Share Public Health Transcript: Tackling Equity, an Introduction

Season 1 Episode 17

Hannah Shultz Welcome to Share Public Health, the Midwestern Public Health Training Center’s podcast connecting you to public health topics, issues, and colleagues throughout our region and the country, highlighting that we all share in public health. Thank you for tuning into this ten-part series on health equity. Over the course of this series, we will discuss a broad range of topics connected to health equity. For additional resources and information, be sure to check the podcast notes or visit mphtc.org/healthequity.

Hannah Shultz Welcome to the introductory episode of this series centered on health equity. My name is Hannah Shultz and I am your host for today. I work for the Midwestern Public Health Training Center, housed at the University of Iowa College of Public Health and I am very excited to welcome our three guests today. Dr. Rima Afifi is a professor and chair of the Department of Community and Behavioral Health at the University of Iowa College of Public Health. Through her work, Dr. Afifi works to promote social, community, and policy environments conducive to wellbeing. She is specifically interested in intervention and implementation science, working to encourage bridges between research and practice. Dr. Afifi is one of the faculty leads of the Health Equity Advancement Lab, known as HEAL, at the University of Iowa College of Public Health and has been immeasurably helpful in putting together this whole series.

Dr. Rima Afifi Thanks for having me. I’m very excited about being part of this series.

Hannah Shultz Our next guest with us today is Dr. Maria Bruno. Dr. Bruno is the Executive Director for Belonging and Inclusion & Assistant to the Vice President of Student Life at the University of Iowa. Dr. Bruno is a clinical psychologist and has worked with a broad range of populations. Dr. Bruno’s areas of expertise include trauma, training and supervision, and multicultural principles. In her time at the University of Iowa, she has advocated for a more equitable, inclusive environment, and infuses her work with an understanding of belonging as a basis for health. Dr. Bruno, thanks for coming over and joining the public health world for a little while this morning and contributing to this episode.

Dr. Maria Bruno Hello, thank you so much for inviting me. I feel so honored.

Hannah Shultz And finally today we have Dr. Paul Gilbert. Dr. Gilbert is an assistant professor at the University of Iowa College of Public Health. Dr. Gilbert focuses his work on alcohol use disorders, particularly in the ways that gender, race/ethnicity, and sexual orientation shape drinking patterns, risk of alcohol use disorders, and use of treatment services. He also does work with Latino communities in non-traditional settlement states through participatory, action-oriented research. Along with Dr. Afifi, Dr. Gilbert is one of the faculty leads at the Health Equity Advancement Lab at the University of Iowa College of Public Health. He is also chair of the College’s Diversity, Equity, and Inclusion Committee and you will be hearing from him as a host in a couple of the episodes later in this series. Dr. Gilbert, thanks for joining us and thanks for your work hosting a couple of the other episodes.

Dr. Paul Gilbert Thank you, I’m really excited about this series and glad to be a part of it. Thanks for thinking of me.

Hannah Shultz So I’m gonna start our conversation by reading the CDC definition of health equity. “Health equity is achieved when every person has the opportunity to ‘attain his or her full potential’ and no one is ‘disadvantaged from achieving this potential because of social position or other socially determined circumstances.’ Health inequities are reflected in differences in length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment”. So, in this podcast series of 10 parts, we’re going to be talking about many different areas of health equity and health inequity. So today I want our conversation to focus on exactly what health equity is and how it plays out. So, to get started, do any of you have reactions to that CDC definition or thoughts as we get started with this conversation?

Dr. Rima Afifi I can go ahead and get started. I actually like that definition a lot. I particularly like the emphasis on allowing people to achieve their full potential. I think whenever any of us in society doesn’t have that opportunity to achieve their full potential, then all of us lose. All of society loses. So, I do think it’s important to create environments that are conducive to uplifting everybody’s potential to achieve their wellbeing in health.

