Disrupt Bias and Build Equity in Fatality Review Systems (and all systems!)
John is an 8-year old Black boy who died due to drowning. At the time of the incident, John was swimming with his summer camp at a public pool. He had just reached the height minimum to be in the “big kid” area. John was last seen alive 5 minutes before he was discovered under the water. He was wearing a yellow camp bracelet which signified he could be in the big kid area. John had minimal exposure to swimming lessons what was comfortable in the water.
His county Child Fatality Review Board met to assess what happened and what might have prevented John’s death. Comments ranged from asking why his parents hadn’t gotten him into swimming lessons to thinking about how racist policies like redlining limited his access to such opportunities. This hypothetical case served as the through line for an important session on Identifying Preventability: Using Multiple Frames, at the 2023 North Carolina Child Fatality Prevention System Summit, co-sponsored by the Jordan Institute for Families. Presenters Abby Collier and Sasha Mintz, from the National Center for Fatality Review & Prevention, engaged participants around how to build equity into the system of Child Fatality Reviews.
Abby and Sasha highlighted how widening racial and geographical disparities in child deaths are a cause for concern. Looking at CDC data from 2018-2021, they presented the following statistics:
- Black children die from injury at 4x the rate of Asian children and 2x the rate of white children
- American Indian or Alaska Native children die from injury at 3x the rate of Asian children and 1.5x the rate of white children
- Children in rural communities die from injury at 2x the rate of children in urban communities
So what do we do to address these disparities? The presenters talked through the spectrum of prevention strategies: primary (prior to the incident), secondary (at the time of the incident), and tertiary (response to the incident). Primary prevention strategies focus on preventing death from occurring and are focused on systems and policies. Secondary prevention strategies work to identify risk and mitigate that risk with interventions, in this example with inclusive access to swimming lessons or by providing pool fencing. At the tertiary level strategies include determining if emergency responders were available and if there is access to needed medical care or medical intervention.
They used Dr. Camara Phyllis Jones’ “Cliff of Good Health” (watch an overview here) to demonstrate how something can happen, typically outside of our control, that drops us off the cliff of good health, highlighting how these events can be structural in nature, like a lack of health insurance or amenities for physical activity. A layered intervention strategy is optimal, which, might include fencing such that one never falls over the cliff, safety net policies that keep the fall from becoming worse, to medical care that helps us return to good health as soon as possible after the fall. But our systems are inequitable, we don’t all have equal access to these levels of prevention – disparities in access to care, differences in opportunity – because of socioeconomic factors including systems of privilege and oppression. These include racism, ableism, sexism, transphobia, etc. And these systems all intersect to compound risk. This requires us to think about how we advance equity in our systems.
To drive home how racism influences this system, and John’s drowning, Sasha and Abby shared the example of redlining, in which the US government created maps outlining in red where Black residents lived and were thus deemed risky for investment and homeownership (view Durham’s redlining map overlaid with present-day geography ). This gives us an understanding of why Black children are more likely to drown – historically, white children had greater access to swimming pools, desegregation led to white residents moving to neighborhoods with private facilities, while public facilities were not maintained or closed down completely, giving Black children less access to pools and swimming lessons.
They concluded with a set of action steps:
- Recognize and challenge our biases – be empathetic, see differences, be an ally (with permission – seek permission to intervene)
- Recruit and retain diverse team members – does your team reflect your community?
- Have community agreements – listen, let all speak, co-create
- Consider neighborhood and community context – Systems are often the root cause constraining individual choice, ask how the environment might have impeded health and well-being in your system
- Identify strengths, not just deficits
- Engage with families and communities – practice authentic engagement, don’t tokenize
- Make findings and recommendations at multiple levels
Doing work to promote equity is a journey, taking continual work, and not a destination.
While our colleagues from the NCFRP used an example from their system in their presentation, we can all learn from this format and we can all tailor content to our own systems, be it early childhood education or the criminal legal system. Check out another example here that traces two children’s trajectories across systems.
View the full talk here.