Podcast: A conversation on Radical Inclusion

Erin Rodriguez: Welcome to this conversation about radical inclusion. I’m Erin Rodriguez, Executive Director at Root Cause and Root Cause is a nonprofit consulting group that helps foundations, nonprofits, school districts and public agencies to design, implement and measure strategies that enable more people to achieve lifelong success. My guest speakers today are leading a project about infant mortality in Guilford County, North Carolina, that is using a practice of radical inclusion to engage with the community and include their voices in a strategic planning process to address infant mortality in the county. Jean Workman is the Executive Director of the Guilford County Coalition on Infant Mortality, which is a program of the Guilford County Department of Health and Human Services. And Consuela Greene is a principal consultant at Root Cause. The Guilford County Coalition on Infant Mortality was formed in 1991 as an initiative of the Women’s Health Division of the Guilford County Department of Public Health, with the goal to increase public awareness on infant mortality and to develop strategies to provide for more healthy birth outcomes. The Coalition’s motto is “Creating Futures One Baby at a time.” The 2019 county birth data revealed that Guilford County’s infant mortality rate was 9.3 Per 1,000 births, a nine percent increase from 2018.

This rate is nearly 37% higher than North Carolina’s rate of 6.8 And 66% higher than the national rate of 5.6. 66% of Guilford County infant deaths were African-Americans from all socioeconomic levels, making the infant mortality rate for African-American infants two to six times higher than the rate of white and Hispanic infants. In Guilford County in 2019 the infant mortality rate for black babies was 14.6, while the rate for white babies was 6.6 And 2.3 for Hispanic babies. This preterm birth rate also has persistent racial disparities, with black mothers having the highest preterm birth rate at 13.3 compared to white women at 9.7 And Hispanic women at 8.2. The Coalition identified its need for a collective action strategic plan and sought out Root Cause for support. Together, we are building a strategy that envisions bold goals, developed Collective Action strategies, is radically inclusive, and designs the Coalition in order to address the stark health disparities in birth outcomes and infant mortality in Guilford County, North Carolina. Today, we’re going to share with you some information about what radical inclusion looks like on this project.

Jean and Consuela, thank you so much for having this conversation today. We’re here to talk about radical inclusion. So I guess the best first question is, what is that? What is radical inclusion and why is it important on this project?

Consuela Greene: Erin, that is a really great place to start. When I think about sort of what is radical inclusion and why is it important for the work that Jean and I are doing together in Guilford County with the Coalition, it becomes really important, one to tell you where I first saw it and why I thought it was really applicable to the work that was ahead of us. There was an article that I read some time ago put out by The Equity Lab, and I was drawn to a tag line in the article that kind of made me dig deeper. And then in digging deeper, I found a framework that I think really has some great components that that will serve this work going forward. So the tagline said, racism and inequity are products of design and they can be redesigned. I wholeheartedly believe that. I think so often we feel like that is too daunting. Right. But one of the other premises from The Equity Lab is that they have a framework called the Equity X Design. And one of the core beliefs of the framework is actually sort of that to ‘be seen’. Right. So it’s ‘to see’ ‘be seen’ and to then redesign and reimagine together is the short summary of the framework itself. But I was really drawn to the so the core belief around ‘be seen’ in the tenet around radical inclusion that’s built into this framework. And the framework itself is a practice that really merges both consciousness of racial equity, work with the methodology of design thinking and the things that I’m drawn to in both of those spaces, to see it all in one framework is amazing. But the piece around radical inclusion that’s built into the framework, it’s about being intentional, about bringing diverse stakeholders together, and that means across race, role, gender and socioeconomic status to really not only build relationships to lay the groundwork for community, but to then really build the relationships that are necessary to identify, be clear on what the issues are and really come together to identify solutions and redesign what is possible in a community.

So we had submitted a proposal to do the strategic plan for the Coalition, building off of some common approaches that we’ve used for strategic planning. And the more we started to understand the context, both the history of what the Coalition has done, what it may have not done yet, and even more importantly, the more we dug deeper into the issue of, I’d say, both prenatal or pregnancy, birth and child outcomes. So when we started digging into what that story is, as you said earlier in the overview, what became really clear is that you cannot, as a coalition, a county wide coalition, put a few people in a room and think that you’re going to come up with the right plan, the right solution.

The Coalition has been around for almost 30 years. It’s been working on this issue for as long as it’s been around. A number of other folks in the community are working on this issue. So the one thing we did was take a step back at our approach and really start to think about, well, how will we engage stakeholders even in the strategic planning process. Right. And it needed to be beyond an interview here, a conversation there. And so we pivoted and the pivot to include a radical inclusive approach to engaging stakeholders in the process. That became critically important because Jean was clear at the very beginning. She doesn’t want to keep doing the same thing. And if we’re not really going to address the racial inequities, when you look at these health outcomes, then what are we doing? Right. But to really do that would mean that you’ve got to have different people at the table, people that may not have even known there was a table that existed before.

