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

Reclaiming a Social Justice Frameworkfor 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 the “Social 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:

SafeAffordableHousing

SocialConnection

& Safety

QualityEducation

Job Security

LivingWage

Access toTransporta-

tion

Availabilityof Food

Dennis Raphael, Social Determinants of Health; Toronto: Scholars Press, 2004

What Does a Social Justice Framework for Public Health Look Like?


SocialConnection

& Safety

QualityEducation

Job Security

LivingWage

Access toTransporta-

tion

Availabilityof 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 ImbalanceLABOR

MARKETS

GLOBALIZATION&

DEREGULATIONHOUSINGPOLICY

EDUCATIONSYSTEMS

TAXPOLICY

Social Determinants of Health

Disparity in the Distribution of Disease, Illness, and Wellbeing

InstitutionalRacism

Class OppressionGender

Discriminationand Exploitation

SOCIAL NETWORKS

SOCIALSAFETY

NET


SocialConnection

& Safety

QualityEducation

Job Security

LivingWage

Transportation Availabilityof Food

Psychosocial Stress / Unhealthy Behaviors

Adapted from R. Hofrichter, Tackling Health Inequities Through Public Health Practice.

Changing the QuestionsInstead 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?


Who lacks health care coverage and why?


What policy changes would redistribute health care resources more equitably in our

community?


How can we create more green space, bike paths, and farmer’s markets in vulnerable

neighborhoods?


What policies and practices by government and commerce discourage access to

transportation, recreational resources, and nutritious food in neighborhoods where

health is poorest?

The Workshops40 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

Conversation Dialogue

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 is different from DEBATE

Debate Dialogue

Highlights competing factions

“Best” solution

Emphasis on persuading

Highlights commonality of purpose

Multiple, complementary solutions

Emphasis on listening


Dialogue is different from TRAINING

Training Dialogue

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 ofHealth Equity

(Finding a Common Vocabulary)

ExploringUnearned Privilege

Day 1 Day 2

Seeing the HealthConsequences of

Privilege and Oppression

Creating Health Equity

Day 3 Day 4

Two-week Interval between Days 2 and 3

The Workshop is Dialogue-Based

Dialogue Triggers are generally of Three Types:

The Lived Experienceof Participants

Constructs thatEnable Dialogue on

Oppression & Privilege

Analysis & ApplicationTo Real-LifeScenarios

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

ChallengingConversations

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

Workshops

Decision to examine and

challenge one’sown beliefs and

assumptions

Recognizing opportunities to

model one’s own work for others

Respectfully challenging others’ assumptions, actions, beliefs

Recognizing one’s own powerto challenge or change policiesand practices

Establishingpolicies and

practices thatpromote

equity whilerespectingindividuals’personal

resistance

Modeling policies and practicesthat promote equity.

Messages thatreverse prevailingoppressive norms

Messages that promotechallenging

dialogue

Building powerIn the public

arena to advance newnorms that challengeinequity

Illuminating inequityfor those with thepower to change

policies and practice

Messages thatchallenge inequitable

policy and practiceMessages that

encourage self-examination ofassumptions, actions, beliefs

Organized action to challenge and change inequitablepolicy and practice

Personal Interpersonal

Institutional Cultural

Pathways to Change across

Four Levels

Organizational practice encourageschallenging dialogue



assumptions

Recognizing opportunities to

model one’s own work for others




The Personal / Interpersonal

Pathway(Dialogic)



assumptions






resistance





The Interpersonal / Institutional Pathway

Organizational practice encourageschallenging dialogue

Modeling policies and practicesthat promote equity.


Building powerIn the public

arena to advance newnorms that challengeinequity

Organized action to challenge and change inequitablepolicy and practice



The Organizing Pathway






assumptions





resistance


Messages that promotechallenging

dialogue

Messages thatchallenge inequitable

policy and practiceMessages that

encourage self-examination ofassumptions, actions, beliefs



The Cultural Pathway

“Trying on” Ideas about Power

“Powerless” “Power Over”(coercive power)

Powerthe ability to

get what you want

“Selfless” “Selfish”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 FindingsConceptual 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 Questions—Social 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 FindingsAwareness Questions—Oppression:

“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 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

Doak Bloss Health Equity and Social Justice Coordinator

[email protected]

mailto:[email protected]

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

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