by Jill Sakai, PhD, writer
During the “Understanding Privilege” session at APHL 2022, attendees engaged in an activity to help identify some of the many sources of privilege in our society. In response to a series of questions about their personal experiences, participants added or removed beads from a string. Are your employer’s decision makers of the same race as you? Have you always been comfortable with others knowing your sexual orientation? Did you graduate from college debt-free? Add a bead. Have you ever been followed in a store? Did you have to work as a teenager to support your family? Is it difficult to find appropriate hair products? Remove a bead.
At the end of this “privilege walk,” each person had a collection of beads that represented the overall balance of these factors in their life. Each, however, arrived at that endpoint along a path shaped by their unique life circumstances.
As this activity revealed, privilege is multifaceted and shaped by a myriad of factors: Some are innate, some chosen, some assigned by others. Some may be earned through effort and others granted through circumstances outside our control. Collectively, those facets shape the prism through which we view the world and through which others view us. But too often, we do not see the privilege that shapes our own prism. And by allowing ourselves to remain unaware, we help perpetuate the social factors that grant us advantages.
“Privilege really buffers the impact of structural, social and economic barriers and sometimes can remove them entirely,” said Ren Salerno, PhD, director of the US Centers for Disease Control and Prevention (CDC) Division of Laboratory Systems (DLS). “Those who receive privilege often overestimate, overlook or doubt the existence of barriers that they’ve never encountered. And I think that’s why it’s really important for all of us in public health, including those who work in public health laboratories, to continually educate ourselves about privileges that we may not even know that we have and to continually expand our perspective and the perspectives of those around us.”
Due to systemic patterns of discrimination and stigma, many of the same factors that confer privilege are also social determinants of health, including race and ethnicity, socioeconomic status, gender identity, geographic region, housing status, employment status and education level. And the social, economic and structural obstacles that lead to poor health outcomes overwhelmingly affect communities that are also medically underserved, including communities of color, people with disabilities, LGBTQ+ individuals, women, people who are incarcerated, people who lack stable housing and those who live in rural settings.
Knowing that privilege underlies many of the inequities that reside within the public health system, it is critical to ask what roles public health laboratories and their laboratorians might play in addressing some of these inequities in their workspaces and in the communities they serve. These efforts start with education—in the classroom, in the workspace and as individuals—about how to identify and acknowledge the sources and effects of privilege in public health. With a greater understanding, laboratorians can embrace allyship and start to harness the power of privilege to drive positive change.
Making Privilege Visible
Allowing privilege to remain unspoken perpetuates inequities. For this reason, recognizing and naming sources of privilege are necessary first steps toward addressing them. That starts with exploring how privilege functions within institutions.
“Privilege is operating even in places where we’re doing health equity work,” said Mighty Fine, MPH, CHES, director of the Center for Public Health Practice and Professional Development at the American Public Health Association (APHA). “And it’s important for us to acknowledge that and call it out so we can shift that paradigm.”
That will require open, honest conversations about privilege and its impacts to help make them visible to everyone. Such conversations can be hard and uncomfortable at times, “but it’s okay to be uncomfortable, as long as we’re respectful,” said Michelle Rodemeyer, chief financial officer of the Missouri State Public Health Laboratory.
Too often, mentions of privilege evoke shame and defensiveness, which get in the way of open communication. Much of that stigma arises from two myths, Fine said.
First, acknowledging privilege “does not mean that you didn’t work hard or that you don’t deserve what you have,” Fine said. That idea is rooted in the myth of meritocracy—that equal effort and ability will result in equal success. But in fact, social systems are built on biases and assumptions that preference and reward some identities over others.
Nor does extending privilege to others diminish one’s own. That’s the myth of the zero-sum game—by giving to or supporting others, ground is lost or something important is given up. But that is not how success works. Supporting a multitude of identities results in a stronger system that benefits everyone more fully. (For more on these myths, see the work of Camara Jones, MD, a social epidemiologist and physician at Morehouse School of Medicine.)