Dr. Paul Gilbert I agree. I really like the CDC’s definition. It has the central idea that’s important that we want to maximize opportunities for good health. But I always feel like it needs a bit of a follow-up because there’s a risk of thinking that it’s just convincing folks to make healthy choices. It’s not at all about that. That is a portion of health, but when we focus on health equity it’s more about the context and the structures and the larger things. Especially things that are not under any individual’s direct control that we want to create the opportunities for good health. So, I like it but I always feel like it needs a little bit more of a follow-up explanation or going a little deeper.

Hannah Shultz And on next week’s episode we’ll be talking about the social determinants of health, which will get more into what some of those other non-behavioral things are that influence health.

Dr. Paul Gilbert Exactly, yeah.

Dr. Maria Bruno My thoughts and reactions to the definition are similar. I like it while I also believe that we have to be cautious whenever we are trying to utilize definitions. I think what’s missing for me is really highlighting the values that will guide us to change behavior.

Dr. Paul Gilbert I like that a lot, too. Oftentimes in classes I’ll emphasize to students that, you know, our focus on equity or correcting inequities is driven by our values, by our ethics. We have a moral obligation to correct situations. Health disparities, the differences that we see are the end result of this whole chain of things that happen, but it really starts with our commitment to the values, so thank you for that.

Hannah Shultz So, health equity is kind of a buzzword right now. Everyone’s talking about it. Everyone thinks it’s important, but sometimes we kind of stop there. So, can you all talk about what is health equity, what’s the difference between equity and equality, or inequity and inequality? How do all those play out in conversations about health and in public health practice?

Dr. Paul Gilbert I think one of the easiest, well maybe – I don’t know if it’s easy, if anything about this is easy. I should say one of my starting points is to differentiate always. It’s not just an inequality, it’s not just that there is a difference, but there’s more going on behind the scenes. There’s something about systematically privileging or disadvantaging different groups, different social groups, different identities that have say, historical roots or structural components, things that as i said before, are not under any individual’s direct control, but that influence everything about their life and their health outcomes. The other thing I’ll often tell students is, you know, our goal is equity, that everybody has the opportunity to maximize their health, but it doesn’t necessarily mean that everyone’s going to have the exact same outcome. There’s always going to be variation. Folks will even make poor choices and that’s just part of life, but what we want to do is maybe pay attention to the range of differences bringing the top and the bottom closer together, the well and the unwell closer together, or correcting all those structures and systems and histories that lead to these differences. Maybe that’s more the nuance that I think of.

Dr. Rima Afifi I can jump off from there. Just to follow up, I think a little bit on what Paul was saying – so our health and wellbeing is determined by many, many, many factors. Biology is one of those factors, but other factors include . . . we’ve talked a little bit about behavior. Social and structural and physical environments affect our health. Policies affect our health. Healthcare, of course, affects our health. What we know is very little of our health status or health outcomes, as a society, as a community, as individuals, is actually determined by biology. Most of it is determined by all those other factors. So when I think about inequalities and inequities, inequalities may be things that are not unjust and unfair because they are biologically-driven. If we take, for example, breast cancer. Females will always have more breast cancer than males. That isn’t an inequity, it’s an inequality, it’s a difference between two groups of people based on biology. But anything else that’s not biological is an inequity and is something that’s unjust and unfair and is something worth thinking about in terms of how do we change the conditions that created that. If then you just focus on female breast cancer, if the rates of female breast cancer were just biological then we should see the same rates of breast cancer in females across all demographics, across all countries. And that is not what we see. We see big differences in breast cancer in females depending on a whole variety of socio-demographics and a whole variety of other things, which then makes it an inequity because it isn’t related to biology, but related to social and physical environments, to healthcare access, to policies etcetera.

Dr. Paul Gilbert You just mentioned the proportion of health that could be attributed to things like biology and social factors and such. There’s a paper that I often like to cite. Alvin Tarlov published . . . I guess it may be sort of a commentary or summary review paper in 2006. Maybe we can include the link in the show notes. It showed that all of genes and biology and access to healthcare and individual health behaviors account for less than half of the variance in health outcomes. So, the social environment, the social context, accounts for at least half, a little more than half, and those are things that we rarely think about when we think about health. So, that’s always a good reminder, thank you.

