Intersectionality in Healthcare

[00:00:00] Jared: Welcome to the med+Design Podcast, the place where innovation, design, and health care intersect. Today, we're honored to host a truly remarkable guest, Doctor Lisa Bowleg, a figure whose work not only challenges but reshapes our understanding of health equity through the lens of intersectionality. Doctor Bowleg is the founder and president of Intersectionality Training Institute, an establishment at the forefront of integrating the critical concept of intersectionality into health research, policy, and practice. Her dedication to advancing health equity and social justice is unparalleled, guiding her groundbreaking research that examines the nuanced effects of social structural stressors, intersectional stigma, and discrimination on the health outcomes of marginalized communities.

With a career that spans several impactful NIH funded projects and prestigious awards, Doctor Bowleg's contributions to the field are both profound and inspiring. Her work provides a crucial framework for understanding the complex interplay of factors affecting health disparities among many oppressed populations. Today, Doctor Bowleg joins us to share her insights on the importance of intersectionality in health care, the challenges and opportunities in the fight against health inequities, and a transformative power of research informed by intersectionality. Her stories of resilience, innovation, and the path forward promise to enlighten and inspire all of us. So without further ado, let's dive into our conversation with Doctor Lisa Bowleg.

Welcome.

[00:01:17] Lisa: Thank you. What a lovely introduction. I'm just honored to be here. Thank you for the invitation.

[00:01:22] Jared: Thank you so much. Thank you. And I think to get started, if you could dive into telling us a little about what intersectionality is. I think, It's such a complex base of research. What is it?

How is it being applied today? What are some of the outcomes that you've seen, positive outcomes that you've seen for oppressed populations through your research and, through the populations that you've been serving.

[00:01:43] Lisa: Mhmm. So where I wanna start is that intersectionality is at once complex and very simple. And so I like to talk about intersectionality and start with its history.

Because that sort of tells you some of the sort of the nuance of it, which is its history is very much grounded In the lives of black women in the US and also in the lives of black feminist and black lesbian feminist activism. And so we could talk about one of the sort of first articulations, written articulations of intersectionality In the Combahee River Collective 1977 statement. And so this is a group of women who've been organizing and doing lots really important grassroots work on a variety of, timely topics, violence against women and so on and so forth. And one of the things they talk about is that how the systems of oppression are multiple and interlocking. Right?

So we're talking about racism as it interlocks with sexism and heterosexism and class exploitation. And they talk about the understanding through that lens how those systems create, the conditions of their lives as black women or black lesbian women. And so intersect and so we can find intersectionality. We can go back into early narratives.

We can look at, Julia, Anna Cooper is writing about intersectionality without using that name. So fast forward to the present and how we're talking about intersectionality is about this sort of integrated sort of analysis, this critical framework that examines how the sort of multiple systems of oppression. And so we are talking about racism, sexism, heterosexism, and you could keep on going. And how understanding those systems really helps explain and provides a much more complicated and complex and nuanced understanding of health inequities that many people from different marginalized groups or historically oppressed groups face. That sort of intersectionality in a nutshell.

[00:03:48] Jared: And I guess before we talk about ITI a little bit. Also, who would you say would be maybe the founder of intersectionality as a study? And also, I know that In your newsletter, Intersectionalia the January edition, you mentioned the 3 c's or c threes. And if you could just dive into that a little bit as well before we go.

[00:04:07] Lisa: Yeah. I would say that sort of nobody owns intersectionality. It's really comes out of women of color talking about this sort of their experiences and how historically, when people have talked about women, they've meant white women. And when they've talked about, some people of color, it's been black men and how women have fallen through the cracks.

And so I think it's very important this history that it doesn't come out of the academy. It's very much grounded and from the ground up is really important to intersectionality and how we see it at the Intersectionality Training Institute. But in terms of these c threes, in terms of, the women who've carried intersectionality along and on whose shoulders we stand, Combahee River Collective, 1977. As I said before, thinking about that as one of the sort of the first articulations of intersectionality. Then Kimberle Crenshaw who is a critical legal scholar, just an intellectual powerhouse who is credited with coining the term intersectionality and really using the law to show examples from the law how black women have been fallen through the cracks in terms of legal theory.

And so Kimberle Crenshaw is around 19 89, 1991. And then there is the amazing, indomitable Patricia Hill Collins, who is a sociologist black feminist, and her 1991 book Black Feminist Thought, is really talking about this interplay between sort of micro level experiences and how they reflect these larger macro level inequities. And so these serve different threads, and so that's why I call them the c threes. And what I say to all our trainees and everybody I mentor is, when you're talking about intersectionality, you absolutely need to cite that lineage.

Combahee, Crenshaw, and Collins.

[00:06:03] Jared: The c threes. And with them being the foundation that maybe the Intersectionality Training Institute was built upon and carrying this torch forward. What is the mission of your institute and its significance in advancing health equity and social justice?

[00:06:18] Lisa: Happy to talk about it.

