There are dozens of “Diversity,” “Diversity and Inclusion,” or “Diversity, Equity, and Inclusion” officer jobs opening up across the medical field in response to calls for real solutions to medical inequity, in stark contrast to increasing criticism of diversity and inclusion-centered frameworks for addressing structural inequities. I can relate to thinking that a DEI office would provide a good solution to structural health inequities. I have designed and held some of these jobs myself, and I hold one right now, in fact, whose job description I wrote. I also think the criticisms are good ones, and that ultimately this surge in the Diversity Industry is the wrong move. Let’s talk about why.
Diversity
“Diversity” pretends that the problem is that certain people didn’t show up, when they were kept out. Sociologist Sarah Mayorga says that “diversity” usually means “a seat at the table”—without talking about why people were absent in the first place. She argues that conversations about systemic privilege are swept under the rug, and a new dynamic emerges that centers being the “good type of white person” and “having” diversity. She says that diversity as a commodity becomes a thing that privileged leaders can have rather than something that’s about relationships with other people. Ultimately, she argues, diversity frameworks co-opt calls for consciousness and creates structures in which unconsciousness is renewed and previous unjust power structures (she focuses on whiteness specifically) can be re-inscribed and re-ignored. Mayorga emphasizes equity and anti-racism as an alternative to commodified diversity. She captures the deep need to interrogate the values that led to Black absence in the first place.
Another problem with the “diversity” framework is that it only comes up as a problem. Madhavi Bhasin points out that rushed problem-solving can result in companies investing in initiatives that don’t work, which can hurt their image more than not doing anything because it makes their efforts look insincere. Bhasin encourages initiatives that celebrate difference and educate employees (like teaching about Stonewall during Pride month). Isn’t that just the feel-good stuff Mayorga says we should be avoiding? Not necessarily. There’s nothing inherently un-liberatory about feeling good, and feeling good is an important part of what makes a team actually work, which is why it’s important to make sure everyone can get their needs met in order for a celebration to feel good. In my experience, the work involves a mix of hard fights and great dance parties. Sometimes on the same day.
Bhasin also emphasizes the importance of connecting with people at the level of their specific experiences and thinking flexibly about how structural power relations impact users and their patients and workers and their families; for instance, gender equity efforts have to include dads being empowered to show up for kids, or parenting labor will be displaced from dads, most often onto moms. During the pandemic, women have been pushed out of the workforce to an unprecedented degree. Women were already paid less than men and are often structurally expected to take on care work. As families have needed to adjust to school closures and inaccessible childcare, moms have been left holding the bag. If we think about how our policies might contribute to or confront this pattern, we need to be thinking both about moms who work for our org and moms who co-parent with our org’s employees.
Another potential problem with the diversity framework is that public shows of commitment to diversity can actually make people take the underlying issues less seriously. Rachel Thomas gives a fantastic breakdown of some research on “diversity branding” like diversity statements and awards. She shows that these cues about culture make people at the top of hierarchies dramatically less likely to believe that there could be a problem. In case comparisons, even a single sentence about diversity awards made experimental participants less likely to believe that discrimination had occurred in otherwise-identical cases. Thomas also points out that justice has to be treated like any other business goals: it has to be part of the basic fabric of the organization, and it has to be done well to have good effects.
Inclusion
“Inclusion” reaffirms that some people always belonged, and some people are new. Because of a longstanding culture of “last in, first out” in US businesses, this means that the recently-included have inherently precarious positions. In fact, Kimberlé Williams Crenshaw’s foundational legal paper about intersectionality centrally described a 1976 case in which five Black women sued GM over its seniority policy. The women asserted that because seniority was only available to people who had not been previously excluded from the company in the first place (GM didn’t hire Black women until 1964), seniority was not a neutral basis on which to determine layoffs in the early 1970s. The company’s defense was that there were white women and Black men in the company, so Black women could not claim to be discriminated against on the basis of gender or race. Adopting an “inclusion” framework sets a low ceiling on what could be accomplished and what the organization views as desirable.
