Prior to joining the Pasadena Public Health Department in 2014, the reluctance of my colleagues in municipal government to name and work to address the impact of institutional racism was the most challenging barrier of my career.
I worked in a variety of municipal operations outside the public health arena in cities big and small. Discussions on racial inequity were consistently reframed as challenges stemming from socioeconomic status and the result of personal behavior. As we advance our understanding of social determinants of health equity, it becomes clear that socioeconomic status and personal behavior are insufficient explanations for health disparities in our communities.
The fact remains: discussing racial inequities is a deeply personal and sensitive topic for many people including staff in health departments across our nation.
In Pasadena, I use the Human Impact Partners Health Equity Guide as a strategic roadmap to enhance our ability to facilitate these discussions. Our focus is to build organizational capacity through a culture of continuous learning to advance our understanding of equity and power. Eighteen members of the department have completed the Racial Equity Institute Phase I training, a two-day class on the foundations of historical and institutional racism. The Department established a Health Equity Committee that serves as an advisory body for health equity initiatives and plans in-house development opportunities to advance our understanding of social determinants of health and health equity.
In March 2019, the Health Equity Committee began meeting twice a month to advance department-wide understanding and practice of health equity. The Committee immediately recognized there were two audiences in our organization: those trained on health equity approaches and those who were not.
The group launched a monthly reading group dedicated to health equity topics and a monthly email highlighting programs using a health equity lens. From the start, it was clear these broad development components were insufficient to reach staff who were unfamiliar with health equity and the importance of it to our work in public health. The Committee set out to address the gap by innovating and adapting a tool described in When the Rules Are Fair, But the Game Isn’t (Multicultural Education, v13 n1 p14 Fall 2005).
The Health Equity Committee designed and offered Equity Monopoly in November 2019.
The key for the metaphor is that one group of players starts the game 30 minutes prior to a second group; creating the difference in opportunity, experience, and success. I co-facilitated the activity and as I walked the room, I was struck by how many of the players who started the game late began to blame themselves for their inability to succeed.
As I walked the room, I heard phrases such as “I can’t catch a break.”
The players who started late were also unusually ecstatic to buy an available property, even ones that had little value or potential for leading to success. In contrast, I found the early players adapted their strategy after the late players started. The early players frequently sought to make deals with each other and teamed up against the players who started late.
In the activity debrief, the group reflected on the experience and it didn’t take long to make the solemn connections between the game and what we see (and experience) in society.
Ultimately, Equity Monopoly highlights the disparities produced when systems unfairly provide advantages to one group over others. We found the metaphor to be an effective method for connecting each player’s experience in the game to real world experiences related to power and inequity.
As a tool, Equity Monopoly provided an opportunity to shift the narrative and discuss the impact of historical and institutional racism on the opportunities for individuals to enjoy a healthy life. The program was well received and the evaluation results demonstrate the potential for advanced discussions about health equity.
- Half the attendees worked in program areas where health equity is not a central component of their daily work and 72% of the attendees were not previously trained on health equity.
- Attendees rated the activity 4.5 out of 5 when asked “Did your understanding of health equity improve as a result of this activity” and 4.8 out of 5 when asked “Was this activity meaningful to you.”
- More importantly, 78% of the attendees have attended at least one of the two monthly health equity reading groups since attending Equity Monopoly.
Needless to say, our work in Pasadena is not done. These initial activities are the foundation needed to tackle more complex goals related to community engagement, staff training, and policy development. We must take the next steps to develop our ability to engage community partners in discussions about the root causes of inequity. In contrast to my early career experience, I am optimistic about the power of these internal discussions to change the way we engage externally and refine our ability to improve public health in Pasadena and beyond.
Interested in trying Equity Monopoly in your agency, download the procedure and please share the results of your experience with me. Your feedback will help my department improve our tool.
Manuel Carmona (he/him/his) is the Deputy Director for the Pasadena Public Health Department, a 2017 Health Equity Awakened Fellow, and a current participant in the National Leadership Academy for the Public’s Health. He is relentlessly collecting tools for his health equity toolbox. Want to help him?
Send Manuel an email at email@example.com.