So the mission of the Intersectionality Training Institute is basically to advance health equity and social justice With the application of intersectionality to health equity research. It's mostly social and behavioral science research, but here's the most important part. For me, with fidelity to core tenets of intersectionality. And what I mean by that is, people have been talking about and writing about intersectionality for lots of different disciplines. Right?

So there's women's studies, there's feminist studies, and but one of the sort of key themes is this attention to power and privilege. And if we're not attending to those, we're not talking about intersectionality. And so when people are talking about multiple identities and all that, I'm like, no. No. No.

Everybody's got a multiple identity. That ain't it. It's really about the sort of social justice lens that is absolutely paramount to any type of intersectional analysis.

[00:07:15] Jared: If you could just dive into a little bit of some of what you all do there. I know you have your trainings, and you have your salon as well and just so many things going on.

So I was like, oh my gosh. You must be so busy.

[00:07:26] Lisa: Yeah. It's insane. It's really a passion project in the sense that so I've been applying intersectionality to my research.

I'm primarily an HIV prevention researcher and found intersectionality to be such an important frame for understanding and moving beyond these sort of historical individual level lenses that we learn. I'm trained as a an applied social psychologist. And so my training was very much about, understanding health and what people do through these sort of social cognitive lenses. So what people so take HIV, and condom use. So that a lot of my work is in that area. But a lot of it is just through a lot of the sort of conventional frameworks is through the prism of people's perceptions, their attitudes, their risk perception, all of that. And my work is very much interested in trying to understand HIV risk and what protects people, and my work is mostly focused on black men at different intersections of sexuality. And how factors beyond the level of the individual shape and constrain opportunities to engage in protective behaviors.

And so I'm thinking about and you talk to black men in my research for 5 minutes, and you're talking about incarceration. You're talking about unemployment. You're talking about the link between unemployment and having a criminal record. So it factors larger than the individual, and I found intersectionality to be a very useful framework for bringing both of those together, the sort of individual level experiences and then the history of intersectional structural repression.

So what happened then is that so I've had several NIH grants, and I've written several articles on intersectionality. And I was fielding a lot of emails and a lot of calls about intersectionality. Can you review my grant and how to do this and all that? And so one day in frustration by, my husband's sitting in my home office, and I say, this is another request for some intersectionality. I should start an institute.

He says, I think that's a great idea. I said to him, I think you're nuts. And so then I, well with some time, realized, wow. There really is a need for some place where people who are interested in this type of work can go to get training about it because there are some academic programs where you could find an intersectionality course. When I was on the faculty of the School of Public Health and the Department of Community Health and Prevention At Drexel University here in Philadelphia, for example, I taught a course on intersectionality, but it's rare.

And so that pretty much was the genesis. And so what We do. We do several things. We do a lot of things as you noted. Our sort of premier event is the intersectionality summer intensive.

And what that involves is that people apply to come and spend a week, a full week, in Philadelphia, sort of where we are walking them through. Okay. Here's what it is. Here's what it looks like when you apply it and things you need to know and here and whatever you don't do this. How do you apply it to your qualitative, quantitative, and mixed methods research?

And so that and it's intense. People have said, boy, you weren't joking when you said it was intense, but it is so wonderful because people come and find people who speak their language around sort of social justice and the intricacies of taking a framework that was not designed for research. It doesn't come out of the academy. And so those of us in this field are really trying to figure out, okay. How do we how do we integrate this in a way that's meaningful and useful for research?

So that's one of the things we do. Also we do trainings. And so for institutions who are interested in finding out, what is this intersectionality thing, because a lot of peep it's in vogue. It's what is it? What does it mean for our organization?

And so people will hire us, and we will some we will do customized trainings. We already have some sort of standard trainings about intersectionality 1 0 1 where we talk about the benefits of intersectionality for whatever work they're doing. So there's that. We also have a free monthly Intersectionality research salon. So these are virtual, and I always tell people in my head, it's like where it's the sort of the Dark Towers, Harlem Renaissance.

I want people to think, be I want them to think we're in Madam CJ Walker's daughter's, fabulous Townhouse in Harlem. We're, all dressed up with great drinks and all that, but it's really chill. And so people come, and I invite people to bring drinks, and we typically have a guest. And what I love about our salons are so they're organized around a theme related to the guest, but no PowerPoints. These are not academic webinars.

None of that. And we typically you know, we will share what the guest It's been has written and so people can read that. And we ask the guest, so what have you been thinking about or grappling with intersectionality wise? The guest talks about 10, 15 minutes, and then we're off to the races. We open it up to everyone.

And so people have opportunities to ask questions, to network. And it's been amazing. For example, somebody was asked a question about intersectionality in India, and they talked about being in Chennai, and somebody on the Zoom. And they're like, I'm in Chennai now. And so it's that's really what and also the other magic that happens in the salons is lots of sharing of resources because, invariably, the guest or someone there is talking about different books, articles, and so that's that's in the going on in the Zoom chat.

