Equity,Justice,and the Role of the Health Promotion Profession in Dismantling Systemic Racism

Abstract

In his 1963 “I Have a Dream” speech, Dr Martin Luther King Jr said:

This is no time to engage in the luxury of cooling off or to take the tranquilizing drug of gradualism. Now is the time to make real the promise of democracy. Now is the time to rise from the dark and desolate valley of segregation to the sunlit path of racial justice. Now is the time to lift our nation from the quicksand of racial injustice to the solid rock of brotherhood. Now is the time to make justice a reality for all of God’s children. It would be fatal for the nation to overlook the urgency of the moment.

And while some meaningful progress toward racial justice has happened since then, systematic racism¹ is a pandemic that we must confront² at this moment. This editorial reviews current issues in race-based well-being disparities — particularly for Black Americans —and issues a call to action for health promotion researchers and practitioners given that we share a professional and moral duty to support health improvement for all citizens.

Racial equity is characterized as “just and fair inclusion into a society in which all people can participate, prosper, and reach their full potential”³ and is a reality when “racial disparities in health, education, wealth, and other areas do not exist.”⁴

On all of those fronts, there is much work to do. The vast majority of Black Americans experience at least one form of racism (systemic, interpersonal, or internalized) every day, regardless of their level of education, socioeconomic status, or profession.⁵ It can be subtle or explicit, including underrepresentation, microaggressions, or a lower likelihood of being hired, developed, advanced, or promoted.⁶ There is a stark and shocking lack of representation in corporate America: Fewer than 1% of Fortune 500 CEOs are Black.⁷ Survey data from over 3500 professionals revealed that nearly 80% of Black individuals reported having experienced discrimination or fear of it. Nearly 40% do not feel it is ever acceptable to discuss their experience of bias, which in turn results in increased feelings of isolation and alienation that increase their risk of leaving their company within a year by 3-fold and their risk of being disengaged by 13 times.⁸ Black workers feel less supported and committed to their jobs than their non-black peers⁶ perhaps in part because many struggle with feeling inauthentic and having to put on a facade.⁶ Some have described being Black as having an emotional tax in the workplace.⁶ Managerial biases persist even in highly competitive high-performing teams and organizations. One study of National Basketball Association playing time revealed that team performance is related to coaches’ subsequent racial bias. Players received more favorable treatment from same-race coaches after their teams won a game.⁹ The shift to remote work in light of the COVID crisis may create different challenges for Black team members who feel the need to code-switch at work (ie, adjusting speech, appearance, or behavior to receive more fair treatment or opportunities).¹⁰

Black Americans are faced with substantial and pervasive income inequality, and there has been no progress on closing those gaps in the past 70 years. In 2016, the median wealth of a middle-class Black household was $13,024 as compared to $149,703 for a typical white middle-class household. In fact, the wealth gap is widening¹¹: By some estimates, the median wealth of Black families could drop to $0 by 2050.⁶ As Stacey Tisdale explains in the “Knowing Well, Being Well” section of this issue of the journal, the wealth gap is attributable in part to redlining and a long legacy of segregation^12,13 but could easily be exacerbated by future of work trends (ie, automation and digital technologies).¹⁴ Blacks could experience more disruption because the support roles they are more likely to fill (eg, food service, truck drivers, office clerks) are more prone to be adversely impacted by automation. One examination of the expected impact of automation by 2030¹⁴ evaluated “economic intersectionality” (ie, compounded effects) of race, gender, age, education, and geography as it relates to the future of work for African Americans. The results were bleak—adverse intersectionality is expected to occur due to (1) a compounding of overrepresentation in lower paying automation-displacement-prone jobs and (2) underrepresentation in highest growth geographies. Black men fared worst of all in these projections. In some regions, declines in job growth for Black Americans is expected to occur even as job growth rises for white employees. To avoid the potential downstream negative effects on income generation, corporate leaders, advocates, and policy makers must ensure that blacks can share potential gains of automation in those regions by promoting skills to help mitigate challenges (eg, benefits to support higher education, reskilling to facilitate transitions to higher paying roles/occupations, and ensuring hiring criteria matches jobs).¹⁴

