Ichiro Kawachi, MD, PhD

IchiroTrained in both internal medicine and epidemiology, Ichiro Kawachi, has been a pioneer in the field of social epidemiology. Dr. Kawachi’s first foray into public health began as a doctoral student in New Zealand in the 1980’s, when he published a paper quantifying the estimated annual deaths due to second-hand smoke. This paper stoked the ire of the tobacco industry but ultimately led to the passage of historic legislation in New Zealand limiting cigarette smoking and tobacco use. Currently the chair of the Department of Social and Behavioral Sciences at the Harvard School of Public Health, Dr. Kawachi is a professor in social epidemiology and has taught for over 20 years. He has published over 500 articles on social determinants of population health. His books include the Health of Nations with Bruce Kennedy, Social Epidemiology with Lisa Berkman (Oxford University Press, 2000; Completely revised 2nd edition forthcoming in summer of 2014); and Globalization and Health and Social Capital and Health co-edited with S.V. Subramanian and Daniel Kim.

Career in Profile

  • 1985 – Received M.D. from Otago University, New Zealand
  • 1991 – Received Ph.D. from Otago University, New Zealand
  • 1993-NOW – Professor, Harvard School of Public Health, Department of Social and Behavioral Sciences

You have several titles: professor, department chair, social epidemiologist, and more recently, behavioral economist/scientist. Tell me a little about your work in each of these roles and which one is consuming the most of your time these days.

I spend about 75% of my time on research, 20% on teaching, and the remainder on administration. I’ve been very conscientious of trying to protect research time. I have a lab – the Society and Health Lab – that currently has a dozen postdoctoral fellows from all over the world. I try to prioritize research including a NIH-funded R01 project on the aftermath of the tsunami and earthquake in Japan. We’re in the field right now, trying to trace the people who were affected by the tsunami.

I’m still very passionate about teaching. I spend at least twenty percent of my time teaching. My classes are Health and Society, which I’ve been teaching here for over 20 years. I do that twice a year in the summer and the fall. I teach about 400 students altogether each year. Recently, I recorded Health and Society for edX. Thirty-two thousand students registered for it. It was really amazing to see this because as you follow the online chat in the classroom, you can see that the very time if you drop a pin from where one of these comments came from, within a day or so, you quickly draw a map of the world. I also teach Behavioral Economics, which started out small and has done the equivalent of going viral in the classroom because we are in the largest lecture theater now at the Harvard School of Public Health. The chair’s duties are administrative, shepherding academic and strategic concerns of the department. I try to keep it to a tenth of my time.

You were trained in medicine, became an epidemiologist, and have been a leader in the field of social epidemiology. You co-wrote the book on social epidemiology. How did you come to do this work?

I trained as a physician in New Zealand. I switched to epidemiology when I got fed up with doing downstream medicine day after day. It wasn’t what I expected. What I had underestimated was the sheer repetitiveness of day-to-day clinical medicine. I trained in internal medicine. I’d say that 80% of my patients had heart attacks, strokes, congestive heart failure, or chronic respiratory disease. If you take those four diagnoses, they comprise about 80% of internal medicine, at least it was when I was practicing. The bread and butter of medicine are these common things.

What do these things have in common? A lifetime of poor behavior, smoking, stress, bad diet, lack of exercise. So I started to realize that there must be a better way to go upstream and try and prevent these people from ever getting any illness. So, that was my initial stimulus to go from clinical medicine to doing something upstream, such as tobacco control.

I became very active in the New Zealand Public Health Association at that time. I was elected as the National Secretary. Just at that time, the Health Minister of New Zealand was Helen Clark, who later became the longest serving prime minister of New Zealand, and who is currently the head of the United Nations Development Program in New York. Under her leadership, she decided to pass legislation to ban all forms of tobacco advertising in New Zealand and to restrict smoking in workplaces. She was way ahead of the curve. She started thinking about this in 1989 and it finally passed in 1991. This was right at the time when I decided to make the switch to public health. So I became very excited by this.

I spent a lot of time lobbying for the passage of this legislation. That’s how I got interested in public health. Through my interest in tobacco control I then did a PhD in Epidemiology and then came to Harvard, now over 20 years ago. My initial reason for coming here was to study the benefits of stopping smoking in large cohort studies. While I was here, I met Sol Levine, who was one of the founding chairs of my current department. I got exposed to this idea of health inequality. I suddenly realized that the problem of tobacco control is actually one of health inequality. I suddenly realized that unless you tackle inequality, you aren’t going to really tackle tobacco control. People smoke because it is one of the cheapest pleasures, it is one of the few things that someone can have for himself/herself in a life that is full of stress and chaos and few options. That got me interested in social epidemiology.

Twenty years ago, when I was recruited into this department, I wanted to use the term social epidemiology to distinguish what I was doing from what I had been doing before, which was chronic disease epidemiology. At HSPH the students have to declare a major field of study for their thesis. One of the first things I did, when I took on one of my earliest doctoral students [was to suggest] that he declare social epidemiology as his field. Much to my annoyance, this was rejected by the school’s Committee on Admission and Degrees. In 24 hours it had come back and the chair of the Committee had said that there is no such field. That got me sufficiently riled and I decided to work on a textbook. Lisa Berkman also had the same idea and already we got a book contract from Oxford University Press. So we decided to write the textbook together and we declared the arrival of this field. These days, no one questions that there is a field of social epidemiology. Len Syme had been doing similar work for years but I guess he never used the term social epidemiology. The same with Sir Michael Marmot. They were doing it. But they hadn’t declared it an academic discipline. The past twenty years can be seen as an effort to build a training program in social epidemiology, which is what we say that we have at Harvard.

Describe your interests and focus in behavioral economics. What are the implications of this field on public health practitioners and policy? Does it represent a fundamental shift in how we are approaching research and interventions?

I became interested in behavioral economics when, five years ago, I became chair of the Department of Society, Human Development and Health. We are now called the Department of Social and Behavioral Sciences. Being a chair of a behavioral sciences department, I decided to review the curriculum. What are we teaching our students about behavior? Much to my amazement, it turned out that there was nothing in our curriculum about behavioral economics, which has been in the background of economics and psychology for the last thirty years, as it really started in 1980.

I was amazed by this gap because on the one hand you have those behavioral economists and psychologists who don’t speak to public health people, yet all of their examples concern health behavior. They’re practicing public health without a license! On the other hand, when I looked at our curriculum, we are the behavioral science department at the School and there wasn’t a single course listed on our whole department roster that taught behavioral health. So I decided that we better quickly fill this gap.

I think behavioral economics is very interesting because it does seem to me a remarkable confluence of ideas – in disparate fields from psychology to neuroscience to economics and public health – to more fully understand the basis of human behavior. I don’t think that by any means it’s a panacea, but it’s something new that we haven’t done. I think if we do it right, it has the potential at least to reduce inequalities as well. Because we know that all the things we speak about in behavioral economics – the heuristics, the biases, and the problems of delayed gratification – all of these things are even more acute in populations that face poverty and scarcity. To the extent that we can address these things, it has the promise of reducing inequalities and boosting the effectiveness of health behavior interventions.

What is a career success or highlight that you are particularly proud of?

My most efficacious paper to this date remains my 1987 article published in the New Zealand Medical Journal, which I wrote when I was a doctoral student. I always tell this to my students, because much as I try to work toward writing elegant papers in high-profile journals, the one that really had public impact is still the one that I wrote as a doctoral student in epidemiology. Back in 1987, the New Zealand Parliament was starting to debate whether or not they should pass legislation to restrict second-hand smoking. I had this idea to calculate how many deaths second-hand smoking in New Zealand causes. I used the technique of Population Attributable Risk, which I had learned in my epidemiology courses. I got some numbers and did a calculation. I discovered that nearly (an estimated) 300 Kiwis (New Zealand residents) were killed every year by inhaling second-hand smoke in the workplace and the home. Three hundred deaths each year might not seem like large numbers, but in New Zealand, that’s roughly two-thirds of the annual death toll from traffic accidents.

My point was that the New Zealand Traffic Ministry spent millions of dollars in anti-drunk driving campaigns, so why didn’t New Zealand government take passive smoking just as seriously. I published in the New Zealand Medical Journal and it had enormous impact. It was picked up by local anti-smoking organizations that held a demonstration in front of Parliament where 300 of them got dressed in crosses and laid down in front of Parliament. Politicians started to cite it in their speeches to Parliament. The next thing I know, I got a letter attacking the paper. Someone submitted a letter attacking the paper and it was written by none other than Nathan Mantel, who every public health student knows because of the Mantel-Haenszel odds ratio. This world famous statistician turned out to be a consultant for the tobacco industry.

When I saw that letter, I knew that I had made an impact. I had sufficiently disturbed the tobacco companies that they had paid this world famous statistician to attack my paper in the New Zealand Medical Journal (which I doubt he had ever read before my article appeared). To this day, I contend that that was the most important, directly policy-relevant paper I’ve written. It just shows that I peaked early. Students can still do really important work. I’ve never had that kind of success since then.

What is a challenge that you’ve faced or continue to face in your career?

A challenge in behavioral economics and social epidemiology is the massive disparity in power between “us” versus “them”. In this country, at least, economic power has become so concentrated in the last 30–40 years, it’s becoming harder and harder to make an impact through the mechanism of democracy. If you want to make some point of view, it is hard to get it represented through the ordinary channels of media.

It’s exactly like Joseph Stiglitz described in The Price of Equality. He articulated what I always wanted to say about income inequality’s corrosive effects on the body politic. His argument is that the concentration of wealth in the top one percent is distorting political decision-making in a functioning democracy. It is distorting media, the rules of the game by which the economy is run, and I think this is a huge challenge both inside and outside of public health.

To get something done within public health, you have to influence institutions, the laws, and regulation. Developing evidence is the initial step. We also say that lots of policies get made on the basis of no evidence. If there is a will to do it, they’ll do it. If you want something to be passed, at least on our side, you have to have evidence. What researchers at the School of Public Health are doing is providing the knowledge base. As has been said before, that is only one of the ingredients. You have to have the political and popular will to do something and you have to have an appropriate strategy to translate that evidence into policy. Unless those things come together, you won’t get change. The problem with growing polarization is that you can produce lots of evidence but the political will is stuck.

Is there a persistent public health problem that still concerns you today?

I have to say that it is health disparities, persisting inequality between rich and poor countries, and persisting inequality within rich countries. The field of social epidemiology is really an attempt to focus attention on that problem.

It is not enough that the average gets dragged up. You have to lift everybody. There is a lot of attention on global health but basically, you don’t need to go that far. Look in our backyard. You will see disparities in life expectancy that span the entire globe. A man born in a New Orleans’ parish has a life expectancy in his ‘50’s, compared to an Asian-American woman born in a rich Bergen County, NJ, who has a life expectancy of 90. A forty-year difference in life expectancy pretty much spans the average differences in the countries of the globe. I tell young, idealistic youth who want to make a contribution to global health that you don’t have to go all the way to Malawi. You can do something in rural Mississippi. Health centers like the one in Mound Bayou, MS, because basically it’s the model of physician responsibility. The primary care doctors basically said that it’s not enough to provide primary care, you’ve got to invest in educating the people, making them leaders, and make it self-sustaining (Editor’s note: Mound Bayou was the first community health center in the country).