And the other part of what’s important about that is it becomes critical that you figure out a way for a coalition to actually center the people you’re hoping to help make improvements for and with right. But in order to do that, they have to be at the table when you’re even making meaning of the issue, when you’re figuring out strategies, you can’t bring them to the table later because then they have to either accept the plan that you came up with or you’re always bumping up against, “this plan doesn’t quite align with the needs of the community.” And so the aim of this was to really bring folks together in this phase of planning as the Coalition figures out its path forward and most importantly, how do we do that from planning and understanding the issue to actually designing strategy? We’ll talk a little bit more about what that pivot was. But I think the biggest pieces, we’ve had an opportunity to engage over 90 people within the community and both a combination of discussion series, as well as really integrating a diverse stakeholder convening group for the actual sort of building of a Theory of Change logic model and really helping to shape the strategic plan that’s ahead. So that’s the kind of what is it and why it’s important. But I’d love to turn it over to Jean to share kind of what was resonating for her in that shift.

Jean Workman: I think in the beginning of our process of getting the collective action, strategic plan going in our community, it was vital and important to me with the Coalition to make sure community voices were at the table. And when I say community voices, I mean community members, people who don’t get paid because they’re a professional in the maternal health space to be at the table. But moms and dads and lost parents, families who have experienced infant loss, families who have experienced discrimination in maternal health settings, faith community members to be at the table with us to build out this work. But I only have so many connections in a community, and I’m a white woman in Guilford County. And so my commute, my connections may even be limited from who I wanted to be at the table. And my past work in my career has not always revolved in the maternal health space. And so I loved this idea of radical inclusion as we began to build it out because it is all about being intentional. You may not know the people that need to be there to make the invite. So you identify who does know those people. You build those relationships, create that connection, and then make a personal invitation to those individuals to be there inspiring the vision of why. And then I think it also allowed us to think about who are our stakeholders, who’s important to be there, why is it important for them to be there and to get them to understand the importance of their voice being at the table. And then what I’ve loved about it is, as Consuela said, having over 90 people invited for our stakeholder discussions or 90 people committing to be there for stakeholder discussions and then however many actually came, which I think was close to 80 for the stakeholder discussions, we had at least 10 that were community members, people in the community that identify as parents who aren’t being paid because they work in maternal health spaces and they were actively involved in the conversations. It was beautiful to hear their perspectives and their voice. And then as we’ve convened each of the stakeholder groups to build out the Theory of Change, we’ve identified who’s not at the table each and every time and each and every time we’ve identified who’s not there. I’ve made a concerted effort and invited our working group to have a concerted effort of going to the people not on the list and identifying who could be there and then making that personal invitation, asking them to be a part of it. And as a result I’ve built of rich relationships in the community and really inspired a vision and ignited this flame in a lot of different people for this change in this movement that needs to happen in Guilford County of not doing the same of what we’ve done, not assigning the blame of why we’ve got infant deaths and the disparities in the way that we do in Guilford County, not assigning the blame to the individual anymore and developing one more program that’s going to work to address the individual, but to really work in this movement at systems level change. And that’s been a beautiful piece to this work, and I’m glad to see that it happened.

Erin Rodriguez: I’m curious what had to shift or change in the original plan for the strategic plan to make this happen, is this how you thought you would kick off this work or was this new to you, Jean?

Jean Workman:  Well, I think if I’m quite honest, what had to shift or change to make it happen was COVID-19. A pandemic happened. And rather than the idea that we would be convening or implementing the work kind of in that traditional way, originally we were going to do interviews with about twenty five people that we had identified in the list and call them up and do an interview. Or if it had not been for COVID, we would have done in-person interviews to talk to them about their ideas about infant death in our community and the disparity rates. But COVID had happened and it was, I don’t know, an ‘aha’ moment for us as a working group, a planning group, the brilliance of Consuela reading this article and saying, well, why don’t we just open this up to everyone for stakeholder discussions and let’s invite folks to participate and offer up times that makes it more conducive to anyone’s schedule. So we offered a morning, time and afternoon and the evening timeframe, which then allows for a lot of parents who work who can’t be, because it’s not part of their daytime job, to be able to be at the table to be a part of the conversation. I also think through using virtual platforms like Zoom, it gave some anonymity. People didn’t have to show up and be compared to others and how we are dressed and how we are behaving with one another. You could turn off your camera, and you could speak if you wanted to, where you could remain anonymous and just listen. You could add to the chat, which gave, I think, some equity in voice for individuals for being there. So really and then the more we did it, the more we want to do of it because of the new people that are at the table. I’ll tell you a great example of this, I participated in an event with another organization over the weekend, a town hall group and parents were involved. We were talking about food insecurities and infant mortality. And one of the women, the moms in the group, met me through the Zoom link on Saturday and she reached out to me and we met last night. She wants to be a part of this. She immediately signed up for our stakeholder discussion convening that’s happening tomorrow and she’s very excited and said, use me in any capacity that you can. It’s just become this beautiful piece of opening it up and not to mention she’s got an amazing story to tell about her birthing experience that will be used and amplified later on in a very creative and wonderful, powerful way for our community.

