Back to Basics Partnering with Survivors and Communities to Promote Health Equity at the Intersections of Sexual and Intimate Partner Violence From National Resource Center on Domestic Violence & National Sexual Violence Resource Center ©2021 National Resource Center on Domestic Violence & National Sexual Violence Resource Center. All rights reserved. This publication was supported by the Grant or Cooperative Agreement Number 6 NUF2CE002510-02-04, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services. Table of Contents Acknowledgements 2 Introduction 3 Health Equity is Our Work 4 Sexual & Intimate Partner Violence are Interconnected 5 COVID & Health Inequity 8 Stories of Survivors at the Intersections 11 Building Capacity for Health Equity Work 15 Partnering for Health Equity 17 Moving Forward: A Call to Action 21 Actualizing Your Commitment to Health Equity 24 Conclusion 26 Additional Resources 27 References 28 Acknowledgements We would like to thank the following authors for their contributions to this document. National Resource Center on Domestic Violence writing team: Patty Branco, Senior Technical Assistance and Resource Specialist Casey Keene, Director of Programs and Prevention Ivonne Ortiz, Director of Training and Technical Assistance Arlene Vassell, Vice President of Programs, Prevention & Social Change Breckan Winters, Program Specialist National Sexual Violence Resource Center writing team: Jennifer Grove, Prevention Director Mo Lewis, Prevention Specialist Louie Marven, Training Specialist We are grateful to the following individuals who provided their time and wisdom in reviewing and offering recommendations for this document: Timike Boyd Jones, M.S., Primary Prevention Program Specialist, Indiana Coalition Against Domestic Violence Morgan D. Dewey, Digital Communications Specialist, National Resource Center on Domestic Violence Darin J. Dorsey, Founding Director, Baobab Abolitionist Coalition Candace Girod, Health Scientist/Program Evaluation and Translation Team, National Center for Injury Prevention and Control (NCIPC), Centers for Disease Control and Prevention (CDC) Annika Leonard, Founder/CEO, Priceless Incite LLC Jacqueline Miller, Founder/CEO, Healthy Actions Intervening Responsibly (H.A.I.R.) Tonjie Reese, Founder/CEO, eleven24 Marci Taitt-Lamar, Co-Director of the LGBTQ Institute on Intimate Partner Violence, National Resource Center on Domestic Violence Kari Thatcher, Prevention and Evaluation Specialist, North Carolina Coalition Against Domestic If Black women were free, it would mean that everyone else would have to be free since our freedom would necessitate the destruction of all the systems of oppression. – Combahee River Collective (as cited in Taylor, 2020) Introduction For many, the COVID-19 pandemic has been an eye-opening and life-changing experience. It has also changed the way we work and live in society. It has magnified systemic racial and gender inequities, urging us to do our movement work in bold and innovative ways. We, as advocates and activists dedicated to ending gender-based violence, must work together for health equity and racial justice. It is clearer than ever that this is key to fostering healthy and thriving communities. This paper makes connections between health equity and our work to prevent sexual and intimate partner violence. It centers the stories of survivors at the intersections of systemic racism, violence, and oppression. It explores ways to build both individual and organizational capacity to address health inequity. And, it offers a call to action for those ready to commit to health equity in their gender-based violence prevention work. We know that our efforts will benefit everyone when we center those who are most harmed. That is why we focus on the lived experiences and well-being of Black women in this document. This paper is the collaborative work of a multi-racial group of writers and reviewers. Black women were involved in envisioning, drafting, and editing this paper. We believe change-makers at the local, state, and national levels can benefit from this information. Health Equity is Our Work Health is a basic human right and need. It refers to a person’s physical, mental, and social well-being; it’s not merely the absence of disease or illness (World Health Organization [WHO], n.d.a). In our efforts to promote safety and well-being for all, we strive for health equity. That is, a society where every person, no matter who they are, has a chance to be as healthy as they want to be (Centers for Disease Control and Prevention [CDC], 2021a). While health equality may also be a common goal, it is different from health equity in an important way. Equality means giving everyone the same access to resources and opportunities. Equity takes social injustice into account. This helps us understand that individuals and communities have different needs. These needs are based on lived experiences of oppression and/or privilege. Different needs call for different levels of support and resources. While health equality may also be a common goal, it is different from health equity in an important way. Equality means giving everyone the same access to resources and opportunities. Equity takes social injustice into account. To achieve health equity, we must create healthy environments for people to live, learn, work, love, worship, play, and age. These conditions are the social determinants of health (SDOH) (CDC, 2021c; Solar & Irwin, 2010). They help us understand how our environments impact our health and why some communities have better access to the things that promote good health. The World Health Organization created a framework (Solar & Irwin, 2010, p. 6) for the social determinants of health that outlines the mechanisms and pathways contributing to unequal exposure, unequal vulnerability, and unequal health outcomes. These differences are often referred to as health inequities. Health inequities across the SDOH are avoidable, unjust, and actionable. Key social determinants of health include: Health Care Access and Quality: Understanding and having access to things like primary care, health insurance, and health information. Education Access and Quality: A person’s level of education from early childhood and beyond, and their ability to read and process information. Social and Community Context: Includes community connectedness,1 civic participation, workplace conditions, and incarceration. (For an explanation of connectedness, see page 3 of Promoting Individual, Family, and Community Connectedness to Prevent Suicidal Behavior [CDC, n.d.].) Economic Stability: Experiences of poverty, job and