Taking Action –The Boston Public Health Commission’s Efforts To Undo Racism

1. Taking Action –The Boston Public Health Commission’s Efforts To Undo Racism Barbara Ferrer Ph.D., MPH Deputy Director Boston Public Health Commission

2. Racial Disparities in Boston Health Issue Black White Asthma / Male 5-14 (Hosp) 6.4 1.7 Birth Weight (Less than 3.3lbs) 3.4% 1.0% Body Weight 63% 46.% Breast Cancer (Morality) 24.2 per 100,000 20.7 Cervical Cancer (Mortality) 8.4 per 100,000 2.2 Death Rate (Mortality) 1028.1 per 100,000 942.8 Diabetes (Mortality) 33 per 100,000 15.2 Health Insurance 11.5% 6.1% Heart Disease (Mortality) 224.8 per 100,000 230.6 High Blood Pressure 26.4% 16.6% HIV / AIDS (Mortality) 24.9 per 100,000 7.2 Homicide 19.7 2.5 Infant Mortality (Mortality) 13.6 per 1000 2.8 Hospitalization 155.3 per 1000 108.4 Lung Cancer (Mortality) 66.8 67.2 Prostate Cancer (Mortality) 71.4 per 100,000 27.5 Smoking during pregnancy 6.8% 9.4% Drug Related Mortality 11.7 13.0 Suicide (Mortality) 3.5 8.1 Teen Birth Rate 63.696 per 1000 10.242

3. Definition of Racism • Any type of action or attitude, individual or institutional, which prescribes and legitimizes a minority group’s subordination by claiming that the minority group is biogenetically or culturally inferior. O’Sullivan, J., See, K., Wilson, W.J. (1998). Race and ethnicity. In: Smelser, N.J. (Ed), Handbook of Sociology, Newbury Park, California: Sage Publications, pp 233-242.

4. Racism Definition Race Prejudice + Power = Racism Prejudice defined as “a preconceived idea, usually one that is unfavorable”

5. Levels of Racism • Institutional - differential access to the goods services and opportunities of society by race. • Personally-mediated - prejudice (differential assumptions about the abilities, motives and intentions of others based upon their race)and discrimination (differential actions toward others based upon race) • Internalized - acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth. Camara Jones, MD, MPH, Ph.D. Levels of Racism: A Theoretical Framework and a Gardener’s Tale, American Journal of Public Health, Volume 90 (8) August 2000

6. How Can Racism Affect Health Status? • Differences in socio-economic status, exposures and stresses by “race” • Differences in access to health care services • Differences in diagnostic testing, treatment, and the quality of care received within the health care system

8. Median Annual Earnings, Full-Time Workers, 1999 SOURCE: Project HOPE Center for Health Affairs, based on overlap of February and March Supplements to the 1999 Current Population Survey.GRAPHIC: Boston Public Health Commission, Research and Technology Services.

9. Selected Socioeconomic Indicators Boston Overall and Black Residents, 2000 Boston Black Overall Residents Indicators Less than High School Graduation or GED 21% 27% % of Population Below Poverty Level* 20% 23% % of Children (Under 18) Below Poverty Level* 26% 28% % of Adults 65 and Older Below Poverty Level* 18% 23% Median Household Income in 1999** $39,629 $30,447 *Based on income in 1999 **Estimated Median Household Income in 1999 NOTE: These data from the US Census include Hispanics in the racial category for Blacks. DATA SOURCE: US Department of Commerce, Bureau of the Census, American Fact Finder, Census 2000, Summary File-3 Sample Data DATA ANALYSIS: Boston Public Health Commission, Research Office

10. Health Insurance Status, by Race and Ethnicity, 1997: Total Nonelderly Population DATA: Urban Institute analysis of the March 1998 Current Population Survey. SOURCE: KMCU, Medicaid Today: Profile of a Program and the People it Covers, 1999. GRAPHIC: Boston Public Health Commission, Research and Technology Services.