Dr. Maria Bruno Some of the research that I found, specifically from the Robert Wood Johnson Foundation, was really helpful to me because I am not a content expert. I just wanted to, first of all, share that, but the way they understand inequity or health inequity is that it refers to unfair, avoidable differences arising from poor governance, corruption, or cultural exclusion, which I found to be really enlightening for me. Then, inequity for them, they refer to inequity as uneven distribution of health or health resources as a result of genetic or other factors, or the lack of resources. So circling back to your point about the biology, I really think that we often forget about that. We don’t all have the exact same DNA. Our bodies metabolize things very differently, so we often forget about other factors outside of, you know, our regular considerations. In regards to disparity, they also identified that as the difference in health and healthcare between population groups. As I sit here and I think about . . . I identify as a Latina woman and members of my community don’t always have access to healthcare. Because they don’t have access to healthcare or don’t have access to medication, we often have a tendency to utilize emergency rooms and things of that nature. We’re already at a disadvantage.

Dr. Paul Gilbert Yeah, yeah.

Hannah Shultz I think you all highlighted some really important things here which will come up in later episodes as well, but particularly looking at health behaviors and how health behaviors aren’t always the most important predictor of health outcomes. In last week’s episode of Share Public Health, we heard from Dr. Brian Castrucci from the de Beaumont Foundation. At one point in Brian’s interview, he talks about how so much of our environment is advertising and who we spend time with in our social environment, that we aren’t always . . . even when we think we are making decisions for ourselves, so much of it is from what’s around us. So, it might be a health behavior, but it doesn’t mean it was a health choice. That can vary greatly depending on who your family is, who your community is, who you are living with and around.

Dr. Rima Afifi I think Paul started us of really well on this, but I think we do need to talk about behaviors because I think that people always focus in on behaviors and sort of blame people for their behaviors. I think we’ll get to blaming later in the episode, but behaviors are also socially-patterned, as you’ve suggested. Behaviors are not volitional. So, we’re not completely volitional. A lot of people think that behaviors are completely in our control, but again if you look across socio-demographic groups or across countries, if behaviors were completely in our control, then they should be the same across all these categories of individuals, or across all these zip codes, or all these countries. And we don’t see that. I mean, if you take substance use, for example, tobacco smoking. If it were completely a volitional behavior related to what I know and my biology, then rates of tobacco use across the world and across communities should be exactly the same. That’s tobacco use as a behavior. But in fact we see very different rates of tobacco use according to policies, according to social marketing, according to a lot of other social and environmental factors. There is almost a risk that when we focus too much on behavior, we actually victim-blame. I think that’s important to bring out in this sort of thinking about health equity. So, sorry to take us on a tangent, but I think it’s an important thing to bring out.

Dr. Paul Gilbert Yeah, and I agree. A lot of times we don’t pay attention to the context that behaviors happen, in that for smoking as an example, your neighborhood could be targeted with pro-tobacco advertising. You might not have any other stores in your neighborhood except the corner store of the gas station, where tobacco products are available. You may be working a job where the only time you can get a break from your work is a smoking break. The context shapes the behavior to a tremendous extent that we don’t always recognize.

Hannah Shultz Thank you for bringing that back. I think we can look at any number of health behaviors and point to how it’s so much more about our built environment and social environment than the decisions we’re making. This training center in previous years has focused a lot on diabetes, which is another really good example of health behaviors that lead to health outcomes, but it might not necessarily all be about those behaviors. It’s not about making choices that leads to those behaviors. So, I think that kind of ties into another thing that’s often linked to health equity, which is social justice. So what do you all see as that connection between health equity and social justice? Is working toward health equity working for social justice? Are they one in the same? Or how do those two kind themes or practices work together?

Dr. Paul Gilbert Well, I think it’s the same. Working for health equity is working for social justice. Yeah, I just see it as the same.

Dr. Maria Bruno I have a very strong reaction to that. I do think that it is extremely important. The reason I say that is, as a clinical psychologist, unfortunately I hear the numerous amounts of stories specifically from underrepresented populations when they’re in systems that really are not created for them to thrive. Unfortunately, their health deteriorates. So they go from being brilliant, energetic, full of life individuals to individuals who have actually maybe had an early onset of schizophrenia because of the environment. So, I do think they are together and they’re not separate.