Consuela Greene: And I would say the other shift that became really important, so, you know, the one thing that existed in the original plan was that we were going to create a sort of cross sector, small working group that would really partner with Jean and Root Cause really all along the way, both in designing the planning process, figuring out who in the community we should engage with. And early in that process, we did a sort of stakeholder map exercise and out of that, over one hundred or so folks were identified both in a combination of research and through the working group, really actively participating and thinking about who else, do we know someone at that organization and some of those things. I’d say the working group became a strong part of the team because you have a long list of potential people that might want to be engaged but the actual act of getting the information out, we had a an intentional engagement process where we would send the sort of large distribution list blast, and then we broke up that list of some really important stakeholders and split that among the working group and then they followed up with either an individual phone call or a follow-up of a personal email. And then ever since that first time of reaching out to folks, we’ve started just doing engagement analysis along the way because there are still some key stakeholders that may not have shown up at a convening yet, but we know they’re core to the strategies going forward. And so it’s forced us to flex and how we work. So it’s not just one approach for engagement. One is actually holding these convening and discussion series and then the other includes direct meetings with some other potential core partners and engaging other folks that may not have plugged in to some of the other parts of it as we’re building. So, again, that no one, whether you’re a decision maker, a power broker in terms of funding or individual folks living in the community who have who have gone through this sort of continuum of care and Guilford County and have lots of experiences with the quality or lack thereof, with the ways that the health care and supports that are provided to families help in ways that they sometimes can be barriers or hindrance for families being able to live out their full lives the way that they want to.

And along the way, what also was really interesting, I’d say we were like, oh, we’ll do some discussion series. And then we’re like, OK. And after we did the discussion series, there was so much interest to stay a part of the process that we then blew up our Phase 2 plan where it was going to be, you know, “bring some decision makers to the table for one meeting”, “bring some front line folks to the table for another meeting” to really start thinking about strategies. And now we’re still inviting those same folks that we invited to the discussion series to each and every convening as we’re building the Theory of Change, as we’re figuring out what the big goal is, what’s the impact that the Coalition wants to make and what are the strategies along the way? And you’re seeing some of those same folks that have been consistent from the discussion series throughout. And that still includes a really diverse group of stakeholders. Some core engagement from community members and parents in the community have stayed consistent. And even for this sort of next phase of planning, we keep one evening session open. Sometimes it’s small, but we’re like, we’re still going to do it right. And part of it is, you know, we still think that there’s barriers and there’s other ways that we’re going to have to continue to think about radical inclusion. Language barriers and finding ways along the way to be more inclusive of representation from different cultures and ethnic groups that where English may not be their first language. And how do we adapt for that? That will become important as we start thinking about some of the strategies around community engagement.

But what is what’s been really remarkable about just sort of where we are now is that it allowed for us to really both try it. All right. Try on what would it look like to just decide that there’s no boxes around who should be in the discussion and then out of that, really thinking about how do you keep that going? And then then you can see how it will actually fold into the future plan for the Coalition. One of the emerging core strategies that’s really both come out of this process, but come out of what we’ve been hearing from community is that there’s got to be a critical kind of community engagement, core strategy folded into this. And I can see the ongoing designing of sort of a radical inclusion, radically inclusive approach to the work going forward.

 Erin Rodriguez: I have a lot of curiosity about how those traditional decision makers and power brokers have reacted to this process, are they are they glad to be at the table? Is having so many people hard for them to get used to, given that they’re used to being the primary voices in the room?