11. Access to Specialty Care by Adults, by Race and Hispanic Origin, 1994 SOURCE: Authors’ tabulations ofThe Commonwealth Fund 1994 National Comparative Survey of Minority Health Care. GRAPHIC: Boston Public Health Commission, Research and Technology Services.

12. Percent with No Doctor Visit in Past Year:Adults 18-64 in Fair to Poor Health, 1995 and 1996 * * * WOMEN MEN *Sample too small to make accurate estimates. DATA: National Health Interview Surveys, 1995 and 1996. SOURCE: Brown et al 1999.

13. Pharmaceutical Use by Persons with HIVReceiving Medical Care, 1996 * * * *Significantly different from whites in multivariate analysis to adjusting for CD4 counts, sociodemographic characteristics, and insurance. DATA: HIV Cost and Services Utilization Study (HCSUS). SOURCE: Shapiro et al, 1999.

14. Health Care Access Indicators for Massachusetts Racial/Ethnic Groups 1999

15. Do you think the average African American is better off, worse off, or just about as well off as the average white person in terms of access to health care?

17. Summary "Disparities in the health care delivered to racial and ethnic minorities are real and are associated with worse outcomes in many cases, which is unacceptable. The real challenge lies not in debating whether disparities exist, because the evidence is overwhelming, but in developing and implementing strategies to reduce and eliminate them." -- Alan Nelson, retired physician, former president of the American Medical Association and chair of the committee that wrote the Institute of Medicine report, Unequal Treatment: Confronting Racial and Disparities in Health Care

18. Evidence of Racial and Ethnic Disparities in Healthcare • Disparities consistently found across a wide range of disease areas and clinical services • Disparities are found even when clinical factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are taken into account • Disparities are found across a range of clinical settings, including public and private hospitals, teaching and non-teaching hospitals, etc. • Disparities in care are associated with higher mortality among minorities (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1995)

19. Black and White Differences in Specialty Procedure Utilization Among Medicare Beneficiaries Age 65 and Older, 1993

20. Potential Sources of Racial and Ethnic Healthcare Disparities – Healthcare Systems-level Factors • Cultural and linguistic barriers – many non-English speaking patients report having difficulty accessing appropriate translation services • Lack of stable relationships with primary care providers – minority patients, even when insured at the same level as whites, are more likely to receive care in emergency rooms and have less access to private physicians • Financial incentives to limit services – may disproportionately and negatively affect minorities • “Fragmentation” of healthcare financing and delivery

21. SUMMARY OF FINDINGS Racial and ethnic disparities in health care exist and, because they are associated with worse outcomes in many cases, are unacceptable. Racial and ethnic disparities in health care occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life. Many sources – including health systems, health care providers, patients, and utilization managers – contribute to racial and ethnic disparities in health care.

22. “If racism was constructed, it can be undone. It can be undone if people understand when it was constructed, why it was constructed, how it functions, and how it is maintained.” ---People’s Institute For Survival and Beyond

23. Principles of Anti-Racism Work • Race is a political construct that establishes and maintains white privilege. • There is a need to develop a common set of definitions and an analytical framework for understanding racism and its central role in perpetuating racial disparities in health. • Undoing institutional racism within the health care system requires participatory structures/strategies that allow for leadership and decision-making to rest in the hands of those “being served.”

24. Core Functions • “Assessment”…how is racism at play here? • “Policy development”…what policies/standards/protocols can dismantle institutional racism? • “Assurance”…which organizing strategies are effective in bringing about change?

25. Addressing Differences in Access to Care • Support/fund neighborhood-based providers • Identify and reduce barriers to health care utilization • Work to protect/expand publicly-funded health insurance programs

26. Addressing Differences in Treatment • Provide anti-racism training • Train medical interpreters • Review provider practice patterns • Review institutional policies and procedures • Establish a community review board • Identify “best practices”/treatment protocols

27. Addressing Differences in Socio-Economic Conditions • Participate in “community mapping” of assets and challenges • Create forums for discussing racism and it’s impact on health • Participate in community-led efforts to address and eliminate racism

28. Framework Improvement in the health status of non-dominant populations can be addressed by focusing on both political issues of lack of equal opportunity, discrimination, and exposure to differential risks as well as by specific quality improvement initiatives within the health care system.