This feature was interviewed, transcribed and partially edited by our guest editor, Ted Henson. The photo was provided by Maki Miyashita.

Tom Bodenheimer, MD, MPH

BodenheimerAfter graduating from Harvard Medical School, Dr. Tom Bodenheimer spent time as a Peace Corps physician in Costa Rica, where he learned about the political economy and health infrastructure of rural Latin America.   This led him to wonder how the US might adapt successful public health models from the developing world, such as promotores, or community health promoters.  Upon his return, he practiced primary care for 32 years in San Francisco’s Mission District, a primarily low-income, Latino community.  He has written and co-authored several books on health policy, including Understanding Health Policy and Improving Primary Care. Dr. Bodenheimer has spent the past 11 years of his career in the University of California San Francisco’s (UCSF) Department of Family and Community Medicine, where with his colleagues, he works with primary care providers to improve health care service delivery.

Career in Profile

  • 1961- Graduated from Harvard College
  • 1965- Graduated from Harvard Medical School
  • 1965-1966- Interned at Boston City Hospital, Harvard Medical Service
  • 1966-1967- Worked as a Research Assistant in Neuro-Anatomy, National Institutes of Health
  • 1967- Served as a Peace Corps Physician in Costa Rica
  • 1967-1968– Consulted for US Department of Health Education and Welfare
  • 1968-1969– Served as a Urban Coalition Fellow in Community Medicine at the San Francisco General Hospital
  • 1969– Completed MPH at University of California, Berkeley
  • 1969-1971– Resident in Internal Medicine at University of California, San Francisco
  • 1972-1975– Physician at the South of Market Health Center
  • 1974-1976– Researched at the Health Policy Advisory Center
  • 1975–1979– Physician at Mission Neighborhood Health Center
  • 1980–2002– Physician at BayWest Family Health Care
  • 1991-1996- Associate Clinical Professor, Department of Family and Community Medicine, University of California, San Francisco
  • 1995-96– Worked as the Hospital Utilization Manager at BayCare Medical Group
  • 1996–2002- Clinical Professor, Department of Family and Community Medicine, University of California, San Francisco
  • 1998–2000- National Correspondent, New England Journal of Medicine
  • NOW – Adjunct Professor in the Department of Family and Community Medicine and Co, Director of the Center for Excellence in Primary Care, University of California, San Francisco

Can you talk about your decision to transition from practicing primary care to influencing health policy through your position at the University of California-San Francisco?

In primary care, there was this total divorce between primary care and populations. In primary care, we thought about who’s coming in today or tomorrow. People didn’t even know who their population was or who was on their panel of patients. Even though I have a Master’s in Public Health [MPH], I turned off that way of thinking for a long time due to the pressures of private practice, but now I’m getting interested in it again. I was always really interested in health policy, even during my 1-year MPH program at the University of California-Berkeley. Even while I worked as a primary care physician, I itched to keep my hand in health policy, so Kevin Grumbach and I co-wrote Understanding Health Policy. I did some writing as a physician, and I kept my interest in health policy throughout my career as a practicing physician, but didn’t have much opportunity to do much with it until I left the practice. I like to write. It’s fun.

My health policy work had to get pretty truncated while I worked in primary care, but being in a private practice really teaches you how the health system works, from the bottom up. Not from the very bottom, which sadly is where patients are, but primary care is close to the bottom. This was during the time when Health Maintenance Organizations [HMO] came into being, so we had HMO contracts and PPO Preferred Provider Organization [PPO] contracts and we were in different independent physician associations and we had to worry about different managed care issues … We learned a lot about health policy just by trying to keep our practice working in the crazy world of California in the 1980s and 1990s.

You’ve done a number of things in your career, so what are one or two highlights?

When people ask, what do you think you did with your life? I say, “I tried to take care of a lot of low-income, mostly Latina patients, and tried to do the best I could to make their lives better”. To me, that’s the best thing I’ve done.

In terms of highlights? When I left the practice, I had no idea what I was going to do. I realized, “I have to go…I’m too burned out to do this any longer”. I went to a conference up in Seattle that Ed Wagner’s group [GroupHealth Research Institute] was running, and I met people that I’d never met before – Ed Wagner, Kate Lorig – and I realized, “I want to work on patient self-management”. I know that if patients aren’t part of what happens, it’s not going to work.

So my main focus at UCSF has been patient self-management, mostly through health coaching. Health coaching works with people with chronic conditions to help them understand their disease, and gain the knowledge, skills, and confidence that they need to care for themselves as best they can. For example, if a patient with asthma doesn’t know how to use the inhaler, then the inhaler isn’t going to do any good. Using an inhaler is a skill. So a doctor gives patients a prescription for an inhaler and nobody will show them how to use it, they’ll use it incorrectly or they’ll use the wrong one, and it’s useless.
Virtually every chronic condition has some skills associated with managing it. Behavior change is a big component of chronic disease and preventive care, and we have a method for dealing with behavior change that is called ‘action plans’. Rather than saying: “you have to lose 10 pounds”, you ask: “What would you like to do to make your health better?” Let the patient give you their long-term goals. Then you say, “Well, how can we implement an action plan to get you there?” Baby step by baby step – that’s what the action plan is. The action plan might be: instead of eating a pint of ice cream each night, I’ll eat half a pint. Whatever they’re confident they can succeed in.

Medication adherence is a big issue in primary care, and health coaching helps patients overcome their numerous barriers to taking their meds, whether it’s cost barriers, not believing it’s important to take their meds, not remembering – whatever the barrier might be. So the summary of health coaching is helping people to be engaged in their own health.

There’s a part of public health that’s health education, and then there’s primary care, and health coaching is a space where the two meet. So it strikes me that health coaching is a way that health education can operate within primary care, by working with patients to manage their chronic conditions.

Let me push health coaching a little farther. A colleague of mine and I co-wrote a paper. We ask people to create action plans to change their behavior, but we don’t change the community in which they live. So a lot of times people live in a poor neighborhood where there are a lot of fast food outlets, and we ask them to create an action plan to improve their eating. Fast food is cheap! We haven’t done the “upstream” work so that our patients can achieve their action plans, because the environment around them doesn’t support their action plan.

We wrote a paper where we coined the phrase “evidence-based health.” Evidence-based health has 3 parts. First, evidence-based medicine – so the care team does all the things that have been shown to work. Second is health coaching, helping patients to incorporate the evidence into their lives. The third component of evidence-based health is community health, or all those upstream factors that make it difficult for patients to fulfill their action plans. This takes guideline-driven medicine, adds on the self-management piece to help people implement the guidelines themselves, but also recognizes the toxic environment in which many of us live. It’s like housing and asthma. You can do all the action planning you want with patients with asthma, but if you don’t deal with the mold in the walls, it’s not going to make much of a difference.

So it’s primary care engaging with the patient, and also looking at the broader context in which the patient lives or works?

Exactly. It’s where primary care and public health need to come together. And of course, that’s the big divide that nobody’s been able to figure out. Because primary care folks are too busy to deal with public health, and I think a lot of public health people care about primary care but they’re in a different world. The two worlds need to be in one world.

I often think of public health and primary care on a continuum, community to individual, but we’re often not talking to each other.

JAMA just had a 50-year issue on the progress on reducing smoking to improve population health. It was a wonderful issue, and they pointed out that most of the effective interventions have been public health interventions – the cigarette taxes that increase cost, smoke-free zones and mass media campaigns. Our counseling hasn’t made nearly as much of a difference as the public health measures. One author pointed out that most people who stopped smoking just did it by themselves. By now, thanks to public health messaging campaigns, almost everybody who smokes knows that it’s bad for them, it’s just hard to quit. So it’s pretty clear that with regards to smoking, which is still the biggest killer in the US, public health has been enormously successful, way more than medical care.

On that note, you also do work in health policy. Can you talk about that?

There’s the macrosystem and the microsystem. For example, how much primary care providers get paid. Because they get paid a lot less than specialists, most medical students don’t want to go into primary care and it’s harder work. So that’s a macrosystem health policy issue. The microsystem, in contrast, is what happens at the level of the individual practice or clinic.

Our group at UCSF is called the Center for Excellence in Primary Care. Most of the work we’ve done is microsystem work. We try to figure out how can we help practices work better. How can we help them use data to drive quality improvement? How can we help primary care teams work together? See more patients? Primary care doesn’t have enough capacity to see all the patients who need primary care. We’ve also developed models for providing intensive health coaching for complex patients – the 10% of patients who incur 70% of costs. All of those things are microsystem improvements that desperately need to be done, because a lot of primary care clinics don’t work well at all.
This relates back to the macrosystem, because if medical students train in primary care clinics that don’t work well, or all the doctors are unhappy and burned out, then the students say, “I don’t want to go into this!” So the two are related.

Can you illustrate what that looks like?

One of the practices we’re working with is a pediatric practice. One of their goals was to improve cycle time. Low-income families come in, it’s a teaching clinic, so they see a resident. The resident then goes to the attending to get precepted, the patient’s sitting there with kids bouncing off the wall. Finally the resident comes back, maybe with the preceptor. Then the kids haven’t gotten their immunizations yet because the preceptor has to approve the immunization order, so then the families have to wait even longer for the LVN [licensed vocational nurse] to get everything ready. So families are waiting a long time, and it’s really hard for patients with small kids to wait so long. Our analyses showed that roughly 50% of the cycle time – which was 2 hours – was waste and 50% was value-added.
We had to figure out how to reduce the waste, and a lot of it had to do with the workflow for immunizations. If we could get the immunizations approved earlier and done while parents were waiting for residents to come back, we could maybe reduce the cycle time by half an hour. That’s an example of the kinds of things we try to do with clinics. Sometimes we fail and sometimes we succeed.

When you think about public health or primary care, what do you see as a persistent challenge?

I think it’s where the dollars go. It’s something like 3% of the total health budget, which is about $2.25 trillion, goes into public health, and about 6% goes to primary care. A lot of it goes to specialists and hospitals and to interventions that aren’t evidence-based and that patients don’t even need or want. Some of it is end-of-life, unnecessary surgeries, unnecessary tests. There’s a whole movement called “Avoiding Avoidable Care”. To avoid care that’s unnecessary, and thus drive down costs.
We need to completely redistribute the health budget so that way more goes into public health and primary care. There is plenty of money in the healthcare system, and it is maddening to see the priorities of where that money is spent. It’s the paradox of excess and deprivation.
There are so many people who have so much care that they don’t even want, and a lot of this is driven by fee-for-service payment. And then there are a lot of people at the other end – the uninsured, minorities, vulnerable populations – who don’t get care. It’s a huge challenge and it won’t be easily solved. So much money goes into the far downstream care of people who didn’t get the upstream prevention and primary care that they need.

What might it take to solve this problem?