Outside the workplace, the discussion about the significant societal, economic, and health impacts of COVID-19 cannot neglect the disproportionate burden borne by black and brown communities¹⁵ due to pre-existing conditions, lack of access to health care, and overrepresentation among “essential workers” in low-wage jobs. Another implication of the historical redlining and segregation is that Black Americans are more likely to live in areas adversely impacted by toxins and pollutants—and therefore are at an increased risk of numerous chronic conditions (eg, asthma) and COVID.^12,13 Unemployment figures reflect further inequities: The service industries that employ higher proportions of members of communities of color were hardest hit by COVID-19. The April employment data indicate that fewer than half (48.8%) of Black adults were employed.¹¹ Even simple public health practices such as wearing masks have the potential to create risks of triggering racial stereotypes and racial profiling.¹⁶ As Drs. Laura Morgan Roberts and Courtney McCluney wrote, “The experiences of employees of color are not special interests or adjacent details to the story of how organizations respond to this moment in history. Rather, centering and uplifting employees and communities of color can define our organizational footprints for generations to come. Doing so has always been important; it is now more urgent now than ever before.”¹⁷

And most disturbing of all are the more insidious manifestations of systematic racism in repeated instances of relentless dehumanizing injustice against Black Americans.³ Dr Ella Washington² explained that the blurring of the work and home boundary makes it impossible for Black employees to disconnect from what is happening when they witness these egregious instances of racial injustice. The psychological distress of events such as the deaths of Rayshard Brooks, George Floyd, Breonna Taylor, and Ahmaud Arbery cannot be overstated.^3,5 Racial trauma of this nature can overwhelm a person’s ability to cope and adversely affect physical and mental health outcomes.¹⁸ How organizations and colleagues respond has important implications for the psychological safety of Black team members³ particularly if they feel that the organization lacks adequate resources to address threats to their racial identities or have failed to create cultures that are inclusive, caring, and safe.¹⁸ While employers can stand with employees by creating a safe space and provide access to adequate mental health benefits (ie, experts/culturally competent counselors in racial trauma),^3,5,17 these events must also serve as a catalyst for renewed conversations about race.

This is a moment of reckoning.¹⁹ Given the increased public awareness of discrimination and inequity, there are higher expectations for business leaders to address social issues^6,20 and to engage in corporate social justice initiatives that bolster communities—including racially just workplaces.^17,21 This is by no means a new conversation. #BlackLivesMatter began in 2013 in response to the acquittal of the man who shot the unarmed Trayvon Martin. The deaths of unarmed Black Americans, including Michael Brown, Eric Garner, and Walter Scott, in the years since have maintained the movement.^22,23 But recent events sparked an awakening of white people to the Black experience.²³ As a recent New York Times article explained, “Cries of ‘I can’t breathe’ call out in compelling shorthand America’s enduring racial chasm in every measure of well-being: health care and infant mortality, wages and wealth, unemployment, education, housing, policing and criminal justice, water quality and environmental safety.”²⁴

There are both a business and moral imperative^4,6,25 for organizations to advance racial justice and create truly equitable, diverse, and inclusive workplaces, including more and improved representation for Black leaders. As FSG and PolicyLink report, “Business leaders need to realize that racial inequity is bad for business—it keeps people of color from participating fully as employees, consumers, and suppliers.⁴ It results in greater costs in hiring and retention, smaller market segments, and fewer suppliers to choose from.” In addition to leading to greater innovation and profitability,^4,6 racial equity will lead to a more equitable society.²⁶ Many large corporations took to social media with messages about social justice and systematic racism in the weeks after George Floyd’s death, including Nike’s “For once, don’t do it, let’s all be part of the change” campaign. Their white letters on a black background seemed to serve as a template for other large consumer brands, which was characterized by one commentary as “homogeneous and largely meaningless wallpaper” given how ill prepared many of these companies are to back up their messages with meaningful actions.²⁷ While the social media posts are a good start,² words won’t be enough²⁶ to address what amounts to corporate brutality.¹⁹ The time has come to tie public statements that Black Lives Matter to actions.^13,28 Corporate leaders have to be firm and clear about their values both in and out of the spotlight.² Some organizations have taken initial steps¹⁹ (eg, Disney pledged to donate $5 million to social justice organizations such as the NAACP). Ben & Jerry’s and Nickelodeon also took action.² This must be a true turning point within every organization¹⁹—to embrace antiracism, listen,^5,19,29,30 learn,¹⁹ lean into discomfort,¹⁹ and set aside typical defensiveness.^3,19 Racial equity has to be a core strategy,⁶ and the C suite must be vocal champions inspiring their organizations to implement that vision.^4,6

The need to get one’s house in order² hits close to home. Health and wellness are far too white.^23,31,32

Given that psychological safety is so fundamental to well-being, we have to ask if it is possible to truly promote well-being in the absence of a more diverse health and well-being workforce.