And then what else? You just talked about and then we've started trainings for individuals, which are the sort of all day virtual trainings. We just did one this past Friday called Land that Grant about applying intersectionality to NIH grant applications for example. And then as you noted, we just launched Intersectionalia, which is our new newsletter that can be found on our website. Yeah, delightfully tiny team doing a lot.

[00:13:26] Jared: Mhmm. Oh, yeah. And also what is the research that the institute is working on. What kinds of research are you all putting out?

I noticed that at the end of your Intersectionalia of volume 1 you'd actually been cited in a couple of different papers, and I thought that was really awesome. And so what was some of that work that I guess

[00:13:45] Lisa: Oh, no. The wonderful thing about so we don't do research. We are very much focused on training people about how to integrate intersectionality into their work. In my other life as a professor at the George Washington University.

And I'm definitely doing NIH funded work that integrates intersectionality, and I'll be happy to talk about that. But the institute itself is not doing that. So no. About those citations, what I found is that people who are writing about intersectionality in different context, and so I think there was one related to applying intersectionality to nursing, for example, have started citing us, the Intersectionality Training Institute, as a resource for training. And that was okay.

Okay. Okay. Wonderfully gratifying and rising. I didn't ask people to and so that's a wonderful thing that's happening as more people learn about us and as news about us travels.

[00:14:42] Jared: Okay. Yeah. I was like, you're getting recognized all over the place, and I just kinda wanted to highlight that. And another thing that I've noticed from just trying to research the I ITI a little bit more is your cross disciplinary approach. And so how do you feel like this has really enhanced the impact of, innovation and the research and practice that you all are working on there with your trainings?

[00:15:02] Lisa: Yeah. I think that any type of critical work and when I'm talk when I use the word critical, I'm talking about sort of any framework that is focused on interrogating, challenging the status quo, particularly with regard to power and privilege. So intersectionality sits aside, feminist theory and queer theory and disability act all of that. And so is by nature cross disciplinary.

And so that means we are, we're in a little bit of psychology, but very small. It means that engaging with sociology and public health and women's studies. And we even go beyond that. And in one of our sessions about our transforming health equity through the application of intersectionality, I give this I show this slide of sort of the history of intersectionality, and it includes these sort of narratives that I talk I told you about. And so it includes, for example Brother to Brother, which is an anthology written by black gay men years ago.

That's really relevant. And a lot of the sort of feminist writing, Angela Davis, Bell Hooks the fabulous, Audre Lorde. All that. And so it's by nature cross disciplinary and not just rooted in these conventional disciplines like psychology.

[00:16:15] Jared: I see. And just talking about, yourself a little bit, so what is your origin story in intersectionality? What sort of inspired you to take this work on and become a superhero?

[00:16:26] Lisa: Superhero. There you go.

I don't know about that. But, I well, am a black woman, and so and I grew up born and raised in the Bahamas. And that's really important to my story because when you're born and raised in a country that's black, you don't spend a lot of time thinking about race or I certainly didn't because I was raised in this black upper middle class for Bahamas, maybe not for US family. And when you're in this context where all the people you admire look like you, the prime minister looks like you. The teachers that you love look like you.

The smart kids, they look like you. But I came to the US for college in when was that? Say, 1984 and very much learned, how salient race is and be what it means to be black in the US. And so when I was at Georgetown, and I took my first women's studies course with the wonderful Professor Margaret Stets, who is now at the University of Delaware. And, the women's studies is one of those sort of critical bodies of study that just blows your mind open.

I said everybody needs to take a women's studies class. Everybody should take a women's studies class. And so one of the things she said to me, she was asking, so are you aware with all of this black feminist writing? And I was not. And she suggested that we do an independent studies tutorial.

And one of the best things that ever happened to me because that's where I'm reading Bell Hooks and Angela Davis and Audre Lorde, and they are all talking about intersectionality. They're not using that term. Because as I said, Kimberle Crenshaw coined the that term circa 1989, but that was really foundational to me. And so but I didn't you know, it wasn't until later in my career that it made sense. Wait a minute.

That stuff that I was reading about In the late eighties, it's so relevant to the work that I'm doing in HIV, for example. And so I was a policy analyst initially, I analyzed one of my first jobs out of college was analyzing state HIV legislation and policies and really getting to see wait a minute. There the law had a very different view of this group of people black gay men in terms of HIV, then how it's all white gay men and what it was saying about black women. And so that it was doing that type of work that was really and it was just learning. And every project I did, I started to become much more critical about what was missing.

And, again, the reason these people have HIV It's because they're simply not smart enough to use condoms. I'm like, wait. Wait. Wait. Wait.

Wait. Wait. Wait. There's a larger story here that explains why HIV is densely concentrated in these communities, which kinda happen to be the same communities who have been buffeted by Intersecting structural repression. There's a larger story here.

And so that became just absolutely foundational and fundamental to my research.

[00:19:34] Jared: Your answer led into so many more of my things I wanted to ask you about. So I'm so glad. I think it's interesting. So you said that maybe you're not a superhero, but one of the things you definitely are is a mentor and a leader.