Dr. Paul Gilbert You know, I think that’s a great example of, again, this notion of equity, like not having the same quality of care, or being at a disadvantage. You may have access to care, but that’s not the end of the story. It’s the quality of care you’re receiving, yeah.

Dr. Rima Afifi I mean, I think for me, they are also very much linked. When we started off the definition of inequities, we did focus on the fact that many of these, both disparities and equities, occur in communities or populations that have been marginalized and disadvantaged as a result of historical oppression. The minute that you use that as a definition for health equity, you’re in the social justice realm automatically. Social injustice is related to historical oppression, historical and continued oppression. To remove inequities automatically means to remove injustice.

Hannah Shultz You bring up an interesting point there. I think a lot of people, especially in rural areas . . . our training center covers Missouri, Iowa, Nebraska, and Kansas, so four very rural states. In a lot of rural areas, there’s not a whole lot of diversity. There’s not much racial diversity or socio-economic diversity, with some important exceptions to that. Why do people who are living in communities that don’t see much diversity, why is it important for them to consider equity? How is equity or inequity at play in those communities?

Dr. Paul Gilbert I would counter and say there is diversity everywhere around us. It may not be dimensions that we always think about, like socio-economic diversity. That absolutely happens in rural and urban areas. There’s rural-urban differences in your context, the facilities you have available, the services, the quality of education, and healthcare, and so on. As you noted, we oftentimes in this country think about racial/ethnic diversity first. That may be different. Even rural Midwestern areas are diversifying rapidly in terms of race/ethnicity. So, it’s there. It’s just . . . maybe it’s a muscle that we have to exercise, to practice looking for the dimensions of diversity that is there. My rationale for it always is that equity is good for everybody, even if I’m in the top position as a white male. Ensuring that there’s equity around me and my community lifts all of us up. It’s good for all of us. So, I think that’s something, maybe a good starting point for folks that aren’t used to looking for it or maybe aren’t aware of the different dimensions of inequities and historical injustices.

Dr. Rima Afifi When I think about this, I like to use an approach that the Racial Equity Institute brings about. They use an approach called the Groundwater Approach. I’ll explain it a little bit because I think for me it really makes this issue of why equity is important clear for everybody. The Groundwater Approach sort of goes like this: You have a home and you have a pond. You come out of your home one day and you look in your pond and there’s one fish that’s dead. At that point, you’re asking questions about why the fish is dead, but mostly it’s questions about the fish, like there must have been something wrong with the fish. The fish did something wrong, you know, all those things that we talked about before in terms of behavior. You sort of let it go. It’s one fish, it’s fine, it’s gone. The next morning you get up and you go out to your pond and you see half of your fish are dead. You’re gonna start to ask very different questions. Those questions are going to start to revolve around the water that’s in your pond. We’re starting to get there right? About them, it’s social and physical environments, at this point, physical environments. The third day you get and you start talking to your neighbors, and you realize that it’s not only half the fish in your pond that are dead, but half the fish in every pond in your neighborhood that are dead. Then again you’re starting to ask very different questions, not only about the water, but about what is common between you and your neighbors. That becomes the groundwater. If it’s in the groundwater, then it affects us all, whether or not we have a pond and fish or not, we’re still drinking from that groundwater. What we know about inequities is, and the way that we approach it, is it is a lot about that groundwater that we are seeing unequal opportunity and unequal potential across a whole variety of sectors . . . across the education sector, across the health sector, across the housing sector, across the finance sector. So really, it is something that isn’t in our groundwater and it will affect us all. If you look at rural areas and the health issues in rural areas, you’ll often see huge disparities between urban and rural areas. Sometimes worse in urban areas, often worse in rural areas. So, rural areas also have a significant amount of inequity that’s related to the structures, policies, and approaches that we all are promoting. I don’t know if promoting is the right word . . . that we are living with, I guess, or are facts in our communities.