Naomi Day describes “diversity” and “inclusion” as buzzwords that mask the realities of unequal and unfair practices. She addresses the implication that “inclusion” sets up an “us versus them” mentality and raises questions—who is doing the including, and who needs to be included? Who gets to decide which people to let in? Day emphasizes that the ultimate goal is to remove systemic barriers within the organization, but in the meantime, be ready to offer additional supports based on what people need.
Physicist Geraldine Cochran says that people string “diversity,” “inclusion,” and “equity” together without thinking about what they mean or how they relate to one another. If we can’t pay attention to these three words, she worries, how are developing nuanced strategic choices about how to actually achieve our goals? Her piece has some fantastic case studies of how to mess up the recipe and as a bonus she links to Chanda Prescod-Weinstein’s syllabus on decolonizing science.
Kẏra argues that centering “diversity and inclusion” posits a fake problem—i.e. sameness—to avoid acknowledging the real problem, oppression. She posits that the opposite of inclusion—something that can be given or taken away again—is liberation.
The Diversity & Inclusion Industry
The Diversity & Inclusion industry has been going strong for thirty years. And that has critics like Eliza Romero concerned. Romero talks about 2-hour seminars to teach white people behave around people of color, noting that it is ridiculous to require people of color to attend. These trainings are extremely common, but they don’t have a particularly salutary effect and sometimes they make things worse.
A lot of people are happy to sell you a brief seminar anyway. And that has some people raising their eyebrows. And it’s easy to see why. If they’ve done any research into which approaches to their work are most effective, they must know that the answer is “we have no idea, probably it doesn’t do much though.” And if they haven’t done any research into which approaches to their work are more effective, well, that might be worse.
Or maybe they know that this is not an effective approach but it’s the only thing they’re allowed to do. Nadia Owusu and Kay Martinez talk about diversity officers being boxed in, shut out, and sometimes fired altogether for actually addressing the issues they were hired to address. Owusu says that equity work is an ongoing, daily practice and commitment that can’t ultimately be outsourced.
In my current role, brief trainings are a very small part of my overall strategy. Sometimes there’s a specific conceptual confusion or a desire to grow skills in a particular area that is well suited to a brief lecture or workshop, but a need for information or understanding is rarely the problem and should rarely be the solution.
What should we have instead?
Equity
An equity specialist is a demolitions expert who is empowered to bring live explosives into work every day. Because you cannot build without clearing away the old structures. It SUCKS to hear that you have a crack in your foundation, but it still has to come out if you want a solid house. Obviously, you want to have a close relationship and ensure that you’ve got someone who will use their explosives effectively and appropriately, but if there’s never any booms, you should worry, because every foundation in this neighborhood is cracked.
Dignity
Ben Hecht talks about his experience at Living Cities as they approached racial equity. He talks about the need to toss out the model of sticking equity on over top of the structure that existed before, Velcro-style. “To build a new, more inclusive culture, we first needed to be able to see the norms, values, and practices in our institutions that advantage white people and ways of working, to the exclusion and oppression of all others.” Hecht talks about needing to flip the logic of “fitting in” on its head and centering dignity in work.
Specificity
Be specific about the injustices and exclusions you mean to confront, how you’re doing it, and how it’s going. Be prepared to answer questions like “is this actually working?” How will you know if you’re doing a good job? Will it be measured in the presence, absence, or content of qualitative feedback? Is there a retestable measurement in place to track progress?
Advancing Equity & Inclusion: A Guide for Municipalities has a ton of solid resources and strategies. But it says inclusion! I know, it’s fine. It’s from 2015 and they were using the language that Ottawa would connect with. Some of the other language they use also won’t vibe with US uses, but their strategies are solid.
Set actionable, specific goals, concretely measure how you’re doing, and share that information. What will you do if your goals aren’t met? Have a plan that is action-oriented and stays engaged. A question I ask a lot is “would we be willing to make this figure public?” If you don’t want to, you’re already in a situation where you hope users don’t find out about something. Fix that thing.