Well, I know what the healthcare budget would look like – channel the money that’s being wasted on unnecessary care in specialty and unneeded hospital admissions, etc., and redirect it into primary care and public health. How to get there is political.

The will to do the right thing in this country seems to have waned in the last 50 years, and I don’t know if we’ll get it back. So people can see what the solution should look like, but I cannot see how we’re going to get there. I can give you a bunch of platitudes about how we have to elect Don Berwick as Massachusetts’ governor (former head of the Centers for Medicare and Medicaid Services, and former President and CEO of the Institute for Health Improvement) – but it’s much deeper than that. It’s a deep-seated problem and I don’t know how we’re going to solve it. Other countries have solved it because they have political systems that are more rational, I think, and also more humane.
10% of a person’s health is determined by healthcare, and 60% is determined by self-management issues, community issues, education, class, race, anything but healthcare. There’s so much potential for people to live long, wonderful, healthy lives in the 21st Century. People should have the opportunity to do it and the opportunity should be evenly distributed among society, and it’s not. It’s sad to see that the potential of humanity is so variable depending on where you come from, your income, what family you were born into, issues like that. I think that’s, to me, the biggest issue. People call it “disparities.” I think it’s about allowing everybody to have the opportunity to have a long, healthy, happy life, as much as it’s possible.

Joseph F. West, ScD

OriginalIntroduction

After graduating from the University of Illinois, Dr. Joseph West worked in child welfare for two years, where he grew frustrated and decided to pursue a PhD in Sociology.  He was en route to a Master’s in Sociology when he worked on the Project on Human Development in Chicago Neighborhoods, where he met Dr. Felton Earls, a professor in Public Health and Social Medicine at Harvard.  Dr. Earls convinced him to switch paths to public health, and became a key mentor as Dr. West became the first African American to obtain a doctoral degree from the Harvard School of Public Health.  Since then, Dr. West has conducted research in numerous areas including smoking cessation and diabetes.  He has also written and produced several plays including Suga Foot Blues, and the memoir Trod the Stony Road.

Career in Profile:

  • 1994 – Graduated from the University of Illinois Urbana-Champaign with a Bachelors in Sociology and a minor in Economics
  • 1999 – Completed his M.Sc. in Health and Social Behavior
  • 2004 – Completed his Sc.D in Social Epidemiology and Health Policy from the Harvard School of Public Health
  • 2004-2006 – Worked as a researcher on the California Foster Care and Chicago Housing Project Study at Chapin Hall Center in Chicago
  • 2006-2007 – Worked as Project Director at the Center for Study Cultural Diversity in Healthcare at the University of Wisconsin Medical School. Studies included the Neighborhood Disparities Project and the Milwaukee Infant Mortality Project.
  • 2007 – 2013 – Served as senior epidemiologist and project director at the Sinai Urban Health Institute. Work included the Block-by Block Diabetes Community Action Project and the Breathing Freedom Smoking Cessation Project.
  • NOW –  Senior Partner at Whitaker Kinne Group

So how did you end up in public health?

After undergraduate at University of Illinois, I spent two years doing child welfare work transitioning young people involved in foster care to adulthood. I got frustrated with that and I felt that I needed and wanted to go back to graduate school. I wanted to get a Ph.D in sociology and was actually taking classes at Roosevelt University in the evening, studying sociology towards a master’s degree, and then I started working on the Project for Human Development in Chicago neighborhoods.

I was working there during the day, I was going to school at night and that’s when I met Dan Kindlon (sic), Steve Buka (sic) and Dr. Earls. Tony Earls, after a conversation about what I wanted to do and study, he said, “You are not a sociologist, you are an epidemiologist”. I didn’t know what that was, and he said,  “Public health is going to be the key for you”,  and he introduced me to Dan Kindlon, who was part of the project, and wrote that book Raising Cain, that became really popular after the Columbine shootings. Then to Steve Buka, that whole group! So I applied to all these graduate schools and I didn’t get into any except to Harvard.

When I got there I realized why I got into Harvard. It was an eye opener about the graduate process for a Ph.D. It’s a subjective process. I got in because of Dr. Earls. He not only wrote a letter of support, he and Steve, all of the HSPH guys who were working on the PHDCN project wrote letters. They said that this school had not graduated an African American out of the doctoral program and that they would support me. They said I’ve been a part of this project, I’ll have my own data and that they think I should get in. That’s what happened, at least my understanding of it. They made it clear that they were going to mentor me. That was my first introduction to the idea of a mentor and how important mentoring is. Because even though I thought I had the scores and the experience, it was the idea that I was going to continue to work with these scientists that are respected in the field and that they were also willing to allow me to explore some of my own interests while in Boston that led me to public health.

What was working on that project like?

It was incredible.  Field research and collecting data in the field is tough. Its funny because now I am the director of a project where I have people go out to do just that. So I understand what they do because I did it for a year.  Its interesting because when you are in people’s homes, not only are you collecting data on the questions that are on the protocol, you are also collecting data based on your interaction and experience with them in that moment.  I was one of the few research assistants that actually did that.  There were people who went into the homes and only asked the questions and circled the boxes on the list, even though at the end, at the back of the protocols there were all these pages with space for notes. People didn’t write down information about what they were seeing and what was going on and what was happening in the house etc. They didn’t do any of that, but I did. I would try to fill up mine, because there was a lot that I thought was relevant in that home or in that community that was beyond the questions and the boxes. With my team now that’s the hardest thing to get them to do. I try my best, but my team is guilty of that.  They don’t feel comfortable writing it and they don’t feel comfortable commenting. I say all this to say that I realized then that I wanted to do more. I wanted to do more than just to collect the data, I really wanted to do more.

What is one of your greatest career challenges?

Finding the time to write.  Whereas some people can analyze a large dataset and then write, I have to interact with the community or with my team on a daily basis. It’s challenging to block off time to write. I’ve also had to learn to speak to different audiences and to different issues.  My greatest challenge has been putting together my body of work.  I’ve found my stride.  I know exactly what I want to write about and where to build my research. I’ve started another book and I’ve got my focus. I feel a bit of pressure because of my age.  I may not have reached some of my personal benchmarks, but I have reset them, and I want to really reach those goals. If you don’t outline your career steps right now, you will probably bounce around, and will not build a cohesive body of work. I want to build a coherent body of work and continue to grow.

What is something in your career that you feel really proud of?

My diabetes work.  I got the grant funding and started working in the community through the Block by Block project, and there’s been some spin off.  We’ve been able to fund other activities in the neighborhood, to start a dialogue about diabetes and food.  We can engage the community around these issues.  In the Lawndale Diabetes Project – a follow up of the Block by Block project – we train health educators to go door to door within the community.  They talk with residents about diabetes, provide basic guidance around diet, exercise etc.  After we work with people to get them advice and support, they can be turned over to disease management and then follow up with doctor appointments etc.  So now, I’m at that point in my career where I have enough, in terms of ideas and experience, to really produce.

I am fascinated that you’ve written a book that is not entirely public health related, and that you are also producing plays that seem public health oriented. Can you talk about those projects?

By my understanding, I was the first African American male to obtain a doctorate from the Harvard School of Public Health.  I wrote Trod the Stony Road to try to make sense of my journey.  I live in the community where the Lawndale diabetes project takes place.  I also lived in East St. Louis, a pretty challenged community.  I had a brother who used to be in and out of prison.  So how does a kid come from this type of background make it all the way to Harvard?  I talk about all the things that I went through, from an attempted suicide when I was 13 to having a gun to my head, and then I talk about grace and my sense of space.  That I was spared for a reason, or maybe for some kind of purpose, was something I needed to make sense of.  I felt like I was just stumbling forward, trying to make sense of it all. That’s why I wrote that book.

As an undergrad I did a lot of theater, and I’ve realized that my creative side is just as important as my scientific side. I like to write!  I’m doing diabetes scientific work, and that’s what for one audience.  But there’s another audience that needs to understand the human side of diabetes.  Suga Foot Blues is the story of a female dancer who has Type II Diabetes. She hasn’t taken great care of herself, so she is going to lose her foot. We all know all the clinical issues that come with poor management of Type II Diabetes … but what about when she goes home and has to deal with the emotional issues?  What happens in that home?  Because it’s not just her, she has a family and they have to deal with it, too.  It’s how I take my day-to-day profession and turn it into art.   It is about the healing power of art, theater and the spoken word; it’s about how you take relevant, quantitative, quantifiable data and translate it into art.

So when it comes to public health, what matters to you and why?

Public health really is about human development and what people need to learn early in life.  Adult behavior change and learning is difficult, even things like washing your hands are difficult. Our relationship to food, our cultural rights and rituals with food…a lot of people are not connected. There are a lot of social networks but people are not connected. We have a culture that promotes recklessness with each other and with our selves.  We all struggle with learning.

Many of the poverty-related health issues relate to lack of empathy and understanding.  It’s not strictly economic.  Before diabetes, I worked on a smoking cessation project where we tried to reach out to young pregnant girls. Most were exposed to large amounts of second hand smoke.  Their challenge was that they didn’t have a place to stay, so they might be with their parents or grandparents, and say their mother had a boyfriend and they both smoked.  “I can’t tell them not to smoke just because I’m pregnant, because they’ll say, ‘You’re the one that’s pregnant, you move.’  Or maybe her boyfriend is really abusive and she can’t tell him to not smoke.  You realize that there are people that don’t have empathy for her or her child’s health. That’s not racism! That’s not poverty! That’s a lack of human development and empathy.

Our diabetes project has a cooking class, and one participant said that when she tried to cook a really nice meal and serve with right portion sizes, her family looked at her like she was crazy.  “I’m supposed to eat this little bit of food?  You are supposed to fill up my plate.  You’re the one that has diabetes, not us!”  If people aren’t supportive, what can you do?

Policy makers also lack human development and empathy.  They create policies without understanding how those policies impact people’s lives.  We have illiterate policy makers and legislators. They can read what’s written, but they can’t understand the human condition.  There’s a gross degree of lack of understanding on both sides of the aisle.

So what is your ideal solution?

That’s a challenge. We have to start on both ends.  We have to engage people at a grassroots level to talk about their own health, well-being, community, family.  I see so much fragmentation and brokenness in communities now.  We have to think about how we can be connected together.  At the other end, we have to get politicians and policy makers and legislators to have honest discussions about policy.  We have not had a truly honest discourse about policy.  Everything is a sound bite, and you can’t grow on a sound bite.

Sandra Witt, DrPH

Sandra Witt - for collageIntroduction

Dr. Sandra Witt spent 14 years at the Alameda County Public Health Department, where she played an integral role in pioneering health equity practice. She worked on programs and policies responsive to public health issues affecting County residents with the goal of eliminating health disparities.  This work, along with her leadership in health surveillance, monitoring, and technical assistance, won her an Outstanding Manager of the Year award.  Sandra is currently the Program Director of Healthy Communities (Northern Region) at the California Endowment, where she, along with the Senior VP of Healthy Communities and her counterpart in the Southern Region, oversees the implementation of a place-based initiative to strengthen some of California’s most vulnerable communities.  Her commitment to achieving social justice in public health, plus her insights and experiences in transforming public health practice to achieve health equity, make her an obvious public health hero.

