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Turning the Tide: Systemic Racial Inequities and the Social Determinants of Health

October 14, 2020

Challenges in areas ranging from education to the environment, gender to governance, health to housing don’t exist in a vacuum. Each month, Abt experts from two disciplines explore ideas for tackling these challenges in our monthly podcast, The Intersect. Sign up for monthly e-mail notifications here. Catch up with previous episodes here.

Racial inequities are pervasive throughout the social determinants of health. Abt’s Diane Paulsell and Chloe Greene discuss how data, analysis, technical assistance, and input from those who live with these systemic inequities can inform the programs and policies needed to turn the tide. Learn more in this episode of The Intersect podcast.

For more on this topic, listen to episode 15: Racial Bias, Data Science, and the Justice System.

Read the Transcript

Eric Tischler: Hi and welcome to The Intersect. I'm Eric Tischler. Abt Global tackles complex challenges around the world, ranging from improving health and education to assessing the impact of environmental changes. For any given problem, we bring multiple perspectives to the table. We thought it would be enlightening and maybe even fun to pair colleagues from different disciplines, so they can share their ideas and perhaps spark new thinking about how we solve these challenges. Today, I'm joined by two of those colleagues, Diane Paulsell and Chloe Greene. 

Diane is an applied social scientist with more than 20 years of experience designing, conducting, and overseeing mixed methods, policy focused research, including national multi-site studies. Her areas of expertise range from early care and education to parenting and family engagement to youth development to family support, and includes nutrition. 

Chloe is a historian and urban planner with over 10 years of experience in qualitative research and analysis, with a particular focus on racial equity and underserved populations. Her areas of expertise include housing and homelessness, equitable development, and community-based participatory research and culturally responsive urban planning in communities of color. 

Thank you both for joining me.

Chloe Greene: Thank you for having us.

Diane Paulsell: Thank you.

Eric: In the United States, more people are beginning to acknowledge there are huge racial inequities within our society, and that those inequities are the results of systemic racism. I know our colleagues are thinking about these issues because they're often mentioned on this podcast, and they're looking at how they affect the work we do. We can identify and acknowledge there’s a problem, but how do we implement solutions? Diane, I'm going to turn to you first. You're relatively new to Abt, but you've got a very big purview, so you've got a good overview of the challenges we're facing in the work we're doing.

Diane: Well, I think there's just increasing recognition that different kinds of policies, whether they're state, federal, local policies, and different kinds of programs affect different people differently. We need to understand that to make sure that everyone has equitable access to what they need. For example, let's take early childhood education. We know there are disparities in school readiness when children arrive to kindergarten, so what can we do to address those disparities? One thing we need to look at is early care and education policies. For example, what role do childcare subsidies play in helping different kinds of families access the high quality early care and education their children need to develop school readiness skills?

Eric: When we're looking at these issues--we see they exist, right? We've identified them through research. How do we address them programmatically? How do we actually make an impact? I mentioned earlier that these are things we've seen how they affect the work we do, but Chloe, I know you're actually addressing these issues on the ground. You want to talk about what you're working on?

Chloe: Sure. I would say in the homeless technical assistance space, there is also, as Diane was saying, an acknowledgement of the fact that, in homelessness, black people, indigenous people and other people of color are disproportionately impacted by homelessness. When you look at black people in particular, that are 13 percent of the population, but are over 40 percent of the population of people experiencing homelessness. Oftentimes people say, "Okay, well, you know, when you take poverty into account, maybe that explains the disparity,” but also, when you're looking at poverty rates as well, that does not explain the disproportionate impact. Then you have to start to look at our policies around homelessness and also our programs, and really start to dig into why we are seeing this disproportionate impact.

I would say that previously in the homeless space, sometimes some of our programs have been designed to address these things as if homelessness is an individual issue, rather than recognizing that homelessness is the result of systemic inequities. We have to center addressing those inequities in our response. As homeless TA providers, we are working with communities to look at the disproportionate impact and understand “What is it that is making these populations more vulnerable within your local context of your community and how can you address that?” As Diane was saying, you want to ensure that everyone is being served. Everyone's needs are being met.

