics above are reproduced.

Using an Inside-Outside Strategy to Build Power and Advance Equity

HIP recently started the Public Health and Equity Cohort, a group of twelve emerging leaders from public health agencies around the country who are coming together to build their leadership to advance equity within their departments. In developing the 15-month curriculum for the Cohort, we had to think through and articulate a strategy for how health departments could advance equity. Our strategy is based on our experience working with public health departments and with community groups to make change.

It is important to first recognize that inequity exists because groups who benefit from it hold power. Those groups often include rich, white men interested in maintaining their status or expanding and consolidating their wealth and power. They also include corporations – usually run by rich, white men – who benefit from cheap labor and lax regulation. To maintain power, they use racism, classism, and sexism to divide those who should be united in working for change.

To move toward equity, those who want to change the system need to build power. How do allies of those who are negatively impacted by inequities – specifically allies in public health – support the work of building power? Our answer is through using an inside-outside strategy.

On the inside, health agencies, both leadership and staff, must first build their understanding of equity, including racism, classism, sexism and other forms of oppression. This can be done through internal dialogues and trainings such as those that have been done at health agencies in Alameda County, Calif., and Ingham County, Mich., at the state level in Minnesota, and elsewhere. With everyone in the agency involved, it is less likely that a change in leadership would undo this understanding and emphasis.

These agencies then must build the will to act on that understanding, beginning by changing the narrative about what leads to good health – for example, from a medical model that focuses on health care to the social determinants of health – and then using the power of the agency to advance equity. As I’ve written before, this takes tremendous leadership that must be willing to take risks. The model is power with – public health working in close and inclusive partnership with those facing inequities – rather than power over, in which public health institutions try to amass their own power.

But by itself a health agency will never have enough power to advance equity. Political forces favoring the status quo will slap down an agency acting alone. This is where the outside component of the inside-outside strategy to advance health equity comes in.

A demand to address equity should come from the community – from those facing inequity exercising their democratic rights. Health agencies must build relationships and work closely with community groups that can demand change and hold the agency and others in government accountable to their needs. They can also come to the rescue in tough political situations and have the health agency’s back.

Not every community group can support this kind of work. Best suited are base-building (or grassroots) organizations, staffed by community organizers. A base-building group is one that:

  • Brings people who identify as part of a community together to solve problems they themselves identify. These people often become members of the organization and are referred to as its base.
  • Helps a community identify common problems or change targets, mobilize resources, and develop and implement strategies to reach their collective goals.
  • Works to develop civic agency – the capacity of citizens to work collaboratively across differences to address common challenges, solve problems, and create common ground ¬– among individuals and communities to take control over their lives and environments. Ultimately, these groups are working to strengthen democratic processes.

So, for the outside part of the strategy, health agencies must learn how to partner with and support these kinds of base-building community organizations, who typically work to address the social determinants of health (even though they may not call them that). This is not easy, but health agencies from San Francisco to Kansas City to Boston have been leading the way.

This inside-outside strategy reflects at least one way to build the power to advance equity in a lasting and sustainable manner. Members in our Public Health and Equity Cohort will be exploring what this all means for their work, and trying to understand how to grow in this way.

To learn more about how these some of these ideas have been implemented, see:

How Does HIA Bring Change?

There is a dirty little secret among HIA practitioners: We don’t all agree about what makes the work we are doing effective and about how doing HIA will lead to change. This became clear to me during conversations that started during the “Advocacy and Objectivity in HIA” panel at HIA of the Americas earlier this year. But these differences crystalized for me flying home last week from the National HIA Meeting.

The terms advocacy, bias and subjective have been thrown around a lot lately in the HIA field – terms that reveal deep differences among practitioners. I think there are at least three distinct theories of change held among our community.

1. Data alone.  Subscribers to this theory of change believe all HIA practitioners need to do is to provide decision makers with data about health and health disparities. Armed with that data, decision makers will make better decisions.

2. Data and consensus. Subscribers to this theory believe that the best way to make change is to reach out to stakeholders with diverse views, which usually include community members and, depending on the HIA, could include people from different agencies, project proponents, and decision makers from across the political spectrum. With data and good facilitation, consensus can be reached regarding the impacts, recommendations, and report. That process and the findings will lead to decision makers making better decisions.

3. Data and Power. Subscribers to this theory believe that change is most likely to come from strong data combined with an HIA process that is used to build power in disenfranchised communities that face inequities. With this increased power and strong data, the voices of those most impacted will be heard and decision makers will make better decisions.

Each of these theories has its merit and each may have its time and place. Each has examples it can hold up that show that it leads to decisions that improve health.

But, in our experience, if HIA is really a tool to achieve health and reduce inequities, combining data and power is the most effective way of getting there. History shows that the other two are challenging ways to truly change policies, plans, and projects that create inequities, especially if those in power don’t have the will to do so or if there is ideological tension around the proposal my ding. Those in power, in favor of a status quo that benefits them and is harming the disenfranchised, are simply not willing to yield power in the face of mere data.  And the compromises that result from consensus building between those who have power and those who do not usually support at best a middle ground that does not significantly benefit those most harmfully effected by decisions.

This is why at Human Impact Partners we do our HIAs in partnership with community organizing groups whose focus is building leadership in low-income communities and communities of color, lifting the voices of populations left out of decision-making discourse, and building the power of those communities.

We know the data and power theory works. With our partners, we’ve used it over the last couple of years to win over $40 million in affordable housing in South Los Angeles (our USC Specific Plan HIA and Farmers Field HIAs), substantial increases in funds for alternatives to incarceration in Republican-controlled Wisconsin, and better policies for racial integration of schools in Minnesota. We’ve used it to raise awareness about the harmful impacts of detentions and deportations on immigrant children and families. And, through those processes, we’ve left behind not just awareness and better policies, but more importantly, a community that is more engaged in our democracy and more empowered to fight on their own behalf in the future.

In Closing the Gap in a Generation, the World Health Organization Commission on the Social Determinants of Health declared: “Any serious effort to reduce health inequities will involve changing the distribution of power within society and global regions, empowering individuals and groups to represent strongly and effectively their needs and interests and, in so doing, to challenge and change the unfair and steeply graded distribution of social resources (the conditions for health) to which all, as citizens, have claims and rights.” The great Brazilian philosopher and educator Paulo Freire said it more simply: “Washing one’s hands of the conflict between the powerful and the powerless means to side with the powerful, not to be neutral.”