By Jill Sakai, PhD, writer
The events of 2020—a global pandemic, visible police violence against people of color, worldwide protests and economic challenges—thrust health disparities and social inequalities into international spotlights.
Against a backdrop of rising awareness of the societal and health consequences of injustice, prejudice and inequity, an increasing number of state and local officials are declaring racism a public health crisis. The Anti-Racism in Public Health Act, introduced last fall in both houses of Congress, sought to amend the Public Health Service Act to provide for public health research and interventions targeting the effects of racism and police violence. And on April 8, the director of the US Centers for Disease Control and Prevention, Rochelle Walensky, MD, MPH, issued a commentary declaring racism a “serious public health threat.”
“Racism is not just the discrimination against one group based on the color of their skin or their race or ethnicity, but the structural barriers that impact racial and ethnic groups differently to influence where a person lives, where they work, where their children play, and where they gather in community.”
Such acknowledgments are small but important steps toward counteracting the harms of centuries of systemic discrimination. And they speak to the growing realizations that existing health systems do not equitably serve the American public and that change is urgently needed.
Public health laboratories can play a key role in this transformation. Laboratories across the globe provide essential screening, testing and surveillance services to protect all members of society—centering diversity, equity and inclusion (DEI) at the heart of public health’s mission to deliver positive health outcomes to all communities, including those that have too often been overlooked and underserved.
A Table for Everyone
To be most effective in this role, public health laboratories must foster their own culture of inclusion and acceptance, recognizing the differences that exist between individuals and respecting and supporting a diverse workforce that embodies a variety of cultures, backgrounds and lifestyles. An inclusive environment supports diversity in all its forms, welcoming people’s differences and ensuring their needs are acknowledged and accommodated to allow them to be successful.
“Diversity is important for productivity, for talent management, for innovation, for communication,” said Marilyn Bibbs Freeman, PhD, M(ASCP), deputy director of the Virginia Division of Consolidated Laboratory Services. “To serve a community that’s diverse, we should strive as hard as we can to look like the communities that we’re serving.”
Mighty Fine, MPH, CHES, director of the Center for Public Health Practice and Professional Development at the American Public Health Association, compares a diverse workforce to a large box of crayons, offering a range of perspectives, identities and experiences.
“Your outputs can only reflect the richness of your starting palette,” he said. “If you’re missing colors from the box, you’re limiting what you can collectively accomplish.”
Public health laboratories do not yet match the broader American palette. According to the 2018 APHL Workforce Survey Report, state public health laboratories are predominantly white, with Blacks and Hispanics comprising just 7 and 3 percent of survey respondents, respectively. Respondents were two-thirds female and somewhat younger than the overall state public health workforce, with about 60 percent being under 50 years of age.
Building more diverse public health laboratories will take intention, time and ongoing commitment, beginning with an honest assessment of the current state. As one of his first priorities in 2020, APHL President Bill Whitmar, MS, convened a new task force to promote DEI principles and practices in APHL’s operations and activities. One of its first undertakings is a diversity survey for member laboratories to capture a portrait of employees based on demographic and cultural factors such as gender, age, race, sexual orientation, religion and political affiliation. The DEI Task Force is also planning an inclusion survey to assess how well laboratorians feel heard and supported in their workplaces.
Recruitment and retention efforts need to be a priority, said Bibbs Freeman, who is chairing the DEI Task Force. Numbers alone aren’t enough, but they offer both a starting point and a way to measure progress toward equity, where many groups are represented and all have the supports and resources they need to be productive.
“I feel strongly about creating some baseline metrics on where we are with diversity as well as inclusion, because I don’t think you can have equity until you have those two things,” she said.
Seen and Heard
Chenelle Norman, MPH, is focusing on the individual stories behind those numbers. When Norman, quality improvement manager in APHL’s Newborn Screening & Genetics Program, joined APHL’s Emerging Leader Program (ELP) in fall 2020, she had been thinking a lot about the role of race and equity in society. After extensive discussions, the fall class of ELP Cohort 13 decided to undertake a project focused on DEI and exploring the experiences of minorities within public health laboratories.
Cohort members interviewed several colleagues who identify as minorities in some way, such as race, religion or sexual orientation, about their experiences—positive and negative—working in a public health laboratory and whether they had encountered any misconceptions or prejudices related to their identity. Some of the interviewed staff recalled instances of feeling conspicuous or racialized, such as having their name mispronounced, having assumptions made about their ethnicity or ability to speak English, or comments—overt or indirect—about their hair texture or style.
“What really stood out to me as a consistent theme were these stories of not being comfortable with being yourself and presenting yourself as you are, because you don’t want to be deemed as different or ‘other’ or called out in a negative way,” Norman said. “In 2021, you think we’d all be accepting of each other’s differences. But minority groups still struggle with the need to fit in. And the stress of that, I think, is really harmful.”
Constant awareness of how one is perceived is exhausting, she noted, and feeling responsible for being a representative of a minority group adds a lot of pressure. What’s more, negative or uncomfortable interactions can affect work if individuals do not feel their work or opinions will be trusted by others.
