The Health Fund’s dedication to health equity is embedded in our new strategic plan. While each of our grantmaking teams already incorporate various equity-related goals into their work, we are committed to establishing a broader, organization-wide approach that enhances our pursuit of greater health equity. We are undertaking this journey with a deliberate, learning-oriented mindset to ensure that our effort is durable and promotes unity among Michiganders. While the Health Fund’s journey continues, we remain committed to uplifting a variety of other voices that present their own, unique interpretations of how to pursue health equity.
In that spirit, we’re pleased to present the perspective of Dr. Kimá Joy Taylor, who recently spoke at our “Sharpening the Focus on Equity in Behavioral Health” convening. During her keynote presentation, Dr. Taylor shared the definitions she uses for common equity-related terms, and many attendees asked if we could make those definitions available after the event. This guest blog post features Dr. Taylor’s definitions and ideas, as well as her perspective on how language shapes and conveys equity work.
Understanding history is key to eliminating inequities in behavioral health; few policymakers, researchers, and in some cases practitioners recognize how past policy fuels current inequities and poor outcomes. Our society has used a racist and moralist lens to create structures meant to punish—rather than treat or support—people who have a mental health concern. And we’ve deferred to punitive system responses, including criminal and legal ones, for substance use and other mental health concerns.
After the murder of George Floyd and during the height of the pandemic, the word “equity” (and “health equity”) was used in almost every sentence in private and public sectors. At times the words meant reckoning with the past to build a more just future for all people regardless of race, ethnicity, sexual orientation, gender identity, and other intersectional identities; at other times the words seemed to simply be an advertising meme. However, as the fury has died down, I am left to ask, is equity still a thing? Are we as a society willing to undertake the difficult policy, practice and programmatic changes needed to address past inequities and ensure equitable outcomes within the behavioral health space?
We do not truly know the answer to this question until we understand one another and create shared definitions, goals and outcomes. Without these we will fail to achieve a goal of improved health outcomes, much less ensure people receive the full range of respect, support, and services that support positive outcomes.
Not every person will use the same word for each idea or the same definition for each word, which is normal. Language matters, but more than simply what words you use, you also have to know what each person means by those words to understand where there is or is not synergy—and where one can or cannot partner on shared goals. It’s important for us to share our definitions and meaning so we understand one another and can transparently identify areas of difference and agreement while moving towards overall improved wellbeing and the elimination of inequities.
This blog is about those definitions that I use to serve as a base to center health equity and achieve equitable outcomes in the behavioral health field. My words and definitions may change and grow as I receive new information from individuals, articles, and systems, making this an iterative process that often includes a need to reclarify and maybe even redefine. The definitions I’ve included here are in service of my behavioral health goal: To center health equity and achieve equitable outcomes in the behavioral health field requires equitable access to and outcomes from a full continuum of community based, accessible, non-punitive, culturally and linguistically effective, evidence informed physical, mental and substance use health and social services. Equity also requires addressing societal determinants of health in ways that can improve outcomes across all areas of a patient’s/client’s life whether they are using substances or not.
So let’s dive deeper into what some of the key words and ideas mean to me:
Starting with health equity, I tend to use the Robert Wood Johnson Foundation definition:
“Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”
For the work that I do, I focus on equitable outcomes; equitable access to services is important but does not tell the whole story. I am a product of my training, which taught me that outcomes are what matter. Health equity is different from diversity, though people often interchange the concepts. Diversification is “the practice or quality of including or involving people from a range of different social and ethnic backgrounds and of different genders, sexual orientations, etc.” Diversity is important; you cannot possibly form an agenda that will achieve equitable outcomes without having people affected by the issue at the table. But diversity is not enough if there’s not true inclusion, listening, and power to change or develop policies, programs, and practices that assess and create structure to achieve equitable outcomes.
In my earlier years some researchers, providers and advocates focused on decreasing health disparities, which in our minds was similar to the concepts of equity today. However, the righteous pushback pointed out that some differences in outcomes are not due to injustice but are natural. For example, there are different rates of uterine cancer by age. Thinking about equity forces one to look at the “why” of those differences—the root causes—and remove obstacles such as poverty, discrimination, forced powerlessness, and lack of access to good jobs with fair pay, quality education, housing, safe environments, and health care. Equity is more than finding differences. It is seeking the root causes to eradicate differences when they are unjust and unfair.