Dr. Maria Bruno I love that example. I am familiar with it as well. I really appreciate it because I think it stretches us to think about other factors versus just the one person, right? We have the tendency to blame someone and we see that all across any kind of difficulties. One of the things that I would also like to add to everything that has been shared is regardless of the specific demographics, also considering access to resources and what is available for folks, right? So, there are certain areas that would have high-tech machinery or medical equipment or whatever the case may be, or even just like clinical psychologists, or social workers that are available to them in a lot of rural areas. That’s actually one of the areas where we don’t have enough mental health providers for folks. Even though there is a homogenous community, they might not have the same access to the resources to help them be able to thrive.

Dr. Paul Gilbert You know, that’s, to jump off your point, I think about that often times in terms of alcohol treatment services. If you’re living in a small town somewhere, you may not have treatment accessible to you. You may require an hour’s drive. Depending on where you work, especially if you’re in agriculture, there are times of the year you can’t get away for an hour’s drive to therapy. So, the second part of that too is, well, okay, maybe we can have technological situations. There’s a lot of interest now in telehealth for rural medicine and that’s great. There are services available online, you know, recovery support groups, but then you get into the question of the infrastructure. Do you have sufficient Internet capacity in your area? I mean, that is a real barrier that we have not resolved in a lot of places. So, that might be an example of inequities in terms of your geographical location and how we just don’t put resources in rural areas.

Dr. Rima Afifi I did want to also just sort of come back to this idea of why it’s important for everybody. I think there’s many things that we could say about this, but I mean, evidence of course shows if you just take sort of income inequality, we know that countries that have lower GDP have much worse health outcomes than countries that have higher GDP. But, even within countries, you can see that gradient. Evidence also shows that the bigger the difference between the highest earner and the lowest earner, the much worse the health outcomes are for everybody in that country. So, if you take the United States, among all the other Organization for Economic Cooperation and Development countries, so all sort of countries that middle- to high-income, the United States spends almost the most on healthcare, if not the most, but its outcomes are towards the bottom of all those countries because the income inequality within the United States is huge. So, if you think about, just to give an example, the expected age of deaths for women at the lowest 1% of income distribution in the United States is 78.8. For women at the top 1% of income distribution, the expected age of death is 88.9. It’s like 10 years difference for women. For men, it’s even worse. For men in the lowest 1% of income distribution, they’re expected age of death is 72.7 and the top 1% is 87.3, so 15 years difference between those that are earning the least and those that are earning the most. It’s important to think about these differences and those are clearly not biology.

Hannah Shultz Thank you for those responses. I did want to flag a couple of things that came up. Dr. Gilbert, a few minutes ago you mentioned diversifying communities. Later on in this series, we’re going to have a whole series on immigration and talk about what some of those new destinations are in Iowa. Some of those communities in Iowa and in our region that have long been destinations for immigrants. The whole idea of place matters and location matters as a huge determinant for health will be the topic of an episode in a few weeks as well. So we’ll come back to a lot of these conversations throughout the next 9 weeks. So, thank you for starting to introduce some of these topics. I want to shift gears just a little bit. So, in the next several weeks we’re going to be talking about things from race to disability to sexuality to location, and some of these topics are really uncomfortable for people. I know, frequently, I get into conversations about race and people get a little anxious that they don’t want to come off as racist, so it kind of stops any way to move forward with that conversation. So, why is it so important that we have these conversations and how can we make progress on any of these topics with people who may be a little more hesitant to fully involve themselves and engage in these kinds of conversations.

Dr. Paul Gilbert I think there’s always a discomfort because these are big issues. It can be challenging trying to understand the historical context, the scope of things, especially when they’re out of your control. Who likes to try and grapple with something that you don’t have direct control over? That’s just hard, but specifically since you mentioned race, I think a lot of times people are reluctant because they just don’t know how to talk about it and they haven’t had the practice. So, my response is well, we have to face things. We have to face facts. Maybe putting on my scientist hat, like, let’s just deal with things as they are. We just have to practice. We also have to realize that, especially for white folks talking about race, that is not the same as talking about racism. You can talk about being white, the experience of being white, and contrast that to other people’s experience. That is different from, say, reinforcing the racist hierarchy or white supremacy. That’s a totally different thing, but to acknowledge that yeah, there are differences, and you happen to fall into the dominant group, or all the stories are about you and your experience. You’re at the center of everything. It takes practice and we’ll get there. But, we do have to be intentional about that. I guess my – yeah, I keep coming back to like talking about being white is not the same as talking about being racist. But, oftentimes, because we haven’t had practice, we get that confused.