food security, and housing stability. Neighborhood and Built Environment: A person’s access to quality housing; reliable ways to get around; and healthy food, air, and water. It also takes into account neighborhood crime and violence occurring in the community. In our work to prevent gender-based violence, we share a vision for a world where individuals, families, and communities thrive. To realize this vision, we must create social and physical environments that provide every person the opportunities for good health and positive well-being. This means that health equity is our work. Sexual & Intimate Partner Violence are Interconnected All forms of violence are interconnected. This includes sexual violence, intimate partner violence, and other kinds of harm, such as child and elder abuse. They share many of the same root causes, based in power and control. Additionally, survivors of one kind of violence are likely to experience other forms of violence, and sometimes these harms are caused by the same person (Finkelhor et al., 2011). A recent study found that 16.4% of women in the U.S. experience contact sexual violence2 at the hands of an intimate partner in their lifetime (Smith et al., 2017). There are a variety of factors in our lives that allow violence to happen. These factors exist at the society, community, relationship, and individual levels. Shared risk and protective factors (Lewis, 2019) are the conditions at each level that make someone more or less likely to use or experience violence. Some examples of risk factors are rigid gender roles, social isolation, and lack of economic opportunities. Protective factors can make a person less likely to use or experience violence. They also increase resilience, or a person’s ability to navigate hardship. Examples of protective factors include caring relationships, access to mental health and substance use services, and more. (For more examples of risk and protective factors, see the “Shared Risk and Protective Factors Across Multiple Forms of Violence” chart on pages 8-9 of Connecting the Dots: An Overview of the Links Among Multiple Forms of Violence [Wilkins et al., 2014].) Risk and protective factors (NSVRC, 2019) are connected to the social determinants of health. Creating healthy environments for people to live, learn, work, and play in prevents violence and builds resilience. People are more likely to thrive when they have access to quality health care, economic stability, and a healthy environment. A key factor driving health inequity in the United States is racism (CDC, 2021b). The Centers for Disease Control and Prevention has recognized its impact on the health of our entire nation. They name racism as a serious threat to the public’s health (CDC, 2021b). Sexual and intimate partner violence harm Black women at alarming rates. This happens within a context of individual and systemic racism. During their lifetime: 45.1% of Black women experience sexual violence, physical violence, and/or stalking by an intimate partner (Smith et al., 2017) 35.5% of Black women experience some form of sexual violence (Smith et al., 2017) 21.2% of Black women report being raped (Breiding et al., 2014) Black women are more likely to die by intimate partner homicide than women of other races/ethnicities (Petrosky et al., 2017; Violence Policy Center [VPC], 2020)3 53% of Black trans people have been sexually assaulted at some point in their lifetimes. Non-binary people with “female” on their original birth certificates are more likely to have been sexually assaulted in their lifetimes (James et al., 2017). Black trans women are more than twice as likely to experience violence by a family member because they were transgender as non-binary people and trans men (James et al., 2017). “Throughout much of U.S. history, the rape of Black women was widespread and institutionalized” (West, 2013). During slavery and the Jim Crow Era (History.com Editors, 2021a), it was legal to rape or sexually assault Black women (Brown, 2021). This violence included forcing Black women to reproduce. In the racist logic of the slave economy, this meant creating more Black people who enslavers would claim as property (Prather et al., 2018). To this day, stereotypes about Black women have been used to justify the lack of social support after rape (West & Johnson, 2013). Black women and girls are often seen as hypersexualized and denied victimhood (Kendall, 2020). As such, they are subject to sexual violence by various sources — from family members to intimate partners to police officers.4 Often, Black women tell no one about the abuse they experience. This is a direct result of historical trauma, racism, and oppression. Many cultural considerations can also hinder healing and help-seeking for Black women survivors. These include expectations of strong Black womanhood and efforts to protect Black men, among other factors (Ujima, 2018).5 It is critical to also note Black women’s resilience and resistance throughout history through current times. Black women have actively resisted the violence inflicted upon them in many ways. For example, some enslaved women aborted forced pregnancies as an act of resistance (Prather et al., 2018). They refused their exploitation for the purposes of birthing more children into slavery for the economic benefit of white slave owners. Black women have a long, rich history of leading and organizing against violence and oppression — across the U.S. and abroad. COVID & Health Inequity Health inequities in the United States have deep roots in white supremacy and colonialism. This is true from the transatlantic slave trade to the Jim Crow Era (History.com Editors, 2021a) and through to current times. This history of racism (Joyner & Lee, 2020) and anti-Blackness (Ross, 2020) has ensured negative health outcomes for Black people. Anti-Blackness is a form of racism that is specifically damaging for Black communities. It describes society’s general inability to recognize Black humanity (Morris, 2020; Ross, 2020). This white supremacist and colonialist legacy has denied Black women (including trans women) the right to govern their own bodies. It has denied them adequate access to quality health care and reproductive rights (Brown, 2021). It has also resulted in a disproportionate impact of sexual and intimate partner violence on Black women (Petrosky et al., 2017; Smith et al., 2017). The COVID-19 pandemic has magnified systemic racial and gender inequities (National Institute for Health Care Management [NIHCM], 2021). These include inequities within the U.S. health care system. Some claim that COVID-19 is the “great equalizer” or