Camara Phyllis Jones, M.D., Ph.D., in addition to serving as a co-chair of the Roundtable’s Racism and Bias Action Group, was the workshop keynote speaker. Her presentation provided an entry point to understand racism, its impact to confer disadvantages; advantages to individuals and the whole society; and mechanisms through which it operates.
Dr. Jones began by pointing out that although the original title of her presentation was “new aspects of racism,” she chose to entitle it “again and still,” especially in the context of COVID-19:
It is my observation that most people in this country are still in denial that racism exists, that it has profound effects on the health and well-being of the nation. Every now and then, as with Hurricane Katrina, as with the Flint water poisoning, Charleston massacre, or Charlottesville marches, the general population is jolted out of it complacency.… As this pandemic wanes in a year and half or 2 years, we cannot let the country slip back into racism denial.
Dr. Jones explained that the goal of her presentation was to equip participants to do three things: name racism in a way to invite conversation; address how racism limits the representation of Black men and Black women in science, engineering, and medicine; and present theoretical principles for organizing and strategizing to act.
In discussions about racism, Dr. Jones drew on allegories, which she said often help in airing issues that people are hesitant to talk about. She shared two such allegories at the workshop.
The first allegory she calls the “two-sided sign” (Figure 2-1). Briefly, she described an experience as a student at Stanford Medical School when she sat in a restaurant with friends and noticed a sign facing inside the restaurant that read “Open.” She realized this meant the other side, facing outside, read “Closed.” In other words, she continued, while the diners inside could enjoy a meal, those outside could not gain entry; moreover,
those inside might not even realize the existence of the sign or that it served to keep out prospective customers.1 “I know it’s hard to see if you only see ‘Open,’” she said. “Part of your privilege is not to have to know” whether the privilege relates to race, sex, nationality, or other causes. But, she continued, “Once you do know, you can act.… Our challenge is that once we have a hint about a two-sided sign, we cannot forget this knowledge going forward.”
Dr. Jones defined racism as:
A system of structuring opportunity and assigning value based on the social interpretation of how someone looks (which is what we call “race”) that unfairly disadvantages some individuals and communities; unfairly advantages other individuals and communities; and saps the strength of the whole society through the wasting of human resources.2
Breaking down this definition, Dr. Jones stressed racism as a system of power, rather than an individual’s character flaw or moral failing. Race, she continued, is not a biological or cultural construct but a social interpretation of how one looks. In her own case, she noted she would be considered three different races in three different settings: “Black” in the United States, “White” in Brazil, and “Colored” in South Africa. Furthermore, “if I were to stay in any of those settings, my health and educational outcomes would become that of the group to which I was assigned, even with the same genes and abilities in all those places.”
In terms of the impacts, Dr. Jones noted that the reciprocal to unfair disadvantages to some people is unfair advantages to others. “That is the whole issue of unearned white privilege that we hardly ever talk about because it makes some people uncomfortable,” she said. While she said she used to apologize for bringing up this point, “Now I acknowledge that discomfort. I say if you feel that discomfort, lean in. Because I have come to recognize that the edge of our comfort is a growing edge.” Referring to the last part of her definition above, sapping the strength of the whole society can be seen in not investing in full public education and thus missing out on genius to better the world, whether to find a cure for COVID-19, land humans on Mars, or any number of advances.
In her writing and research (e.g., Jones, 2000), Dr. Jones identified three levels on which racism operates:
- Institutionalized racism, “the constellation of structures, policies, practices, norms, and values that taken together result in differential access to goods, services, and opportunities of society by race.” Examples she gave include differential housing, education, and employment opportunities, which also have an impact on health.
- Personally mediated racism, “differential assumptions about the abilities, motives, and intents of others by race, and differential actions based on those assumptions.” Examples include instances of prejudice and discrimination, she said, including police brutality, physician disrespect, or teacher devaluation. Whether intentional or unintentional, and whether acts of commission or omission, personally mediated racism can affect Black men and Black women from reaching their potential in science, engineering, and medicine, she observed.
- Internalized racism, “acceptance by members of the stigmatized ‘race’ of negative messages about their own abilities and intrinsic
worth.” Examples include self-devaluation, resignation, and hopelessness, and internalizing the myth of white superiority, including what is referred to as “the white man’s ice is colder syndrome.”
Another allegory that Dr. Jones often shares is called “The Gardener’s Tale.”3 She developed it after seeing the difference in her own garden of flowers planted in rich, fertile soil compared with those planted in poor, rocky soil. In her allegory, a gardener preferred red flowers over pink and provided more favorable soil (institutional racism) to the seeds that would grow red flowers. The gardener began preferring the red flowers since they looked more vigorous and perhaps cut the pink flowers since they were not thriving (akin to personally mediated racism). Finally, the pink flowers wished they, too, could be red (internalized racism). Solutions to this disparity could begin with telling the pink flowers that they, too, are beautiful, but that is not sufficient, Dr. Jones said. Telling the gardener not to pluck the pink flowers might be helpful, but, as Dr. Jones said, the underlying issue—the fertility of the original soil or, to extend the allegory, the institutionalized racism—must be addressed.
