As a health worker, power is the most important prescription I will ever write. No, this is not a prescribing tutorial. Today I am going to be exploring three Ps in health equity- power, positionality, and privilege.

Firstly, I believe that power and privilege are good- IN MODERATION.

Power grants access to resources that can influence our chances of achieving goals and influencing others. Power gives us opportunities and freedom. Why wouldn’t you want power?

Secondly, power is not random.

Power is socially constructed by dominant groups and historical events with enduring consequences today. The ultimate consequence is that power gives access to more resources such as education, wealth, health, security, protection from environmental toxins, and nutrition. In this race of life, some of us will start a couple of steps ahead. Where you start is dependent on how much dominant ‘currency’ you possess.  This currency, broadly speaking, relates to identity, networks, norms, and values, which are weighted based on your immediate context.

 As a researcher exploring the lived experiences of Black women accessing reproductive health care, being a Black woman gives me power in this space because I have an ‘insider’ status. However, ‘Black women’ are not a monolith. As an African woman, I have more cultural ‘currency’ on issues relating to African women compared to those affecting, for example, Caribbean women.

Being a Black woman who is also an obstetrics & gynaecology doctor may give me power in some situations due to society’s perceived hierarchical status of the medical profession. In a different context, however, my medical affiliations may position me as an outsider, perceived as part of a group that has historically enacted reproductive injustice towards women of colour.  Have you been in situations where you’ve held the currency of power and the privileged position of being an insider? Equally, have you had experiences where you have felt powerlessness and the disadvantages of being perceived as an outsider?

What is positionality?

 Positionality is the position from which we see the world around us. It’s dependent on our identity, reflects on our worldview and how we approach things in social contexts. Different dimensions of our identities often, unknowingly, shape interactions we have in our schools, communities, work environments and academic fields. Our positionality determines our gaze and impacts who we choose to collaborate with, what we prioritise, how we ask questions, make decisions and interpret findings.

Why is it important to know about our positionality?

 An awareness of one’s positionality helps us understand that objectivity is an illusion. Positionality is a reflexive process of appreciating biases, power, privilege, dominance and oppression in ourselves and others. Positionality helps us build empathy and courage to address unfair power dynamics to promote equity and social justice.

 Various aspects of one’s identity confer advantages and disadvantages. Dominance is an aspect of our identity that gives us power based on social norms and values. Due to the history of the world, many societies are dominated by standards which prioritise white, male, cis-gendered, heteronormative, European, North American, middle-class, non-disabled and Christian values.

There is absolutely nothing innately wrong with being white, male, cis-gendered, heteronormative, European, North American, middle class, non-disabled and Christian. However, it is problematic when these identities are upheld as the universal standard, even in spaces where these do not represent the majority. Identities, norms, values, and networks only become problematic when they ‘other’, dominate and unfairly give advantages to a few whilst disadvantaging the majority. Therefore, dominance is the root of all systems of oppression.

Are you still with me?

We all have dimensions of our identity that put us in a place of dominance that others often see but are invisible to us. This is the essence of the final P of health equity- privilege.

 We are frequently resistant to recognising our individual privileges because being privileged is associated with not having worked hard for whatever resources we may have access to. But I argue that it is possible to have worked hard and also benefit from privileges you have not earned and have little control over, for example, your gender, your race & ethnicity, the family and social class into which you were born, your passport, etc.

As privileged beings, we tend to highlight aspects of our identity where historically or socially, our role is that of the oppressed versus the oppressor( beneficiary/ dominant). For example, white working-class men might tend to recognise the socio-economic challenges of being working class but fail to notice the social advantages of being white and male. As a Black nondisabled English-speaking woman, I am more likely to notice the disadvantage of being Black and female in some spaces and less likely to appreciate the advantage of speaking English and not having to navigate the London tube as a wheelchair user.

Privileges are like automatic doors that swing open as we approach them. It’s hard to appreciate doors when they are opened to you. We only notice them when the automatic function fails and we slam straight into a hard glass surface(ouch!)

 Because we are a product of our environments and lived experiences, it is normal for us to understand people, values and norms closer and more similar to ours. Beyond our centre, we have biases. Our biases lie at the edge of our positionality privileges and lived experiences. This is our blind spot-the source of resistance, discomfort and lack of empathy in these conversations.

I believe that power and privilege are NOT a zero-sum game. The real issue is too much pIE.

 The concept of a zero-sum game means if I gain, you lose and vice versa. It implies that there are only so many slices of pie to go around. And is particularly appealing to those with the most pie, scarcity or fixed mindsets.

The reality is that society is suffering from situations where certain groups engorge themselves on more pie than they can digest, whilst others can barely scrape at crumbs.

How much pie do you actually need?!

I believe that there is no zero-sum game in redistributing power because the benefits must be viewed in the medium to long term. It is possible to share power and privilege by recognising that you can never truly lose what you have already benefited from in the past. Resist the seduction of a scarcity mindset and appreciate that when individuals are given a fair, level playing field to succeed, the whole of society benefits from their success and maximal self-actualisation in the long term.

As I stated earlier, I believe that power and privilege can be good things. However, too much pie, power and privilege is a bad thing.

The moment our privileges and power begin to encroach on another’s autonomy, freedom for self-determination and actualisation is the moment we become problematic. Excessive privilege and power, once recognised, can only be redistributed intentionally and fairly by introducing accountability.

 In summary, understanding, acknowledging and then interrogating power, positionality, and privilege is the first step to addressing health inequities.

 So, once we know better, then we can do better. Doing better involves an active choice.

I look forward to continuing our conversation about ACTION in part two, “Prescribing Power: Allyship & Accompaniment”.

P.S

As always, if my thoughts this week struck a cord, piqued your interest, or you’d like to explore some of these ideas further or have questions, leave a comment and write to me HERE.