And something that I've heard you talk about before is that your mentor does not necessarily have to look like you, but shared values can also be a connecting factor between you when you're a mentor. And what are the benefits of mentors from different cultural backgrounds from your experience, and what are your also philosophies on mentorship now that you're position of influence and influence to the next generation.

[00:20:06] Lisa: Mhmm. I guess I you know, in talking and thinking about mentorship, I very much use my own story. Margaret Stents is white, but, staunch, fabulous feminist who really got me and was really, committed to, oh my god.

This woman is smart, and we think, but she needs to have this foundation. Excellent. Excellent quality in a mentor. My next mentor doctor Faye Belgrave, who is now in administration and diversity, equity, and inclusion at Virginia Commonwealth University was a black woman.

Same kind of thing in terms of understanding that when I was in my doctoral program, I was working full time doing the state legislation and policy work. And so Faye very much understood how I needed to move. I couldn't participate in all these different research teams and publications because guess what? I had to get back to the office. That job was paying for me to be in my doctoral training program.

And then the third mentor who has been absolutely instrumental to my success is doctor Jean Tashawn from the University of California San Francisco, a white woman, white social psychologist. I had the privilege of being accepted into the visiting professor's program at the Center for AIDS Prevention Studies at the University of California San Francisco. So this is circa 1999, and so I'm a new professor and Faye. The one I told you about was the one who said, Lisa, I really think you could benefit from this program.

That's what you need. You need mentors who know things that you don't know, don't have access to, but who know what you need. And it was a program for people who were doing HIV prevention research, mostly focused in racial ethnic minority communities. And the whole sort of goal of the program was we need sort of new innovative approaches to HIV. And so I was accepted into that program.

Oh, fabulous. 3 consecutive months in San Francisco with super smart people learning how to write an NIH grant. Why was that important to me? Because as I told you, I was working full time. I didn't even know what an n I didn't know what an r o 1 I couldn't tell you what a r o 1 was from a cucumber.

I didn't know anything about the NIH research process. But I got into that program, and I describe my meeting with Jean as love at first sight. We just clicked. And she also with someone who really got what I needed.

Because, for example, the program was very much focused on training us how to write these NIH grants. I've left my program with 1 peer reviewed publication for my rotation. I wouldn't get a job today, not with that resume. I had a bunch of policy publications, but those don't count. Peer reviewed publications are the coin of the realm in academia.

And so I was very much worried about, am I going to get tenure. And how and why am I writing an r o 1 publication? Do I can't a grand application if I don't even have these publications. And Jean was just like, okay. We're gonna work this out.

I will talk to the people in this program. And so just really understanding what I needed and the type of support I needed. And so these are sort of stories that I've learned from mentors. And why I say that one of the most important attributes of a really solid mentor is the one who gets you who you are uniquely, and what your needs are, what your strengths are, what your weaknesses are, and is really focused on helping you get to where you want to be. Not where they want you to be.

Creating you in their own image. No. No. No. And so that's why I see that I see That's really important.

But I wanna say one other thing about mentorship because I don't think you get it all in one mentor. There's the mentor who is really good at networking, for example, there's a mentor who's really good at emotional support. When you call up a girl, wait till I tell you what these undergrad said to me today. And then, there's the mentor who's really strategically helping you with no.

This is how you write a method section or this critiquing your work. So there are diff you're not necessarily gonna get it all in one person.

[00:24:24] Jared: I love that.

And so talking about now another one of your loves is research. And when some people think about research at a very surface level. They think of it being objective and free of bias because it's supposed or in your in that's what we were taught that it is. But, obviously, If you look right under the surface, that is far from the case. And so has how has research subjectivity created further inequity in health care and health care outcomes?

[00:24:53] Lisa: Look. The first thing is this notion of subjective or objectivity is a myth and it's very much grounded in the sort of postpositivist, , framework of understanding research. And particularly 1 of the criteria is axiology. Axiology has to do with the role of values in research. And conventionally, particularly in the way most people are taught research, certainly, and I'll talk about what I know best in sort of psychology and social behavioral science, is this notion of objectivity being prized and that if this experiment is designed, that there's no bias, and the who the researcher is will not shape this in any way.

And so I could give you this design, and it's gonna be you know, the findings are gonna be the same. That is ridiculous. We know that research is shaped. There's so much research anecdotal experience about who we are shapes who the researcher is, shapes the types of questions, what they see, what they don't see. Who's funding the research? If the tobacco industry companies are funding it, guess what they're gonna say about smoking, for example.

And so this notion about objectivity in research is a myth and one that I often debunk in the qualitative class that I teach at George Washington, where we start with go into the sort of philosophy of science, and I'm always surprised How few students, and these are doctoral level students, have even gotten that? There's not they're not taught to be critical about the whole research enterprise. And so no. I don't subscribe to that. I think it's about the importance of reflexivity.