Effective health promotion solutions that meet the needs of a diverse array of team members cannot be developed without more representation of those voices and perspectives. If an employee calls an employee assistance program, will there be culturally and racially diverse experts with whom they can speak?²⁸ Are we sensitive enough to the fact that there is more stigma about mental health among black team members?³³ Social media posts like #WellnesssoWhite and #BlackintheIvory underscore just how much progress is needed. Dr Jasmine Roberts recently wrote, “As academics, we occupy some of the most privileged spaces in the world. We have access to ground-breaking research included in top-tier journals. We are scholars. We are educators. We are researchers. We have Ph.D. degrees, medical degrees, and master’s degrees…and yet we cannot somehow figure out how to engage in anti-racist scholarship for personal and professional growth.”³⁰ Whether we work in corporate, not-for-profit, or academic settings, we must ask how, as a field, we can use white privilege to support Black colleagues and to ensure that there is a diversity of thought in all of our well-being initiatives.²³ Many are saying that it is time to desegregate the workforce in health care and make mastery of the effects of structural racism a core professional medical competency.¹³ The same could be said for all health and well-being professionals. In her farewell speech as the outgoing President of the American Medical Association, Patrice Harris said that it is up to us “to demonstrate how to understand more…to be the voices our country can trust in this time of trial, and to lead on action to move us forward in this difficult, perilous time.”³⁴

Health care organizations have a unique opportunity to play a key role in addressing systematic racism given their economic power and that they are anchor institutions in many communities.³⁵ Nationally recognized healthcare experts are sounding a rallying cry. Dr. Alan Weil, editor of Health Affairs, said, “In the face of current events, it is time to speak not only of the social determinants of health, but also of the social determinants of death.” Similarly, Dr. Donald Berwick³⁶ wrote that making true progress on racism will require that we embrace the moral determinants of health—and most notably, social solidarity. He went on to say, “Healers are called to heal. When the fabric of communities upon which health depends is torn, then healers are called to mend it.” Others have underscored that addressing inequities will require altering the fundamental material conditions that foster the inequities in the first place (ie, social, political, educational, and health care) and that perpetuate and maintain systematic racism.¹³ Some public officials are taking note. The mayor of Boston, who declared racism a public health emergency, plans to transfer 20% of police overtime budget to social services.³⁷

Some corporations are also actively pledging to create more racially just and equitable organizations.²⁰ CEO Action for Diversity and Inclusion has formed the largest CEO-driven business commitment to advance those efforts in the workplace.⁷ More than 1000 CEOs have committed to make changes to build cultures that welcome diverse perspectives and experiences and that enable dialogue. CEOs can share and receive feedback on the actions they are taking. The site features stories and educational messaging to promote meaningful equity, diversity, and inclusion efforts and has created an interactive bus tour entitled Check your Blind Spots.⁷

Given that racism is in fact a public health issue²⁸ and is everyone’s problem,^2,3 what are some specific steps individuals can take to be true allies^38,39 and continually strive to be antiracist?⁴⁰ How can organizations and the health promotion profession begin to address equity and justice?⁶

One of the first steps must be to break the silence^3,41 by discussing racism, by listening to and supporting people of color in our personal and professional settings when they speak out about their experiences with racism,⁴² and by speaking out about any form of racism.³⁹ Drs Roberts and Washington³ provided sample language that allies and colleagues can use to start a meaningful dialogue. Equally important, we must educate ourselves and our colleagues about our nation’s racist history and previous and ongoing injustices against Blacks,³ confronting the systematic racism in our country that they represent.^4,38,39 Numerous resources (eg, the 1619 Project,⁴³ the Smithsonian National Museum of African American History, and Culture How to Be Antiracist website⁴⁴) are readily available. For more ideas, please see bit.ly/ANTIRACISMRESOURCES or any of the following:

Articles: https://hbr.org/2020/06/confronting-racism-at-work-a-reading-list?utm_medium=email&utm_source=newsletter_daily&utm_campaign=dailyalert_not_activesubs&deliveryName=DM84345

Podcasts: https://www.wbur.org/artery/2020/06/05/podcasts-to-listen-to-about-race-america

Books: https://nymag.com/strategist/article/anti-racist-reading-list.html

Research resources: https://group.sagepub.com/blog/we-cant-just-go-back-to-normal-research-based-resources-to-help-you-teach-talk-and-learn-about-structural-racism

TED talks: https://www.youtube.com/playlist?list=PLDToukXRDVMSkxrabFfSb5u6cE82huRpD&fbclid=IwAR1nnLa9DPMjwp4GlzhGaIr-Hvrgs0hAlpBsW2qKZDSMODLnnDPJCJvV1GA