Community based in my goal is meant to highlight the idea that a full continuum of supports and services should be a part of the community and should be easily accessible, culturally and linguistically effective, non-judgmental, and, most importantly, non-punitive. The full continuum includes sustainable prevention, harm reduction, treatment, recovery, and social services for behavioral health but also a full continuum of physical health and social services. The idea is to change policies that reinforce the criminal legal system as an appropriate “treatment” for a health condition. That was the past response, but we need new community based, geographically accessible services that focus on providing care and services that lead to equitable outcomes by race, age, ethnicity, sexual orientation, gender identity, ability, and other intersectional identities.
Culturally linguistically effective care, as I define it, is an important piece of equitable outcomes. Having worked in remarkably diverse clinical settings I know cultural competence is not a useful term because we are not going to be competent. The very idea goes against the idea of person-centered care. Individuals are too diverse. “Culturally linguistically effective care” is a little step beyond culturally linguistically responsive care. The latter is important, but having treated patients it’s clear to me that you can provide linguistically representative care and still talk past someone in a way that may not create the client/provider partnership necessary to improve wellbeing. I think of culturally linguistically effective care as working in partnership and effectively thinking about working with patients to improve health as they define those health desires and outcomes. It is more of an action step.
Evidence informed is the next area of my goal. I lean towards evidence informed which is inclusive of but more expansive than evidence based language. The research conducted to prove the “evidence base” often excluded certain populations; thus the evidence on which we frame many of our decisions is not the whole picture. It does not mean it is always wrong: for instance, many medications provided to kids have only been tested in adults can be helpful for children, but it is not the whole picture. There are cases where those medications may not be as effective, or providers wished there was a remedy specifically for children.
Equally as important, the “evidence base” often excludes community voice and community work. Because of historical exclusion, racism, and stigma, communities have developed and defined their own services and responses that support well-being and eliminate inequities. They have evidence to show that the services and support are effective for community members, but they are not funded to do the double-blind studies or the randomized control studies that are the supposed “gold standard.” (Though even the “gold standard” has a legacy of discrimination. For instance, criminal legal responses like mandatory and lengthy incarceration sentences for drug crimes did not demonstrate in randomized control or any other study to be more effective than actual provision of behavioral health services; these were still implemented and continue to be sustained.) We need to look at—and pay for—successful but under-the-radar approaches, as well as developing new, innovative solutions that build on past and current success. We should assess these for equitable outcomes and adjust as needed.
Finally, societal determinants of health, is my attempt to move away from “social determinants of health” language. Social determinants of health have started to mean what individuals don’t have, or how to make up for “individual deficits,” around transportation, food access, and educational opportunities. This allows systems to ignore the fact that broader societal structures have created and continue to create these inequities. Society decides where transportation routes go; society decides to initiate and sustain housing segregation; society decides which schools they put money into and which schools they do not. All of these decisions lead to and worsen inequitable health outcomes. So, while it is important to provide that individual a ride to a clinic visit, it is also important to understand why they need that ride and others do not. We must ask what society has determined to be fair, and whether it should be rectified so people have a fair and just opportunity to be as healthy as possible. I
With these definitions, let’s return to my behavioral health goal:
To center health equity and achieve equitable outcomes in the BH field requires equitable and access to and outcomes from a full continuum of community based, accessible, non-punitive, culturally and linguistically effective, evidence informed physical, mental and substance use health and social services. Equity requires addressing societal determinants of health in ways that can improve outcomes across all areas of a patient’s/client’s life whether they are using substances or not.
You can see how this goal might translate differently with someone who applies a different set of definitions to the ideas contained within it. And even with the context of my definitions, there is a lot of work needed to build trust and partnership with impacted communities, acknowledge and eradicate historical injustices, and to train, build, and pay for health and social services that will lead to equitable outcomes. Understanding one another’s words often reveals an uncomfortable fact: achieving equitable access, quality or outcomes is a long-term endeavor. It requires us all to move beyond the idea that creating three simple talking points or principles will achieve a legislative, administrative, or political win. It is hard, but not impossible if we all engage with a shared goal and a willingness to share our definitions and perspectives.
Kimá Joy Taylor is the founder of Anka Consulting, a health care consulting firm, and a nonresident fellow at the Urban Institute.
She most recently served as the director of the Open Society Foundations’ National Drug Addiction Treatment and Harm Reduction Program. She oversaw grantmaking that supported the expansion of access to a nonpunitive continuum of integrated, evidence-informed, and culturally effective substance use disorder services.
Before joining the Open Society Foundations, Taylor served as deputy commissioner for the Baltimore City Health Department, a health and social policy legislative assistant for Senator Sarbanes, and a pediatrician at a federally qualified health center in Washington, DC. She is a graduate of Brown University, Brown University School of Medicine, and the Georgetown University residency program in pediatrics. In 2002, Taylor was awarded a Commonwealth Foundation fellowship in minority health policy at Harvard University.