Why bringing health equity efforts into alignment with a race+ equitable culture matters
By Monica Biswas I Director
“What does racial equity have to do with health equity?” This is a question I’ve heard a lot in ProInspire’s work supporting health-equity focused foundations to develop a race+ equitable culture internally, especially as they aim to allocate resources responsibly and in alignment to their values.
I believe the question often comes from true curiosity about how to bridge two concepts that seem vaguely connected—health equity and racial equity. They share the term “equity,” and we know that structural and interpersonal racism impacts health, but it’s not always clear what strategies and tactics can impact both of these goals.
Other times, I think the question may be another way of asking, “If we’re already doing health equity, why do we need to do race equity?” Through my observations and conversations with colleagues, the answer I’d offer here is that when leaders focus on health equity work externally, but don’t simultaneously strive to embody racial equity practices and culture internally, it can cause a deep dissonance that shows up as tension, conflict, and polarization within the organization.
For example, news of microaggressions that begin as interpersonal can spread across an organization and fuel a lack of psychological safety for different groups of staff based on race, gender, sexual orientation or other dimension of identity. Decisions about whether to affirm or soften language about racial equity polarizes staff with different perspectives. Conflicting approaches to trust-based philanthropy can create tensions between board and leadership, or amongst differing staff roles like finance and program departments.
These unresolved tensions persist and tear at the cultural fabric of the organization. Further, they exacerbate the burnout experienced by philanthropic staff and leaders who are already taxed and navigating multiple crises in our external landscape. That’s why we believe it’s critical to our missions and visions to bring health equity efforts into alignment with a race equitable culture.
Let’s get clear on our definitions first.
Health equity has been defined as:
- The absence of avoidable or remediable differences among groups of people (World Health Organization)
- Everyone has a fair and just opportunity to achieve their highest level of health regardless of race and ethnicity, sexual orientation and gender identity, disability, or other determining factors like socioeconomic status (Grantmakers in Health)
- Everyone has a fair and just opportunity to be as healthy as possible. 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 health care.” (Robert Wood Johnson Foundation)
It’s widely held that health inequities cannot be effectively addressed without excavating the ways structural racism has been built into our country’s systems, including, but not limited to healthcare, housing, education, economy, and law. At an interpersonal level, health equity requires building community partnerships based on dignity and respect, and challenging long-standing philanthropic norms around credentials defining whose voice matters, what qualifies as valid data, and who has the power to make decisions.
At ProInspire, we define a race+ equitable culture as one where one’s racial identity does not predict one’s access to psychological safety, sense of belonging, or opportunity and thriving in the workplace. We lead with race because research and our own experience shows time and time again how people of color experience personal and professional disparities inside and outside of an organization’s culture and structures. The “+” refers to the acknowledgement that multiple and intersecting dimensions of identity (such as gender, generation, (dis)ability, sexual orientation, language, citizenship, and others) and power create or disrupt the cultures that support the inequities.
A race+ equitable culture challenges the premises of white dominant norms and operational practices that are common in social sector organizations because racial disparities often exist within organizations as it relates to hiring, retention, attrition, psychological safety, and access to opportunity. It supports an organization to prioritize equity (that staff have the resources they need to experience psychological safety and sense of belonging) over equality (that staff have the same resources). Race+ equity practices, therefore, aim to create spaces for belonging and voice, balancing power, and defining clear and transparent decision-making.
We believe the values and practices that are cornerstones of a race+ equitable culture are the same ones that support organizations to do the work that leads with human dignity and trust, creates conditions for power-sharing with communities, and dismantles the systemic structures that stand in the way of achieving health equity.
The way we see it: addressing racial equity within the internal organization is the perfect training ground to build the muscles needed for health equity approaches.
Four Core Connections
Let’s break it down, what are those values and practices, exactly? We’ve identified four core connections between a race equitable culture internally, and the ability to effectively address health equity externally with communities. Both race+ equitable culture and health equity must:
- Acknowledge historical oppression and harm, and work to build and repair trust at structural, organizational, and interpersonal levels. The health of communities has long been impacted by structural racism in the form of redlining and voter disenfranchisement, economic disinvestment in communities of color, and interpersonally through implicit as well as explicit bias by physicians offering treatments or pain medications.
- Value lived experiences as expertise. In fields of medicine and public health, academic and other formal credentials reign supreme, dictating positional authority, power, compensation, and establishing a hierarchy of human worth mirrored in white supremacy.
