By: Scott Orsey
I just lived a deeply insightful week that I believe would challenge even the most steadfast worldview. It came months into a department-wide introspection called our Pathways to Action initiative, which involved holding town hall meetings for team members to reflect on our office culture and developing a strategic plan going forward. The plan focuses on how we support and treat our colleagues, especially those of color, and recommends improvements to recruitment, communications, supporting businesses owned by people of color and other areas. Our ambition is lofty – to make our workplace, community and world a better and more equitable place. Our goals focus on achievable action that will make a difference for our team and hopefully, if successful, will serve as a model for others.
While we’ve been working on this for many months, it was because of this particular week, that I found myself at a new question: Why are we so negative?
The week began at the trailing end of Black History Month. The Pathways to Action team chose to engage in a self-study to learn more about the difficult topic of institutional and systemic racism. They selected the memoir “Black Man in a White Coat” by psychiatrist Damon Tweedy, MD for a book-club style discussion. At the time, the session, facilitated over a webinar, seemed like many others that I experienced in my career. The facilitator was excellent, my colleagues were open and honest, the session was an earnest conversation, and we all learned a little about ourselves and each other. I, for one, came away with a far better sense of how pervasive racism is in healthcare practice, how assumptions affect standards of care, and closer to home, how often we factor race unknowingly into how we approach each other.
The book club was followed a few days later by a full day of dialogue with Renee Boynton-Jarrett, MD, ScD, a pediatrician and epidemiologist at Boston Medical Center. Dr. Boynton-Jarrett was the featured presenter at the annual Paul H. Dworkin, MD Pediatric Grand Rounds Lecture, which is named in honor of Dr. Dworkin who leads Connecticut Children’s Office for Community Child Health (the Office). Her presentation, titled “Restoring Dignity: Addressing Structural Racism, Childhood Adversity and Child Health Through Reimagined Community Partnerships,” echoed many themes of our work including the importance of seeking leadership from the community, tackling our work from a strength-based approach, and centering our work on dignity. In addition to her prepared remarks, Dr. Boynton-Jarrett was kind enough to make a day out of it by attending various meetings with Office team members. These meetings provided her with an opportunity to learn more about our efforts to address structural racism and offered team members a chance to learn more about successes from her Boston non-profit Vital Village.
As thought provoking as the week had been so far, it wasn’t until the very last event when I arrived at the question that inspired me to write this reflection.
Different Outlooks on Determinants of Health
Connecticut Children’s hosted a screening of the feature length documentary “Black Men in White Coats.” While echoing our book-club title – the movie is unrelated to Dr. Tweedy’s work – it covered similar ground by interviewing Black physicians who shared their journeys, perspectives and challenges.
After watching the documentary, I participated in a discussion group and was asked about a comment made by one of the physicians interviewed in the documentary. The doctor said that he views social determinants of health, which are the circumstances in which people live, work, learn and play, as social impediments to health. I was asked about my impression of this rewording. I had not considered this question before, and it had not occurred to me while watching the documentary.
In collecting my thoughts, I landed on two ideas.
The first is the importance of language. Words matter. The term “determinants” is academic and a word substitution that can add impact and understanding, in my estimation, is a good thing. “Impediments” certainly conveys the inherent barriers and challenges that are typically intended when healthcare providers invoke social determinants as a concept.
The second impression was a bit more visceral. Having just experienced Dr. Boynton-Jarrett’s daylong session about the merits of framing our aspirations through a strength-based lens, the word “impediment” stood in stark contrast. I was first introduced to strength-based approaches many years ago in learning about asset-based community development (ABCD). In that practice, socially minded providers are encouraged to consider the strengths of the community they serve. Starting with the “assets” instead of the “needs” discourages us from thinking of families as “consumers” of social services. Why? If our communities consume services, then we are encouraged to produce more, creating a negative feedback loop of increased need. ABCD challenges us to think of our communities as “producers” of value. We are then motivated to strengthen their ability to produce, which is a far better goal than increasing consumption.
Turning Negative into Positive
In one of her talks, Dr. Boynton Jarrett noted that we set a low bar for outcomes in the communities we serve when we use a deficiency lens. Strength-based framing is more ambitious. She challenged us to consider whether we would set an uninspired goal for our own children, such as to live in a community free of violence. No, we would aspire to far more. We would want our kids to have access to arts, sports, friends, education, health and so on. We would want our kids to have access to fulfillment and happiness.
In considering both of my initial thoughts from the documentary discussion group, I strongly believe we should not accept these word gymnastics. Instead, we should set a high bar for the communities we serve, one that is positive instead of negative and builds on a strength-based approach.
It is also worth noting that the word “determinants” does not actually imply negativity, despite its typical usage in health care. How many times have I heard people say that so-in-so is affected by social determinants? We all are! A “loving family” is just as much a social determinant as an “abusive caregiver.” Determinants are agnostic to harm or value. They are simply factors.
Which gets me back to my question: Why are we so negative?
Why do we start with screening for a need or concern? Instead, shouldn’t we also screen for the positives—the social “accelerants” of health? Shouldn’t we focus more on promoting health and preventing diseases? By working from a strength-based position, we will promote the results we really aspire to: eliminating structural racism and ensuring the best outcomes our children.
Scott Orsey is the associate director of operations, business strategy and institutional engagement for Connecticut Children’s Office for Community Child Health.
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