Career in Profile

  • 1977 – Obtained BA in Sociology and Health from McGill University
  • 1983 –  Obtained MA in Latin American Studies/Anthropology from University of Florida, Gainesville
  • 1985 – 1990 –  Health and Development Officer, International Development Research Centre, Ottawa.
  • 1991 – Obtained MPH from UC Berkeley
  • 1997 – Public Health Consultant, International Health Programs of the Western Consortium for Public Health
  • 1998 – Completed Dr.PH in Maternal and Child Health, UC Berkeley School of Public Health
  • 1998 – 1999 – Epidemiologist, Alameda County Public Health Department
  • 2000 – 2010 – Director of Community Assessment, Planning, Education and Evaluation, Alameda County Public Health Department
  • 2007 – 2010 – Deputy Director of Planning, Policy and Health Equity, Alameda County Public Health Department
  • 2011 – present – Director, Healthy Communities (North Region), The California Endowment

You’ve worked on health equity practice from two different perspectives, a local health department and a foundation.  Can you tell us a little about your work in each?

During my time at the Alameda County Health Department, we recognized that we could continue to provide needed services – and the community certainly needed services – but it was also important to figure out how we could change the social conditions that created the need for services and entrenched health inequities to begin with.  We felt that the real focus of health equity is not just health disparities – the outcomes in health status – but rather the root causes that create those disparities.  Today it is widely recognized that there are huge differences in life expectancy based on where you live.  Your zip code matters.  When we were starting this work we invested resources to get people to understand that the opportunities in place have a lot to do with how long and how well you live.

Currently I work at the California Endowment, where I’m the Director of Healthy Communities (Northern Region).  We have a $1 billion, 10-year initiative that focuses on building healthy communities where children are healthy, ready to learn, and safe.   The initiative selected 14 places across the state that had 1) poor health outcomes and social inequities, and 2) experience and interest in working together to solve community problems.  We started with a planning process that created a space for community voice to shape community priorities.  Each site came up with a community plan, which  guides the Endowment’s grantmaking on strategies that support efforts that meet the community’s priorities to improve health.

Moving to the foundation was an opportunity to further the work we’d started at the health department to figure out how to support efforts, which change the social conditions that create poor health outcomes.  The Endowment has an incredibly bold and big vision of what change can look like, which is exciting.

Often times, the residents that are most marginalized in our society are not included at the  decision-making table or processes that directly impact their lives. They need to be included in shaping the solution.  So equity and inclusion are core elements of how we think about this work.  A key piece is recognizing which issues are important to our communities – especially ones that disproportionately affect low-income communities of color – and then raising the profile of these issues within our communities.  Another piece is creating opportunities to educate policymakers about how these issues affect our communities and the health of our communities. Another key component of our work  is focused on power-building — building the leadership capacity of adults and youth to advocate on their own behalf. We also foster collaboration so that people from different perspectives can come together to develop policy solutions.

For example, in Fresno the young people raised the issue of school suspension and expulsion.  They felt that these disproportionately impacted young men of color and we know that suspensions and expulsions can contribute to a trajectory into the criminal justice system.  So we supported organizing to bring attention to these issues within their communities.  The Endowment’s statewide policy branch also realized that these concerns could be addressed through statewide policy.  State and local advocates worked together to identify positive school discipline practices and policies. One of those practices is implementing restorative justice, which can bring down suspension rates quite quickly.  After a lot of organizing by our local and state partners a number of state bills passed that addressed suspensions and expulsions in schools.

If you only think about health in the context of the doctor’s office, you miss opportunities to affect the many other factors that impact a community’s trajectory to good health, like school discipline policies and practices.

 I’ve heard you speak about “health equity practice.”  Can you tell us more about that?

Public health departments, as they stand now, are not really set up to focus on broader social conditions.  So when we think about transforming public health practice to address health inequities – what we call a health equity practice – we have two grounding principles.  First, in all the work that we do, we should think through how policies or practices impact health inequities.  This helps us think through where to focus first.  Second, we ask if there are processes for the people who are most impacted by these decisions, to have the opportunity to participate in shaping the solution.  Those perspectives and lived experiences are key to the conversation.  You need to think about both if you want to engage in practices to address health inequities.

Health equity practice is part of a broader public health move to change the social conditions that impact health.  Poor health outcomes often concentrate in particular places.  Place is where you live, work and play and shape the opportunities you have to be healthy and productive.  This analysis was key in leading us  to recognize we have to focus on changing the social conditions that create these inequities.  In health equity practice, we’re looking for ways to change policies and practices in institutions that work in education, housing, transportation, economic development, etc. so that everyone’s health can be improved. A core component of health equity practice has to be focused on creating and institutionalizing mechanisms for the most marginalized to participate in decision making on issues that impact their health and well-being.

Let’s say I’m working in a health department and want to widen my health equity practice, do you have any suggestions for how we might go about doing that?

I can share how we did it at Alameda County.  At the health department, we were very intentional about working directly with residents and community organizations in areas that had the lowest life expectancy.  These communities identified their priorities, and we partnered with them to bring in other partners to address  those issues.  So that’s one place to start.  In our work at the Endowment, as well, we’ve started with what communities, residents, and community based organizations identify as the priorities.

There’s an internal piece of this work and then there’s an external part of the work.  A big piece of equity and inclusion is understanding the historical legacy of racism and how that impacts our communities.  The health department invested in the development of a curriculum for all staff to understand these topics.  We covered: What is public health? What is the broader environmental and political context within which health is produced? And why do certain neighborhoods look the way they look?  What are the historical reasons or policies and practices that we, as a society, put in place, which created the opportunities for some and disadvantages for others?

This built a shared understanding within the health department. At the same time we worked with communities and learned from those experiences as well. If we don’t look at what we do as an institution and identify how we create barriers to inclusion and perpetuate inequities, we cannot reach our goal of achieving health equity. You don’t end up working with the community.  You think you’re doing things for the community, but really you’re doing things to the community.

I don’t want to underestimate the importance of this step.  It requires leadership and willingness for honest self-examination.  It also requires a willingness to understand how our processes have impacted our populations.  It helps the organization understand hurdles to the work and what it means to build authentic relationships with the community and residents.

For the external work, when figuring out how to begin engaging residents and community organizations, one step we took was to tap into the assets of our own staff.  At the health department, our staff came from all over, including many from these very communities. We created opportunities in-house for staff to talk to us about what was going on in their neighborhoods.  We showed them the data, but we also wanted their reflections about : What’s going on?  If you were going to talk to somebody, who would that be? Are there organized groups there? Are there CBOs we should link with?

Honestly, I think we sometimes forget our staff and our internal resources.  For example, community outreach workers are in many communities, and they became essential for putting us in contact with folks whose houses they regularly visited.  Through those kinds of connections we could begin to go out, meet people, create opportunities, and pull people together for community meetings.  In many of our communities, particularly our most marginalized, historically things have not changed.  There’s a lot of distrust of systems– appropriately so as there has been a history of broken promises.  Part of the process is developing a relationship with residents and getting a better understanding about what the realities are.

We also wanted to think about the assets of local communities.  So we visited a lot of churches, for example.  In one of our communities, we reached out to a school principal to coordinate efforts around fielding a community survey to identify priorities.  Every year, the principal asks her teachers to go out and meet her students’ parents because she wants her teachers to understand the community that her students live in.  We wanted to do a community survey.  We already had a group of residents who shaped the questions in our survey.  So she teamed her teachers with our health department staff and community folks to administer the door-to-door surveys together.  That was a powerful partnership – with residents and between public health and the educational system.

This work is really big and can sometimes feel overwhelming. I think it’s important to break it down and figure out where to start.  The truth of the matter is that there are multiple entry points into this work depending on where your health department is and where the communities are.

Jack Geiger, MD, M.Sc., ScD

J Geiger - for collageIntroduction

Dr. Jack Geiger and colleague Dr. Count Gibson are often credited as the pioneers of the community health center movement in the United States. Dr. Geiger was active in the Civil Rights movement in the early 1940’s and, after completing his medical training, participated in the Freedom Summer in Mississippi in 1964. Within the following years, Dr. Geiger helped organize residents in Bolivar County, Mississippi, and in the Columbia Point Public Housing Project in Boston, MA, to establish the nation’s first two community health centers. The health centers were funded through the Office of Economic Opportunity, the agency directing the so-called War on Poverty. The early health centers provided important medical services but also addressed the social determinants of health such as poverty, unemployment, malnutrition, and environmental health issues. There are now over 1,200 health centers nationwide, which were modeled after these community health centers.

Career in Profile

  • 1941-1943 – Studied Liberal Arts at the University of Wisconsin
  • 1943-1946 – Military service
  • 1947-1950 – University of Chicago, Division of Biological Sciences
  • 1950-1954 – Science and Medicine Editor, International News Service
  • 1954-1958 – Completed MD, Western Reserve University School of Medicine
  • 1958-1959 – Intern, Harvard Medical Service, Boston City Hospital
  • 1959-1960 – Completed MSc in Epidemiology, Harvard School of Public Health
  • 1959-1961 – Postdoctoral Research Fellow, Social Science in Medicine, Harvard University
  • 1961-1962 – Instructor in Preventive Medicine, Harvard Medical School
  • 1962-1963 – Assistant Medical Resident, Harvard Medical Service, Boston City Hospital;
  • 1963 – 1964 – Senior Resident in Medicine, Harvard Medical Service, Boston City Hospital and Research Fellow, Thorndike and Channing Laboratories
  • 1964-1965 – Clinical Assistant, Harvard Medical Service, Boston City Hospital; Assistant Professor of Public Health, Harvard School of Public Health
  • 1965-1966 – Associate Professor of Preventive Medicine, Tufts University
  • 1965-1971 – Project Director, Tufts Comprehensive community Action Program; Director, Division of Community Health, Tufts University School of Medicine
  • 1966-1969 – Professor of Preventive Medicine; Director, Division of Community Health, Department of Preventive Medicine, Tufts University School of Medicine
  • 1969-1971 – Professor and Chair, Department of Community Health and Social Medicine, Tufts University School of Medicine, and Chairman, Ambulatory Care, Tufts-New England Medical Center
  • 1971-1978 – Professor and Chair, Department of Community Medicine, State University of New York at Stonybrook, School of Medicine
  • 1978-1997 – Professor and Chair, Department of Community Health and Social Medicine, City University of New York Medical School
  • 1983-1984 – Senior Fellow, Center for Advanced Study in the Behavioral Sciences, Stanford University
  • 2004-2007 – Visiting Professor of Epidemiology, Mailman-Columbia School of Public Health
  • NOW:  Arthur C. Logan Professor of Community Medicine, Emeritus, City University of New York Medical School

What led you to get involved with the creation of the community health center movement in the United States?

We all stand on the shoulders of others. The contemporary community health center, and the development of community-oriented primary care, was really developed in – of all places – apartheid South Africa in the mid-1940’s by Sidney and Emily Kark and their colleague physicians and others. There were more than 70 community health centers in South Africa serving Africans, Indians, and some poor whites.