Productive conversations about privilege and its impacts will require debunking these myths and shifting the narrative toward a recognition that equitable practices work toward a collective benefit. Creating space for these conversations in the laboratory empowers individuals to ask questions, share their experiences and speak up about injustices they see or feel.
Hearing other peoples’ experiences can be a powerful way of starting to see your own privilege as well. “There’s a lot of misconceptions,” said Rodemeyer, who is also a member of the APHL Diversity, Equity and Inclusion (DEI) Task Force. “Ten years ago, I didn’t feel like I had a privileged upbringing. But as I’ve met people and heard their stories, I see how I did.”
“These open and honest conversations are so necessary because they create an opportunity to build a shared understanding of our varied experiences, which can engender empathy and are a foundation for healing,” Fine said. “My grandmother used to always say, ‘Change is on the other side of a conversation.’ I really believe that.”
Moving Toward Health Equity
As with privilege itself, addressing the resulting inequities in care first requires being able to see them. By providing services at no cost to patients, public health laboratories offer the most equitable testing possible—and often the only option for many individuals and populations who are underprivileged. In that “safety net” role, Rodemeyer sees for labs an unwritten mandate in health equity.
“We level the scale a little bit.”
Public health laboratories offer a unique service to their communities, Salerno agrees. He encourages laboratorians to lean into that role.
"From my point of view,” he said, “I think the most important message for public health laboratories is that they have a responsibility to engage their communities to determine where medically underserved populations live, and how they gain access to testing services.”
That requires the willingness and the ability to really understand the community and its needs. What role does the laboratory fill in community healthcare? What services are being provided that people might not be able to access elsewhere, and are they being offered in an accessible and socially relevant way?
At the laboratory level, that might mean having programs and staff dedicated to identifying underserved communities in their jurisdictions and enhancing access to the specific testing services needed in those communities—whether it is measles or sexually transmitted infections. It might also mean developing partnerships with existing organizations, or extending services to meet people where they are. For example, during the height of the COVID-19 pandemic, many public health laboratories created mobile laboratories to bring testing services to communities that lacked access to testing locations.
Such efforts require people in-house who understand the community. Diversity of thought and experience are important in any organization, but especially so in public health, notes Kelly Winter, PhD, MPH, chief of the Training Workforce and Development Branch in CDC’s DLS.
“When we have a public health workforce that better reflects the diversity of populations we serve,” she said, “we increase the likelihood that our public health programs and initiatives will be relevant, actionable, successful and sustainable.”
Diversifying that workforce starts with dismantling the effects of privilege in the educational pipeline, from recruitment and admissions to job placement and advancement, said Laura Magaña, PhD, president and CEO of the Association of Schools and Programs of Public Health (ASPPH).
Through a close examination of academic public health programs, ASPPH has generated a set of recommendations on education, practice and research. They aim to help institutions review and redesign admissions criteria, curricula, teaching approaches and measures of student success to ensure that they reflect principles of diversity, inclusion and antiracism. “We use an equity lens for everything that we’re doing,” Magaña said.
The organization is also working to broaden entryways into academic public health, looking at community colleges and continuing education programs as well as bachelor’s and graduate programs to make sure paths are in place to help students from underrepresented communities access educational opportunities, as well as the resources and support they need to succeed in and beyond school.
For example, some ASPPH-accredited schools and programs no longer require GRE scores from applicants. This requirement constitutes a systemic barrier for a diverse pool of applicants, Magaña said, and there is very weak evidence that GRE scores predict academic success.
“It’s a barrier for some who have not had those opportunities but could, if they came to our institutions, be great public health professionals.” Other efforts reflect a shift toward a broader view of what it means to be a successful public health professional. This year, ASPPH launched a workforce development center, working with laboratories and other partners to identify necessary competencies for an effective, inclusive public health workforce.
“We’re living in a world that is changing so much,” she said. Professionals are used to ongoing training to keep up with technical developments in their fields, she notes. It’s time to take a similar approach with professional and social competencies—skills like resilience, communication, working with diverse teams, leadership and problem-solving with an inclusive perspective.