And reflexivity is something that qualitative researchers talk about quite a bit and something that I think the quantitative researchers could benefit from too this notion of this sort of introspection about how who we are, or so our demographics, our values, our disciplinary training, all of that, how that shapes the research. I'm still as much as I critique, social psychology, I'm still very much trained in the sort of Western, mostly quantitative model and the sort of social cognitive, of frameworks. And so I have to be really conscious about that and how that shapes the types of research I do, the types of questions that I ask. And it's so it's really about using the biases or at least acknowledging the role that those subjectivities may play in our research.

[00:27:22] Jared: That's fascinating.

Also, within intersectionality, it's a field study that seems to be largely conducted by people either in or adjacent to the oppressed populations that are highlighted in the research. And with many of these people coming from these populations leading the charge, would you say that finding funding for these initiatives is a struggle since they're not really coming from a place of power or privilege to start with? And a last little part is if you have any ways that you've found to fund these sorts of impactful initiatives that you've been a part of?

[00:27:54] Lisa: There's two things to be said about that. It is true that many of the but not most because I can tell you that, we've had quite a bunch of scholars for, white, upper middle class, heterosexual, all western who are really passionate about intersectionality comes through our trainings.

But it is also true that most or many of the intersectionality scholars come from, historically oppressed groups. That's a fact. But one of the things that many of them have written about is this sort of epistemic resistance to intersectionality. And so there are publications about how they're not able to get there are articles on intersectionality published, for example, because intersectionality just seem like a fad or that's not real science, for example. And, some of them have applied that the issue is that who's doing the research.

Right? And so that's one barrier. As for funding for research the National Institutes of Health, has released its own study showing that it was mostly black. The data were not intersectional. They rarely are.

It's just single access focused on race, but showing that compared with white researchers black investigators who are less likely to be funded. And so the NIH has been quite ardent in their trying to right this, right this wrong. And there are lots of sort of good things that are happening, but so so much of that is so structured in. For example, after that report came out, there was another study that showed that one of the reasons that these were mostly, like, black and I think latino, I'm not sure, but certainly black researchers were less likely to get NIH funding. It was because a lot of their work a lot of the questions they were interested in asking were commute were grounded in their interest to the communities that they're from.

And NIH was much more interested in these sort of mechanistic larger questions. And so there are all these it's so it's really complex. 1 of the things I'm doing you know, my little contribution to this, I hope, is because I have been successful in integrating intersectionality into my NIH grants and I've have also been successful and privileged in some ways to talk to different program officers at NIH, is I'm then training the next generation about, okay. Here's what it needs to look like. This is what worked for me.

But I'm getting some stories small. We're just into our third year, but I'm getting stories now about people who've gone through our training, and have gotten their first r o 1 and or crediting some of the things that they learned at the Intersectionality Training Institute with their successful grants. And so that's one of those things that I'm doing. And NIH and I know this because in preparing for my Land the Grant training last week, I got to see all of these different notice of special interest about intersectionality and NIH's stated interest in using an intersectional lens in different applications. And so that's how we're contributing to that conversation.

Another piece of your legacy also is just as a leader. You're a lady in the c suite as well, and I wanted to talk about intersectionality in the c suite. Why is it that, so few executives are people of color or women? And, especially thinking about the venture capital world the amount of women founders seeking capital compared to male founders is just astronomically different. And what are some of the barriers in play here?

And, what are some of the work being done to overcome this? And I think It's just nice to see that there's I've even seen, for example venture capitalist groups that only fund women founders now. And I'm like, okay. I love that people are taking attention to this and trying to at least point us in a better direction, but we're still not there, of course.

It's funny to hear you describe me as a c suite because, the Intersectionality Training Institute is the littlest street that can, but it's very much a sort of it's an organization of a sort of bootstrap by me. Nobody works full time in this business. We have a tiny team. There are 4 of us. And actually, this is a really good opportunity for me to say who they are.

Sarah Paget, who is our sort of manager of client relations and just she's just amazing. She started as my executive assistant. Jenne Massie is the director of operations, an amazing strategic thinker. And then Meredith Loui who helps us with program research, and then there's me. And so we're just, you know so the c suite, I was like, Yeah.

Where would that be? What would that look like? So but we're doing the thing, and we do amazing work. And I'm so proud of my team and enjoy working with them so much. But, the answer to the question of why so few is, intersectionality has the answer for that.

It's the intersection of racism and sexism. That it's really clear about who was able to even be educated historically in the US who has access to power. There are instances of homophily, which is about, people feel very comfortable with people who look like them. And of course, if most of the people who are rewarded and have access to capital and all that are white straight men, guess who they're going out to play golf with and all of that.

And so that's that. And then in terms of the investment, yes, there are groups like Pipeline Investors, which is a VC an equity firm focused primarily on women of color. And why that's important and it's cisgender women and transgender women of color. And why that's important is because women has historically meant white women. And so when we talk about women, women's success in any field.

The question I'm always interested in is, okay. That's fabulous. But are these racial and ethnic minority women? Are these women because there are so many barriers for that group. And so intersectionality is always inviting us to ask about power and privilege and to ask questions about who's intersectionally invisible, who are we missing.