- Expand data and metrics beyond quantitative or clinical metrics and AI sources. Concepts as nuanced as health, wellbeing, and thriving cannot be simply defined and measured with quantitative metrics alone. AI algorithms are documented to be biased and have limitations embedded in their structure.
- Be accountable to the communities served by the organization. “Nothing about us, without us” is a motto from the disability justice movement demanding that the community be meaningfully engaged in decisions impacting them. Without meaningful representation, approaches can be savioristic or paternalistic and actually perpetuate the methods used to create inequities in the first place.
Promising Practices
So how do you demonstrate these connections through your practices, both internally and externally? The below chart offers some promising practices as a starting place for philanthropy seeking health equity impact, as well as building an internal race+ equitable culture.
| A Health Equity Oriented Foundation … | A Foundation with a Race+ Equitable Culture… |
|---|---|
| Acknowledges historical oppression and harm, and works to build and repair trust by: | |
| – Naming the ways the social sector has perpetuated power dynamics and saviorism through complicitness in redlining, disinvestment, food deserts, and forms of structural racism that impact the health of communities. – Engaging in truth and reconciliation processes about the origins of the foundation and how it can both disrupt or perpetuate health inequities in communities – Equipping teams to call out specific incidents of racism and commit to repair with community and within the organization | |
| Values lived experiences as expertise by: | |
| – Engaging in listening and meaning-making sessions that gather deep and nuanced perspectives from community, beyond community representatives – Establishing community advisory boards or community-oriented seats on a foundation board | – Supporting cross-functional teams, with staff of different identities, lived experience, and levels of positional authority, to create a race equity strategy, and guide its implementation – Understanding the role of each team—programmatic, administrative, operations, finance—in contributing to the mission. |
| – Making decisions with input from, or by, people who are impacted by the decisions. – Defining our decision-making processes and communicating transparently about them: what the decision is, who will make it, how input will be gathered and used. | |
| Expand data and metrics beyond quantitative or clinical metrics and AI sources by: | |
| Measuring “health” not only through clinical metrics, but including social determinants of health, as well as conditions for well-being and thriving that are informed and defined by the communities themselves. | Measuring “belonging,” “psychological safety,” and other staff experiences through multiple forms of data—qualitative, anecdotal, and observations of how people are engaging—along with standard staff survey data. |
| – Measuring returns on investment and progress on racial equity not solely by quantitative outcomes and dollars invested. Qualitative data and stories are included in how impact is measured. “Stories are data with a soul.” – Engaging in ongoing feedback loops, making meaning of data and insights regularly and in partnership with staff of different levels of positional authority to identify where new insights might inform pivots to approaches or plans.Being responsive to changing conditions and new insights and willing to pivot to incorporate new awareness. – Investing in meaning-making collaboratively with staff to help co-create solutions. – Vetting AI tools and sources, and ensuring processes for reviewing outputs and triangulating with other non-AI sources. | |
| Be accountable to the communities served by the organization by: | |
| – Following community leadership to identify the desired outcomes, metrics, and measures of impact – Developing or updating investment protocols to ensure investments are not in misalignment with the health equity objectives the foundation is seeking – Updating administrative processes to avoid excess burden on communities – Assuring Board members hold their fiduciary responsibility for the foundation in balance with the foundation’s mission and desired community impact | – Sharing decision-making power on desired outcomes, metrics, measures of impact with staff – Making decisions about internal culture within the backdrop of the mission and impact for communities: Will staff with similar lived experiences as community members feel a greater sense of belonging? Will a policy or program that fosters a sense of belonging enable staff to do the same with their communities? |
It feels important to also name here that even when connecting these efforts, organizations still often must exist in opposing paradigms. Change doesn’t happen overnight. So even as you are experimenting with these, or other practices, you may also notice polarities and tensions from being in both the “before” and the “after” of change. Some paradoxes we’ve observed include a foundation implementing a 3-5 year strategic plan, while also trying to incorporate emergent processes and ongoing feedback loops that inevitably shift strategy. Foundation staff pushing for divestment of certain types of investments based on their values, while finance committees prioritize maximizing returns. Or, leaders looking to build power with communities, while board members expect their perspectives to be elevated. Our advice is to name the polarities, put them in conversation with each other, and keep going!
When asking, “What does racial equity have to do with health equity,” the question is not merely a semantic one.
There are consequences when we don’t truly consider the intersections. In an era when the threats are great, and our attention is being pulled in so many directions, it’s essential we don’t waste our time, energy, and resources on siloing racial equity culture work and health equity impact. It’s time we move from a more coordinated place, recognizing the intersections of these efforts. Our impact will be better off for it.