ALL leaders should have equity-related tasks that they are genuinely responsible for. Your staff equity expert should act as an internal consultant, a partner, and a librarian, but the work of equity has to be structurally shared or it will definitely get forgotten about.
If things get lean, keep the equity work. Equity work is often structured as an extra thing, a cherry on top of work that’s already good-enough without it. When crisis strikes, equity work is the first to go. And that’s part of how inequity in healthcare is created in the first place. When a crunch happens, your first question should be “who is most impacted by this crunch?” Don’t cut any services to them. They have enough on their plate.
Any time you adopt a new policy, have an explicit conversation around who will be differentially impacted by that policy. Incorporate that information in the plan. Decide whether you’d be comfortable publishing your logic about the policy considering this information. If not, keep scheming.
Accountability
The last step, and the one that is most often overlooked, is accountability. You need to set policies, and you also need to uphold them. You need to make commitments to equity, and then you need to measure how you’re doing and dynamically adjust your strategy. When I talk to leaders about vaccine distribution and COVID-19 inequity my question is “how will you know if the vaccine is being administered equitably?” Often, a lot of data about equity either never gets analyzed or gets analyzed but not used.
One of the ways that Officer of Diversity roles break down is it is really two roles. The explicit role has to do with cultivating the environment of the business for workers and/or users, but to do this effectively often means needing to challenge leadership. Because of the power dynamics within leadership-diversity staff relationships, this can require emotional gymnastics in which the diversity officer needs to be straightforward enough to get things done but cautious enough not to hurt anyone’s feelings. There are a few ways to account for this in your plan.
Ultimately, the culture needs to include skills for handling uncomfortable feedback and conversations about equity should be commonplace and routine. I absolutely love Kim Scott’s Radical Candor: Be a Kick-Ass Boss Without Losing Your Humanity as a tool for developing these skills and as a test case for recognizing where professional norms in other organizations reinforce structural oppression. This book is about crafting cultures of feedback generally, but this is just one of many types of important feedback that helps the team grow together. This is also an important theme in Atul Gawande’s The Checklist Manifesto: How to Get Things Right; Gawande puts checklists as the explicit centerpiece of his argument, but a keen reader will see that an equally necessary part of his argument is de-hierarchizing leadership enough to allow lower-ranking workers space to hold decision-makers accountable. Have a plan, get used to sharing responsibility for it, value information about what’s going wrong. Kim Scott and Atul Gawande’s tools here are especially helpful in thinking through how this approach can and should transform all of the work, and not exist in a closet somewhere. It’s not a coincidence that these practices are necessary to addressing problems that are explicitly about hierarchy, but they also improve effectiveness and team culture beyond the scope of macropolitical power dynamics.
One way to structurally support the equity champion is to break the role of culture transformation and the role of product or service transformation into two separate jobs. This is already present a lot of the time when there’s an external consultant: the person who wanted the consultant and went to bat to bring them in probably isn’t the CEO. That person will automatically back their consultant, and it leaves the consultant more space to work. One option is to keep that energy by having your equity specialist report to someone whose responsibility for the project explicitly includes advocacy for the project and its specialist. The report should be someone who is totally committed to the value of equity and they should have the structural and practical power to push back against anybody in the organization if needed. Another option is to hire more than one specialist and explicitly construct a plan around handling these two aspects of the work effectively. In this case, when the person whose primary job is product or service transformation runs into culture problems, they have a teammate to refer those issues to so they can keep working, and there isn’t as much tension between prioritizing internal versus external changes. The person they report to should still be prepared to back their play when they need to disagree with big bosses.
Shame Resilience
One of the hardest things about medical ethics is that clinicians are often trained to imagine ourselves as (a) good triumphing over evil, heroic badasses who are staving off illness and ignorance and even death itself, and (b) objective and rational thinkers. The superhero identity helps us cope with exploitative and abusive internships, horrifically long hours, secondary trauma, and exposure to terrifying pandemics, environmental disaster, workplace violence, and (for marginalized clinicians) the additional stresses of marginalization at school and work. The expert identity helps us cope with feelings of uncertainty and powerlessness, especially as we become increasingly specialized (and thus increasingly aware of the massive cloud of medical knowledge we will never master) and as the business of medicine increasingly strips away the humanity from the work.
