Norms, White Supremacy & Health Equity

Earlier this week, I found myself ranting on LinkedIn about the New England Journal of Medicine. It has an occasional series in it called Efforts Toward Equity. My rant was about how most of the articles so far have described efforts to reduce disparities, not inequities. It seemed to me that if the best known journal in the US, and perhaps the world, can’t get that right, then the entire field is doomed. Inequities are here to stay. 
 
But working on inequities is hard. If they result from unfair and unjust social arrangements, then overturning those arrangements is the work. They’re usually codified in structures – laws, policies, regulations, practices and norms. My Health Affairs article with the former leaders of The California Endowment illustrated how communities with power can overturn the first three, perhaps four. But what about ‘norms’? What even are they? 
 
“This is just how things are done around here.” That’s the sentence I hear in my head when I think of ‘norms’. But these unquestioned ways of doing come from somewhere. And if an institution’s ways of doing are not addressing – and perhaps creating – inequities, we have to examine them. Given that inequities in health in the US are patterned on the basis of race, we have to ask if our norms, our ways of doing, are, in fact, racist. 
 
This is tricky territory. And it’s one I’ve been exploring with a US public health department since March 2023. Its leaders understood that the race-based inequities they see in the populations they serve mean that there is the possibility that their norms – the way the department does things – may be racist. That doesn’t mean that any individual within the department is racist, only that how they operate might be patterning health outcomes along racial lines. 
 
However, seeing and addressing ‘norms’ can be hard. They essentially stem from our culture and so the job of work is to see our culture. In 1999, Tema Okun, a racial equity practitioner and teacher, wrote a document with her colleague, Daniel Buford, trying to illustrate white supremacy culture. As Okun tells it, that document had very little impact but it was catapulted into the limelight in 2020 after the murder of George Floyd. This prompted Okun to update it. 
 
What the document (now a pretty bonkers website) proposes is that white supremacy was codified by Europeans to aid their colonizing. They were largely male, Christian and from different countries, such as England, France, Portugal, Spain, and the Netherlands. They needed a way to justify their colonizing, including the way they were treating the people of these ‘new’ lands. To do that, they codified their norms as superior – and hence any other norms as inferior. For instance, Europeans tended to record knowledge in written form. In other cultures, knowledge is recorded in other ways, such as oral storytelling, movement art, singing or dancing. To help define themselves as superior, they elevated the importance of the written word over other ways of recording knowledge. Okun and Buford call this the worship of the written word.
 
It could be argued that the worship of the written word is a norm that continues to hold public health back. We rely on ‘evidence’ to justify our interventions, which is usually in the form of the results of research published as a scientific article. This is important, of course, but what it often misses are the insights to be gleaned from lived experience. Perhaps, then, our reliance on ‘evidence’ is an echo of white supremacy culture and why our interventions continue to fail to address inequities in health, especially those patterned by race. 
 
This is difficult stuff, I know. And now is hardly the time to suggest we ignore knowledge gained from scientific research. However, if our norms are part of the issue and if they come from our culture and if that culture is influenced by the white supremacy attitudes of former European colonizers, these are the kinds of questions we have to ask ourselves. 
 
Another example. Okun and Buford suggested that European colonizers tended to reduce the complexity of life, including our relationships with each other and all living things, into either/or, yes or no, right or wrong. It could be argued that this hyper-segmented way of thinking has influenced how we organize ourselves in health – by specialty or functions, such as restaurant inspections or vaccine delivery. Doing so has meant that we’re not aware of how different specialties or functions could interact and potentially synergize. Perhaps the ‘classic’ example of this is the way so many health departments opened equity functions, rather than trying to bake equitable practices into existing functions. 
 
Is it a tough sell that worshipping evidence and hyper-segmenting health stems from the attitudes of European colonizers? Perhaps. But what Okun & Burford’s work provides is a list of things to think about (see below). That’s what my collaborators in the aforementioned health department have been doing. Unfortunately our attempts to make sense of and write up the work has been thwarted by the current US government’s attitude to anti-racism, pro-equity work. Our fully-drafted article explaining the work in depth has been put on ice for fear that it will put a target on the health department’s back. 
 
Perhaps that’s why journals like the New England Journal of Medicine are playing it safe. It’s perfectly understandable. I just wish they didn’t say the efforts are towards equity. Efforts toward equity are out there. And they deserve a proper airing and debating. Sadly, however, they’re increasingly in the shadows. 
 
Pritpal S Tamber

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Okun & Buford’s nine characteristics of white supremacy culture are: 

• Fear
• One Right Way
• Either/Or and the Binary
• Denial & Defensiveness
• Right to Comfort and Fear of Conflict
• Individualism
• Progress is Bigger & More / Quantity Over Quality
• Worship of the Written Word
• Urgency

The image below the title is by Otto Dettmer / Ikon Images.