Dr. Maria Bruno I so appreciate my training as a clinical psychologist. I think it has really helped me develop sophisticated, empathic skills for humans. I identify as a humanistic clinician, and so what I mean by that is that I really firmly believe that people are genuinely good people. So, I would encourage us to really begin with recognizing where you are, individually gaining your own self-awareness, learning to recognize your own biases. There are so many resources available to folks that if you felt uncomfortable, you can do a lot of training online. So, I would encourage folks to do that and we can provide some links if people are interested. I also believe that everybody has areas of their lives where they have privilege and areas of their lives where they have non-privilege. We must obtain knowledge to increase our own ability to understand others. I would really encourage folks to demonstrate cultural humility. If you don’t know something, it’s okay to say I don’t know. Hopefully, the people that you’re conversing or interacting with will also be generous with you. If they’re not and they have any kind of reaction, I would also encourage just to sit with our own discomfort of what is going on the moment, just to be present, to be with people, and to demonstrate empathy.

Dr. Rima Afifi I really appreciate both of those responses because I do think that’s exactly how we need to be thinking about these issues. The other thing I think that’s been helpful for me is, again to go back to sort of that groundwater approach, is when we understand the groundwater approach, then we also understand the issue of uninentionality or implicit bias. I mean, this is water, so to speak, that we’ve all been drinking and we may not have seen it another way. So, we are all prone to potentially saying things or doing things that are hurtful to other people. Acknowledging that that, for most people, it is not intentional, I think is an important thing. It does open the space for all of us to grow and learn intentionally together in this process. It’s a difficult. This is difficult work and it’s work that needs to be continuous, it’s not work that we can do today and then forget about, and come back to it in 6 months, if we really want to change these conditions. It’s a value as we’ve already stated. It’s a commitment to hard work all together, to sitting around the table and being willing to be uncomfortable. In fact, I think if we’re not uncomfortable, we’re not doing the work.

Hannah Shultz Thank you. A couple of things came to mind following that values conversation. One of the things that I’ve been thinking about in my work recently and in the work that we’re doing as a center, is that we spend a lot of time talking about health equity, creating health equity trainings, and doing all of these things. I think it’s one of those things that it’s either all or nothing. So, we consider health equity in everything we do or we consider health equity in nothing we do. Because if it’s one of those values that’s going to drive our work, your values have to be present at all times. They’re not something that’s only there when it’s convenient, or when you have the time to think about it, or when whatever health department calls and asks you. It has to be a part of everything that we do all the time. Something that I was thinking of, Dr. Gilbert, when you were talking, was I grew up in a very small, white community in Iowa and I remember in third or fourth grade we started studying the 1960’s in human rights, in the 1960’s. I was obsessed. I read everything I could. I self-assigned myself tons of reports. I was, like, writing all the time about this, and I was like isn’t it so great that they took care of that all those years ago and now everything’s solved and we don’t have racism anymore? Obviously, as I grew up, I realized that wasn’t quote the case, but I think it did take me quite a while to realize that that was one part of the struggle and racism is still very, very much present. I came to college and the University of Iowa is much more diverse than the community I grew up in. Interacting with some of those classmates and roommates that I had, I was like, wait a minute, I thought we solved this? Why is this still a thing? So, I think it’s important for those of us who maybe don’t interact with people who have different experiences than us and who maybe aren’t thinking about these things at all times, to recognize that other people do have different experiences and we can’t center everything we do on our experience. Or else, we are unintentionally leaving out those other people, those other histories, as we’re making policies or doing our own practice.