And often when we're talking about the c suite we're missing a lot of women of color, a lot of brilliant women of color in the US.

[00:34:12] Ty: There's a concept in the business literature It talks about hiring for culture fit, which, is just so misguided when you think about, we just talked about that dynamic of wanting to hire people that look like you versus, by contrast, looking at where are the gaps in our organization, what perspectives are missing, and then hiring based upon those gaps on the team to make sure you have a more robust complete picture of society.

[00:34:38] Lisa: And that it's a strength. It enhances diversity, enhances what you're going to do.

There's been so so much research on this and psychology as well about what happens when you have these different people in the room. It's really a wonderful experience. It's value added. It's you know, it shouldn't be seen as some punitive, oh god. We gotta hire we gotta hire people who only look like us.

[00:35:00] Ty: It makes the organizations stronger as a result of having a lot of different perspectives and backgrounds and also being able to say, that's a really bad idea. We should not go forward with that. There's plenty of teams that were missing that voice.

You shouldn't do this. Do it and with catastrophic outcomes. Yeah. Yeah. Yeah.

I was curious. Have you run across systems thinking just as in the business literature?

[00:35:25] Lisa: I don't think I have. I think it's something that comes up in terms of some of the business coaching that I've done. But say more.

Would you one of my favorites, it's a book called Simple Complexity by William Donaldson. And you think about systems of power, it's written from the perspective of how do large organizations govern and respond to complexity. So it's more from a kind of, I don't know written from how do you lead a large organization. Some of the concepts he introduced are like hold ons, which are basically dynamic groups within an organization that are responsible for a given attribute. And as you were talking about intersectionality, the systems thinking dynamic popped up with well, that's a whole on you've just identified, and you see the interlock between different whole ons then lead to a larger system. So from an intersectionality lens, looking at systems thinking then is an explanatory model for how organizations perpetuate a system and then also a model for then how to affect change in an organization as well.

[00:36:34] Ty: So it's just it's a wonderful book, and I just the connecting those 2 dots, I think, would

be super cool. So I love that.

[00:36:41] Lisa: And I think that's and no, I'm not familiar with that, but, I think that's another example of why people find Intersectionality is so fascinating. For example, I'm I know people who've gone through the institute who are applying it to AI And machine learning. And so it's really the sort of framework that people can this lens that people can use in lots of different areas.

And yeah, system thinking and intersectionality. Why not? Let's do it. Let's do it, Ty. Let's do it.

[00:37:10] Jared: Another big topic I wanted to touch on as well is just taking risks and being bold to enact positive change for oppressed populations. People from these populations have historically had to take incredible risk in the face of racist adversity in order to create change. And so what sorts of risks do you foresee that need to be taken in the health care sector specifically for oppressed minorities to start having better outcomes?

[00:37:34] Lisa: So much of that is in the hands of structure and not just individual level action. And so I think on the level that I work, it's about training people who have some level of power and privilege.

Because the people that come to the Intersectionality Training Institute, these are mostly you know, these are people with PhDs, the occasional MD. And so people who are trying to advance their careers and do really good work and they want more equitable outcomes. And so I'm training a group of people who many of them have that they've gotten to where they've arrived at professionally because they're really good at following the rules. You don't get a p you don't get a PhD by being really risky and say, I'm not gonna do a dissertation.

I'm gonna submit this art project. No. Let's not gonna work. And so these are people, my and myself included, who are trained in following the rules and wanna get good grades, and this is how you do it.

And so what I say is okay. I am going to introduce you or enhance your understanding of this framework and what it can do and its power. And It's risky because you're gonna be talking about things that people don't wanna talk about. People don't wanna hear about oppression. They don't wanna hear about structural racism.

They won't wanna talk about, black trans women and those sort of issues that it's it's stuff that makes people really uncomfortable. And It's not territory where we say that the problem the reason why this person has such poor health outcomes and can't manage their diabetes It's not because they are not adherent to their diabetes medication. It has a hell of a lot to do with where they grew up, what they had access to, the conditions of their lives, and all that. It's risky. People don't like talking about this.

And so the risk I'm talking about our sort of professional risk because you may not get that grant. You may not get that thing published because people don't like what you're saying about racism. And so my job is to push is to tell this next generation, listen. We're not gonna get to where you wanna get by doing the same old thing, by using the same old individualistic approaches, by putting everything on the individual without understanding the larger context that shapes life for these groups or the sort of historical systems that explain, the health of poor black people in the US or poor native American people or just native American people, it's a whole sort of shift. And so that's this type of risk that I'm talking about and teaching people how to think about structural change.

Because that's the other part of intersectionality. Patricia O'Collins is very clear in her writing that intersectionality is not just about really cool analyses and fancy analyses and having something to write innovative in the in your NIH application. It is really about a tool for praxis, the sort of social justice, because that's the next step. It's for action. So it's not just for you to publish it and put it on the shelf of a peer reviewed journal.