Consuela Greene:  I will say and Jean you can definitely fill in the gap on this, I will say we also made it where because there are larger turnouts for our meetings, there’s sort of a full room and then there’s a break-out in each of the meetings where you’re able to kind of break out into smaller groups. And then it allows folks to actually connect with people they never would have connected with outside of this process. And we don’t put a lot of effort in who’s going to be in the breakout room. So it could very well be a community member and a leader of a large agency in the same discussion or an elected official that may have decided to attend. Because the other piece of radical inclusion is that there’s no silos and ideas in some ways, and it allows for leveling the playing field of feedback and perspective is equally valued. There’s no side room for the people whose opinion matters the most, if that makes sense. But the process itself is literally kind of flattening out that process, right, of getting perspective and designing something with the community. I co-lead a breakout room in each of our sessions, and I’ve had doctors that are a part of the conversations that have really valued and welcomed listening to community members perspective of their experience receiving care.

 I’ve heard from folks working in some of the nonprofit social service programs where they’re like, I’m just glad that we’re finally doing it right. And sort of the excitement folks that have been in this work for a long time, seeing some momentum that they haven’t seen in a while. And then there are still some decision makers. And I’d say, we’re also doing this in the middle of COVID and key stakeholders on this issue, our public health officials and leaders from large health care systems. And there’s a lot of competing priorities given the pandemic and some of those things. So we’re doing a concerted effort to keep them up to speed. So everyone that’s on the distribution list, they get notes and updates from what just happened in the meeting and then some targeted reach out conversations, calls and meetings are happening with some other key stakeholders. But I don’t know Jean if you’ve heard direct feedback from folks, I just know that’s what I’ve been experiencing, at least in the groups.

Jean Workman: And I would say I think it’s created that, like you said, equal playing field. People were able to take their title hats off. And so when you’re in that breakout room, when you’re in the larger group, if you don’t know who others are, unless you know who others are. And I think it takes away the trepidation to speak up and out over something. And one of the breakout sessions where a community mom spoke and it was an interesting moment. She was at work. She was in a child care facility with children running about and she kept apologizing that she was so sorry. But it was really important for her to be there that day with us. But she was at work and I kept I wanted to say stop apologizing. The fact that you’re making space for us today is so vital and important. You know, that could never have happened otherwise without this pandemic and being in a virtual space at a meeting. If we had shown up at the convention center to hold these with a grand launch, the food, and people show up dressed to impress– we took that away. And I just think that there’s some incredible beauty in what’s transpired from that with providing equity for those. And, you know, Consuela said, yes, we do need to think about how are we approaching other cultures that may not speak English and having them at the table as well and being more equitable. Just bringing that up today, I wrote it down as an item to think about as we’re moving forward with the work because and that creates an even larger, inclusivity to have at the table.

Erin Rodriguez: Jean, I’m curious of your preconceived ideas? Because as leaders, we go into every project thinking we have some idea of what we’re going to come out with on the other side, keeping those in mind, I’m really curious what the sort of biggest aha or surprise has been for you from the content of these radically inclusive meetings that you’ve been having. What did you learn that you didn’t know ahead of time?

Jean Workman: Well, I think the excitement well, first, first and foremost, it’s validating, I don’t know that I already knew it, but the excitement of folks in our community to be a part of this, what I’m saying is a movement. I’ve had numerous colleagues reach out to me to say thank you for thinking differently, moving the Coalition in a different strategic way to stop doing what we’ve always done and creating a new direction for moving forward that really is bold and a bit confrontational on what needs to happen with tackling structural racism and implicit bias and really naming what something is in our community to tackle. I think that’s been surprising. I think another surprising piece has been hearing from a funder in one of our convenings that data is data, but it’s people that are impacted and wanting to see the people impacted, like paint the picture. And so when we’re thinking about what our bold goal would be or goals, plural goals of reducing infant mortality by a certain percentage, reduce eliminating disparities altogether, reducing preterm birth, reducing low birth weight. While that is important to have an outcome, measurement is also important when we’re naming these goals to put a picture behind it and for the community to see, what does that mean for our community if we make a reduction for the overall health of our community.

I’ve been saying from day one, it’s so important that in Guilford County, North Carolina, I look forward to the day when African-American families can no longer say their babies die at a larger rate, a higher rate than white families. We need to have equity in that, or for any family, it should all be either zero. No infant deaths are occurring, which is very Pollyanna thinking, I believe. But I just think that eliminating that disparity gap is so important and having the validation of the community behind me with that, that I know that that’s fighting off a lot to say that that is so ambitious. Just say that in five years we might eliminate racial disparities with infant deaths. But I think our community deserves that. And then hearing it back from our service providers who have been working in the trenches and see it every day and deal with lost families that have experienced that every day, I think it’s powerful and I think it’s well deserved to do it and have that goal. If we don’t achieve it in five years, we will achieve it. And so making it important.