that “we are all in this together” (Galasso, 2020). But the lived experiences of Black, Indigenous, and People of Color (BIPOC) and the research data contradict this. The reality is that BIPOC are at increased risk of getting sick and dying from COVID-19. Black communities, in particular, are suffering at disproportionate levels. Black Americans are dying of COVID-19 at three times the rate (Pilkington, 2020) of white people.6 Essence Magazine (2020) found that one in four Black women know someone who has died from COVID-19. Also, 44% of Black women know someone who has contracted the coronavirus. Disproportionate vaccination distribution makes matters worse. At the date of this writing, Black Americans are receiving COVID-19 vaccinations at far lower rates than white Americans (Recht & Weber, 2021). The journalist Linda Villarosa (2020) addressed this topic on The Daily. She outlined three main reasons Black Americans are dying from COVID-19 at disproportionate rates: 1) Proximity to the virus. Black Americans are more likely to hold essential and frontline jobs. These jobs tend to come with more exposure to the virus. 2) Discrimination in the health care system. Racism influences the kind of medical care delivered to Black patients (Villarosa, 2018). 3) Underlying health conditions. Because of health inequity, Black Americans are more likely to have the underlying conditions that can make COVID-19 worse. These include heart disease, diabetes, stroke, and asthma. a) The environment drives this disproportionate rate of underlying health conditions. For example, Black people are more likely to live in polluted areas.7 (See also, “How your zip code affects your health as a Black woman” by Jen Laskey [n.d.]). b) A second factor is weathering (Demby, 2018), or accelerated aging. Racism takes a physical toll on Black people’s bodies. This toll leaves Black people more vulnerable to all kinds of illness. These factors reveal long-standing inequities impacting Black people and other people of color. COVID-19 lays bare the preexisting conditions of intersectional (AAPF, n.d.a) and structural inequity in our society. The African American Policy Forum (AAPF) examines these issues in the webinars: Under the Blacklight: The Intersectional Vulnerabilities that COVID Lays Bare (AAPF, 2020) When Misogynoir is a Pre-Existing Condition: Black Women’s Health Through the Twin Pandemics (AAPF, 2021) Dr. Camara Jones also discusses the links between racism and COVID-19 in a related webinar. She explains how barriers to health equity include white supremacy ideology and a narrow focus on the individual. Solutions, in turn, include finding power in our shared humanity and collective action. Epidemics of Injustice: Social Change in Practice — Crisis at the Nexus of Racism and COVID-19 (Jones, 2021) COVID-19 has also harmed survivors of sexual violence and intimate partner violence. We know that factors that add stress, isolation, and financial strain can further compromise survivors’ safety. This pandemic has elements of all three (National Domestic Violence Hotline [NDVH], 2020). Common quarantine orders have included shelter-in-place, stay-at-home, and social distancing. These necessary measures have put domestic violence survivors at risk of abuse (NDVH, 2020; National Task Force to End Sexual & Domestic Violence [NTF], 2020; YWCA, 2020). The pandemic has also increased risk for sexual assault and coercion. Survivors facing housing insecurity have reported coercion and harassment by landlords (DOJ, 2021). Those who face harassment at work may endure the abuse in silence for fear of losing their jobs (Asian Pacific Institute on Gender-Based Violence [APIGBV], 2020). Sexual violence increases during public health crises and disasters. (Sexual assaults increased by 45% during Hurricane Katrina and the post-disaster recovery [Klein, 2012].) So, we have reason to believe that it is increasing during the COVID-19 crisis as well. Food service workers have reported a dramatic increase in sexual harassment during the pandemic. More than 40% of workers reported a noticeable change in the frequency of unwanted sexualized comments from customers. Comments often cited include: “Take off your mask so I know how much to tip you.” Many comments are even more sexually explicit, such as, “Pull that mask down so I can see if I want to take you home later” (One Fair Wage, 2020). Survivors of color, in particular, have been dramatically harmed by racism, economic inequity, and COVID-19. According to the report, Measuring the Economic Impact of COVID-19 on Survivors of Color (Ruíz et al., 2020): Survivors of color are at greater risk of facing food and housing insecurity during the pandemic. Financial insecurity is greatest among Black and Brown women survivors. Survivors who lack financial resources during the pandemic are at greater risk of going back to someone who harms them. Experiencing sexual coercion by a landlord leads to a greater risk of food and housing insecurity. Survivors of color are at greater risk than white survivors of halting their education during the pandemic. This is especially true for those who have experienced financial abuse. Black and Brown women survivors are at the greatest risk of being unable to pay their bills due to the financial impacts of COVID-19. After an illness or a medical condition lands us in a doctor’s office or a hospital, our work, our focus, should be healing. Not fighting the systemic mistreatment that threatens our very lives. - Ericka Stallings (2018), The Article that Could Help Save Black Women’s Lives Stories of Survivors at the Intersections The stories of Black women suffering and dying at the intersections of systemic racism, violence, and oppression (Virginia Sexual & Domestic Violence Action Alliance, n.d.b) in the U.S. are countless and widespread. This section includes some of those stories, which contain accounts of racial and sexual violence. The racist belief that Black people do not experience pain like white people do has been a part of this history. And it has influenced the quality of medical care that Black women receive. Black patients receive inadequate treatment for pain not only compared with white patients but also relative to World Health Organization guidelines (Villarosa, 2018). In the 19th century, Dr. James Marion Sims performed experiments on enslaved Black women without anesthesia (Holland, 2018; Zhang, 2018). He is credited as the “father of modern gynecology.” His use of enslaved Black bodies for medical tests falls into a long history of anti-Blackness in the medical field. See also the Tuskegee syphilis experiment (Nix, 2020) and the Henrietta Lacks case (Skloot, 2018). Forced sterilizations and hysterectomies have also been used as a tool to control the Black population within the U.S. (Brown, 2021). All of these experiments reflect a long history of Black women being denied victimhood, personal agency, and control over their own bodies. And this is a direct link to enslavement (History.com Editors, 2021b). This context still impacts the quality of health care that Black women receive today. Inadequate health care results in high rates of maternal mortality. Black women are two to three times more likely to die from pregnancy-related causes than white women (Petersen et al., 2019). It also leads to high rates of infant mortality and other health issues facing Black women (Brown, 2021; Martin & Montagne, 2017; Prather et al., 2018; Villarosa, 2018). We must center these stories in our work. We must acknowledge the additional and overwhelming burden on women of color — especially Black women — who fight for not only their health, but their very right to it. Stories from women of color shed light on racial disparities in health care (Grady & Edgar, 2001). Common inequities include the effects of stereotyping, economic discrimination, and lack of respect. Other common experiences include language barriers and improper diagnosis or treatment. This is especially true for Black women. In the stories below, Susan and Chaniece were physicians. Shalon spent her career investigating public health disparities. Sadly, their deaths illustrate how the health care system fails to listen to Black women’s health concerns — even when they are health experts. Being part of the medical and public health systems did not protect or save their lives. We understand that these stories are painful to read. You may find it easier to skim the stories listed here or skip ahead to the next section, Building Capacity for Health Equity Work. For white readers, we encourage you to read these stories in their entirety. The intention of this section is to illustrate the lived experiences of Black women in this country and to center these women as the experts on their own experiences. We honor the Black women whose stories are featured here, as well as the Black women who will read or choose not to read these stories. As you center Black women in your health equity efforts, keep in mind that this work is not only about addressing trauma and oppression. It is also about acknowledging and celebrating the fullness of Black womanhood. It includes honoring Black joy, creativity, resilience, and liberation. We must commit to the safekeeping and defense of Black humanity. Chaniece died just two days after childbirth from preventable pregnancy complications. She was a 30-year-old Indianapolis physician (Burke, 2020). Danielle dealt with excruciating knee pain for three months when her doctor failed to treat her injury, minimized her pain, and denied her medication. An MRI later revealed her torn ACL among other serious damage (Glass, n.d.). Janine is a survivor of child sexual abuse and domestic violence whose last baby did not survive childbirth. She reflected, “with every child, with every labor, I have just been made to feel like an animal — at the mercy of whoever is in the room” (Tanis et al., 2019, p. 27). ‘Black people have thicker skin than Whites’ is a belief held by many White Americans. Such stereotypes lead to underestimating the pain level of Black people. At times, White Americans will fail to even recognize that a person of color is in pain and needs help. (Azab, 2020) Kayla’s roommate called 911 for help escorting Kayla to a medical facility during a mental health crisis. Instead of getting the care she needed, Kayla was killed by police who attempted to arrest her on a warrant for someone else with the name she was given at birth. Police referred to her using anti-trans slurs and failed to properly monitor her vital signs or administer life-saving treatment (AAPF, 2015). Kelli is a survivor of domestic violence who was incarcerated after killing her abuser in self-defense. While she was in prison, doctors sterilized Kelli against her will by performing a hysterectomy without her consent during a routine surgery to remove ovarian cysts (Walsh, 2020). Kim suffered severe complications after a liver transplant. She was ignored by doctors and repeatedly denied pain medication in the many days leading up to a corrective, although preventable, additional surgical procedure (Hylton, 2018). Marie’s doctor refused to carry out her pregnancy prevention choice. She is a 25-year-old survivor of human trafficking and domestic violence (Tanis et al., 2019, p. 21). Pamela suffered a miscarriage at 20 weeks pregnant while incarcerated. For weeks, her repeated requests for medical care were brushed aside and subject to lengthy approval processes that delayed her access to treatment. She ultimately miscarried while shackled to her bed, while two male officers watched (American Civil Liberties Union [ACLU], 2021). Shalon died of complications related to high blood pressure three weeks after giving birth, and just hours after returning from an appointment with her doctor. She was a 36-year-old epidemiologist for the Centers for Disease Control and Prevention and a lieutenant commander in the U.S. Public Health Service (Chalhoub & Rimar, 2018). Sza Sza, a Jamaican trans woman and asylum seeker in the United States, was denied information about COVID-19 while detained by ICE. Her requests for access to hand sanitizer and antibacterial soap to try to stay healthy were also denied. She reflected, “I just want something antibacterial, so we don’t get sick. Before I spoke up, they hadn’t given us any demonstration on how to even wash our hands properly” (Castro, 2020). There’s really no such thing as the ‘voiceless.’ There are only the deliberately silenced, or the preferably unheard. – Arundhati Roy (2005, p. 30) Susan was a 52-year-old physician in Indiana. She died of COVID-19 after her symptoms and pain were ignored, and her pleas for pain medication were denied (Nirappil, 2020). Terika died of leukemia due to complications from an unsuccessful bone marrow transplant. They were unable to find her an ethnically matched donor (Gift of Life, 2018; Meraji & Demby, 2021) It’s racism — not race — that affects Black women’s health. – Dr. Kiarra King (Glass, n.d.) The National Resource Center for Reaching Victims wanted to learn about two key aspects of the COVID-19 health crisis. One was its impact on underserved victims of crime. The other was how to equip crime victim service providers to respond to those needs. To achieve this, they held a series of listening sessions with survivors. Along with partner organizations, they put their findings in COVID-19 Survivor Impact Briefs (National Resource Center for Reaching Victims, n.d.). These briefs summarize the issues and strategies that emerged from the sessions. Building Capacity for Health Equity Work Health equity is our work — our collective work across fields and movements. If we imagine a world built on health equity, we can clearly and directly connect this vision to our goals. It is a world in which all people have access to quality health care, education, and economic stability. It is a world that values social connectedness and prioritizes neighborhood health and safety. It is a world where everyone has access to healthy food, clean water, and quality air to breathe. This world promotes the protective factors that allow people to thrive free from violence and oppression. In fact, efforts to achieve health equity advance various forms of liberation. This is because health equity intersects with racial, gender, economic, and environmental justice (Virginia Sexual & Domestic Violence Action Alliance, n.d.a). At its core, the work of our movement to end gender-based violence is to dismantle systems of oppression. What is needed to advance health equity, thus, draws on advocates’ core competencies. Advocates can help bring health equity to social structures and systems, and we have work to do in our organizations. We have to advance health equity there first. Agencies have caused harm and created barriers to equity — for both advocates and survivors. The movement has perpetuated anti-Blackness and practices of white supremacy culture (Okun, 2021). This shows up in many ways (Futures Without Violence, 2019). For example, white women hoard power, ally with systems that oppress Black women, and perpetuate a single story (Adichie, 2009;9 Nnawulezi & Sullivan, 2014; Nnawulezi et al., 2020). We must be willing to take a hard and honest look at these areas. This inward-facing work is necessary to build our capacity to impact larger systems change. See the call to action from Arlene Vassell (2020), HERE and there: An open letter to white women in the movement to end gender-based violence. In their framework for health care organizations to improve health equity, the Institute for Healthcare Improvement (2020) outlines five key strategies. These strategies can be applied to any organization that wants to build capacity to center health equity as a priority in their work. 1. Make health equity a strategic priority: Does your organizational vision, mission, and goals explicitly articulate your commitment to equity? 2. Build infrastructure to support health equity: Is language around advancing equity built into job descriptions and workplans? Is this expertise and perspective represented and valued on your board, staff, and volunteers? 3. Address multiple determinants of health: Do your agency practices make space for the intersectional nature of survivors’ lives? Does your messaging and programming reflect your understanding of the ways multiple forms of oppression interconnect? 4. Eliminate racism and other forms of oppression: Is your organization doing the internal work necessary toward becoming an anti-racist organization? How are you actualizing your commitment to racial justice? Are you actively accountable to marginalized communities in your area? 5. Partner with the community to improve health equity: What movements, organizations, and activist groups can you learn from, support, and collaborate with to center those most impacted? Systems advocacy seeks to change institutional practices that are unfair, unjust, or inequitable. Thoughtful efforts center the needs and experiences of survivors, especially those most marginalized. These efforts are accountable to survivors facing historic and present-day inequities and injustice (Branco et al., 2020). Systems advocacy focuses on policy change at all levels. It is necessary to bring about the health equity we wish to see. Transformational collaborations that promote equity require a commitment to understand structural racism, admit how what we design is influenced by it, and acknowledge how each of us, our work, and our organizations is shaped by it. - Z. Ruby White Starr in Transformational Collaboration: Considerations to Apply a Racial Equity Lens (2020, p. 5) Partnering for Health Equity Existing community partnerships have changed in the COVID-19 pandemic. Unable to gather in person, partners rely on videoconferencing more than ever before. This change may be especially notable in local communities, where partnerships are most often in person. For some, increased videoconferencing options may have removed barriers to partnerships. For others, the digital divide and other aspects of work and life in the pandemic may add new challenges. In many ways, the pandemic has revealed a reliance on old and ineffective ways of working. Meaningful partnerships are intentional, fair, and beneficial to everyone involved. All parties share in the responsibility, and also the resources and rewards. To work towards health equity means investing in transformational collaborations. These recognize and work to dismantle anti-Blackness and other types of racism. They focus on breaking down the structures that perpetuate oppression. We cannot do true health equity work without applying a racial justice lens. This means centering the voices of those most marginalized and oppressed. It also means following their lead — at every step in the process. This requires intention and ongoing accountability to Black, Indigenous, and People of Color. From the beginning, women of color have envisioned a movement based on this approach. But white-led mainstream programs have discarded this vision. This has resulted in silencing and discrediting the leadership of BIPOC organizers (Aldridge et al., 2013; Mcduff et al., 1977/2020). Collaborations with Black- and POC-led heath-centered initiatives are essential to advancing health equity. Advocates in the movement to end gender-based violence have much to learn from this work. For years, white women have primarily occupied the most powerful leadership roles in the movement. Mainstream anti-violence organizations must enter into these partnerships with respect, humility, and openness. They must be willing to offer support in ways that may be unfamiliar. Often, anti-violence agencies will bring an unwritten “menu” of offerings to new collaborations. Instead, they must be willing to “order off the menu,” or discard the menu altogether. This is the only way to invest in