Personal, institutional, or systemic?

We’ve spent this exhibition looking at many of the ways race, racism, and bias can shape pregnancy, birth, and postpartum health. Now we're going to bring a lot of that pattern recognition work around and jigsaw it together around this: that recognizing a problem and knowing how to solve it are two different things.

Once we see something isn’t working, the next question naturally becomes: Where is the problem actually coming from so I can know how to attack it to fix it?

Sometimes the answer is an individual person. A clinician dismisses a patient’s concern. A nurse speaks disrespectfully. A hospital leader makes a poor decision. Those choices matter, and people should be accountable for them.

But sometimes replacing the people doesn’t change the outcome.

A new clinician joins the unit, and patients describe the same experience. A hospital hires new leadership, updates its policies, or requires another training, yet the same gaps remain. When the pattern stays the same after the people change, it’s worth asking whether the problem reaches beyond any one individual.

This chapter looks at three places a problem can exist: the personal, the institutional, and the systemic. Personal problems involve the choices people make. Institutional problems involve the culture, policies, priorities, and practices within an organization. Systemic problems are larger still. They include many of the things we’ve explored and explained in depth throughout this exhibition — laws, funding, education, transportation, housing, and other systems that shape what institutions, and the people working inside them, are able to do.

Imagine a clinician dismisses a Black patient’s report of severe pain. Where did that response come from? The clinician learned from someone. That instructor learned from someone else. Medical schools decide what research is taught. Researchers decide which questions are worth studying. Institutions decide what gets funded. Scientists decide who participates in research — and who doesn’t. Over time, some ideas become accepted as fact while others are ignored or forgotten.

That’s one reason it’s helpful to zoom out. A single interaction may be influenced by decisions made months, years, or even generations earlier.

That doesn’t mean every clinician is responsible for every decision that came before them. It does mean that the care someone receives today can be shaped by ideas, policies, and systems that existed long before either the patient or the clinician entered the room.

These levels aren’t separate from one another. They’re constantly interacting. A hospital can replace one clinician without changing its culture. It can update its policies without changing how people were trained. It can improve training while still working within larger systems shaped by staffing shortages, insurance reimbursement, transportation, or the availability of maternity care in a community.

The same is true when a hospital identifies a racial gap in its maternal outcomes. A workshop may help clinicians recognize assumptions they hadn’t considered before. That’s valuable. But it won’t reopen a closed birth unit, create paid family leave, expand Medicaid, or make childcare available during prenatal appointments. Different problems live in different places, which means they also require different kinds of solutions.

This framework can also explain why conversations about equity sometimes feel like people are arguing past one another. One person is talking about what happened between a patient and a clinician. Another is talking about hospital policy. Another is talking about the neighborhood, insurance system, or state budget surrounding that hospital. Each person may be naming a real part of the problem. The mistake is assuming that only one part can be real at a time.

Recognizing systems should never become a reason to excuse harmful personal choices. At the same time, holding one person accountable shouldn’t keep us from asking why the same problem continues to appear in different hospitals, different communities, and different parts of the country.

Before we can choose a lasting solution, we have to understand where the problem lives.

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