29. Strategies • Build/support community partnerships • Promote an anti-racist work environment • Re-align external activities to address racism

30. Build Community Partnerships Structural • Create mechanisms for involving community residents in designing, implementing, and evaluating programs/services 2. Establish a community review board to provide oversight of research and evaluation activities

31. Build Community Partnerships Activities 1. Sponsor “Undoing Racism” training opportunities for community residents/clients • Develop and implement a community needs assessment process that examines and documents issues related to racism • Participate in community-based coalitions

32. Promote an Anti-racist Work Environment Structural 1. Assemble an internal team to guide on-going anti-racism work • Increase opportunities for shared decision-making that involve staff across disciplines and job titles • Create/adapt a grievance review process/mechanism to address complaints about racism in the workplace

33. Promote an Anti-racist Work Environment Assessment Activities • Provide all employees with anti-racism training • Develop multiple methods to assess how racism is at play within the institution 3. Assess workforce composition by race/ethnicity and develop strategies for increasing diversity at all levels 4. Create/use a tool to assess “institutional racism” that can identify challenges, suggest quality improvement strategies and measure progress

34. Promote an Anti-racist Work Environment Policy Development 1. Establish shared vision/mission/goals that articulate an institutional commitment to undoing racism as a central public health activity and create a corresponding set of performance measures to assess progress 2. Review sick leave/bereavement/family leave policies and amend as needed to reflect differences in cultural norms/health status

35. Promote an Anti-racist Work Environment 3. Review performance evaluation criteria to assess its ability to respect diverse cultural values 4. Establish recruitment and retention policies that reflect the need for increased representation of people of color in all service and leadership positions 5. Establish standards on ‘community inclusion’ for all projects, programs, services, evaluations and compliance mechanisms

36. Promote an Anti-Racist Work Environment • Establish standards for creating culturally competent health education materials, program materials, and compliance mechanisms • Develop a uniform standard for collecting staff & client race/ethnicity data that adheres to the principle of self-identification and includes ethnic sub-groups.

37. Refocus External Activities Structural • Create an inter-departmental working group within city government to develop a blueprint for “undoing racism” across city departments • Work with community residents, medical schools, teaching hospitals, and health centers to incorporate “cultural competency” curriculum and training opportunities and to support “pipeline” efforts to create a more diverse workforce

38. Refocus External Activities to Incorporate Anti-Racist Strategies Assessment • Sponsor “undoing racism” trainings for health care providers and their clients • Prepare and distribute an annual health report describing racial/ethnic disparities in health outcomes

39. Refocus External Activities Policy • Link funding for all health activities to efforts to reduce racial/ethnic disparities in health outcomes by including language in all contracts with vendors that requires: - collecting client race/ethnicity data - preparing annual reports that include information on health outcomes by ethnicity - developing projects to reduce documented disparities - assessing/improving institutional “cultural competency”

40. Refocus External Activities Policy 2. Explore possibility of creating cultural competency licensure requirements and expanding cultural competency training for providers

41. Refocus External Activities Assurance 1. Target funding to support initiatives addressing documented racial disparities in health

42. What Does It Take……. • Commitment to social justice • Ability to collect and use data to demonstrate racial disparities in health • Willingness to ask questions and listen to answers • Tools for understanding and assessing how racism is manifested

43. What does it take….. • Ability to shift from a focus on individual personal health behaviors to a focus on institutions and systems (requires “training” and “skill building”) • Community leadership/coalitions addressing racism • Desire to work “across issues” • Willingness to shift existing resources to support anti-racism work