How do you use, like, a targeted universalism approach in a sense to where the intended outcome is that everyone has a home, right? I hope that most of us in America wants to see everyone housed, but recognizing that what is required for a black person to be housed or someone who has had justice involvement to be housed is going to look very different for a family of four or what have you. Everyone is going to have different things that'll get them to a place to where they can be housed. Taking a targeted approach based on those populations to ensure that we're meeting their needs, and we're getting people into homes.

Diane: Chloe, you just raised something that's really important, which is targeted universalism. I think that is a great strategy to work on increasing equity, and what that means is that even though a program is universal—in other words, everyone can have access to it—we know that there are barriers that prevent some people from having access to that, and those barriers are greater for communities of color at times. 

For example, let's take preschool, universal preschool. Maybe some families can't access it, even though everyone is eligible, because of transportation issues. Maybe in some cities, this is going to be rolled out in stages. To be targeted within the universal program, we might roll it out in communities where we know there are high disparities in kindergarten readiness first, or if we can only provide full day pre-K in some schools, maybe we target those schools for the full day pre-K. By doing that, we're trying to increase equity. It is universal, but within the universal offering, we target extra resources towards the families that need those resources to address inequity.

Eric: Chloe, you mentioned poverty. Diane, you're talking about early education. We're talking about a whole life cycle of inequities just between those two poles, right? Is there more we can be doing to connect those dots and then address them holistically?

Chloe: I would say that targeted universalism is definitely an approach that we should be taking to address these issues, but I think there are other steps to ensure that we're getting to a place where we're seeing equitable outcomes. I think a big part of that is first acknowledging historical context is really critical to any equity work that you do, because history really speaks to why we are experiencing present inequities. It should not be shocking when we look back on that history, when we look back on housing history and look at the discriminatory practices in terms of home ownership and contract leasing and redlining, and all of these things that we instituted in communities that are rooted in racist and discriminatory policies, got us to this place.

It's important to honor that and recognize that. One, because it helps us to understand, really, the gravity of what we're grappling with when we're handling these issues, but it also, again, reminds us,   like, these are systemic problems. We cannot address them by looking at an individual and saying, "Okay, well, how did you get here? Like, what did you do that brought you to this place?" It's really “What is going on in our community? What is the local historical context that brought us to this place, and how do we undo those things so we don't see this happening again in the future?”

Eric: And that speaks to the difference between wealth and income, and that historical context, and then how does that play out in terms of where the opportunity is moving forward. I want to ask, Chloe, I think the work you're doing is pretty impactful in the short term, right? I mean, it's technical assistance and you're enacting approaches. How is that working out?

Chloe: It's difficult, but it's necessary work. I think a really critical piece of that work is involving people with lived experience in addressing homelessness, and that has been something that has been a part of the homeless technical assistance work for some time, but I think there is heightened attention around the need for that. Particularly with the pandemic, communities are looking at, like, "Okay, we are seeing, again, black people, indigenous people, and people of color are disproportionately impacted by the pandemic as well, so how do we get people housed during this precarious time and ensure that the programs and the policies really are meeting the needs of the people who are most impacted?"

It's very difficult to do that without speaking to and hearing from the people who are living it every day, and recognizing that they have the tools and they have the knowledge base to help us come up with programs and policies that are going to move us forward towards equity. Anyone who knows me knows that Ella Baker, I think she's the most amazing person ever, and she always used to say that strong people don't need strong leaders, strong people need tools. They need resources, they need skills, and people supporting them in building their skills so that they can do the work of fixing things their own problems. They have the ability to do that, so let's support people in doing that.

A lot of the work in working with people with lived experience is supporting them in solving the problems that we already know they have the capacity to solve, and seeing them as true partners and experts in the work. Making sure that they have a seat at the table when decisions are being made, that they're really being listened to and that isn't just like, "Oh, you're just a body here. We're trying to fill a requirement,” but it's like, no, I'm actually taking everything that you're saying into account. We're weaving that into how we're addressing things, and that informs our work moving forward. I can provide an example in Oakland. 

