The authors set out a call to interrogate power and analyse privilege to create and sustain healthy communities. This article is part of the Building Healthy Communities collection.

According to the World Health Organization, inclusive, healthy and just communities are places that continually create and improve the physical and social environment to enable all people to be mutually supportive in all functions of life and to develop their maximum potential.¹ It is suggested that only 16% of health outcomes are determined by the quality and availability of health care; and the social and economic determinants of health, including where people live play a more significant role.²

This goes beyond the quality of physical structures in the urban environment or the space inside a home. It is about understanding neighbourhood conditions and the availability and quality of other determinants of health, such as employment, healthy food, childcare, schools, transport and recreation space. We know geographic disparities in health, which often fall along lines of ethnicity and socioeconomic status, are growing and can exist even between people living in adjacent neighbourhoods.³ Health professionals and urban development practitioners therefore have an important role to play to ensure the practices and processes governing the design and development of our urban environment are inclusive and equitable for all and ultimately contribute to improved population health.

A call to action: interrogate power and analyse privilege to create and sustain healthy communities

The scale of current and potential inequalities in the urban environment demands a revolution of purpose and accountability. The challenges we face in building and sustaining healthy and equitable communities demand new forms of thinking, problem solving, governance, and decision making. Most importantly, it requires that we learn the skills of interrogating power and analysing privilege. 

Whether resources do, or do not, flow to communities is a direct product of both individual and institutional power. Power is defined as the ability to direct laws, policies, and investment that shape people’s lives. Privilege is the accumulation of benefits of special rights. Both power and privilege have been extracted and hoarded, consciously or not, by certain groups at the expense of others based on social categorisations including, but not limited to, class, ethnicity, religion, physical ability, and gender.^4,5,6

We call on health professionals, planners, public servants, developers, financiers, and engineers – in fact, all practitioners working at the intersection of health and the built environment – to shift their normal course of business towards adopting practices that recognise privilege and cede power. This requires pushing against conscious and unconscious practices and the societal beliefs and norms that marginalise, exclude and perpetuate inequity. We charge this community of practitioners to dismantle the structures, systems and practices that reinforce inequity. Even with best intentions, data-driven interventions, and evidence-based improvements, we will inadvertently perpetuate inequities and widen disparities if we are not conscious of our own power and the power structures within which we work.

We know that power and privilege can be complex and sometimes overwhelming concepts, but we can and must engage with them. We have proposed steps below for health professionals, policy makers and urban development practitioners and other stakeholders to begin the journey. We make this call to action to fundamentally shift the way we plan, build, program, advocate, and legislate our communities to ensure the health and quality of life for all. While it may seem a daunting task to connect this aspirational call to on-the-ground practice, we urge that this not be a reason for inaction since “professional silence in the face of social injustice is wrong.”⁷

 

Steps for examining power and privilege in support of healthy and inclusive communities

1. Create and/or seek out “Brave Spaces” to explore the role of power in your work

Confronting power and its role in our work begins by creating “Brave Spaces”. Brave spaces are intentional environments and settings that facilitate the courageous, uncomfortable, and honest exploration of social categorisations such as physical ability, race, ethnicity, class, and gender identity and the privilege or marginalisation that is extended to individuals based on these categorisations. 

Brave spaces are created and maintained by a transparent commitment to practices that allow difference and celebrate new forms of action and strategy. You create brave spaces when you:

• Speak your truth and listen deeply to the truth that others speak
• Learn the truth about historical trauma and accept its impact on yourself and those you serve
• Understand and honour your own experience and the experiences of others in equal measure
• Bring your vulnerability to the table and create the space for others to be vulnerable
• Invite yourself to make mistakes and be generous with the mistakes of others 
• Acknowledge the limits of expertise – an expert frame can shut down learning 
• Hold yourself and others accountable to practices that affirm diversity and inclusion

2. Understand the role that power plays in your current work

Within the brave space created above, consider as an urban developer, policy maker or health professional, a program, policy initiative, or other effort that you are working on to improve the physical, social and economic conditions of communities and ask the following:

• What is the problem I’m trying to solve?
• What decisions, policies, and practices have historically contributed to the problem? What is the root cause of the problem?
• What is the formal and informal, the visible and invisible, decision-making or governance structure shaping the problem?
• What would it look like if the problem is solved?
• Who consistently benefits from the problem not being solved?
• Who consistently suffers from the problem not being solved?
• Are the people most affected by this problem represented in the decision-making process?
• In seeking data, what sources of data are considered legitimate, and by whom? Are there credible sources that are being suppressed or dismissed because the power structure has deemed them unreliable?