“This has to be part of curriculum,” said Magaña. “These topics have to be really embedded.”
Often that can be accomplished through changes in the way material is presented or evaluated, such as active learning, scenarios that include multiple viewpoints, case studies and working in unfamiliar communities. Faculty should be trained to recognize their own biases and learn to integrate cultural competencies into their teaching. And programs need to create space for students to talk about questions of privilege and discrimination. “That’s how you learn—by being uncomfortable, by being out of your comfort space,” Magaña added. “We need to expose our students to develop these other competencies.”
That support also needs to extend beyond graduation. ASPPH is working with institutions to clarify advancement pathways for professionals from underrepresented minorities and boost equity in research support. Nationally, they are advocating for loan forgiveness programs. APHL and CDC’s expanded laboratory fellowship program and new internship program are bolstering opportunities for students and early-career scientists. In collaboration with organizations that serve underrepresented groups and communities, they are working to identify and eliminate barriers to participation in and completion of laboratory training programs. And CDC’s DLS has a core health equity goal of increase diversity within the fellowships and internship program by 40% by 2025.
“These are exactly the type of barriers that we need to eliminate,” said Magaña.
A Workforce That Walks the Walk
To build an inclusive workforce, hiring, training, support and promotion should all be reframed around equity by actively looking for and rooting out effects of privilege. It starts with how recruitment is approached, said APHA’s Fine.
“It’s not enough to say you welcome diverse applications and provide equal opportunities—you have to proactively seek out people with the backgrounds you want and engage with the communities where they are. Where are you seeking and sourcing your talent? [A posting on] Indeed is not enough,” Fine said. He also recommends rethinking how to write position descriptions, focusing on plain-language descriptions of the duties and needed skills. Positions should sound attainable to people with varied backgrounds and help individuals see how different experiences and skillsets may be transferable to the role.
Laboratories can show their commitment to inclusion and employee support by being transparent about hiring, evaluation and advancement criteria and policies. Consider using orientation and onboarding to show new hires how diversity and equity principles are operationalized in the organization’s values, suggests Fine—how performance is reviewed, how promotions and opportunities are given, how to report issues and what the process entails. Presenting clear, established policies up front can help employees feel more empowered to speak up when necessary and are a way to start shifting the culture of the workplace. Then, follow through—remember that the effects of privilege can lead individuals to view circumstances through different lenses. And people notice how they are treated, Fine noted. Are microaggressions called out? Are some individuals’ work scrutinized more than others?
“You start to question if what is happening to you is because people have assigned your abilities to how you look, as opposed to your actual capability,” he said.
Above all, open and transparent communication from leadership is critical to build trust and get buy-in from staff. Nandhu Balakrishnan, PhD, director of Clinical Microbiology at the Georgia Public Health Laboratoryaphl.org and a member of the APHL DEI Task Force, emphasizes the importance of inclusive leadership for building an effective public health infrastructure. That means making space for everyone in the laboratory to share their voice, then listening with an open mind.
“To build a robust strategic plan for the laboratory, you need to know your people and understand what is working and what’s not working,” he said. “It’s all about the mindset—understanding perspectives and respecting and appreciating people cultures, views, ideas and thoughts.” Setting these expectations starts from the top down, Rodemeyer added, with the backing and involvement of the leadership team. But it is not enough to just say these conversations are important.
“They have to lead by example,” she said. “I think they have to talk about it … and bring up those subjects.”
An equity-centered workplace means each employee is supported and their skills utilized, with access to resources and advancement for everyone in the organization. Mentoring and individual support can be transformative, Balakrishnan said. When he immigrated from India to the US for postdoctoral training, he had relatively few resources. He credits a series of mentors with enabling him to advance his training, find positions, learn how to succeed in the laboratory and ultimately get his green card. A good mentor should be able to help identify strengths and weakness, point out mistakes in a constructive way, and provide tools to help fill in skill or knowledge gaps, he said.
“At each and every step of my career, people have really helped bring out the best in me, even though I made errors, even though I wasn’t born a leader,” he said. “They gave me the opportunity to grow professionally and personally.”