Oakland recently went through a system modeling process, and part of that was an equity analysis. They did focus groups with people experiencing homelessness and, through those focus groups, they found that people were telling them, like, "Look, the homeless system is playing an active role in displacing us from our neighborhoods and from our homes," and hearing them say that, the people who did the analysis came back to us and said, "Like, I have been doing homeless assistance work for decades and the things that I learned in the hour-long meeting that I had with people experiencing it from day to day is more than I have learned in the decades that I've been doing this work. And recognizing like, okay, you hear from someone that “You are playing a part in displacing me,” that's a difficult thing to receive, but it's necessary that we receive that. 

Then you ask yourself a question of, like, "Okay, well, what are we doing that is leading to you being displaced from your home? How do we correct that?" They were looking at how they were addressing these things and oftentimes, people who were living in Oakland prior to experiencing homelessness because of the high cost there, the homeless providers were like, "Okay, well there is housing, but it's in the next county over." Oftentimes, people were being moved to those counties just because that's where the housing was, but after having that conversation, they were like, "Okay, we really need to look at how do we ensure that there are affordable housing options in Oakland, so that people can stay in their homes? People can stay in the neighborhoods that they've known their entire lives." That's a part of the work, that's an important piece of the work, and that's equity work.

Diane: Chloe raised the issue of lived experience and the importance of hearing from people who are affected by inequitable policies. I think that's really essential for identifying those systemic issues and lifting them up so that we understand what the root of the problem is. Before I came to Abt, I did some work with the Robert Wood Johnson Foundation, which is focusing on health equity. We used something called the equitable evaluation principles in our work, and that's a central part of the equitable evaluation principles is giving participants and evaluation ownership and giving them a voice, and the research and some other ways to do that are having advisory groups of participants doing something called “member checking,” where you actually go back to your sample and say, "These are the findings that we have drawn out of what you've told us. Does this sound right to you?" Using participants as data collectors. There are all kinds of ways that you can bring in participant voice and I think it's really essential to the work to raise up those systemic issues that sometimes we don't see, because it's policy for a long time. We don't see how the policy doesn't affect everyone the same way.

Eric: Well, I was just going to ask, how do you see applying those approaches in other areas, and you just answered that question for me, but I think you're also indicating how the research and analysis feeds into the technical assistance, right? Like expanding that data source, so we can then address these issues.

Diane: Another one of those principles is about doing research and evaluation that is in service to building equity, right? We know that there are lots of disparities. We don't need to spend more time counting those up and looking at percentage differences between different populations. What we need to focus on is trying to understand what are the drivers of those disparities, and then what strategies we can use to improve, to increase equity, to move equity forward. That's what we really need to learn more about is identify promising strategies, and then test them and see if they improve equity, if they increase equity. 

Our childcare system right now is going through a big struggle with COVID. We've lost a lot of our childcare capacity in this country. What if when we build it back, we were to center on people of color and we were to say, "Well, what kind of childcare would best meet the needs of this population?" For example, parents who might work a changing shift schedule, or they might work a second or a third shift, and we built a system around meeting the needs of the families experiencing the greatest inequities. I think we would see a really different kind of system, and we would see quality dollars flowing towards different kinds of childcare providers and arrangements than they do today. 

I hope that that happens as we move to the other side of COVID, but that's just an example of how we can use research and evaluation in service to increasing equity and in every area of human services across all the social determinants of health. When we're looking at policies and innovative programs, we need to ask the question, does this increase equity?

Eric: Well, it's interesting because we're at this moment which is hopefully an inflection point, where we're seeing and can talk about social determinants of health. We're seeing how actual health disparities are really brought out as we look at the effects of COVID and, in the meantime, we're seeing in our justice system issues that are really drawing attention to disparities. It seems like it's a real opportunity for us to take this mindset and take these approaches, and they're applicable across the social determinants of health. Hopefully, this is our moment.