transformational collaborations. And those who hold power must be willing to give up power and offer more than they take. Explore the work of these Black-led organizations working to advance health equity: The Afiya Center (https://www.theafiyacenter.org) works “to serve Black women and girls by transforming their relationship with their sexual and reproductive health through addressing the consequences of reproduction oppression.” Black Feminist Future (https://www.blackfeministfuture.org) “is an initiative informed by the legacy of Black feminist organizing, grounded in the current pulse of movements and located at the emergent need to amplify the power of black feminist leaders, organizations, and movements for the 21st century.” Black Mamas Matter Alliance (https://blackmamasmatter.org/ )“is a Black women-led cross-sectoral alliance. We center Black mamas to advocate, drive research, build power, and shift culture for Black maternal health, rights, and justice.” Black Women’s Blueprint (https://www.blackwomensblueprint.org) “envisions a world where women and girls of African descent are fully empowered and where gender, race, and other disparities are erased.” Black Women’s Health Imperative (https://bwhi.org ) works to “lead the effort to solve the most pressing health issues that affect Black women and girls in the U.S. Through investments in evidence-based strategies, we deliver bold new programs and advocate health-promoting policies.” Black Women for Wellness (https://www.bwwla.org) “is committed to the health and well-being of Black women and girls through health education, empowerment and advocacy.” Girls for Gender Equity (https://www.ggenyc.org) “is an intergenerational grassroots organization committed to the physical, psychological, social, and economic development of girls and women.” Liberation Medicine School (https://www.liberationmedicine.org) is “a Black Trans-led movement to build an autonomous healthcare system that supports Afro-LGBTQI+ healing & liberation.” Mothering Justice (https://motheringjustice.org) “empower[s] a well-organized group of mothers that can engage fellow mothers and law makers around a variety of issues that affect working families.” Sister Love, Inc. (https://www.sisterlove.org) works “to eradicate the adverse impact of HIV, sexual and reproductive health rights and justice challenges impacting women and their families through education, prevention, support, research and human rights advocacy in the United States and around the world.” Sister Reach (https://www.sisterreach.org) works “to empower our base to lead healthy lives, raise healthy families, and live in healthy and sustainable communities by using a four-pronged strategy of education, policy and advocacy, culture change and harm reduction.” Sister Song (https://www.sistersong.net)“is a Southern based, national membership organization; our purpose is to build an effective network of individuals and organizations to improve institutional policies and systems that impact the reproductive lives of marginalized communities.” S.O.U.L. Sisters (https://soulsistersleadership.org) “mobilize[s] systems-involved girls, femmes, and TGNC youth of color — Black, Brown, and Indigenous — to interrupt cycles of state violence, poverty, and oppression.” This organizational list is not exhaustive, but it is a starting point. Networks of groups working to advance health equity are thriving in many communities across the country. These networks are places to learn about the needs, gaps, and strengths specific to your community. They offer opportunities to show up in ways that will make a great impact. On a national level, the National Collaborative for Health Equity organizes a Truth, Racial Healing and Transformation initiative (n.d.). This initiative brings together several partners invested in doing this work through a racial justice lens. Connect with those doing racial equity work in your community to find out how you can join these networks. Use your organizational resources to help advance their goals toward collective liberation. Collective liberation acknowledges that all peoples’ struggles are connected. It rejects the white supremacist value of individualism that divides us. It means we must work together because “Until we are all free, we are none of us free” (Lazarus, 1883). Building meaningful partnerships requires humility and time. Establishing and taking care of a relationship and getting to know people and communities is an ongoing commitment. This work can be affected by staff turnover, an inability to coordinate schedules, and other barriers. Tensions like the pressure to produce something and show progress toward a stated goal can get in the way. Have upfront conversations about how you will handle conflict when it comes up. Talk about how you’ll be transparent, how you’ll make changes when needed, and even how you’ll end the partnership if the time comes to do so. These are key strategies for strong partnerships that last. If you have come here to help me you are wasting your time, but if you have come because your liberation is bound up with mine, then let us work together. – Lilla Watson, 1985 (as cited in Leonen, 2004) We do this work from the heart because we live it … We laugh and cry about it. We are in a fight to save ourselves, our mothers, our aunts, our daughters, our sisters. Equity for Black women is equity for everyone. - Jada Shirriel, CEO of Healthy Start Pittsburgh (as cited in Idia, 2020) Moving Forward: A Call to Action In our work to prevent gender-based violence, we share a vision. This vision is a world where individuals, families, and communities thrive. In this world, everyone has the opportunity for optimal health and well-being. We can create that world when we center those most impacted (Centering Voices Workgroup, 2018) in our violence prevention work. The action steps below offer concrete ways to actualize this commitment. Listen to Black women, including trans women. Respectful listening includes hearing multiple voices and compensating those who share. It means following up with those you have heard to ensure their input is honored. The path to health equity begins with making this commitment. We must make it at every level of decision-making around issues that impact health and well-being. If you are not Black, start by listening. Your Black coworkers and colleagues have been sharing their stories, lived experiences, and wisdom for many decades. Their voices and leadership in this movement are important and should be acknowledged. Prioritize Black women who are most marginalized. Amplify and center the voices and lived experiences