How can you then work with communities? It's about thinking bold, like citizen science. What types of sort of community projects that can you do informed by research that can be really sorta transformative. It's about speaking truth to power. It's about saying to NIH listen.

This community group down the street, no. They don't have anybody with a PhD, But they have been in this community for 40 years. They know how to get people immunized. They have the trust of the community. And so why we need some type of mechanism that will get money to support and build the infrastructure and capacity of people of the communities to do research.

It's that kind of bold risky thinking that I'm interested in. I'm not interested in, doing the same thing over and over again.

[00:41:23] Jared: Yeah. Absolutely. Another talking point that I've heard you discuss before that actually floored me or just I really thought this would have more impact, which was the fact that access to health insurance has been on the rise for many oppressed populations.

But at the same time, with this rise in access, health outcomes have largely stayed the same, very poor. And so if access to health insurance and health care was not one of these main drivers of these unfortunate health outcomes, What else would you say is behind that then?

[00:41:57] Lisa: Oh, that's easy. Structural racism, , and intersecting oppression. So the unequal medicine report, which one of the amazing things about that report, you're not gonna find the word racism in that report. In that sort of landmark study. But they found that all of the different sort of racial ethnic minority communities that they looked at had insurance. That's not the problem. It's like that interface that happens between health care providers and people who come from what you know, whatever that other group is. It's sort of structural barriers like, health like, providers only having 15 minutes to have an interaction, to even bond.

There's so many other factors that access gets you in the door. But if you're in a okay. You're in the door of a hospital that's been historically underfunded and it's gonna provide horrible care. There's just so many larger topics.

And so I this is an opportunity for me to talk about Metzel and Hansen's wonderful framework about structural competency, and it's focused on medical trainees and how do we train people in health care to understand this sort of larger structural context that sort of shapes health outcomes. And so they give an example. For example, they give a missus Jones, that may not be her name, who is late to her appointments all the time. Historically, we're gonna say, come up with some type of cultural formulation about those people. They just don't care about their health care, they just won't take the medication.

Why won't we even let's not even bother about it. But if we understand, oh, in order to get here, missus Jones needs to take 5 buses and needs to drop her grandkids off and this sort of larger understanding of, how people's lives are shaped by these larger structural decisions and certainly oppression, then that gets us in a very different direction. And it gets us beyond realizing that access is very important, but it's just it's just 1 piece of the puzzle.

[00:43:59] Jared: Absolutely.

It kinda reminds me of one of my fields of research was nutrition and around how food deserts exist across the country as well. And people are also even for myself as well just As a kid growing up in America watching TV and whatever, what we learn to eat is something that I think is very harmful to our bodies as well, and I think that's just a greater societal thing at play. I don't even know if it's part of intersectionality at all.

[00:44:28] Lisa: It certainly is, and it's one that I've written about using an intersectional framework, and one of the things I did is I looked at a lot of the different health messages people get about, eat healthy and fruits and vegetables. Listen.

I got a pretty decent salary as a professor, and I go into Whole Foods, and I'm gobsmacked by the cost of spinach, for example versus people who live in areas where they can't you know, there is no grocery store. There you have maybe a corner store, and guess what? They're not able to provide fresh vegetables. And so there's so many layers that intersectionality brings to pretty much any topic of inequity.

[00:45:06] Ty: We're working with doctor Jane Little on sickle cell and looking at care transitions from adolescent pediatric care to adult care. And we're just looking at some of the issues for these teens as they are going from having a care provider help them get to their appointments to then having to then manage it on their own. And then one of the stories that came back was if one of these young adults let their symptoms get away from them and they have to present to the ER, just some of the structural racism they encounter where the symptoms they're presenting with sickle cell, the accusation from the frontline workers is that you must be on drugs. They're having to be not only are they dealing with a health crisis, but they're also having to fight a system that is biased against them. It just it's just overwhelming what was up what these teams were up against as they're trying to figure out how to navigate a health system that's not always there to help them.

[00:46:03] Lisa: Same thing in terms of black women and maternal morbidity rates, 3 times that of white women regardless of socioeconomic status. So rich black women are going through this and this notion of they show up at the ER or the hospital, and they're being asked to take a drug test or assume that they're all of that. This is documented in research. So there's a new it's growing, body of research. Small but growing on gender racism, which also is related to intersectionality and it and looks at this sort of unique intersectional space that black women occupy and what happens when they show up in seeking care, and the stories are horrific.

This one study also found this was just this is striking to me. This study also found and the wonderful thing about the studies, it involves community participation as well in divine designing the types of questions. They found that white women who had black partners also reported a lot the same mistreatment from because the hospital staff is also bonding to this. Okay. Who's this black man?

And so it's it's a mess. But this is why it's so important for us to be naming these topics that make people feel really uncomfortable because we're seeing the clear, inevitable outcomes.

[00:47:23] Jared: We are getting so close to the end, and I still have a few more questions I just wanna talk to you about. One is just, we've talked about so many heavy topics today, rightfully so. and where are things getting, brighter?

