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.

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.