When explaining the power of community engagement to reveal and address the invisible causes of health inequities, I draw on my Chinese-American culture and use the metaphor of a bowl. We use the bowl to eat and drink as well as to scoop things. On our wedding day, we use the bowl to offer respect to our parents, and on New Year’s Day, we use it to offer thanks to our ancestors. The dimensions and materials used to form the bowl are important: it should be able to hold both solids and liquids, both hot and cold; it needs to fit comfortably in one’s hand and also stay balanced when placed down. At the same time, what makes the bowl useful is its empty space; without empty space, it wouldn’t be a bowl. Hence, the bowl represents the power of joining together opposites. The outside represents control, borders, and limitations, whereas the bowl’s inside represents space, freedom, and opportunity. By joining these opposites together, something transformative happens—the two original boundaries are no longer distinguishable and are transformed into the new creation.
Similarly, in the field of public health, the intent of community engagement is to bring together a community’s insider view with a professional’s outsider view so that both can be transformed into a third view that is new knowledge. Yet, as Tim Schwantes noted in his blog Authentic Community Engagement Requires Vulnerability:
[For professionals] an openness to divergent ideas can make many of us nervous…There are a lot of ways we justify not reaching out to people in the community. And when stakes are high or a lot of resources are invested, control is something we cling to tightly (“we” being nonprofit organizations, government representatives, and foundations, among others).
A consequence of clinging to entrenched thinking is that professionals and communities diminish the opportunity to transform each other’s conventional ways of knowing, which in turn undermines the potential to discover new causes of problems and create new solutions. For example, many visible racial inequalities of the U.S. health care system were eradicated during the Civil Rights Era, such as unequal access to services within the transportation, housing, education, and healthcare systems. However, today’s system structures opportunity and assigns value based on race phenotype, unfairly disadvantaging some and unfairly advantaging others—whether intentionally or not—and produces inequities that are more difficult to address. In order to solve these problems, we will need conversations that take us into territory where we have not yet been.
In order to form a community-academic partnership committed to understanding the nature of racism and address its institutional manifestations, the 13-year-old Greensboro Health Disparities Collaborative (GHDC) in North Carolina is grounded in an anti-racism framework and the principles of community-based participatory research. GHDC focuses on a racial analysis of how and why institutions from all sectors in our society interact to maintain a race-based hierarchy. The rationale is that stakeholders from institutions often work for equity with different understandings of racism, each relying on discipline-specific frameworks, personal feelings, and popular opinion.
Through this racial analysis, GHDC’s participating organizations have established a common lens and vocabulary to: a) critically analyze structural issues of race and class, rather than characteristics of individuals and groups; and b) address both the explicit and subtle ways that racialized patterns in American history, culture, and policies permeate structures and practices within and across systems (such as business, education, criminal justice, and health care) to create and sustain inequities. A more detailed description on the genesis of GHDC and infrastructure created for ensuring equitable decision-making power among all partners can be found at www.greensborohealth.org.
All GHDC members recognize that our mission statement reflects the power of the bowl: Our mission is to establish structures and processes that respond to, empower, and facilitate communities in defining and resolving issues related to disparities in health. With this approach to community engagement, we are seeking to meld different perspectives into a new way of thinking in the pursuit of an equitable health system.