of Black women who are most oppressed. These include Black women who are trans, incarcerated and undocumented, sex workers, and those who are Deaf or living with HIV or disabilities. As U.S. Rep. Ayanna Pressley has said, “those closest to the pain should be closest to the power.” Commit to dismantling white supremacy. White supremacy is embedded in American culture. As a result, we internalize both racial superiority and oppression. We must understand the ways in which white supremacy culture (Okun, 2021) shows up in ourselves and our organizations. Dismantling it is a life-long journey. Connect with your community. We need to recognize and respect the history and traditions of the community. We must listen to its stories and learn from its members in any health equity intervention (American Public Health Association [APHA], 2015). We must be led by those whose experiences offer unique insight to the systems that cause harm to their communities. Community buy-in and ownership are key ingredients for your health equity approach. Your approach should include ongoing community leadership at every stage. This will help your work be sustainable and have impact. Build trust; be flexible and open to new ways of doing things; and know when to lead, step aside, or follow. Appreciate the value in this process alone. Incorporate a health equity lens. Before engaging in outward-facing initiatives, organizations must assess and build their internal capacity. Examine your organizational policies and practices (Minnesota Department of Health, n.d.). Notice how they shape conditions which may lead to health inequities. Cultural and community values and priorities should shape and inform interventions. Explore changes you can make to ensure universal access. Address the variety of survivors’ intersecting needs with regard to their health and well-being. Universal access means that all people have access to needed health services. It also means that the use of these services does not expose the person to financial hardship. Universal health coverage is a priority goal of the World Health Organization (WHO, n.d.b). Invest tangible resources in respectful health equity partnerships. Black women-led and community-based organizations working on health equity are essential. When a mutually beneficial partnership is formed, invest financial resources to support collaboration that moves health equity work forward. Compensate Black women for their time, expertise, leadership, and storytelling. Engage respectfully, with consideration for the increasing demands on Black women’s time and energy. Advance health equity policies. Advocate for policies that support the health and well-being of Black women and girls. These can include affordable health care, access to reproductive health services, gender-affirming health care for trans people, and tax credits. They can also include wage equity, environmental justice, prison abolition, and voting rights. Connect with advocates, activists, and organizations advancing a health equity policy agenda. Review Black Women’s Health Imperative’s (BWHI) National Health Policy Agenda 2020-2021 (Blount et al., 2020). Then consider how your organization can support the agenda in a meaningful way. Hold systems accountable. Systems must be accountable first to the communities they serve. Health care systems, including public health institutions, have a responsibility to deliver quality, comprehensive, patient-centered, trauma-informed care. Health care systems should put in place anti-Blackness training for medical professionals. They should ensure that medical personnel listen to and address Black patients’ concerns. They should hire more Black women medical professionals. They should monitor and report how white patients under their care fare in comparison to how their Black patients fare. (See the Greensboro Health Disparities Collaborative [GHDC, n.d.] approach.) And they should create new ways for Black communities to access care in response to lessons learned (Brown, 2021) The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. – Ghebreyesus, 2017 Actualizing Your Commitment to Health Equity everyone the same access to resources and opportunities. Equity takes social injustice into account. With this in mind, how might you partner with communities using a health equity approach? Start by understanding the history of policies that have led to health inequities. Let’s take a look at an example. Imagine that people in your city struggle with the impacts of climate change. What connections do you need to understand? Climate change, racism, and gender-based violence are connected. Structural and institutional racism places BIPOC women at the center of environmental injustices. Women’s bodies and livelihoods are often at risk as a result of climate change. Across the world, most people displaced by climate change are women of color (Halton, 2018). Women who are displaced are at an increased risk for gender-based violence. This includes domestic and sexual violence, child marriage, human trafficking, and more (González-Ramírez, 2018; Harvey, 2020; United Nations High Commissioner for Refugees [UNHCR], 2020). Climate change also has a direct impact on resource scarcity. Heatwaves, droughts, and floods can devastate local economies. In many parts of the world, women are already disadvantaged and lack land rights and legal rights (Harvey, 2020). Scarcity of water, firewood, and other resources puts women at increased danger of exploitation and violence. A report from the New York Times (NYT), How Decades of Racist Housing Policy Left Neighborhoods Sweltering (Plumer & Popovich, 2020), makes some important connections. It describes the history of redlining in the United States. Redlining involved the federal government denying mortgages in Black and immigrant neighborhoods. The federal government at this time built and subsidized housing for white families, giving those in middle and lower classes a chance to build generational wealth. Redlining kept Black families out of these programs, denying Black families the chance to build generational wealth. It had devastating consequences for the people in these neighborhoods at the time. These consequences snowballed into further consequences through today. Redlined (Gross, 2017) neighborhoods feel these consequences across the country. The report focuses on the case of Richmond, Virginia. It shows maps of redlined Black neighborhoods in the 1930s. The neighborhoods correspond with hotter temperatures today. The redlined neighborhoods have suffered a cycle of disinvestment. The residents in these neighborhoods have