In 1957, at the beginning of my senior year in medical school, the Rockefeller Foundation – which had heavily funded the Kark’s work along with the South African government at the time – gave me a scholarship to go for four months to study and work at the Pholela Health Center and an urban Zulu housing project health center called Lamontville in Durban. That experience changed my life. It taught me about community health centers and set me on the path to get what I thought was the appropriate training for global health, particularly in the third world.

I had been in civil rights work since I was a teenager starting in 1942. In 1964, at the end of my training, I went to Mississippi as part of  the Freedom Summer with an organization that about twenty of us from across the country had started called the Medical Committee for Human Rights. It was created to be the medical arm of Freedom Summer and the Civil Rights Movement at its peak. That month in Mississippi, I had the chance to take a long look around and realized that I didn’t need to go to Africa, Latin America or Southeast Asia. All those problems existed here in the rural South, the urban northern ghettos, in Appalachia, in the Native American Reservations – not at the same absolute level but certainly at an unacceptable and hideous level, relative to the health of the rest of the population. With my colleague, Count Gibson, who was then chair of Preventive Medicine at Tufts Medical School in Boston, we kept coming back to Mississippi.

At a meeting in December of 1964 with many folks from the Freedom Summer and Indigenous Civil Rights Workers, sponsored by the Delta Ministry of the National Council of Churches, I said what really needed to happen in this country was the development of community health centers that would serve identifiable populations in need. I’d remembered my four-month time at Pholela and Lamontville, and thought we should bring that model here. We would use the principles of community-oriented primary care and population health to deliver services and, although we didn’t use the words at the time, address the social determinants of health.

There was a brand new federal agency – the Office of Economic Opportunity, the so-called War on Poverty – and that gave us our window of opportunity to first convince them to do this, and to make it a part of their community action program and to develop this new model of delivery of healthcare services. In January of 1965, I made my first approach to the people at OEO. After a lot of struggle and convincing, the first grant for the first two community health centers in this country – in rural Bolivar County, MS, and Columbia Point, a public housing project at the edge of Boston – was approved.

How hard was it to launch the first two health centers in the United States?

Columbia Point Health Center in Boston was relatively easy to open. Mississippi took a lot longer. It took a while to identify the site, and then to convince the Poverty Program, which was very nervous about working in place like Mississippi. We also had to deal with concerted opposition by the state Governor, the state public health department, and the state medical society, and all of the other forces aligned.

Despite the fact that their own data showed an overwhelming need – huge, third world level infant morality rates in the African-American population – they recognized that this was a very different model and it would directly empower impoverished black populations as partners in the delivery of their own health services, thus bypassing all the gatekeepers and mechanisms of control that the white power structure had up until then exercised.

How did the new model of care directly empower the populations you were serving?

From the very beginning, one of the most important components of the health center effort – along with the doctors, nurses, public health nurses, and sanitarians and environmental engineers and social workers, and the all other kinds of people that we had managed to recruit and assemble – was what we called community health action, which was really community organizing.  We did careful and prolonged and solid community organization – rather than just picking existing community leaders who tended to step forward and say “Looking for the community? Here we are.” – and organized ten different community health associations in the ten major areas of our 500 square mile piece of Bolivar County. That took time, explanation, and innumerable meetings for people to begin to understand what we proposed to do, and to assess their own health care needs.

What were the most successful interventions at Mound Bayou/Columbia Point?

Simply to deliver medical care but also hospital care in two small black hospitals that existed in Mound Bayou, the town where we were physically based, but with satellite centers at ten different points throughout our target area – to people who had never before seen a physician under the old plantation system. The cotton sharecropper system had collapsed and been replaced by mechanization, and there was profound poverty and profound unemployment. There was widespread hunger. There was widespread unemployment. People were squatting on the land in old plantation shacks and they had no significant prior access to medical care, except for the work of some fraternal organizations that had built those two small hospitals and in effect sold health insurance for 25 cents or 50 cents a week.

To deliver medical care to populations living in those circumstances would have been simply to send people back from the health center into environments that determined overwhelmingly that they would be sick and hungry and burdened with the same illnesses all over again. They were drinking water from the drainage ditch or collecting water in old pesticide drums. They were often living in housing that wasn’t fit for human habitation.

So I would say that our second most important intervention was a series of environmental interventions. We dug protective wells. We built sanitary privies. We thought we would start vegetable gardens as a way to start to combat hunger, and hopefully we would get maybe 100 families to do that. We were sitting on some of the richest topsoil in the United States. A thousand families raised their hands. What emerged from that, as a partner to the health center, was a 500-acre, triple crop, irrigated vegetable farm that grew thousands of tons of greens, potatoes, sweet potatoes, lima beans, peas, kale – you name it – over the next several years. Those thousand families and members traded their labor for shares in the crop – nutritional sharecropping.  But this was a different kind of plantation because with both foundation and governmental help, the Farm Co-op was, as the name indicates, a cooperative. The people who worked the land owned it. We virtually eliminated malnutrition in our target area.

Is there a success that you are most proud of?

There are now more than 1,200 community health centers in the United States delivering care at 9,000 different points of service around the country and taking care of something like 22 million people. And of course that’s not me, that is thousands and thousands of people working in those community health centers and their supporters. The community health center has become the backbone of the healthcare safety net in this country. That’s something that I don’t think we even dreamed of when we were starting those first two health centers.

How far do you think we’ve come, as both a nation and the community health center movement specifically, in addressing social determinants of health?

In the first years of the health centers, it wasn’t rocket science to figure out that medical care alone was insufficient. But national political administrations changed and there were efforts by both the Nixon administration and later, in particular, by the Reagan administration, to block grants to health centers, to hand them back to the states, including the southern states, to remove the direct pathways to community empowerment. While those efforts were beaten back, often by Republican congresses in the face of those presidential efforts, community health centers, starting in 1975 and to some extent ever since, have been increasingly restricted to simply the delivery of personal medical services – primary, preventative and curative care – rather than other kinds of interventions. Although, I should add that many health centers found state, local, philanthropic or other funding sources to undertake efforts to continue doing such additional things themselves.

What has happened now, and that is beginning to happen, is that community health centers and indeed hospitals and other health delivery organizations, are going to have to do this by collaborative efforts with other organizations – with public health agencies, with housing departments, with transportation departments, with county executives – to mount, in collaboration, the same kind of interventions.

What is the most persistent public health problem today and what is your ideal solution?

That one is easy. One word: Poverty. That comes before any specific disease identification, HIV, Malaria, malnutrition, you name it. Because they all are linked to poverty, attended by poverty, spread from centers of poverty. One of the things that is very poorly appreciated is that when the War on Poverty, and the whole series of efforts that it represented – the health programs, the Job Corps programs, Head Start – all of the other things that the Poverty Program did in the 1960’s and 1970’s, when the Poverty Program began, the poverty level in this country was roughly 22%. That’s when Michael Harrington wrote “The Other America” and put this on our national agenda. Twenty-two percent of the population of the United States – a fifth – was in poverty. Ten years later, that proportion was 11%. That is a phenomenal success and should be a guideline for the fact that we need to continue that kind of effort and re-launch it now.

This feature was interviewed, transcribed and partially edited by our guest editor, Ted Henson.

Laura Sanders, LMSW, ACSW

Laura SandersCo-founder of the volunteer grassroots organization Washtenaw Interfaith Coalition for Immigrant Rights (WICIR), therapist, lecturer and professor at the University of Michigan School of Social Work, Laura Sanders wears many hats, several of which converge around the issue of immigrant rights. She co-founded WICIR with her partner, who was undocumented at the founding of WICIR, and other community members, in response to increased levels of immigration enforcement in Washtenaw County, Michigan. Washtenaw County is located within 100 miles of the US-Canada border, which means the region has several border patrol officers and other immigration enforcement officials who are empowered to question and detain residents about their immigration status. This also means the Department of Homeland Security can set up fugitive operation teams to facilitate deportations, which have increased since 9/11. In her role with WICIR, Laura is a community organizer, coordinator and immigrant rights advocate. She works with communities that have experienced numerous immigration raids and heightened surveillance by Immigration and Customs Enforcement (ICE), local police, and law enforcement. Immigration enforcement has tightened since 9/11, to the point where Laura calls this issue “perhaps the most intensively negative civil rights issues of our time.” Laura’s dedication to responding to the effects of immigration enforcement on the lives of individuals, families, and communities traumatized by immigration raids, and her and WICIR’s work to create change among law enforcement agencies make her a true public health hero.

Career in Profile

    • 1982 – BA in Women’s Studies, minor in Psychology from the University of Michigan, Ann Arbor, MI
    • 1982 – Youth Employment Counselor, Washtenaw County, MI
    • 1982-1983 – Counselor and Medical Assistant, Womancare, Ypsilanti, MI
    • 1983-1984 – Outreach Health Educator, The Corner Health Center, Ypsilanti, MI
    • 1983-1985 – Co-Director of Women’s Programs, University of Michigan Human Sexuality Office, Ann Arbor, MI
    • 1984-1985 – Project Coordinator, Student Health Advocacy Board, The Corner Health Center, Ypsilanti, MI
    • 1985-1986 – Community Liaison and Administrative Assistant, The Corner Health Center, Ypsilanti, MI
    • 1985-1987 – Health Educator and Project Director, The Corner Health Center, Ypsilanti, MI
    • 1988 – Family Therapist Intern, Child Sexual Abuse Treatment Unit, Children’s Center of Wayne County, Detroit, MI
    • 1988 – Master of Social Work from the University of Michigan School of Social Work
    • 1989-1991 – Therapist, The Family Awareness Center, Adrian, MI
    • 1996-2002 – Associate Clinical Director, Family Assessment Clinic Child Abuse and Neglect Program, University of Michigan School of Social Work, Ann Arbor, MI
    • 2002-2013 – Trainer and Consultant, Vista Maria Residential Treatment Center for Girls and Clara B. Ford School
    • 1994-2012 – Director of Creative Counseling for Families and Youth, Ann Arbor, MI
    • 1991-NOW – Clinical Social Work Therapist, Group Therapist, Program Coordinator, Ann Arbor, MI
    • 1996-NOW – Faculty member at the University of Michigan School of Social Work, Ann Arbor, MI
    • 2008 – Co-Founded Washtenaw Interfaith Coalition for Immigrant Rights (WICIR), Washtenaw County, MI

What inspires you and the work that you do?

My personal values around equality are fundamental to who I am and all the work that I do. But what really inspires me is anger. It angers me to see people mistreated, or that our community and society finds discrimination acceptable! I’m also inspired by my personal experiences. Certainly my relationship with my partner [who was undocumented when we met] has been very inspirational. I’m not sure I would have understood – and been as close to this issue – if I hadn’t met him. Knowing him, being with him, his community becoming a part of my community: this taught me so much. Without him, I don’t know that I would have understood this issue enough to get this close to it.

