Countering Systems of Oppression

Reflections on Racial Responsibility in Systems Improvement Work

Stacy Scott and Avery Desrosiers
NICHQ Project Specialist Avery Desrosiers, MPH, and Global Infant Safe Sleep Center Founder Stacy Scott, PhD, MPA.

“I grew up in a predominantly white neighborhood,” says NICHQ Project Specialist, Avery Desrosiers, MPH. “As a result, I didn’t feel the color of my skin until I was almost 20 years old. I didn’t understand what my whiteness meant.”

Desrosiers spent several months in Cape Town, South Africa where she studied the strategies used during Apartheid to oppress Black South Africans systematically, and the lasting impact that had on communities. She recalls the stark contrast of mansions overlooking rundown housing projects while travelling along a highway that was constructed with the purpose of segregating communities.

“What I saw was disturbing but it felt removed from my own experiences,” says Desrosiers. “It wasn’t my country, my reality. So, in those moments, I was able to shrug off my racial responsibility.”

Later during a homestay, Desrosiers’ South African host tried to have a conversation with her about race. It wasn’t until this moment that Desrosiers began to realize that being white had affected all her actions and experiences. That oppressive systems existed in many places including where she grew up—she simply didn’t know she had a role in them.

“I don’t even really remember the conversation because I just felt so ashamed and guilty,” she says. “I did not want to admit my own blind spots and felt so ashamed that I had exempted myself from thinking critically about all the ways that racist systems had benefitted me. My reaction was a defense mechanism because I was being confronted with a reality that seemed to challenge my own self-image of being a good person, unaffected by racism.”  

What Desrosiers experienced is a common stress response that can be triggered when we feel threatened or uncomfortable in conversations. However, these conversations, particularly reflective ones about our own conscious and unconscious contributions to maintaining systemic racism, are necessary in all initiatives and programs seeking to tackle health equity. Without these conversations, we (children’s health advocates and stakeholders) can’t acknowledge and address the structural inequities affecting the heath of families across the country.

Acknowledging structural inequities

Black women and women of color experience significantly higher rates of morbidity than white women. Black maternal mortality rates are four times higher than that of white women. And only 7.5 percent of physicians identify as African American and they are more likely to work in underserved communities.  

These inequities, explains Global Infant Safe Sleep Center Founder Stacy Scott, PhD, MPA, result from multiple levels of racism—institutional racism that influences laws and policies, personally mediated racism that influences care and treatment, and internalized racism that changes the way communities of color see themselves.

“Together, this racism affects our systems and communities,” says Scott. “And critically, it affects health programs; it influences how we go about providing services to the populations we are all committed to serving.”

Solutions start by acknowledging racism, acknowledging how one has participated or been the target of systematic oppression, and having critical conversations about the influence of race and oppression on health systems and programs. But, as Desrosiers’ experience exemplifies, having these conversations is far from easy.

“It should be exhausting to be a white person because it is exhausting to be a person of color in this country,” says Desrosiers. “It takes intentional work, reflection, and dedicated resources to target the internalized, interpersonal, and structural ways that prejudice and implicit bias inform our interactions, programs and policies.”

Engaging in conversations about race

It can be tempting for health professionals to gravitate toward a colorblind approach, Desrosiers explains. The attitude 'I don’t see color' sounds equitable. But it mistakes uniformity for equity, disregards differences that should inform treatment and care (such as cultural values or historic trauma), and, critically, it exempts people from participating in conversations about race.

“Supporting equitable health has been a big part of my academic and professional interests, which makes it hard to think of myself as engaging in racism, even unconsciously,” says Desrosiers. “But we all experience implicit bias and we all participate in stereotyping. If we’re always stuck trying to prove we aren’t, we excuse ourselves from the conversations and never unpack what’s informing our perceptions. This keeps us from moving forward and changing our systems.”

Still, unpacking perceptions takes more than acknowledging they exist. It also means preparing for the stress response that conversations about race will trigger—the stress response Desrosiers experienced in South Africa when she was still in college.

“People, especially white people, are socialized to get stressed out when talking about race,” says Desrosiers. “And our biological response to stress might be to cry, shut down, and go silent. This is what happened to me. This is why we need to prepare for those responses, learning to lean into our discomfort. The more we analyze our stress response, the more capable we become of unlearning that behavior. In doing this, we can begin to focus that energy on human connection, understanding what about our internal dialogue caused initial discomfort, and really pursue systems-change.”

How can we do this in a quality improvement project?

Acknowledging inequities, considering how we participate in those inequities, and not shying away from uncomfortable conversations—these are all critical actions for health improvement stakeholders. But what does this look like in a health improvement project?

Below, Desrosiers and Scott have identified six critical questions health improvement participants can bring to each initiative to ensure they’re advancing equity together. They recommend applying each question to each change, policy or practice that initiatives seek to improve.

  1. Have you named the root causes of the inequity at play? If you cannot name it, you cannot measure it, target it or dismantle it.
  2. What would be different if you centered on the experiences of people of color instead of conducting business as usual?
  3. What would it look like if power in decision making, planning, implementation and evaluation was distributed equitably?
  4. Are you collecting data that is stratified by race and ethnicity as you implement your policy or practice?  
  5. How will you assess whether any groups are unintentionally impacted in a negative way by the policy or practice?
  6. What are some key ways that the policy or practice will be sustained, and continued by the members of the community?

Critically engaging with these questions will not be easy, both Scott and Desrosiers caution. It will require recognizing our implicit biases, understanding where individual experiences may come at the expense of other people, and grappling with the discomfort they’ve described. But if we can do this, if we can answer these questions honestly and with intention, we can begin to lay the groundwork for change.