An interview with analyst Julie Cassidy on health equity

Earlier in July, League policy analyst Julie Cassidy attended the Michigan Public Health Institute’s Health Equity and Social Justice Workshop. Here, she weighs in on some questions relating to the workshop and to inequity in the healthcare industry.

Q: What are the root causes of health inequity?
A. We look a lot at “upstream factors” related to a person’s health, such as access to transportation, housing conditions, access to healthy food, that sort of thing. But there are actually factors even further upstream than that, and the three main ones are institutional racism, class oppression, and gender discrimination. Those things have a major influence on the social determinants of health.

Q: Can you give an example of this kind of inequity?
A: We learned that African-American patients on Medicare are three times more likely to have a limb amputated as White patients on Medicare. Both groups had similar health backgrounds. So we talked about why that might be. One reason might be geographic. Hospitals or healthcare facilities in areas with larger-than-average African-American populations might have different practices and policies that ultimately result in more amputations. Additionally, African-Americans might face more barriers than people of other races to measures that can prevent amputation.
But there could also be implicit bias on the part of the healthcare provider, which is a frightening issue. Providers might be making unconscious judgments about a person’s ability to manage their own health, or they might be making judgments about the value of people’s bodies based on race. The doctor might assume “This person is not going to do what I tell them to do to manage this problem, so I might as well just amputate to avoid further problems.” It’s really disturbing to think about. But we need to think about it if we want to effect change.

Q: Can you explain the social justice movement taking place in public health?
A: We learned that public health arose in the first place as a response to industrialization, which is really interesting. Through the public health field, we made all these historic advances in health status through things like the abolition of child labor, food safety, adequate housing and the establishment of the minimum wage. Over time, though, the role of public health began to serve more of a technical and managerial role, while many inequities in society were exposed, and of course many have worsened. We’re now going back to those social justice roots. We’re examining how power imbalances and issues of privilege affect public health.

Q: What was the biggest takeaway from the workshop for someone in your position?
A: I saw that there was still a lot of value in applying the concepts to our policy work. The workshop presented a particular framework that resonated with me: The Four Levels of Oppression and Change. This was helpful to me in thinking about where we can be most effective in promoting a policy change. The levels are: Personal, Interpersonal, Institutional, and Cultural. Cultural refers to those broader ideas about what is normal or right or true. A permanent change requires intervention on all four levels, and one person or even one group can’t make those big changes. Working in the policy area, we focus mostly on the institutional level, but this framework helped me to be more conscious of the right ways to make decisions about the kind of advocacy we’re engaged in.

Q: What are some stories from the event that impacted you?
A: We shared a lot of personal stories about experiences with poverty or injustice, and discussed the trauma that a lot of people with low incomes can face, from infancy to adulthood. We watched a film called “The Raising of America” that detailed the community trauma that occurs. It followed an urban neighborhood made up mainly of people of color. What really stood out to me was that children growing up in this community were experiencing the same kind of stress that causes PTSD, basically from the day they’re born. It’s the same kind of stress that you hear about people experiencing in combat. But in this case it’s constant, not just one isolated event. It’s a lifelong trauma in many cases, and we talked a lot about the community bonds that are necessary to keep people healthy and safe.

Q: What is it that community leaders and groups should be doing to help?
A: Well, there’s a history of disinvestment in low-income communities and communities where there are a lot of people of color. And that comes out in the form of a lack of parks and greenspace, programs for kids—in some of these areas it’s not safe to go for a walk. So there has to be a focus on making these investments in communities where they’re most needed, not just in communities where residents have the money and can decide to pay higher taxes.
In the film, one community put in a neighborhood fitness center. Some people would look at that and say, “That’s a luxury. Why is this low-income community wasting its tax dollars on a gym?” But if your neighborhood is not safe for jogging, if you can’t send your kids outside to play in their own yard, and if we accept the premise that exercise is important to maintaining good health and that people have a responsibility to exercise, then a gym is essential. Those are the kind of things that we should be investing in.

Q: What about the healthcare industry? Other than education, what are some steps that can be taken to combat inequity?
A: As the healthcare field moves more and more toward a team-based model and community- and home-based care, we might need to rethink the traditional credentials used to determine whether someone is qualified to be a healthcare provider. People from families with low incomes, people of color, and people with disabilities face a lot of barriers to getting the education required to provide healthcare under the traditional model. However, we need people from these communities and demographic groups to play a role in public health. They have a perspective that is often lacking, and they can be more effective in connecting with the service population, building trust, and helping doctors and policymakers to better serve these populations.

Q: What can Michigan residents do to help stop this inequity?
A: If you don’t work in the public health or policy field, it can be tough to make a direct impact. But honestly, a lot of it comes back to the importance of listening to people when they talk about their experiences, and just having empathy. These things start close to us, so we have to have uncomfortable conversation with our friends and co-workers and families. We need to have the tools to address these conversations as they come up—to learn to address bias and racism and assumptions, to be deliberate and intentional with the language that we use. We can get at the cultural level of oppression when we begin to examine our personal relationships.

Q: Where could someone go to learn more about health equity and social justice?
A: Some good educational resources could be found at Center for Global Policy Solutions, Demos, the Center for Social Inclusion and the Michigan Immigrant Rights Center. People in Michigan looking to do advocacy work could contact Action of Greater Lansing, Lakeshore Ethnic Diversity Alliance , their local Black Lives Matter groups, or their local health departments. The Ingham County Health Department has some great resources, for example.