Our organization keeps me going. And really, what keeps us going is this incredible relationship with the immigrant community, especially the undocumented community. The undocumented community is still very vulnerable to scapegoating and harm by our immigration policies. It’s also inspiring to meet community members, empower people, watch change happen, see policies slowly begin to shift, and work with people to manage the conditions they’re in.

What is a career success or highlight that you are particularly proud of?

In terms of our organization, I’m very proud of our relationship with our county sheriff. We have really struggled to nurture a relationship with the police and our local police force. We take calls from the community when they’re facing immigration issues, and have documented about 480 calls. Of those calls, half include at least one person who has been detained or deported; hundreds of children have lost their parents or significant providing adults. 30% of those detainments and deportations started with some kind of local traffic stop.

So there’s a process by which people end up getting tagged for immigration enforcement through local police involvement. It’s been very important to raise police consciousness around this issue, especially the devastating effects in the community. We’ve also pushed for policy shifts that separate local police enforcement from federal immigration law enforcement. We got a resolution passed in the Ann Arbor City Council that states that the Ann Arbor police will not be involved in immigration enforcement.

But there are thirteen municipalities in Washtenaw County and then there’s also the sheriff. We’ve really nurtured the relationship with our sheriff, and he’s been very communicative with us. A few cases that came to his attention helped him shift internal policy around how the police will deal with immigrants and immigration issues. That feels like effectiveness.

We’ve also worked with the Coalition for Tuition Equality. We have a group of undocumented teenagers who are DREAM Act students, and we participated in running a program called Sueños that brought parents and undocumented students together for mentorship from social work students. That group became a very powerful voice and became involved in tuition equality. We just won tuition equality for undocumented students at the University of Michigan, and for students who are eligible for Deferred Action Childhood Arrival (DACA) at Washtenaw Community College! So we see these effects happening. These are small local policies, but we believe that these are very important changes because they’re setting our community up for whenever our government gets around to creating real immigration reform. These changes create a base to make people’s lives a little bit more livable. Unfortunately we’re in this big political quagmire that isn’t delivering on immigration reform right now. So, we think very broadly and globally about immigration issues, but we act locally.

What is a challenge that you’ve faced or you continue to face in your career?

There can be a tension between the micro work and the macro work that WICIR does. One of our missions is to provide urgent response for families facing increased immigration enforcement. So we might get a call from a devastated, crying mother where Immigration and Customs Enforcement (ICE) has taken her husband on his way to work. He’s disappeared into some detention center. She has no idea where he is, who took him, why he didn’t come home, her three children are all upset and he’s the provider. Her first order of business is to find her husband.

So this is a micro activity – helping one woman and her family. It’s a crisis intervention. On the other end, we could channel all of our energy towards community organizing around immigration reform, because ultimately we need a policy shift to change this situation. So it’s challenging to figure out how much to pay attention to people’s individual needs, and how much energy do we have to shift policy? Keep in mind, we’re a volunteer organization.

I believe that when we meet the needs of the community, we involve the community. The community then becomes more self-sufficient and more engaged, and those most affected engage in community organizing to change policy. That’s certainly how it’s played out over the last five and a half years. We are proud of it, but it’s challenging to do both. It’s very tough to have enough energy to meet people’s individual needs but also work towards systemic change. Some community organizations decide not to bother with people’s individual needs because it’s just becomes too consuming.

We have a diamond that demonstrates the activities of our organization. Urgent response is at the top. If we do this well, we learn what the community needs in order to be well educated. We learn what policies need changing. Policy change is another mission. By this I mean local and national activism towards policy change. A third mission is to bring the undocumented community into the center of the organization, so that they make decisions about our projects. Our organization is a very nice partnership between the undocumented community and the “allied community” – people of privilege who are linked and partnered with the undocumented community to create change. It’s challenging to continually keep the undocumented community in the decision-making role, and I feel very proud of the way our organization has kept that as a primary mission.

When it comes to public health, what matters to you and why?

Access to resources matters most to me. I’ve learned so much about what it means to be a US citizen and how many privileges that truly entails. Undocumented immigration status gets in the way of accessing nearly every resource in every system. The new policy strategy, especially among conservatives, is to put the squeeze on undocumented immigrants until they can’t survive. Then they can “go home.” Many people experience the United States as their home! We’ve always had undocumented migration and we know that. But no one really cared as much as they care about it now. Since 9/11 The Department of Homeland Security has focused on deporting people. The undocumented community has been scapegoated.

About four years ago, the Michigan Secretary of State instituted a rule where you have to have a social security number in order to get a driver’s license. This comes from the federal government’s REAL ID Act. Michigan’s never had that before. People drove without social security numbers, but they could get car insurance which kept people secure. Now, all of a sudden, if you can’t get a driver’s license, you don’t have an updated photo ID, and that means all sorts of resources are no longer accessible. You can’t legally drive. If the police stop you for something legitimate or illegitimate – racial profiling – or maybe you accidentally run a stop sign, then you’ve got another problem.

Access to resources has become increasingly difficult for undocumented people in areas like driving, health care, and school including access to education, higher education, and financial aid. People are afraid to go to the doctor or the hospital because of their undocumented immigration status. You can get food stamps if you’ve got US citizen children. Otherwise, there are no benefits. We give them a Tax ID Number so they can pay taxes, but we won’t give them a Social Security Number so that they can reap the benefits of paying taxes. It’s silly to say that undocumented people are sucking up our benefits. They’re not eligible for most of them! That’s a major public health issue. The ability to function in the various systems that we interact with daily. All those systems we take for granted, like the ability to have a valid driver’s license or access health and dental care.

Is there a persistent public health problem that still concerns you today?

This may seem like a stretch, but I’m very concerned with our very broken immigration policy, our broken system, and the politics behind it. The undocumented Latino community has been particularly targeted and scapegoated. Until 9/11, we never really had a Department of Homeland Security. Then, we poured a lot of money into that department to prevent terrorism. This is a bit simplistic, but there aren’t that many terrorists to go after, and because so much money was moved towards the Department of Homeland Security, their mission shifted to also focus on the US-Mexico border.

That border happens to be the world’s largest land border between a more developed country and a less-developed country. Whenever you have that situation you’ll definitely have people coming over the border. Our free trade agreements have contributed to the problem by exacerbating poverty in Mexico, Central, and South American countries. Our large US-subsidized agricultural companies put a lot of small farmers out of business. We’re focused on locking down the border, but we’re contributing to the conditions that drive illegal immigration.

There’s just a lot of economic and immigration enforcement policy that needs to be rethought and reworked. This immigration policy is very, very broken. My spouse had an approved application and he waited 16 years for a visa. He would have had to wait 23 years. If you’re in a drastic situation and trying to improve your life, you can’t wait that long. The system is broken for the people who need it. It’s not broken for the businessmen and the others who benefit from undocumented labor and the way the system is set up. Privileged people have benefited. There may not be much impetus to change.

On that notion, what do you think it will take to address this issue of the broken immigration system?

It will take a Congress that’s willing to work – realistically – on something. We’ll need continued organizing and empowerment of the affected community. Change comes from the bottom up for almost any civil rights issue, as opposed to a top down decision made by policymakers. Although I’m frustrated that comprehensive immigration reform has not moved faster, the reform packages we’ve seen so far have included things like an additional $40 billion for border patrol. That will only result in more undocumented immigrants’ deaths as those at the border try to hide and survive. Increased border enforcement and fences have resulted in increased immigrant deaths because people were pushed into more and more dangerous areas. You’re not going to stop undocumented immigration, so you might as well work with a policy that helps. Border enforcement does not.

So even though I’m unhappy with the lack of movement around immigration reform, we also don’t want a bad bill that worsens conditions for immigrants. The more time it takes, the more education and organization occurs at the grass roots level. The DREAM Act students – the young, undocumented youth – have made so much progress in their organizing efforts. The issues they brought to light won the Deferred Action Childhood Arrival policy from President Obama. That’s one indication that grassroots level work creates real, sustainable change. So often we see a Band-Aid approach, or a policy with so many compromises that it’s not even good for the community.

Bob Prentice, MA, PhD

Bob photo 2When Dr. Bob Prentice, PhD, finished his graduate work in Sociology at Michigan State, he packed up his van and drove to San Francisco. Eventually, he landed in the San Francisco Department of Public Health, where he worked for eighteen years, including a five-year tenure as the Director of the Public Health Division. From there, he co-founded and became the Director of the Bay Area Regional Health Inequities Initiative (BARHII), a collaboration of eleven local health departments in the San Francisco Bay Area and beyond. He also served as Senior Associate for Public Health Policy & Practice at the Public Health Institute. Dr. Prentice’s commitment to re-envisioning public health within a social justice context, including his groundbreaking work expanding public health partnerships into fields like land use, air quality management, and transportation policy, make him a noteworthy public health hero.

Career in Profile

  • 1967 – Completed BA in Social Science, Michigan State University
  • 1972 – Completed MA in Sociology, Michigan State University
  • 1982 – Completed PhD in Sociology, Michigan State University
  • 1988-1991 – Coordinator of Homeless Programs, City and County of San Francisco, Mayor’s Office
  • 1982-1996 – Multiple positions with San Francisco Department of Public Health (Health Program Planner, Director of Indigent Programs, Director of Homeless Programs, Director of Community-oriented Primary Care)
  • 1994-1999 – Director, Public Health Division, San Francisco Department of Public Health
  • 1999-2011 – Senior Associate for Public Health Policy & Practice, Public Health Institute
  • 2005-2011 – Director, Bay Area Regional Health Inequities Initiative (BARHII)

 

Can you talk about a career or success or highlight?

The Bay Area Regional Health Inequities Initiative (BARHII) is a regional collaborative in the San Francisco Bay Area with a mission to transform public health practice to eliminate health inequities and create healthy communities. We started out as a series of conversations between the Public Health Officers and Public Health Directors of three counties (San Francisco, Alameda, and Contra Costa). Back then, we didn’t have the granular data that we have now – I couldn’t have told you that people in Bayiew/Hunters Point (a low-income San Francisco neighborhood) have a 14 year lower life expectancy than people in Russian Hill (an affluent San Francisco neighborhood). But we knew that there wasn’t just a randomness to that, it was tied to other things about those neighborhoods. We were all 60’s activists as well as public health professionals and this was not acceptable.

We now know that 10-15% of that disparity comes from health care. So what accounts for the rest of it? That question opens up the possibility of public health involvement outside the traditional realm of public health programs. BARHII partnered with environmental justice groups to push for improved policies in land use, air quality and public transportation. Those agencies were so used to hearing from the environmental justice groups that their meetings almost felt predictable. But BARHII changed the dynamics because we could argue for changes in public transportation policy by saying, “Unless we do something differently, 1 out of 3 babies born in 2000 will develop diabetes in some point in their life – and closer to 1 out of 2 for African Americans and Latinos.”

Environmental justice and public health both argued for improved public transportation and more stringent air quality targets, but we had different approaches to advancing our positions, which were worked out together prior to public testimony. Because we reframed the debate to include public health, the public officials heard these arguments differently. The air quality management district hadn’t always been sympathetic to environmental justice concerns, but as advocates for public health, they’ve come around.