Leaving the allegory, the “gardeners” are those who “have the power to decide, power to act, and have control of resources,” Dr. Jones said, and include government, corporations, foundations, the media, communities to the extent they have self-determination, and institutions such as the National Academies. It is dangerous, she added, when the gardeners (or those in power) are allied with one group only and not concerned with equity. She said two questions often arise when she is sharing this allegory: Why should the red flowers share their soil, and what if the current gardener is not the one who made the decision to plant the two types of flowers in different soil in the first place? Extending beyond the allegory, she said:
That is why we must make the problem of the pink flowers urgent. That is why we have this Roundtable on Black men and Black women in science, engineering, and medicine. We are problematizing it; we are putting it on the agenda. We will not be successful in addressing that inequity unless we understand the differences in the quality of the soil. Secondly, we must make those flower boxes transparent, talking about the differences in the quality of the soil. Third, we must also make sure that people understand
that the pink flowers did not just launch themselves into that poor, rocky soil. So, we must talk about history, and we must talk about how the gardener’s initial preferences for red over pink set up the whole situation.
In a given situation, Dr. Jones stated, it is important to ask how racism is operating in order to identify the levers on which to act. “That’s what this workshop is going to bring us to,” she said, to see how racism is operating in terms of Black underrepresentation in medicine. Related to structures (which she said are the “who, what, when, and where of decision making”), potential targets of interventions might include racial residential segregation, the presence or absence of quality preschool programs, and diversity of medical school faculty. Related to policies (the “written how of decision making”), solutions might include public school funding or affirmative action policies. Practices and norms (the “unwritten how”) might include use of Medical College Admission Tests (MCATs) as a first hurdle to entry into medical school because of the norm that standardized tests are important predictors of success, while an applicant’s “distance traveled” is considered only marginally relevant to success. Finally, values (the “why of decision making”) might include the claim that Blacks are less intelligent or hardworking. Dr. Jones later returned to these levers of action in concluding remarks (see Chapter 6).
Health equity is the assurance of the conditions of optimal health for all people. Achieving it requires valuing all individuals and populations equally, recognizing and rectifying historical injustices, and providing resources according to need, Dr. Jones said. She noted that health disparities can only be eliminated when health equity is achieved.
She identified seven barriers to achieving health equity, namely: (1) Narrow focus on the individual, which limits a sense of interdependence and collective efficacy, and makes systems and structures seem invisible or irrelevant; (2) an ahistorical stance, which disconnects the present from the past and makes the current distribution of advantage and disadvantage seem happenstance; (3) the myth of meritocracy, with the belief that “if you work hard, you will make it”; (4) the myth of a zero-sum game, which
fosters competition over cooperation and hinders efforts to grow the pie; (5) a limited future orientation, unlike in other cultures that focus on the impact of present actions on future generations; (6) the myth of American exceptionalism, which prevents learning from others and creates a sense of U.S. entitlement; and (7) white supremacist ideology, which presents a hierarchy in human valuation with “white” as the ideal and the norm. She commented that, in particular, “The first three barriers are part of why this country continues to stay in denial about the existence and profound impacts of racism on the well-being of the nation.”
Dr. Jones has developed three principles for achieving health equity, including:
- Valuing all individuals and populations equally
- Recognizing and rectifying historical injustices
- Providing resources according to need.
Given the barriers and the need to put these principles into practice, Dr. Jones suggested a number of actions and strategies to workshop participants to increase the numbers of Black men and Black women in science, engineering, and medicine. As in the earlier analogy of the restaurant, she urged looking for evidence of two-sided signs, bursting through the bubble to experience common humanity, and becoming interested and joining in the stories of others. She further suggested taking notice of absences to “develop the skills to see who is not at the table, what is not on the agenda.” She concluded by stressing the importance of revealing inaction in the face of need, and recognizing that action, especially collective action, is power.
Jones, C. P. 2000. Levels of racism: A theoretic framework and a gardener’s tale. American Journal of Public Health, 90(8), 1212–1215.
Jones, C. P. 2003. Confronting institutionalized racism. Phylon, 50(1-2), 7–22.
Jones, C. P. 2014. Systems of power, axes in inequity: Parallels, intersections, braiding the strands. Medical Care, 52(10 Supplement 3), S71–S75.
Jones, C. P. 2016. How understanding of racism can move public health to action: Allegory highlights reality of privilege. The Nation’s Health, 46(1), 3.
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