Dr. Rima Afifi Just to sort of go off that, I think, at one point what we tried to do is ask everybody to think about a situation when they felt excluded. I think there isn’t anybody that hasn’t felt excluded, or there’s very few people, I would say that have never felt excluded. Often in those conversations, they felt excluded because people were trying to put them in a particular box of one identity when they felt they had multiple identities. I think that gives us a little bit of a clue as to how these processes start happening. That all of us have multiple identities and I think we already alluded to that. We all have multiple identities and when we try to box a person, a group, or a community into one specific identity, I think that helps us to understand the process of exclusion. So, sort of bring it back and thinking about when it happened to us may help us also understand. It’s part of the empathy, as well, it may help us understand the experience of other people. The other thing I wanted say is – and somebody once said this to me, I think it was during a training by the Racial Equity Institute actually – is when they said, you know, we all go home at night and we think, okay, what are the great things that we’ve done and sit around the dining room table and share those things, the good things that happened that day. But what if we start to ask ourselves what have I done today that has oppressed or potentially oppressed other people, what have I done today that has potentially excluded other people, what have I done today to potentially limit opportunity? All of us do that, again usually unintentionally, because we are part of systems and structures that are racist, sexist, and ableist, and all those other things. To start to really think about how we do that. So for us, as we’re thinking about enrolling students in our Master’s of Public Health Program, and we start to think, well, what are those rules that we put that either get people into the program or out of the program? How are those rules oppressive? How can we change those rules to make opportunity equal for everybody? So, to sort of flip the question from what are we doing good to what can we do better perhaps.

Hannah Shultz Thank you. I’ve heard you, a couple of times, talk about an exercise you’ve done with groups, a sort of gallery walk. I think that’s a really cool idea for empathy-building. Could you talk just a little bit about what that is and how it’s played out in different settings?

Dr. Rima Afifi Sure. So, a gallery walk is a wall of pictures, basically, or a wall of statements. The statements are usually related to what people have said to others in a microaggressive way. So, a microaggression is – shoot, I don’t have a definition right now.

Dr. Paul Gilbert Usually like the small, casual, daily insults – not the you so-and-so something really bigoted – but not remembering your name, mistaking you for a server rather than a professor. Yeah, the casual, everyday death by a thousand cuts.

Dr. Rima Afifi Assuming that if you are a woman, you have children or are married, or making judgements about a sexual orientation or race or ethnicity, all of those things can be microaggressive. So, a gallery walk is people having shared things that have been said to them that are microaggressive. Sometimes they put their names on that and sometimes they actually hold up a sign and they self-identify as somebody who that microaggression was aimed at, and sometimes it’s just the statement. Others can then sort of walk around, read those things, and realize that actually these are things that are often said. When we did this exercise, we had that gallery walk and the person who was facilitating asked three questions. The first question was how many of you have had something like this said to you and everybody raised their hand. The second question was how many of you have said something like this to somebody else and everybody raised their hands. I think what’s really important about that is, again, it gets back to this idea of groundwater, that we will say things, often unintentionally, that can be very hurtful to other people, unless we intentionally stop, think, engage in difficult conversation, and have cultural humility. The third one was asking whether there were any of the statements at that time that people didn’t recognize as a microaggression. The one that came up the most – and there’s going to be, I think, a series on this podcast that talks about ability and disability – was a statement that said “This movie was lame.” That was the one that people had the most difficulty connecting to microaggression. I think that really shows that our vocabulary, the words that we use, we just use them without thinking about the meaning of what we’re saying. Anyway, I think that’s a potentially powerful activity or exercise. It must be followed then by some work around, okay, how do we start to break this down?

Hannah Shultz Okay, thank you. Dr. Afifi, Dr. Gilbert, and Dr. Bruno, thank you so much for joining us today. I do have one final question, but I wanted to ask if there’s anything you’d like to add to the conversation before we start to wrap up?

Dr. Paul Gilbert I would just say it’s a good thing that this is a podcast series because there’s so much to dig into. We could spend hours and days talking about all of the topics related to this.

Dr. Maria Bruno My comment was also along the same lines. I just want to encourage people to be patient with themselves. It can seem very overwhelming, but just picking one specific area to start, just learning and increasing your knowledge, your skills, and your abilities to be different and to be with people.