A decade later, it’s pretty well established that public health has an important role in land use. But that’s just a starting point for all the factors that go into making a neighborhood like Bayview/Hunters Point. What about employment, gentrification, the tax code, public housing? Those are large scale changes over a long period of time, but I think that’s where the field has to go. We’re just getting started here.

What is a persistent challenge that you see in the field?

Ever since the Reagan administration, a strong political current is that our nation’s collective purpose is to minimize the role of government in every aspect of life. Well, except for the military and sex. That’s made it incredibly difficult to work in a public health department. It’s not just the budget. It’s the ability, as a public agency, to move aggressively in a social or political realm. If public opinion wants to minimize the role of government, how do you do that? Take the idea of regulating sugar-sweetened beverages. It’s not just about fast food and obesity, it’s about the fact that a public agency dares to interfere with people’s lives. Tax and regulate sodas? That’s the nanny state!

Unfortunately, that’s the environment we’re working in. My vision of public health means the field needs to be more aggressive about going into new territory, and it’s not even clear that we have permission to do what we’re doing right now. At least in many people’s minds. The real dilemma is that most factors that really influence health are beyond the purview of health departments. We have to learn to work in other people’s territory, and often, we are not welcome. We have to learn how to deal with that strategically!

Do you have any thoughts on what it will take to address this?

We need to have a strong relationship with the community. We need to work with them as allies in a strategic relationship: they contribute their insights from living in the communities, we contribute data or scientific evidence and public health perspectives. We talk to each other. We weigh in with our respective credibility when major decisions come up. We need partners within the community and other departments who can create the opening for public health participation. Whereas if public health tried to walk in on its own, we might not be welcome.

Regional collaboratives like BARHII are also useful. In BARHII, we used to say: if one health department does it, you’ve established a precedent. We understood local political constraints might mean that Alameda County could do certain things that Solano County or San Mateo County couldn’t do – yet – but eventually, we could leverage the regional precedents to establish a new standard of practice. Our perspective was: Go for it! Take it as far as you can! Let us look in on your work, applaud it, and then use your precedent to help all of us claim legitimacy. For example, Alameda County was one of the first health departments to hire community organizers, but that idea is being embraced in other jurisdictions as well. So regional groupings help move beyond local political constraints. They help all participating health departments think strategically about these structural issues.

BARHII’s influence is not just regional. Other jurisdictions, such as Minnesota and West Virginia, are also embracing health equity, so there is a basis for communication on a national scale. Of course, we had a lot of difficulties, it wasn’t a uniform success. But we wanted to influence the field. Not out of organizational egoism, but the longer we’re outliers, the longer it’s difficult to do the work. If more places engaged in similar work, that established legitimacy to our efforts. It’s like that idea of local health departments establishing precedents within BARHII, but on a national scale. More people doing this work means we can push the field even farther.

Emma Rodgers, MS

Emma RodgersAs a Program Coordinator for the Partnership for a Healthier Bronx at Bronx Health REACH , Emma Rodgers helps to lead a community-based coalition that is working to reduce disparities in health outcomes in the Bronx. Emma attributes her passion for her work to the people, organizations, and spirit of residents and leaders in the Bronx and her family’s positive and negative experiences in the US health system. Emma’s recognition that stress is a major factor in the health outcomes of residents in the Bronx and her conviction for involving communities at the forefront of public health strategies to reduce health inequities contribute to our great respect for her and her work. Emma’s experiences reflect the opportunities and challenges of sustaining coalition-based work to address persistent health inequities.

Career in Profile

    • 2004 – BA in Government from Smith College, Northhampton, MA
    • 2004-2006 – Marketing Coordinator, John Wiley & Sons, Inc., New York City, NY
    • 2006-2008 – Associate Director of Planning and Buying, HN Media & Marketing, New York, NY
    • 2009-2010 – Intern, Division of Violence Prevention, Boston Public Health Commission, Boston, MA
    • 2010 – Graduated with a M.S. in Public Health from Harvard School of Public Health, Boston, MA
    • 2010-2012 – Borough Organizer, Bronx Smoke-Free Partnership, New York City Coalition for a Smoke-Free City, Bronx, NY
    • 2013-NOW – Adjunct Professor, Bronx Community College, Bronx, NY
    • 2012-NOW – Program Coordinator for the Partnership for a Healthier Bronx, Bronx Health REACH, Institute for Family Health, New York, NY

What inspires you and the work that you do?

I would say it’s the resilient and magnificent residents and organizations of the South Bronx. The South Bronx is the poorest congressional district in the country. We’re the hungriest, most obese, most overweight – all of these things that say it’s a terrible place to live, to go to school, to work, raise a family. And yet there are so many amazing people and organizations doing wonderful things. This includes community members who recently became Zumba instructors and are advocating to improve their local park.  There’s also an affordable housing provider who, in addition to creating a new green, mixed-use development that will have a rooftop farm, supermarket, music and recreation center and affordable housing, is also looking to promote bike lanes, and to create a business improvement district. It is really an exciting time in the South Bronx. I feel very privileged to be part of this community and blessed that residents and organizations have included me in their families and in the work that they’re doing.

A lot of your work involves engaging community members and it follows a community organizing strategy. What inspires this approach to your work?

Historically, residents of the South Bronx and other low-income communities have not been involved in most aspects of public health programs. Outsiders, much like myself, would come into the community, identify the needs and the solutions, and implement programs without ever consulting the community. The community is an afterthought, a box that you check when you’ve done focus groups to make sure your program is on the right path. The community is never part of the process and more importantly, they’re never leading the process. In turn, many of these programs have not addressed the real needs of the community, never included culturally appropriate activities and materials, and the programs were unsuccessful and/or unsustainable. Doing true community-based public work might be frustrating to researchers and funders, because it takes longer – ten years, not two, like most grants. However, at the end of the day, it is my experience that these programs are much more successful, because the community is empowered and the real, root causes of these health issues are identified and addressed. Community residents know their community best, not me. At the end of the day, I go home to a different borough and no matter how many years I work in the Bronx and how many degrees I have, I always remember that. My job is to listen and support Bronx residents and organizations in any way that I can to make sure the health of Bronx residents improves.

What is a career success that you’re particularly proud of?

One of the primary goals of the initiative that I’m funded under is to create a borough-wide coalition. Much of my time is spent engaging partners, residents, and city agencies in other parts of the borough where my organization traditionally didn’t work. Last year, I was really proud of the work our group did around increasing access to healthy food. Many areas of the Bronx are food deserts or food swamps. Although fantastic new supermarkets are popping up every year, many communities still do not have access to healthy food in their neighborhood – bodegas and fast food restaurants are their only options. When I started my job, I had very little experience working in the food arena. Our funders wanted us to continue to “adopt” bodegas to transform them into healthy food retailers. However, despite the lack of healthy food, this initiative didn’t make much sense to me as our organizations didn’t have the capacity to help hundreds of individual bodegas and there already seemed to be a lot of organizations doing this work. Instead, we felt we would be much more helpful if we tried to coordinate the existing bodega work, which seemed abundant, but disorganized. It was common for two organizations in the same neighborhood to be doing similar programs, yet neither would know about the other. So, for the last year, I’ve spent a lot of time identifying which groups were doing the work, what resources each group had, what were the most successful programs, and how we could all work together to reach more people and create better programs. To my delight, most of the community groups and city agencies that I reached out to were thrilled to partner with other groups and be part of our larger coalition’s efforts. These organizations met monthly for almost a year, developed joint evaluation tools, shared best practices and many of the groups are now working together on joint bodega initiatives. Although there were many bumps in the road, this was a big win for the Bronx and my program.

What are some challenges that you’ve encountered or that you may continue to face in your career?

Funding is a big challenge. Despite the fact that community organizing is once again “hip” thanks to President Obama and many grant applications require community engagement, there is still very little funding for the work that I do — the pot of money is getting smaller and smaller and many of these larger initiatives are just not being funded at the same level. For many years, Bronx Health REACH was primarily funded through the REACH program (Racial and Ethnic Approaches to Community Health) at the CDC (Centers for Disease Control and Prevention). That was a very large grant that supported a very large staff and our partners for many years. In 2012, we became a sub-recipient of the Community Transformation Grant from the NYC Department of Health and Mental Hygiene; however, this was significantly less funding, supporting only a few staff members. To top it all off, we just received word that the grant will end next fall, two years before it was expected to end.

Another major big challenge is that I’m not allowed to do policy and advocacy work, because I’m funded through the Affordable Care Act. All I can really do is educate people about different health issues and programs and hope that these community groups and residents will take their concerns to their elected officials and they will create legislation or increase funding for health programs. This is very frustrating, because I know that legislation is an extremely effective way to improve the health of a large community – a population-based approach is more effective and cheaper than going door to door. Also, it’s a lot to ask people who have kids, 3 jobs, and other major life stressors to do this work in their very limited free time. I understand why my funding prohibits me from working on policy. However, again, for people who have been doing this work for a long time and know what works, it’s very frustrating.

Finally, from an organizing standpoint, it’s hard to create a coalition when the “peaks” in your campaign are fairly small – an event, creating a curriculum, etc. Advocacy campaigns are exciting, have clear goals – they are something concrete that your community partners can rally around. In some ways, I think our coalition members are not as active right now, because there isn’t a specific campaign that we’re all working on together.

When it comes to public health, what matters to you and why?

Having the community at the forefront of what we do, especially in low-income communities. I think that in addition to making our programs more successful, you can’t morally do a program without having the community be at the forefront of the work. Also, again, it is important to increase funding for programs that focus on reducing health disparities in our country. I feel very privileged to live and work in a city where public health is a priority. Although much progress has been made, it is maddening how different a child’s life can be in one neighborhood versus the next. It’s unacceptable. I am hopeful though with our new Mayor. Finally, there continues to be limited funding for mental health programs and continued stigma around mental health issues in general. In the communities where I work and among my own family and friends, there is such a great need for mental health services. Despite increased attention these last few years, we have a long way to go.

Is there a persistent public health problem that still concerns you?

The challenge in many ways is that a lot of the health issues that are important to me and to others are rooted in poverty. The head of the Bronx District Public Health Office once famously said, ‘The Health Department shouldn’t be called the Health Department. It should be called the Department of Poverty Reduction.’ If we could possibly solve that problem, so many things would be fixed. It’s going to be a long time before an equitable society exists, but I’m encouraged by conversations with community leaders and organizations and grant applications that require public health groups to engage multiple sectors in their work and develop programs that properly address the root causes of health inequities in this country. My most exiting and impactful programs are those that include schools, housing providers, transportation and other sectors.

On the flip side, one of the big successes is tobacco control. The 50th anniversary of the Surgeon General’s report was released in January. When you think about how far we’ve come in this country – especially in New York City — with regards to smoking, it’s pretty amazing. The Bronx is tied with Brooklyn for the second lowest youth smoking rate in New York City at 6.7%. This is a real bright spot for the Bronx and the country.