Where is the things going in a positive direction that you've seen that gets you excited about the direction of intersectionality.

Yeah.

[00:47:42] Lisa: I wanna know where they're getting bright brighter. Show me. I think from my perspective, I just get to see the I think the next the types of research that the next generation will be asking is gonna take us in new directions.

I think that I'm excited about NIH's openness in terms of, different institutes. I'm thinking National Institutes of Mental Health, for example. I'm seeing their interest in Intersectional stigma and intersectional discrimination and understanding, this need for we definitely need more of a structural focus. And so that gives me hope. I think even at NIH with the sort of compass grants and understanding of the need for sort of research teams that would have a an academic PI or a PI with a PhD as well as a community investigator.

So I see lots of promising developments. I don't think that this is a topic necessarily that brings joy and resilience. I think the inequity is kinda built in, but I'm also heartened by seeing intersectionality scholars come up with new ways of thinking. So doctor Ellette, who went through our Intersectionality Training I nstitute, the first course of our summer intensive. And if you know the term health equity tourist, you can thank her for that.

And so she is playing with this concept of intersectional joy. And she's a black trans woman and trying to think about, okay. Yeah. We know about intersecting cisgenderism and racism, and we know about homicides. And we know that.

But there's also these sort of spots of there's an other side of and what do we need to know about intersectional sort of joy and resilience? And it's been a thread in all of my work that we're always you know, we focus on the stressors and intersectional discrimination, all that, but we also wanna know but what's the good stuff? We always ask about that. We wanna know what's protective, what's joyful, what type of social support do you have in your life, what kinda. And so I think that's unharnessed territory because and that needs to be leveraged because so much of research, particularly in the history of psychology, there are opportunities to open that up and ask new questions.

Yeah. Yeah. This it's really bad over here. No doubt. But, are there opportunities for joy, intersectional joy and resilience that can be harnessed to really enhance people's lives and well-being.

[00:50:10] Jared: Absolutely. And, also okay. Last 2 questions. Hopefully, I can get you just what are you currently working on in your research? And also, what's coming up next for ITI as well in the near future?

[00:50:23] Lisa: My current research, I'm really excited about it. I have a grant from NIH. It's an r 21, and it was in response to a call from NIMH, their office of aids, for studies focused on intersectional stigma. And what we did is we developed a measure of multilevel intersectional stigma for black, gay, bisexual, and other men who have sex with men based on it was a mixed method study based on in-depth interviews that we did with men about their experiences seeking HIV prevention care in Jackson, Mississippi and DC. And then we meticulously.

Oh my god. The number of meetings of building a quantitative measure grounded in you know, we call them phrase codes, what the participants have said. And so we've cognitively tested it, and we're gonna validate a measure. But in the meantime, HPTN 0 9 6 was just a sort of large scale HIV sort of intervention trial that's been running and focused on black gay, bisexual, and other men who have sex with men came to us and said, hey. We hear you're developing this measure.

Can we just use it? And I was it's not ready yet. It's not ready. And I'm like, what the hell? And so they tested this measure with 424 black gay men down in the south.

The alphas, the measures of internal reliability can are just wonderful. It performed. Jenne and I were just on the call listening to this news. They're just like, oh my god. So we're really and they only tested a subset of the measures.

So I'm really excited about testing the full measure, which is what the last stage we have to do of this project. And so but until then, the other thing I'm really excited about is I'm writing a paper based on the qualitative data about health care provider stigma. Because this is, what I'm concerned is, the missing link. And that so much of the HIV literature is on men and their multiple stigmatized identities.

But what I always say is wait. Hold up. You don't prescribe yourself prep which is a highly effective prevention tool. So for preventing HIV, either as an injectable or a daily pill, Somebody needs to prescribe that to you.

And so the stories about black men talking about health care providers thinking that their promiscuous or black heterosexual women also are getting a lot of this that they don't think providers don't think they're gonna take the pill. That's the problem, and we can develop interventions around that. And so I'm writing a and my team and I are writing a paper based on the qualitative studies. I'm really excited about that. As for ITI, all I'll drop is I think what we're gonna do is we're gonna be dipping our toe into some self directed learning.

Not everybody has the resources or, ability to come and spend 5 days in Philadelphia or to be in a whole virtual training. And so I we're looking at a larger program that would make our fabulous work more accessible to a much broader audience. That's down the road. I don't know when that's happening, but that's one of the directions I want to pursue with the Intersectionality Training Institute.

Wonderful.

[00:53:36] Jared: Wonderful. And, also, I look forward to the February edition of Intersectionalia as well. I know you're next week. Yeah, we'll be looking forward to that.

But, doctor Lisa Bowleg, thank you for your time today. Thank you for the work that you do. We're really excited to see the research that comes out of ITI or the trainings that come out of ITI and the research that you're working on as well. And yeah, best wishes to you and all the stuff that you have going on.

[00:53:59] Lisa: Thank you.

It was a pleasure. Thank you so much.

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