3. Analyse and Challenge Privilege

Privilege is the accumulation of benefits of special rights, often over time, to a certain group. Think about your work and your role in your community of practice and ask:

• What are the areas of life in which you hold privilege?
• Despite your work to change outcomes, what remains the same?
• Despite changes in the wider professional or sociopolitical context, what remains the same?
• What are the cycles, actions, and processes we repeat regardless of the outcome?
• Does a new protocol or procedure worsen or help existing disparities?

Privilege often shows itself when the status quo is challenged. When such a challenge is presented, and conflict ensues, ask yourself:

• Who or what is blamed for the conflict in the narrative describing the challenge?
• Who or what is sacrificed to resolve the conflict?
• Are there any patterns that you can observe?
• If the problem was “resolved”, did the group or process return to the norm or status quo? 
• Who or what restores things to what they were before the conflict?

 

Ascala Sisk, Deputy Director, Center for Community Investment, Lincoln Institute of Land Policy; Odetta MacLeish-White, Managing Director, TransFormation Alliance; Vedette Gavin, Principle, Verge Impact Partners; Tamika Butler, Director, Equity and Inclusion and Director of CA Planning, Toole Design; Liz Ogbu, Founder + Principal, Studio O; Veronica O. Davis, P.E., Managing Partner, Nspiregreen LLC; Nupur Chaudhury, Program Officer, New York State Health Foundation, Urbanist in Residence, University of Orange; Sharon Roerty, Senior Program Officer, Robert Wood Johnson Foundation; Hanaa Hamdi, Director of Health Impact Investment Strategies and Partnerships, New Jersey Community Capital; Kelly Worden, Director, Health Research, U.S. Green Building Council; Noxolo Kabane, Deputy Director, Western Cape Department of Human Settlements; Shelly Poticha, Managing Director, Natural Resources Defense Council; and Hedzer Pathuis, Strategic Project Manager, City of Utrecht.

Acknowledgements: We would like to thank the all sixty-five fellows who participated in Salzburg Global Seminar Session 595: Building Healthy, Equitable Communities: The Role of Inclusive Urban Development and Investment, whose vast and varied experience helped to shape our call to action. We’d also like to thank the Salzburg Global Seminar and the Robert Wood Johnson Foundation for creating the space to make connections and cultivate bold ideas.

 

1. World Health Organization “Health Promotion Glossary” (2006) www.who.int/healthpromotion/about/HPR%20Gossary%201998.pdf
2. Hood, C. M., K. P. Gennuso, G. R. Swain, and B. B. Catlin. 2016. County health rankings: Relationships between determinant factors and health outcomes. American Journal of Preventive Medicine 50(2):129-135.
3. Woolf, Steven and Braveman, Paula. 2011. Where Health Disparities Begin: The Role of Social and Economic Determinants – and Why Current Policies May Make Matter Worse. Health Affairs, Vol. 30, No. 10: Agenda for Fighting Disparities, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2011.0685
4. Project Change’s “The Power of Words” Originally produced for Project Change Lessons Learned II, also included in A Community Builder’s Toolkit – both produced by Project Change and The Center for Assessment and Policy Development with some modification Racial Equity Tools.org. https://www.racialequitytools.org/glossary 
5. McIntosh, Peggy. White Privilege: Unpacking the Invisible Knapsack. Wellesley Centers for Women, Seeking Educational Equity and Diversity. https://www.cuesta.edu/about/documents/vpaa-docs/1_Peggy_McIntosh_White_Privilege.pdf 
6. Hobbs, Joseph. White Privilege in Health Care: Following Recognition with Action. Ann Fam Med. 2018 May; 16(3): 197-198. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5951245/ 
7. Berwick, Donald M., MD, MPP. Moral Choices for Today’s Physicians, JAMA. 2017; 318(21):2081-2082. https://jamanetwork.com/journals/jama/issue/318/21 
8. Arao, Brian, Clemens, Kristi. From Safe Spaces to Brave Spaces, a new way to frame dialogue and diversity and social justice. 2013, Stylus Publishing, LLC.  https://www.gvsu.edu/cms4/asset/843249C9-B1E5-BD47-A25EDBC68363B726/from-safe-spaces-to-brave-spaces.pdf