Culture of Health Institute for Leadership Development
Online Training Resource Guide
Looking Upstream:
Systemic Oppression as a
Key Determinant of Health Inequities
Course Description
Health inequities are produced through the unequal structuring of opportunities and outcomes
based on race, class, gender, and other structural determinants. Systems of oppression including
white supremacy, patriarchy, and capitalism actively privilege certain social groups (whites, men,
and wealthy) over others (people of color, women, and people with less wealth). This module
provides participants with shared language and conceptual frameworks for understanding the
role of systemic oppression in creating and maintaining health inequities, and outlines core
principles for effective health equity practice.
Learning Outcomes
By the end of this module, participants will be able to:
• Define key terms and constructs related to systemic oppression and health equity
• Explain how systems, policies, and ideologies produce and maintain health inequities in the
U.S. by race, gender, and class
• Apply the principles of health equity practice to at least one specific health inequity
Systemic Oppression Resource Guide
Module Outline
Introduction
A. Welcome and description of CHILD
B. Module Overview
C. Reflection question one
D. Learning outcomes and outline
Reflection Question One: If you had to talk to your neighbor today and explain to them how
systemic oppression creates health inequities, how comfortable would you be having that
conversation?
Unit 1: Terminology
A. Equity, health equity, health inequities and disparities
B. Diabetes example
C. Complexities of equity work and application to diabetes disparities example
D. Reflection question two
Reflection Question Two: Name a disparity that exists in a community where you live or work.
• Do you consider this an inequity, incorporating the moral aspect of the definition?
• Does your explanation of the disparity reflect this?
References and Suggested Readings
• Healthy People 2020. 2017. “Disparities.” (www.healthypeople.gov/2020/about/foundationhealth-measures/Disparities).
• World Health Organization. n.d. “Social Determinants of Health. Key Concepts.”
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(www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/).
Braveman, Paula A., Shiriki Kumanyika, Jonathan Fielding, Thomas LaVeist, Luisa N. Borrell,
Ron Manderscheid, and Adewale Troutman. 2011. "Health Disparities and Health Equity:
The Issue is Justice." American Journal of Public Health 101(S1): S149-S155.
Policy Link and USC Program for Environmental and Regional Equity. n.d.1 “Diabetes.”
National Equity Atlas.
(www.nationalequityatlas.org/indicators/Diabetes/By_race~ethnicity%3A27261/United_State
s/false).
National Institutes of Health. 2015. “More Than Half of Asian Americans with Diabetes are
Undiagnosed.” (www.nih.gov/news-events/news-releases/more-half-asian-americansdiabetes-are-undiagnosed).
Braveman, Paula. 2014. “What Are Health Disparities and Health Equity? We Need to Be
Clear.” Public Health Reports 129(Suppl 2):5–8.
(www.ncbi.nlm.nih.gov/pmc/articles/PMC3863701/).
Cultural Organizing. 2016. “The Problem with that Equity vs. Equality Graphic You’re
Using.” (www.culturalorganizing.org/the-problem-with-that-equity-vs-equality-graphic/).
Center for Global Policy Solutions. n.d. “About Health Equity.”
(www.healthequity.globalpolicysolutions.org/about-health-equity/).
Unit 2: Looking Upstream
A. Babies in river story
B. What it means to look upstream
C. Reflection question three
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“N.d” is noted when a publication year is unavailable.
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Reflection Question Three: Which social identity categories did you identify in your example of a
disparity in the community where you live or work?
• In your original explanation of the disparity, did you highlight who is privileged by this
disparity as well as who is oppressed?
• If not, can you reframe your explanation to show both sides of the story?
• Does this reframing help you move upstream?
References and Suggested Readings
• Mayer, Steven E. 2008. “Saving the Babies: Looking Upstream for Solutions.”
(www.effectivecommunities.com/pdfs/ECP_SavingBabies.pdf).
• Schutz, Aaron and Marie Sandy. 2011. Collective Action for Social Change: An Introduction to
Community Organizing. New York, New York: Springer.
Unit 3: Diving Deeper Into Inequities
A. Race – construct, native genocide and slavery, historical segregation, role of policy, implicit
bias
B. Preterm birth rates example
C. Structural determinants of health
D. Gender – construct, patriarchy, historical roles/rights, role of policy
E. Racial wealth gap examples
F. Class – constructs, ideology, power, role of policy
G. School segregation example
H. New Orleans Life Expectancy and the role of place
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References and Suggested Readings
• Omi, Michal and Winant, Howard. 2014. Racial Formation in the United States. New York,
New York: Routledge.
• Glenn, Evelyn Nakano. 2015. “Settler Colonialism as a Structure: A Framework for
Comparative Studies of US Race and Gender Formation.” Sociology of Race and Ethnicity
1(1): 52-72.
• Heart, Maria Yellow Horse Brave. 2003. “The Historical Trauma Response Among
Natives and its Relationship with Substance Abuse: A Lakota Illustration.” Journal of
Psychoactive Drugs 35(1):7-13.
• Thompson-Miller, Ruth, Joe R. Feagin, and Leslie H. Picca. 2014. Jim Crow's Legacy: The
Lasting Impact of Segregation. Lanham, MD: Rowman and Littlefield.
• Oliver, Melvin L. and Thomas M. Shapiro. 1995. Black Wealth/White Wealth. New
York, New York: Routledge.