Diane: We have to look at the systemic issues. I would like to just read the Robert Wood Johnson's definition of health equity because I think it really illuminates what we're talking about. They say that health equity means that everyone has a fair and just opportunity to be healthier. This requires removing obstacles to health, such as poverty, discrimination and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and healthcare. That's a pretty big job, trying to move all of that forward, but I think in any of these areas where we work, we can almost start anywhere.
As we provide technical assistance and do research, we can be thinking, “Is this in-service to equity? What am I learning about that, and how can I share that with other people, with other organizations, with other public agencies and jurisdictions?”

Chloe: I want to reiterate, Diane, you were saying that, at this point, we're at a place, particularly with research and also, I think, technical assistance and evaluation to where we do understand, like, okay, there are these disparities and we should be moving into a space, like you said, of, “Okay, how do we actually address them? How do we fix them?” I think a really critical piece of that is doing like a root analysis, where we're really trying to get to what is actually causing this issue. 

What you were speaking to in terms of doing research in service of finding solutions to these problems that we already, through decades of research, have found that they exist, right? I don't really think that most people can argue that, based on the wealth of research that supports that we have disparities across all of these different sectors. How do we start to move into a space where we're really looking at identifying the root issue, and you know that you have found that once the problem is completely eliminated? I think oftentimes some of our solutions, because I think people want to see these disparities addressed, sometimes our solutions are addressing causal, rather than like root issues.

Diane: Right.

Chloe: The difference is that with a causal implementation of something, it's like it can be improved, but the disparity isn't eliminated.

Eric: Right.

Chloe: When you're really speaking to addressing it at the root, then we no longer see these issues. I think the work that we're trying to do in the homeless space is really, like, “How do we get to the root?” Then I think, in the homeless space, it's that we are ending homelessness and that housing is seen as a basic human, right. In order to do that, we have to come up with solutions that are addressing the root of the issue, but we also have to be able to recognize the full humanity of every person, because you can come up with solutions that honor the fact that housing is a basic human right, but if you cannot really see the fact that every individual person is a full human being and deserves that right, then your implementation could end up with disparities.

Part of the work is getting people to a place to, to where it's like we all see each other as full people, irrespective of our background. We can honor the full humanity of each person, which is really important in the work.

Diane: One of our colleagues, Chris Tappan, was talking to me about these issues last week, and we talked about the importance of getting at the root. When you say that, it makes me think about system level issues, right? Rather than saying, "Well, your educational outcomes are behind your peers. What do we do to remediate you? How do we fix that, right?" We need to look at the bigger system issues that allowed it to get to this point, right? She was saying, "Well, it's like, if you do that, it's like saying, I need to build a better and better and more efficient way to pull people out of the river, instead of going upstream and trying to solve the problem, so that nobody falls in the river in the first place."

We have spent a lot of time and resources and energy on building better and better ways to pull people out of the river faster and faster, but the problem is that people keep coming. Now we need to address those root causes, those systemic issues to take care of the problem.

Chloe: Mm-hmm, definitely.

Diane: For a young child starting kindergarten, who's not ready, there's probably a component of what kind of prenatal care did that child's mother get, the housing, the employment of parents, the childcare in the early care and education, did they have access to nutrition. There could be environmental pollutants in the neighborhood that are causing that asthma. There's all kinds of things that go into that outcome that have to be addressed that are root causes. Unfortunately, I think the root causes are many.

Chloe: Mm-hmm.

Eric: Well, if I can follow the river metaphor, there are many locks to the river and that's housing, education, health, workforce, criminal justice system. We at Abt are working all of them. Hopefully, we can all deploy to our respective locks and start applying this approach, and start keeping people out of the river.

Diane: I'll say, as a relatively new employee of Abt, that's one of the reasons that I came, because Abt does work across the social determinants of health. I thought, well, this organization has a good chance of being able to look systemically, not only within each of those systems, but across those systems, strategies to address equity in this country.

Chloe: Mm-hmm.

Eric: That's a real good place, I think, to end. Thank you both for joining me.

Chloe: Thank you.

Diane: Thank you.

Eric: Thank you for joining us at The Intersect

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