Arnell Hinkle, MA, RD, MPH, CHES

AH photoArnell Hinkle’s experiences as a restaurant chef and organic farmer led her to pursue a degree in nutrition.  She quickly realized that environmental changes were needed to facilitate individual-level behavior change, and decided to focus on public health nutrition.  She worked on anti-hunger and chronic disease initiatives for several years before founding Communities Adolescents Nutrition and Fitness (CANFIT).  The non-profit, which celebrates its 20 anniversary this year, is dedicated to increasing healthy eating and physical activity opportunities for low-income youth of color and the communities they’re in, with a focus on afterschool and community-based settings.  Her deep commitment to collaborating with communities to improve nutrition and physical activity make her a public health hero.

Career in Profile

  • 1990-1991 – Senior Health Education Specialist, Contra Costa Health Services Department, Martinez, California
  • 1991 – 1993 – Project Coordinator, Contra Costa Health Services Department, Martinez, California
  • 1993 – 1995 – Program Director, CANFIT
  • 1995 – 1998 – Director, CANFIT
  • 1999 – Present – Executive Director, CANFIT
  • 2003 – Robert Wood Johnson Community Health Leader Award
  • 2007 – Mary C. Eagan Award, Public Health Nutrition, American Public Health Association
  • 2008 – Kellogg Food and Society Policy Fellowship
  • 2010 – Ian Axford (New Zealand) Public Policy Fellowship

What inspires you and the work that you do?

There’s a real dichotomy between what we’re fed and what’s possible.  Many people have very little choice available to them.  Economics and other social determinants limit their choices to “which fast food should I eat?” instead of “the breadth of wonderful foods available.”  We try to make sure that people have both the skill and education they need to make healthy choices, and also the availability of healthy choices and safe places to be active.

On a personal level, my life changed when I participated in an afterschool program in St. Louis that brought kids from all over the city to participate in afterschool and summer activities.  I was surrounded by so many people with different ways of being – I remember one of my friends eating a cucumber sandwich.  I had never seen anything like it!  They shared it and it was good, and I thought, “Wow, you don’t have to have bologna on sandwiches?”  It was a radical moment for me.  So I’m aware of the importance of exposing adolescents to other ways of being, and this is one reason our work at CANFIT focuses on afterschool programs.  Especially in communities with challenged school systems, afterschool programs become a place where adolescents can form positive youth-adult interactions, do project-based activities, and just be themselves.  CANFIT makes sure that those are also healthy environments, and uses them as a place to work with young people.

Your career has taken several turns along the way, but is there a particular success or highlight that you are proud of?

We’ve been performing trainings with high school kids around sugar sweetened beverages, and as part of the training we show a video that we co-developed with youth, called PHAT (Promoting Healthy Activities Together).  PHAT uses hip hop culture to talk about healthy eating and fitness.  PHAT showcases youth talking about the importance of eating well and being active, what’s available in their neighborhood, and ends with a dance video.  To create the dance video, we worked with DJs to get clean hip hop beats, some young people came up with the rhymes, and a hip hop choreographer worked with after school programs to develop a dance routine into a dance video.  It’s youth speaking to youth, and 6 years later, young people can still relate to it.  I’m proud of the work and products that we’ve developed over the years because they speak to youth and youth culture, and are still relevant to youth.

Now we use the video in our trainings as a “hook” or conversation starter.  Youth see the film and get ideas, and then we work with them to develop action plans around decreasing sugar sweetened beverages in their communities or for themselves or their families.

Switching gears, what are the challenges you’ve faced or continue to face?

CANFIT also works in the policy arena, and I find that I have to be bilingual, bicultural.  I’m always aware of how to frame things to appeal to which audiences.  So, if I’m with a group of teenagers I might say it one way, and if I’m with a group of funders or policymakers I have to say it another way, and you constantly have to go back and forth between those two vocabularies in order to function in both of those worlds.  I think that grassroots-grounded experience versus academia is always a challenge. People come up with these great ideas that aren’t always necessarily grounded in community and so you constantly have to be the conduit, the reality check. That’s a challenge.  You want to strike that balance, so that research is not just on the community, but for the community, and also works within the community – not just doing research because its convenient to do the research.

The funding is always a challenge.  Because of the way foundation dollars work, you have to shift from project to project, because most places don’t fund general operating costs.  We’re often a training ground for staff; after a couple years with us, they get scooped up by state health department or the county health department.  Because we maintain a network of former colleagues and can bring them in for specific projects, we’ve added a strong “consultation and training” component to our organization. So we try to maintain a lean operating machine and make it work that way.

Is there a persistent public health problem that still concerns you today?

I’m concerned about all of the social determinants of health, like whether people have a livable wage and safe places and education, income.  So much of what we do in public health could be solved if people had higher wages and more education – well, a better quality of education.

In terms of the work that CANFIT deals with, I think we need to take a look at the cost of things – especially the hidden cost of things.  For example, it drives me crazy that the food industry gets tax breaks for donating unhealthy foods to food banks.  If our health values were more aligned with our economic practices, our practices might be in better shape.

Jim Bloyd, MPH

JB 1As an undergraduate at San Francisco State University, Jim discovered public health through a Sociology of Medicine course.  His interest further blossomed as a volunteer in San Francisco General Hospital’s Emergency Room, where he observed that the health problems he witnessed were not rooted in biomedicine, but in social factors like hunger and malnutrition.  He switched career paths from medicine to public health.  Currently with the Cook County Department of Public Health in Chicago, Jim has been heavily involved in Place Matters, a national initiative to address the social, economic and environmental factors that influence health inequities.  Jim’s experiences highlight the challenges and opportunities of working within a local health department, as well as the need to maintain social justice as a central tenet of public health.

Career in Profile:

  • 1988 :  Studied Spanish and Health at San Francisco State University, California
  • 1990:  Studied Behavioral Sciences and Health Education at University of California Los Angeles, School of Public Health
  • 1990-1991: Implemented tobacco use prevention programs in East Los Angeles as a Health Educator for the County Department of Public Health, California
  • 1991-1993:  Worked as a Health Educator at the Lake County Health Department, Illinois
  • 1993- NOW Leads community health improvement planning activities and assists in fulfillment of agency strategic goals as the Regional Health Officer for the Cook County Department of Public Health, Illinois
  • 2007- NOW:  Studying at the University of Illinois at Chicago, School of Public Health as a DrPH Candidate

What is a career highlight for you?

In Chicago, we recently hosted a Place Matters action lab that succeeded in several ways.  Our Place Matters for Health -report in Cook County showed that folks who live in Census tracts where the median household income is $55,000 lived 14 years longer than people who lived where the median income was $12,000 or less.  This underlines the point that the solution is not just to educate people from poorer neighborhoods. There is a whole constellation of living conditions and stresses that follow income lines.  That’s the real issue.

Related to that, in the metropolitan Chicago area, structural racism shows up as patterns of residential segregation. We found that quality of education and educational attainment are stratified by race.  We found that opportunities are also segregated, so that 80-90% of Blacks and Latinos live in low opportunity neighborhoods in metro Chicago.  Public health relates to life expectancy inequities, chronic illness inequities, and we need to work with individuals to increase their collective power.  We need to find ways for individuals and communities to change policies, which will create healthier places for them to live.  Ultimately, we need to wrestle with privilege and segregation and unfair distribution of resources of all kinds.

The report is an example of issues I hold dear, and it was given a very strong vote of approval by our agency’s leadership.  It was a team effort.  There were many people, locally and nationwide, who were working on this national initiative.  It was fun, exciting moment at the end of a lot of hard work.

What’s a challenge that you’ve experienced in your career so far?

Trying to see the work in public health as process. Trying to be patient.  Trying to listen to other people more, and trying to understand that other people are coming from other perspectives, and to feel okay about challenging perspectives that I need to disagree with, and find a way to disagree that is still effective.  I think a challenge is to try and understand my personal responsibility for challenging racism and privilege, especially in the area of race, but in other areas as well.  I may not have played a role creating these systems of privilege, but I can feel good about taking responsibility for challenging and opposing these systems of privilege.

Especially in large, local health departments, it’s a challenge to work in a bureaucracy. You may have more resources, but I can’t say that we’re as flexible, or that we operate as quickly, as I would like.  However, many community leaders and residents welcome discussions on the social determinants and injustices as a way to explain their daily experiences.  They want to know what we, as a health department, can offer them beyond behavior change trainings and education.  Folks have setbacks in their careers, but I’m learning to say, “OK, this is just one day or one battle.  Or maybe there’s a battle I choose not to fight, and I’m gonna choose to work on this.   I’m learning to avoid burnout by not spreading myself to thin.”  This is a time of diminishing resources, so it’s a challenge to keep that perspective in order to keep being effective, keep generating resources for social justice and public health.

When it comes to public health what matters to you and why?

It’s important to make social justice more apparent in the work that we do, and it’s always a challenge.  When it comes to the big picture, health inequities are the most important part of public health.  I try to take an explicitly anti-racist, community engagement, social determinants approach to addressing health inequities.

What is a persistent public health problem that concerns you?

On a practical level, I’m concerned with cutbacks to public health infrastructure, staff and budgets.  It hampers our ability to do our job and to inform the public about the data we collect.  It’s even a challenge to inform the public about health inequities!  Despite the fact that the U.S. ranks among the wealthiest countries in the world, our political priorities mean that that public health is not highly valued.  Building a public constituency is challenging.  People fought for the creation of local health departments, and the public health workforce should not be afraid to take on the politics of informing folks. We don’t have a profit motive, we are accountable to the taxpayers, and I think that’s a very valuable thing.

If we don’t exist … people are paying for that now!  You see it in the widening inequities, premature deaths, chronic diseases, and this is especially true for people of color and low income folks.  We’re still approaching epidemiology through a biomedical risk factor lens.  We need to be evidence- or science-based, which requires a theory of change that can be tested and researched.  For those of us in the practice world, we need to reflect on our theories of change.  Nancy Krieger’s Epidemiology and the Peoples’ Health outlines non-biomedical risk factor-oriented theories.  These theories should guide our work.  Rudolph Virchow recommended that people need freedom from homelessness, illness and poverty.  Awareness of theories can – and should – affect our practice.  It challenges us to question our status quo positions, like our focus on individual behavior change that tends to blame the victim. This puts us in difficult positions, and I think that’s why people don’t think too hard about these alternatives.

What’s your ideal solution to this public health problem?

We have a lot to learn from community organizing and political analysis to understand power.  Who has power and who does not?  I would hire community organizers to challenge unequal or balancing relationships of power, which is called for by the World Health Organization.  A successful community organizer challenges the status quo.

At a practical level, community-based organizations like the Restaurant Opportunity Center (ROC) build power among marginalized people, low-wage earners and communities of color. They address racism and unearned white privilege. We need to build strong relationships with the ROCs and other labor-organizing efforts.  Local health departments can – and are – getting involved with foreclosure and anti-eviction movements, big box retail store and labor, even the 99% movement, equity, and Wall Street.  Public health can make connections to movements that move us towards social justice.  Social justice will lead to health equity, which allows everyone’s health potential to be fully realized.