Part of the reason these organizing identities are SO important is because sometimes, these positive frameworks for who we are and why we’re doing the work are all we have to hold onto. Clinicians are at incredibly high risk of suicidality, substance use, compassion fatigue, and burnout. Part of that is because the way clinical education is set up (particularly but not only for physicians), we’re systematically conditioned to feel like we’re not keeping up and definitely not good enough. This ties in with a major function of white supremacist culture, and it requires the construction of defenses like the superhero identity. But when that superhero identity is the only thing between us and despair, we will fight anybody who threatens it.
And that sets us up, frankly, to kill people.
While I love its secondary argument about the need to shift responsibility structure, Atul Gawande’s The Checklist Manifesto centrally explores how difficult it is to get surgeons to use checklists even though they save patients’ lives, and it’s hard because checklists threaten a surgeon’s sense of competency. Doctors were extremely resistant to handwashing between patient exams because they felt that it implied they were dirty and impugned their gentlemanly status. This also creates a need for epistemic hierarchy—I’m the expert and thus I know more than you—that can overwhelm the “rational and objective” clinician’s willingness to tell the truth. Patients with chronic and rare conditions and patients who are members of marginalized groups frequently neglected in med school curriculum often know more than their doctors about their conditions, because they routinely have to educate their doctors on how to treat them. But this inverts the epistemic hierarchy and that’s a big problem for a superhero expert. A study of doctors who had treated trans patients found that doctors perceived their trans patients’ knowledge about trans health to make them difficult patients, and even described reflexively telling patients that their information was wrong even if they actually didn’t know whether it was accurate. I’m struggling to find this citation this morning so I’m going to have to link that later.
Pandemic management has much the same problem. For decades, there have been explicit recommendations to create equity-centered plans for rationing healthcare in the case of a respiratory viral pandemic, and now that it’s here, those plans still don’t exist, because sitting down and thinking about who to let die is not very heroic. It feels awful. It feels helpless and depressing. So we didn’t do it, and now decisions about who to let die are being made on the fly, without guidance, by exhausted and overworked and traumatized people who have spent the last year hoping they won’t accidentally kill their kids or their parents or their spouse by going to work every day. The result is not equity.
Another place this comes up is that moment when you’ve been working SO hard and pouring SO MUCH into equity work and someone says that you’re obviously not even trying. It can be totally deflating, or even enraging. Is nothing ever good enough? Why can’t people appreciate that you’ve been doing your best? Shame says there’s good people and bad people, and maybe you’re bad people. When shame is activated, it feels like someone is saying we’re bad, worthless, totally awful, or worse, that we actually are. When someone is holding shame and power together, it can trigger some truly regrettable outcomes.
The default shame management technique is avoidance—we can avoid situations that feel threatening and avoid people who have brought up shame for us or who might do so. This is a primary mechanism by which equity leaders get pushed back out of organizations. Active shame management strategies and bringing in new ways to think about harm, error, accountability, and ourselves as clinicians and leaders can give us more effective tools for upholding our patients’ and students’ dignity—and our own.
Conclusion
People who have worked in the DEI industry increasingly agree that this framework isn’t sufficient to address the underlying causes of inequity in institutions. DEI posts can sometimes result in positive changes, but they often fall short of what’s needed and that can degrade trust both between the organization and the public and between the organization and the DEI officer. It’s time for a new approach that takes seriously that oppression is baked into the institutions themselves. An expert position may still be a good investment, but putting that capable expert into a DEI office is unlikely to produce the results we all need.
I prefer to structure my work around public sharing of ideas because the siloing of intellectual labor within expensive and exclusionary universities seems like a bad plan. You can support this work by commenting, sharing with friends, offering critiques, and sharing your own ideas in public spaces. If you would like to support my work financially, you can visit ko-fi.com/han.
Han Koehle 