The Smallest Losers 

Milbank State Leadership Network
Focus Area:
State Health Policy Leadership
Health Equity

Representation can make the difference between life or death. Just as “life, liberty, and the pursuit of happiness” was foundational to the arguments and the architecture of our democracy, so was the concept of representation. And these values have been the essence of our political battles ever since.

I am a pediatrician. During residency, I spent long nights on call with my colleagues admitting fragile newborns to the neonatal intensive care unit (NICU). These units provide expert care to nearly 400,000 premature babies in the United States each year, or 10.5% of live births in the United States in 2021. That rate of preterm births — which occur when infants are born before 37 weeks of pregnancy have been completed — is higher in states like mine, nearly 11.3% of births in Tennessee. That is approximately 360 kindergarten classrooms in our state alone. Some of these infants, who can fit in the palm of your hand, cling to life with the tiniest pieces of plastic linked delicately to the smallest pieces of tubing connected to ventilators that precisely fill their lungs with whispers of air. Meanwhile fluids measured by the milliliter carry nutrition into the umbilical vein because all the others are too small for an IV.

Given their increased risk for long-term neurologic disabilities, learning delays, lung disease, and rates of metabolic disorders like diabetes, the short and long term stakes are high for babies in the NICU. But what is immediately apparent when working in these units is that Black infants are more likely to be born prematurely — with a rate nearly 50% higher than the rate for White infants in the United States. And most tragically, Black infants are 2.4 times more likely and American Indian/Alaska Natives nearly 2 times more likely than White infants to die before their first birthday. A leading cause of those deaths is prematurity.

Prematurity and infant mortality are preventable, and health care workforce diversity – in which people from different groups participate at all levels of the organization — is critical to that work. Racial representation in the health care workforce has a direct impact on health outcomes. When Black infants are cared for by a Black provider, the mortality they suffer is cut in half. Furthermore, preventing and treating chronic conditions like high blood pressure and diabetes in women of childbearing age significantly reduces the likelihood of prematurity. Research shows that adults who receive their care from providers of the same race, gender, and language have better outcomes for conditions such as hypertension.

Despite the evidence for improved health outcomes with diverse teams, racial representation in the health care workplace is both woefully inadequate and increasingly under attack. Over the last three years, what began as questioning critical race theory grew into mischaracterization and villainization of diversity, equity, and inclusion (DEI) work. The work of belonging and celebrating the strength we gain from different backgrounds and perspectives has now become a false threat. State after state has chosen to vilify, defund and even prohibit DEI work. This ultimately comes at a cost, including the lives of the most vulnerable babies in our communities. Decreasing the opportunity for people of color to attend higher education and health professions schools results in decreased representation in the health care workforce. Limiting the attention that an employer can give to the racial representation of teams as they are hiring likewise decreases representation in the workforce. Removing inclusive culture practices in schools and the workplace decreases retention of people of color. This “triple threat” to education, hiring, and retention poses an existential threat to our values. There is no “life, liberty, and the pursuit of happiness” for people of color or for White individuals without representation, particularly in the health care workforce.

Without attention to representation in the health care workforce, health disparities in the land of opportunity will worsen. So, in our current legal and ethical context, what are health policy and health care leaders to do?

  1. Reclaim the words. Diversity is not “woke” or leftist; it is fundamentally American. It is representation. Diversity is necessary for economic liberty — freedom from the economic traps of poor educational systems and employment opportunities. The estimated economic burden of racial and ethnic health disparities in the United States has been estimated to be over $420B due to excess medical care expenditures, lost labor market productivity, and premature death. Diversity is necessary for ethical health outcomes from the very moment life begins. While some states are attacking DEI initiatives in workplaces and schoolrooms, others are recognizing strengths in differences. At a recent business breakfast in Nashville, Tennessee, Governor Bill Lee asserted that “difference is not a platform for demonization.”
  2. Advance diverse representation in your own workplace. Diverse perspectives make for better policy as people from different backgrounds and races and ethnicities consider how to address problems together. Diversifying teams with new hires and intentional retention makes for a better team and for better outcomes in the clinic and the community. Recognize that this can feel like a threat to groups already represented, and commit to work through and past that.
  3. Minimize barriers to education. Invest in historically Black colleges and universities (HBCUs), as well as community colleges and the educational supports needed for all higher education opportunities such as student housing, uniforms, books, and childcare. Colleges around the country are re-thinking strategies to truly expand access to higher education by broadening their recruitment efforts, offering additional supports, and changing decades of other policies that created barriers to educational attainment.
  4. Create a workplace culture within state government and state legislatures where differences in backgrounds, race, and opinions are respected, valued, and promoted. States like Georgia welcomed the most diverse representations to their legislatures ever this year. Many state governments are looking to inclusive employment practices as a solution to workforce shortages. Alaska created the Workforce Matters Task Force within the Governor’s Council on Disabilities and Special Education. Illinois established the Office of Equity within the governor’s office.
  5. Commit to representation in decisions. “Nothing for us without us,” as the motto goes. Look around the room when decisions are being made and continually ask who is not at the table. Tennessee has maintained a weekly open meeting structure in its Health Disparities Task Force as an open mic for community members across the state to hear about and weigh in on the work of state government.

As legislators develop campaign materials for rallies and as policymakers think about what will attract the next headline, we are tempted to back into the corners of the political boxing ring with people who think like us. But given that our society is built on the ideals of equality and opportunity, we must think about the infants in the incubators, the parents longing to hold the newest members of their family, and the families that lost the dreams they had for baseball games and graduations. We must back away from the fight. Instead, think about the smallest losers in the battle over diversity and inclusion. Make a way for them with a commitment to representation.