Organizations can work to create a racial-learning orientation that fosters and facilitates open dialogues about race modeled by senior leaders and supported by manager training.^6,8,19,41 The National Equity Project lists organizational and leadership development references on their site.⁴⁵ Dr. Laura Morgan Roberts and her colleagues recently published Race, Work, and Leadership: New Perspectives on the Black Experience.⁴⁶

We must all commit to being antiracist,^5,30,39,40 which Dr Kendi, the author of How to Be an Antiracist, explains involves supporting antiracist policies through actions or expressing antiracist ideas (eg, racial groups are equal; there is nothing right or wrong with any racial group). Dr Kendi⁴⁰ and others^29,42 have stressed that antiracism is a journey and a process that requires persistent self-awareness, constant self-evaluation/self-examination, and ongoing efforts to improve. For white people, critical elements of that journey include seeing themselves as part of a white group, understanding and accepting responsibility for power and privilege as part of that group, acknowledging that we will get it wrong sometimes,³⁸ and engaging in individual and collective action⁴² using power to create change.³ It can begin with identifying and challenging everyday racism⁴² and taking actions like acting as a sponsor who supports underrepresented colleagues’ work in ways that will bolster the colleagues’ reputation or standing; being a champion who advocates for better representation on boards, presentation stages, and panels; or working to amplify the voices of people from underrepresented groups.²⁹

We can also:

Acknowledge the impact of racially traumatic events on well-being and create a culture in which all employees respond compassionately to the suffering of colleagues¹⁸

Identify our blind spots (https://implicit.harvard.edu/implicit/user/agg/blindspot/indexrk.htm)

Monitor implicit biases¹⁰

Take action to change unconscious biases and to understand the lived experience of Black Americans²⁸

Be more aware of subconscious microaggressions²³

Challenge each other to ensure meetings, committees, and so on, are representative

Collaborate with colleagues from all racial and ethnic groups³⁰

Offer flexibility around establishing boundaries¹⁰

Conduct wage equity audits to ensure pay equity and eliminate disparities in wages of people of color,²⁶ which has the potential to boost gross domestic product by more than $2 trillion²⁶

Give all employees more input into policies²⁶

Ensure existing policies are antiracist^2,40

Encourage civic participation³⁶ (eg, make election day a paid holiday)²⁶ and facilitate voter registration

Consider making Juneteenth a paid holiday to enable employees to use time to reflect and take a meaningful action⁴⁷

Develop more diverse pipelines for roles²

Pay a living wage²⁶

Engage in advocacy or lobbying^26,29,39 (eg, for racism to be declared public health emergency)⁵

Offer paid parental and sick leave as well as full health care coverage²⁶

Create an emergency relief fund²⁶

Match job requirements to job tasks and democratize applications (eg, remove box on job applications which felony convictions that disproportionately disadvantages Blacks; don’t require a college degree if the job doesn’t need higher education, and so on)²⁶

Reimagine equity, diversity, and inclusion⁶ to ensure that it is woven into the culture of the organization and has support from all senior leaders (including white men in leadership roles)

Ensure racial equity is a component of the corporate strategy⁴

Support and address career development throughout people’s careers

Acknowledge the role corporations play in maintaining systematic racism³⁰

Shift from a “color-blind” philosophy to “color-brave”⁴⁸

Resist overgeneralizing³ and assuming all Black experiences are the same²³—instead ask for each individual’s perspective to understand their unique experience

Provide space, unique support, and culturally relevant/responsive resources for Black team members³⁰

As is true for any initiative, we must measure and track progress¹⁹ and hold leaders accountable for the results.⁴⁸ In a recent interview, Mellody Hobson stated that “math has no opinion.” She encouraged corporations to count the various racial groups represented at all ranks or levels within the organization⁴⁸—including the Board of Directors^5,48—and to set targets for improvement. The same is true for diversifying supply chains. Organizations must ask themselves if they are purchasing from Black-owned businesses who face challenges in lending from traditional banking institutions.^23,48 Another important metric to evaluate is philanthropy.⁴⁸

Our Black colleagues, friends, and loved ones are outraged, exhausted, and anxious. There is a consensus that business as usual cannot continue.² We must seize this moment to make sustainable and long-lasting changes that will be meaningful for generations.⁴⁸ In a recent address to the Class of 2020, President Barack Obama said, “You don’t have to accept what was considered normal before. You don’t have to accept the world as it is, you can make it into the world as it should be and could be. You can create a new normal—one that is fairer and gives everyone opportunity and treats everyone equally and builds bridges between people instead of dividing them.”

That is exactly what we are all charged to do. Together, we can create an equitable and racially just future where everyone can thrive. Now is the time.

Sara S. Johnson Pro-Change Behavior Systems, South Kingstown, RI, USA sjohnson@prochange.com

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