The interviewees also called out positive experiences in their workplaces, including many welcoming colleagues, being asked their personal pronouns, observation of Juneteenth as a paid holiday and being able to receive schedule accommodations for religious observances. Some described their laboratory as one of the most diverse places they had worked.
To encourage more of these kinds of conversations in more laboratories, the ELP cohort has produced infographics that summarize numerous tools and resources public health laboratory leaders and staff can use to move closer to achieving diversity, equity and inclusion within their own laboratories. The information defines key terms and offers strategies to improve DEI through four main areas: education and awareness, allyship and advocacy, mentoring, and recruitment.
“The first step is acknowledging that there are differences and what they are. And that’s where I hope our infographic can start those conversations,” said Shannon Griffin, a Cincinnati-based biologist with the US Environmental Protection Agency’s Center for Public Health and Environmental Assessment, who helped lead the ELP infographic project. Fostering intentional discussions can help people learn to see value in each other’s differences, opening the door to being able to recognize and counter implicit biases and microaggressions. The cohort also focused on concrete tips and resources for laboratory leadership, such as ways to reduce bias in job ads, candidate screening and interviews.
Allies in Training
DEI concepts may already be familiar to recent public health trainees, since many are already integrated into academic training in public health. The Council on Education for Public Health, the accrediting body for public health schools and programs in the US, includes diversity and cultural competence among the core competencies required for students in these programs.
“Students who graduate from our programs [should be] able to understand and articulate the ways in which systems of oppression, like structural racism, result in the health inequities that we see,” said Diane Marie St. George, PhD, director of the MPH program at the University of Maryland School of Medicine and chair of the Association of Schools and Programs of Public Health (ASPPH) Diversity and Inclusion Advisory Committee. Different schools fulfill the requirements in different ways. Students at the University of Maryland School of Medicine tour neighborhoods near campus and elsewhere in Baltimore, talking with community leaders and public health agencies about how the city’s history and policies have led to social and health disparities.
In 2019, under the leadership of President and CEO Laura Magaña, PhD, ASPPH adopted a zero tolerance policy against discrimination and harassment. Then “in the summer of 2020, the whole world woke up and sort of recommitted a focus on civil rights and racial justice,” said Linda Alexander, EdD, a senior associate dean at the West Virginia University School of Public Health, who co-led the ASPPH task force that developed the new policy. It became clear, she said, that “we needed to add racism to that and have some intentional work around identifying and dismantling enablers of structural racism in academic public health.”
As chair of ASPPH’s Diversity and Inclusion Section, Alexander is also coordinating with members from other schools and programs who contributed to the task force on efforts to develop a framework to operationalize actions against discrimination, with a focus on education, research and practice. For example, schools might consider whether case studies used in classes reflect diverse perspectives and populations and what communities are included in research projects. Other practices could promote recruitment and retention of students and faculty of color and create reward structures that encourage diversity activities for faculty and staff.
A Welcoming Environment
Training and education lay an important foundation in DEI competency for the public health workforce, but they are most effective when workers enter an environment that supports the same ideals, APHA’s Fine said. “The learning and improvement have to be continual. DEI is more than hitting a benchmark or ticking a checkbox. It should be institutionalized within the fabric of who we are and how we operate within the workplace.”
To do this, laboratory leaders should commit to establishing a framework that integrates DEI into every level of the organizational structure, identify benchmarks and conduct internal audits of policies, practices and behaviors in the laboratory, and build in ongoing assessments to sustain efforts and provide accountability. “We evaluate and assess the work that we do. So why can’t we evaluate and assess ourselves and our commitment to this issue?” he said.
There are many paths to inclusivity, but they share some characteristics. An organization committed to upholding DEI principles should have diverse leadership and staff, a recognition of varied talents, the expectation that unconscious biases are sought out and countered and intolerance of microaggressions. Individuals must feel able to ask questions and share their needs, and managers should proactively check in with staff to make sure everyone is comfortable, not just quiet.
And importantly, workplaces should establish safe, judgment-free spaces for open conversations. The ELP cohort’s resources include best practices and exercises for holding respectful dialogue on challenging topics. Bringing in a trained facilitator or moderator can also help, they found in their own discussions. Being open to hearing others’ experiences, such as those highlighted in the podcast, is a good place to start.
“One of the things that was really wonderful about our group is that we all sort of let down our own guard and those things that you might feel a little embarrassed about, and just kind of approached this project from a very honest and authentic and safe place,” Griffin said. “These are tough things to talk about. And so it was kind of giving each other that courtesy and place to have some difficult conversations and ask some difficult questions.”
It can be hard and a bit scary at first, she added, especially the fear of making mistakes. Culture shifts can take time as people build new habits and unlearn old ones, such as biases and misconceptions. But the most important thing is to start—commit to doing something and keep trying until things get better.
“Workforces can only become stronger when there’s diversity—not only diversity in terms of the way we look or the way we live our lives, but diversity in thought, diversity in perspective,” Norman said. “And when we’re hearing those diverse thoughts and perspectives at the table, then it enables us as public health laboratories to better serve our diverse communities and our diverse public.”
Digital Extra: Hear more about what cohort members learned in Episode 24 of the APHL Lab Culture Podcast.