Hannah Shultz Thank you. I remember the first meeting we had talking about this series. We came up with a list of things to do and decided it could probably be a 2-year long series. So, we narrowed it down to 10 episodes. So, keep in mind that it is a very, very incomplete series, but we will be covering a range of topics between now and mid-March. We have experts from across Iowa, throughout the Midwestern region, and even a couple of national guests, so it’s going to be a really good series. I look forward to it all being released. Just to wrap up today’s conversation, I want you all to all pretend you have a magic wand or can predict the future. What do you want to see happen in this space? You can choose next year, next 10 years, what are your hopes and dreams for health, health equity, public health? Where should we be going?

Dr. Paul Gilbert Wow, that’s a big question.

Hannah Shultz That’s why it’s the last question.

Dr. Paul Gilbert I would gravitate, I think, to something like the phrase that we toss around often, health in all policies, that everything that we do, everything policy has a health implication, even if it’s not explicitly about health. I’d like to see something like we all adopt this equity in all policies, equity in whatever we do, equity in our actions, that there’s always some equity implication. Then, we can bring that more to the forefront and think about that more in whatever capacity we’re working in, or whatever we’re doing, or wherever our communities are.

Dr. Rima Afifi I had the same thought. Just to follow-up on what Paul said, I think one thing that we need to do is . . . we all get very excited about intervention, whether it’s practice, policy, or any intervention that we think is going to make a difference in people’s lives. We get so excited about them that often we don’t consider all of the various aspects of that potential intervention. So, I think if we stop and think about every intervention from the perspective of all these issues that we know may cause increased inequities, we should not be implementing any intervention that either keeps inequity the same or increases inequity. Every single intervention that we implement ought to be an intervention that decreases inequities, at the very least. There are tools and strategies to do that. Health in all Policies is one. There are other ways like PROGRESS that you can think about, where P is place, R is race, A is age. You can take each of those and go, okay, is this policy going to make it worse or better for these particular categories of potential inequity. I think that’s one thing. The other thing is I do think we need to . . . coming back to the value, it is about a commitment to value. I mean, it’s a commitment to a value of social justice and equity. That would be one place I hope that we all move to. Then, we tend to do a lot of focusing on deficits instead of focusing on strengths. If we can also start to shift our paradigm so that we’re searching for strengths in everybody as opposed to deficits. We’re searching for similarities as opposed to differences. We’re uplifting as opposed to othering. Belonging rather than excluding. If we can sort of just shift our paradigm every time we look at an issue, just turn it around. One thing that I’ve been thinking about a lot which seems like such a simple thing, but is difficult, is can we create environments and interactions where dignity is uplifted? So that in every interaction, when we leave it, our dignity is preserved and uplifted. I think that’s a good thing to shoot for.

Dr. Maria Bruno I appreciate what both of you have shared. You said we could have anything happen . . .

Hannah Shultz Dream big!

Dr. Maria Bruno So, I would really like to see the University of Iowa be very intentional about removing all barriers, so that all students, staff, and faculty can have their best life. I know that’s going to take a lot of time and energy, but collectively we can get it done.

Hannah Shultz That’s a strong note to end on, so we’re going to wrap up. Thank you all for joining us. Tune in next week. Dr. Gilbert will be talking about the social determinants of health with Dr. Georges Benjamin from the American Public Health Association and Dr. Nalo Johnson, formerly of the Johnson County Iowa Public Health Department, currently with the Iowa Department of Public Health. So, thank you all.

Dr. Paul Gilbert Thank you.

Dr. Rima Afifi Thank you.

Dr. Maria Bruno Thank you for all the good work you are doing.

Hannah Shultz Thank you for joining us today. Special thanks to Rima Afifi, Anne Crotty, Alejandra Escoto, Paul Gilbert, Kaci Ginn, Mike Hoenig, Kathleen May, Felicia Pieper, Melissa Richlen, Hannah Shultz, and Laurie Walkner. Theme music for Share Public Health is composed by Dave Hoing and Roger Hileman. Funding for this webinar is provided by the Health Resources and Services Administration. Please see the podcast notes for an evaluation and transcript.

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