• Turner, Sarah and John Bound. 2003. "Closing the Gap Or Widening The Divide: The
Effects Of The G.I. Bill And World War II On The Educational Outcomes Of Black
Americans." Journal of Economic History 63(1):145-177.
• Centers for Disease Control and Prevention. 2013. “CDC Health Disparities and
Inequalities Report – United States, 2013.” Morbidity and Mortality Weekly Report
Supplement 62(3): 1-187. (www.cdc.gov/mmwr/preview/ind2013_su.htmlz).
• Project Implicit. n.d. “Implicit Association Test.”
(www.implicit.harvard.edu/implicit/india/takeatest.html).
• Solar, O. and Irwin, A. 2010. “A Conceptual Framework for Action on the Social
Determinants of Health.” World Health Organization.
(apps.who.int/iris/bitstream/10665/44489/1/9789241500852_eng.pdf).
• California Newsreel. n.d. “Unnatural Causes.”
(www.unnaturalcauses.org/episode_descriptions.php?page=2).
• Richard, Katherine. 2014. “The Wealth Gap for Women of Color.”
(www.globalpolicysolutions.org/wp-content/uploads/2014/10/Wealth-Gap-for-Womenof-Color.pdf).
• National Committee on Pay Equity. n.d. (www.pay-equity.org).
• Sobel, Laurie, Adara Beamesderfer, and Alina Salganicoff. 2016. “Private Insurance
Coverage of Contraception.” (www.pewresearch.org/fact-tank/2016/09/26/u-s-lacksmandated-paid-parental-leave).
• Livingston, Gretchen. 2016. “Among 41 Nations, U.S. is the Outlier When it Comes to
Paid Paternal Leave (www.pewresearch.org/fact-tank/2016/09/26/u-s-lacks-mandatedpaid-parental-leave).
• Fullerton, Howard Jr. 1999. “Labor Force Participation: 75 years of change, 1950–98 and
1998–2025. Washington D.C.: Bureau of Labor Services.
• Wang, Wendy, Kim Parker, and Paul Taylor. 2013. “Breadwinner Moms.”
http://www.pewsocialtrends.org/2013/05/29/breadwinner-moms).
• National Committee on Pay Equity. n.d. “National Committee on Pay Equity.”
(http://www.pay-equity.org).
• Wright, Eric O. 2003. “Social Class.” (www.ssc.wisc.edu/~wright/Social%20Class%20-%20Sage.pdf).
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Howard, Christopher. 1999. The Hidden Welfare State: Tax Expenditures and Social Policy
in the United States. Princeton, NJ ; Princeton University Press.
DiTomaso, Nancy. 2013. The American Non-Dilemma: Racial Inequality Without Racism.
New York, New York: Russell Sage Foundation.
Osterman, Paul and Beth Shulman. 2011. Good Jobs America. New York: Russell Sage
Foundation.
Unit 4: Systemic Oppression
A.
B.
C.
D.
Systemic oppression definition/Matrix of oppression
Intersectionality
Interlocking systems of oppression
Reflection question four
Reflection Question Four: Which systems of oppression are present in your example of a disparity
in the community where you live or work?
• How do these systems of oppression hurt entire communities in your example?
• How does this upstream vision inform your recommendations?
References and Suggested Readings
• Collins, Patricia Hill. 2004. Black Sexual Politics. New York, New York: Routeledge.
• Crenshaw, Kimberly. 1991. Mapping the Margins: Intersectionality, Identity Politics, and
Violence Against Women of Color. Stanford Law Review: 1241-1299.
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Unit 5: Principles of Health Equity Practice
A. Effects of systemic oppression
B. Community power
C. Principles
D. Effects of upstream equity work
E. Question 5 and reflection
F. Seeing systems of oppression
G. Question 6
H. Questions for facilitator, concluding remarks, evaluation poll
Reflection Question Five: Which actions would reduce the specific disparity in your community
where you live or work?
1. Change the tax code
2. Elect more politicians from marginalized communities
3. Create cross-sector initiatives
4. Get more women and people of color in management and leadership positions
5. Create policies that build a culture of health for all
Reflection Question Six: If you had to talk to your neighbor tomorrow, after you have time to sit
with this information and digest it, and explain to them how systemic oppression creates health
inequities, how comfortable would you be having that conversation?
References and Suggested Readings
• Prevention Institute. 2016. “Countering the Production of Health Inequities.”
(www.preventioninstitute.org/publications/countering-production-health-inequitiesextended-summary).
• Center for Global Policy Solutions. n.d. “About Health Equity.”
(www.healthequity.globalpolicysolutions.org/about-health-equity/).
• Turner, Sarah and John Bound. 2003. "Closing The Gap Or Widening The Divide: The
Effects Of The G.I. Bill And World War II On The Educational Outcomes Of Black
Americans." Journal of Economic History 63(1):145-177.
• Perea, Juan F. 2014. “Doctrines of Delusion: How the History of the G.I. Bill and Other
Inconvenient Truths Undermine the Supreme Court’s Affirmative Action
Jurisprudence.” Princeton Law Review 75(Summer): 583-651
(https://lawreview.law.pitt.edu/ojs/index.php/lawreview/article/viewFile/344/271).
• Young, Iris (1990). Justice and the Politics of Difference. Princeton, New Jersey: Princeton
University Press.
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