lower incomes. They are less likely to own their homes. They do not have many trees or green space, and they do have lots of concrete surfaces. The neighborhoods have hotter temperatures and higher rates of heat-related ambulance calls. Parents there travel a longer distance to find a shaded park for children to play. Residents have expressed feeling zapped of energy by the end of the day because of the intense heat. These neighborhoods remain Black and Brown. The non-redlined neighborhoods benefited from the investments directed their way. Residents have more wealth and are more likely to own their homes. They aren’t immune to all the negative impacts of climate change. But they have more trees providing shade and cooler temperatures. The people there breathe easier and live longer, with lower rates of chronic diseases including asthma. These neighborhoods remain white. Residents in the non-redlined neighborhoods used their wealth and power for more investment. They have more tree-lined sidewalks and parks. They avoid having highways put through their neighborhoods. Today, neighborhood groups want to bring green space to the redlined neighborhoods. They’re looking for strategies that don’t bring further harm through gentrification and displacement. (They’re focused on equity.) All these disparities came from a racist policy. They contribute to health inequities in Black and Brown communities. Addressing these disparities is our collective work as a movement to end gender-based violence. As COVID-19 deepens health inequity, you can promote health equity by partnering to address the impacts of climate change. This can build community support and connectedness and neighborhood collectiveness. This is just one example of how advocates and activists working to end gender-based violence can partner with communities and follow the leadership of those most impacted to promote health equity. It is in collectivities that we find reservoirs of hope and optimism. - Angela Y. Davis, Freedom Is a Constant Struggle (2016) Conclusion In our work to prevent gender-based violence, we share a vision for a world where individuals, families, and communities thrive. This vision cannot and will not come to be without health equity. In the wake of the COVID-19 pandemic, Black communities are suffering at disproportionate levels. This deepening disparity is a call to action. We must work together to center health equity and racial justice in our work. Doing so requires bold new approaches that follow the lead of those most impacted. It requires meaningful partnerships across fields and movements. It requires dismantling systems and structures that harm Black women and building new ones that honor and nurture them. Because when Black women have the opportunity to be as healthy as they want to be, every person will thrive. 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The Atlantic. https://www.theatlantic.com/health/archive/2018/04/j-marion-sims/558248 1Community connectedness refers to the nature and quality of engagement among community members, including individuals, families, neighborhoods, groups, organizations, institutions, and social networks (i.e., schools, cultural-based organizations, faith communities, social media). It involves the relationships people have with each other as well as their level of engagement with the broader community. In connected communities, members gain a sense of belonging, purpose, and mattering from the experience of both deriving value from and adding value to their community. Stronger connections increase a person’s sense of hope and self-worth and the ability to cope adaptively in the face of adversity. As a result, community connectedness is a protective factor that enhances well-being, fosters resilience, and promotes prevention. A connected community is where people build relationships, develop strong social networks, and thrive. 2Contact sexual violence (CDC, 2020) includes rape, being made to penetrate someone else, sexual coercion, and/or unwanted sexual contact. 3The killing of Black women and girls by the police is also a common reality. But we rarely hear their names or stories in the media. #SayHerName is a campaign by the African American Policy Forum (n.d.b). It brings awareness to the often-invisible names and stories of Black women and girls who have been victimized by racist police violence. The campaign also aims to provide support to their families. 4Sexual violence by police officers is a significant problem facing Black women. But the issue is often invisible within discussions about police brutality. Invisible No More (n.d.) has a searchable database of incidents of police violence against women of color. It includes information on both trans and non-trans women of color. See also, Invisible No More: Police Violence Against Black Women and Women of Color by Andrea Ritchie (2017). 5For more information, see Coffee and Conversation — When Black Women Seek Help: Addressing the Systems and Intersections of Violence in Black Women Survivors’ Lives by Ujima: The National Center on Violence Against Women in the Black Community (2020). 6The pandemic and its death toll have hurt Black communities on many levels. One of such ways is by disrupting traditional Black grieving practices (Peterson, 2020). Social distancing has changed centuries-old rituals like New Orleans’ jazz funerals. The documentary Death Is Our Business (Olive, 2021) examines how COVID-19 has rocked Black mourning rituals in that city. 7Black-white residential segregation is a major source of health inequity for African Americans. This segregation is the result of individual and systemic racism. It includes public policies designed to disenfranchise Black people (Quick and Kahlenberg, 2019). Residential segregation is inseparable from environmental racism, meaning that Black communities face greater harms from environmental factors (Berkovitz, 2020). For example, Black neighborhoods have lower property values. This means that land in those areas is cheaper for factories to buy, leading to greater pollution. In turn, pollution and industrial land use keep property values low. This prevents Black communities from building wealth and power through property ownership. And the cycle continues. 8Chimamanda Adichie was called out for making transphobic comments, and has since apologized. Adichie’s remarks are her own and not the beliefs of NRCDV or NSVRC. Single stories are incomplete, potentially damaging understandings of other people. For example, Black advocates are often “single-storied” in our movement only as doers rather than thinkers, leaders, and visionaries.