From Savior-Designed to Equity-Empowered Systems
Over the course of hundreds of years, racism was institutionalized into U.S. health care systems, propagating organizational practices and policies that marginalize and discriminate against people of color. Today, institutional racism continues to plague the health of children and families across the country. How do we pursue sustainable change? The answer starts with intentionally confronting and deconstructing how health systems were designed.
On NICHQ’s recent webinar, From Awareness to Action: Strategies for Combating Racism in Health Systems, experts from the Global Infant Safe Sleep Center shared opportunities to move towards equitable systems. Below, we summarize their advice.
Today’s Disparities Are Not Accidental
In the U.S., people of color face unacceptable poor health outcomes, including disproportionately high rates of maternal and infant mortality. These disparities can be traced to when the first slave ship with Africans landed on U.S. shores in 1619. Over the next nearly 250 years, enslaved people would endure mental and physical violence, poor working conditions, and many other forms of mistreatment—all of which led to poor health outcomes. This violence continued after the Civil War with the advent of Jim Crow laws, which enforced a system of oppression and segregation.
At the same time, racism was shaping the basic infrastructure of the U.S. health care system. During enslavement, African Americans had little to no access to health care; early American hospitals discriminated against and medically abused Black patients; and, during the Jim Crow era, segregated hospitals in many cases provided inequitable care for people of color or no care at all. Moreover, Black people were largely excluded from the medical profession until late in the 20th century.
“Our history of segregated care of African Americans, where facilities were established by whites to serve Blacks exclusively, resulted in systems based in unequal power dynamics that resulted in unequal care,” says NICHQ Senior Project Director Stacy Scott, PhD, MPH, who is the founder of the Global Infant Safe Sleep Center. “These hospitals were the foundation for what we’ve termed “savior-designed systems,” which are at the root of many of the disparities we still see today. We’ve made progress to improve these systems in recent years, but we still have a long way to go before we have truly equitable systems.”
To achieve equity, we need to be able to describe the systems that exist and the systems needed to achieve equitable health outcomes.
By mapping this continuum—by giving each system a name and definition—we can consider where our current approaches have succeeded and failed, and what we need to do to improve, explains Scott.
Savior-designed systems are originally designed to rescue, save, and deliver services to “vulnerable” communities by members of the oppressing community. These systems:
- do not consider the root causes and institutions that make the population vulnerable in the first place;
- have policies and practices that harm specific racial groups while benefiting others;
- are difficult to navigate by or on behalf of the disparity group; and,
- are impacted by segregation and division, which often results in habits, policies, and institutions that are not explicitly designed to discriminate.
Savior-designed systems devalue individuals’ lived experiences. In response, health care decisions are made without incorporating individuals’ opinions and without considering how racism and oppression have impacted their health and behaviors. As a result, individuals are often blamed for poor health outcomes and labeled as non-compliant, difficult, or rude.
Recent efforts in public health have sought to counteract savior-designed systems by moving toward an ally-based approach.
Ally-designed systems are focused on building self-awareness among the oppressing group while partnering with oppressed groups to spark change. They:
- recognize that individuals’ unique circumstances and social conditions affect their health, and need to be factored into to health care decisions;
- never use individuals’ circumstances as justification for providing anything less than the highest quality care;
- reflect on lived experience, points of privilege, and oppression to inform additional perspectives needed “at the table”;
- intend to identify and challenge institutional and systematic oppression; and,
- unite with disparity groups who are treated unjustly to create a system dedicated to dignity, respect, and equality.
Ally-designed systems are a step forward, but they still operate from within the confines of white supremacy, explains Avery Desrosiers, MPH, a consultant with the Global Infant Safe Sleep Center. “Bringing people into a project or initiative doesn’t mean there is a shift in the distribution of power and ability to inform decision-making or that new voices are represented fairly. With these systems, the power is still maintained by the ally as the champion of the work.”
Ally-designed systems can then unintentionally feed into paternalism, tokenism, and well-intentioned but one-sided approaches that ultimately privilege “expert” voices over the voices of marginalized groups. Ally-designed systems are a start, but they are not enough.