 Consuela Greene:  And I’d say the addition to that piece, too, is  kind of coming from practitioners, providers, community members saying, yeah, you all might have different people working on this issue for a number of years but no one has been working on the disparity issue. No one has called it out as, “this strategy is directly attached to eliminating the racial disparities.” And that feels new and that feels different. And each time we put language in front of folks there, like, be explicit. So the confirmation of that becomes really important, because then when the work ahead happens, it’s a coalition. The Coalition doesn’t run a lot of direct programming so for this to really happen it’s going to require buy-in and shared ownership of strategies of interventions and approaches of being, systems being more transparent of what’s really happening behind closed doors. Are they able to really hear what they’re learning from the community, say what they’re going to do, where their practices may change, and then the community be able to look and say, hey, let me see how you’re doing, though? Right. And so and what you’ve heard from the community, I say the broader community, everyone that’s come together to think about this work is that that’s what they want. Like they want strategies that are really targeting the real issue. Right. And they want strategies that not only are engaging providers and systems to think about what they’re doing differently or how they can do something better to improve the quality of care that that people and Guilford County are experiencing. They also are recognizing in this coming from the provider community that they don’t know sometimes how people are experiencing their services. You know, I’ve worked in direct servers before, I’ve worked in public health before, so often we come up with ideas and we just think that people would just make their appointments. If they could just come to their appointments, they wouldn’t have these low birth weight, preterm birth. And then when you start to unpack what the real experience is for someone who may have missed their appointment or who struggles to keep up with the appointment schedule or really is concerned that, like, the only provider I can go to is right here but I had a bad experience with my last birth there, so I kind of don’t want to go there. But because of other barriers, and this is where the solutions can’t be at the individual level only, they have to actually address the barriers that the individuals are facing in order to really disrupt and change and eliminate what we see as some poor disparity. But that like the decisions around strategies in the push of the Coalition to be explicit, that is really coming from this really radically inclusive conversation and being able to hear from those different perspectives. And that’ll be important in the community. You’ll keep the Coalition honest, right? Because there is a way that you can’t go back now like you can’t or you can. And then they to talk about you. Right.

Jean Workman: Or it’s going to be more of the same. And then you lose the trust from the community. You know, one of these pieces Consuela just hit on is we’re going to be relying on core partners. We’re going to be the conductor of the orchestra as a backbone organization. We won’t necessarily be implementing ourselves all of this work we’re building out. I’m going to need core partners to do what they want to do, what they’ve been doing, but also amplify and go into some different directions. And that takes trust. Someone gave me the quote today, “Move from the blame to empathy and understanding in a community” and we want our health care providers doing that so that we change the narrative of our maternal health stories to be more about positivity, to be more about equity, to be more about non-discriminatory practices that are occurring. And so it will take building that trust. And we’re doing that through this radically inclusive process. We’re saying to the community, your voice matters. We’re walking the talk, we’re making it matter. And we’ll continue to do that throughout the processes as we move forward.

Erin Rodriguez: Well, it’s been great to hear more from both of you about how this has worked. I’ve watched a lot behind the scenes watching team members scramble to cover the breakout rooms so that we’ve got good note takers and all of that radically inclusive information can come back into this project. And I’m really excited to see what the two of you continue to do together.

Consuela Greene: I am too.

Jean Workman: You have no idea how excited I am is coming into this. Last year, when the work started in January of 2020, the Coalition kicked off the year really wanting to get this collective action process going sooner. We would have loved to have had it start in January. It didn’t for many reasons. And in January we kicked off with a racial equity training for our stakeholders in the community. It was a phenomenal training led by a phenomenal group. And at the end of that training that day, I said, folks, because everybody, we were naming racism. That we’ve got to tackle racism in our maternal health settings. We’ve got to name racism as a public health crisis in Guilford County. And I stated, we’re going to do that and we’re going to tic some people off and doing it because we’re going to change up culture and systems that have been moving and working in a particular way for so long. But that’s OK, because we’re going to do it together. And in doing so, we’re going to create this amazing environment for families and women in our community to enter, to be able to give birth in healthy pregnancies, babies that will celebrate their first birthday, and that we won’t have this disparity that we’re looking at. COVID delayed us and getting started. I am so grateful that it did, because it did lead me to Root Cause, to be the facilitator of this process. And we are just incredibly blessed, I think, through this framework and having patience, that it’s not it’s not as quick as I thought it would be. But the beauty in that is this inclusivity of people coming to the table and hearing, hearing their voice and building out something that truly will be solid and achievable in our community.

 Erin Rodriguez: Well, thank you again, Jean, for taking the time to do this, and I love hearing the silver linings of this pandemic moment that we find ourselves in, and I will carry that with me for a few more months as we move forward.