2022 Academy Health — Opening Comments
As a scholar and an academic that is currently between two public universities, I have to say, I don’t have to spend a lot of time doing this. This is the job of others that have been pigeon-holed into the administrative scut work that falls under EDI umbrellas. From where I sit this is at best a retrofit. I’m lucky enough where my status at tenured faculty affords me the opportunity to push to reform and to spend time dreaming/reimagining. When I think about health services research, I believe that a simple retrofit is to stop using harmful datasets, data analytics, and ensure a paid community advisory board is reviewing your aims/work/research.
Harmful datasets are those we know are flawed because they don’t include proportional representations in the sample, ask questions with poorly defined operational definitions (like race) or completely ask the wrong kind of research questions that are grounded in deficits and harms. Harmful data analytics are defaulting to white people as reference (yes, I’ve seen this in nativity studies), or stratifying by race where it is irrelevant. Collecting variables that aren’t helpful — because the inherent assumption in marital status is what? Wealth improves? Cause that’s not true when poor people decide to co-parent, now three people need to live on money that barely supports two. In all seriousness, we need help in our work — which is why community engagement is so important.
Like Epidemiology and parts of Public Health, I see health services research as foundational to understanding Health Equity. The basic science if you will of health services provision and clinical research. However, like basic science (and yes, I can critique them despite the death threats I get — as I was trained as one), the field suffers from historical harms that the work is grounded in that needs to be reimagined. This is yet another reason why diversification of the workforce matters — you ask different kinds of research questions when other perspectives are considered. It deepens the work. I would love to see the field of health services research start to demand, design, and develop better data sets that move us away from what already exists to what is possible. I need you all to begin to propose new methods that can unlock important insights and generate new avenues of inquiry.
My greatest concern specific to diversity isn’t just racial and ethnic representations in who leads the science, what research questions are asked/answered, who owns data and how are they managed or maintained, but my greatest worry right now is specific to epistemological diversity. This is especially true in health services research. I worry we are only studying things that are federally fundable with existing data sets that are fatally flawed and intensely harmful. As someone who unapologetically works in reproductive health, rights, and justice, our inability to diversify the topics we study grounded in community-engaged, collaborative approaches is the only way we get at meaningful data, interventions, and policy.
What are the 2 most impactful strategies that you and your organizations are doing now to improve diversity, equity and inclusion?
In all seriousness, prioritize expanding the opportunities for Black, Indigenous, Latinx and other people of color. I know this make a lot of people uncomfortable, but part of healthcare reparations in my view is the ability for us to stop complaining about the lack of diversification of the workforce and building it. I keep asking some complex questions for the purposes of determining how serious people are in this work. For example, in the leaked Dobbs decision from the Supreme Court of the United States, we know there are 29 states that would immediately criminalize abortion without the federal protections of Roe vs. Wade. That means all the clinic workers, ultrasound techs, medical assistants, nurses, counselors, etc. many of whom come from minoritized communities are at risk for being unemployed. An entire braintrust of people whose employment should be guaranteed given the circumstances around their job loss and yet I see no one mobilizing to operationalize that workforce. It is similar to when rural and other obstetric units close, what happens to that braintrust? If entities and institutions can’t answer these questions then I am suspect at the level of seriousness they have in doing this work.
The second point is just as controversial and that is to stop demanding more rigorous data proving that diversification of the health care workforce impacts health outcomes when we have no evidence that our current workforce composition is the standard for optimal outcomes when we know this isn’t true. Some things are just the right thing to do as both a public good and a moral obligation. According to data from 2015, only 65.6% of the US population is White, however, 83.2% of licensed nurses and 90% of certified nurse midwives are White. While the physician community is more diverse (49% White), only 4% of physicians are Black or African American, 4.4% Hispanic and 0.4% American Indian or Alaskan Native. While 93% of licensed nurses or certified nurse midwives are women, only 34% of physicians are women. While there are more Black or African-American women physicians (54.7%) than men (45.3%), in all other racial and ethnic groups, there are more men than women for Asians (56.4% men), American Indian or Alaska Natives (58.1% men), Hispanic or Latino (59.0% men), and White (65.2% men).
There have been attempts to diversify the clinical healthcare workforce using incentive and pipeline programs. These programs, funded by both the federal government and the private sector, have had mixed results. However, assessments of these programs have shown that 1) People of color in the health professions are more likely to serve minority populations; 2) Health care providers who are people of color are more likely to work with publicly insured and minority populations; and 3) Programs that provide financial incentives to any health care provider who serves minority populations have not been more successful than programs that specifically develop BIPOC health care providers to ensure adequate workforce serving in under-resourced settings. All this to state that if we are serious about reimagining a world where we unleash the creativity of humanity it requires courage and rejection of scarcity and leadership who believe we can change the future. I look forward to our discussion.