The ultimate goal: Equity-empowered systems
Truly equitable health care requires purposefully reconstructing systems that are rooted in and advance equity of the historically marginalized group. These “equity-empowered systems”:
- are built and governed to center on the experiences of disparity groups;
- accept racism and other forms of oppression that adversely impact systems of care;
- place specific emphasis on addressing unique needs and root causes of inequitable outcomes; and,
- share power by not only ensuring diverse representation, but also redistributing resources to establish equitable decision-making, design, and implementation processes.
Equity-empowered systems would amplify lived experiences, provide trauma-informed care, and actively name and address the root causes and barriers of navigating challenging systems, says Scott. In short, they would be a catalyst for population-level health improvement.
“Think about these definitions and then think about the systems you operate in,” says Scott “Are they savior-designed, ally-designed, or equity-empowered? What would need to change for your system to shift further along the continuum toward equity?”
Scott and Desrosiers presented this system design information on behalf of the Global Infant Safe Sleep Center on a recent NICHQ-led webinar, From Awareness to Action: Strategies for Combating Racism in Health Systems.
NICHQ’s Next Steps: Update on the Equity Systems Continuum Initiative
The National Institute for Children’s Health Quality, with funding by the W.K. Kellogg Foundation, is building upon an evidence-informed conceptual framework known as the Equity Systems Continuum to describe and define the systems that individuals and organizations currently operate within: Supremist-Designed System, Savior-Designed Systems, Ally-Designed Systems, and Equity-Empowered Systems. The Global Infant Safe Sleep Center (GISS) developed the original framework and serves as an ongoing partner in the project.
3 Strategies to Leverage Community-Based Research in Maternal and Child Health
During Spring 2021 DARE conducted a series of community listening sessions for the National Action Partnership to Promote Safe Sleep Improvement and Innovation Network (NAPPSS-IIN). Listening session participants were asked about the resources and tools that help them promote safe sleep and breastfeeding/chestfeeding, and additional support needed to meet community safe sleep and breastfeeding/chestfeeding needs. While the analytic results are forthcoming, DARE is excited to share key lessons learned during NAPPSS-IIN community listening sessions.
A Physician’s Reflections on Racism and Treating Sickle Cell Disease
For NICHQ’s current and future work, I am motivated by wanting to be a better version of myself in service of others. Wondering whether my own implicit biases impacted my care of patients and families, I realize that I cannot redo past ER experiences. If I could go back, I would slow down to acknowledge and try to set my biases aside and approach patients from a personally more informed perspective. But now, I can use my past, present, and future experiences to ensure NICHQ is amplifying important lessons from this multi-year effort reflecting the compassion, care, and commitment of hundreds of dedicated professionals in pursuit of equitable, accessible, and quality healthcare for people living with sickle cell disease.
Navigating Well-Child Visits and Vaccinations during COVID-19
Well-child visits and recommended vaccinations are essential, ensuring children stay healthy and are protected from preventable diseases and illnesses such as measles, whooping cough, and seasonal flu. But, as the COVID-19 pandemic persists, data shows that fewer childhood vaccinations have been given and many children have fallen behind on their scheduled appointments. Healthcare professionals should utilize the following strategies to work with parents and caregivers to get their children caught up on missed appointments and recommended vaccinations.
Exploring a Nonbinary Approach to Health
NICHQ is not abandoning the traditional use of the terms “mother” and “maternal.” We are embracing the inclusive language of “birthing person/people” across our work. A move toward inclusive language does not force us to stop using language that so many people identify with; at its core, inclusion is about creating more space for one another. We are taking care to expand the use of these terms in our communications, on our website, in our resources, and eventually, in all our projects.
NICHQ Employee Spotlight: Olivia Giordano
Olivia Giordano, MPH, Project Manager shares how her work with NICHQ’s Supporting Healthy Start Performance Project (SHSPP) is supporting 101 Healthy Start community sites to harness lessons learned, implement innovative approaches to improvement, and ultimately start to close the disparity gap in maternal and child health.