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.

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.

Joe Zanoni, PhD

imageFolio_jz_final - for websiteDr. Joe Zanoni, like many others, considers himself an accidental public health practitioner.  He started his career as an early childhood/special education teacher in the 1980s.  After he was laid off he returned to school, and entered a labor relations program in hopes that it would prepare him to provide training and education for businesses.  This led him to work with labor unions, which in turn prepared him to work with various populations, from teaching health care workers about blood protections at dawn of the HIV/AIDS crisis, to his current focus on the safety and health of immigrant day laborers.  Dr. Zanoni has drawn upon these experiences and the educational philosophy of Paolo Frèire and others, to promote the importance of peer-led education.  He is particularly proud of his research with workers’ centers.  This work has shown how empowering immigrant workers – whose voices are often unheard and whose labor is markedly unregulated – can reduce their rates of death and injury on the job.  We are pleased to profile Dr. Zanoni as one of our public health heroes.

Career in Profile:

  • 1980: Completed his Bachelors of Science in Education, Disabilities at the University of Wisconsin
  • 1980 – 1983: Special Education Teacher at the Madison Metropolitan School District, Madison, WI
  • 1984 – 1986: Infant Care Provider at the Kunkle Center, University of Wisconsin-Milwaukee
  • 1986: Completed his Master of Industrial and Labor Relations at the University of Wisconsin
  • 1987 – 1991: Research and Legislative Coordinator, Service Employees International Union, Local 150, Milwaukee, WI
  • 1991 – 1997: International Senior Representative for Health and Safety, Service Employees International Union (SEIU) in Chicago
  • 1998: Program Manager, Great Lakes Center for Occupational and Environmental Safety and Health, University of Illinois at Chicago, School of Public Health, Chicago, IL
  • 1998 – 2010: Associate Director of Continuing Education and Outreach, Illinois Occupational and Environmental Education and Research Center (IOEERC), University of Illinois at Chicago, School of Public Health, Chicago, IL
  • 2007 – 2010: Instructor at the Division of Environmental and Occupational Health Sciences (EOHS), SPH-UIC
  • 2010 – Completed his PhD in Education: Curriculum Studies at the University of Illinois at Chicago
  • 2010 – NOW: Research Assistant Professor, EOHS, University of Illinois at Chicago, School of Public Health
  • 2011 – NOW: Director of Continuing Education and Outreach at the IOEERC, preparing masters and doctoral graduates to serve as occupational and environmental health professionals in the areas of industrial hygiene, nursing, medicine, safety and epidemiology

Can you tell us about a career highlight?

I’m really proud of the work that I’m doing with workers’ centers because there are so many things that are part of it. I’m most proud of my dissertation, and also the Charla work.  Charla means “to converse, talk or chat” in Spanish.  It’s a social learning process.  I worked on a pilot study through the University of Illinois School of Public Health, where I learned about workers centers.  These centers are community-based groups, and this brought our focus from unions to immigrant groups.  We went to workers’ centers in Chicago and asked, “How do you like to learn?”  Instead of offering them training, we wanted to know, “How can this be part of what you are doing?”

They said, “We don’t really want to come to a training session, we don’t want to be lectured at, we’d like to learn in some kind of informal chat…like a charla!”  “What would that be like?” “Like sitting around doing different things, and then all of sudden we start talking about something.”

I thought “Wow, why don’t we delve into this?”  So I worked with three different workers’ centers to create a team of people that set up Charlas that invite people to talk about health and safety on the job.  The twist is that we’d do it in a communal setting.  I found a Spanish-speaking, culturally relevant colleague and trained him to facilitate three sessions at each workers’ center.

We’ve since continued this work with another research project. We trained peer educators to lead trainings at worker centers.  We had to have authorized trainers in the room, but they co-lead with the peer educators in a small group workshop format.  We have lots of workers employed in these types of jobs, where many immigrant workers die on the job for a variety of different reasons.

We started in Chicago, and when we heard about other Midwest workers centers we created a train-the-trainer program.  In our third year, we expanded to the Southwest.  We’ve also performed assessments to see how we were doing.  We want to know, “What did they learn?  What is the social context of the training? How are the workers’ centers and the peer relationships? How did they develop and how can they extend practices in the job to protect them?”  That work has been very satisfying.

What’s a career challenge that you’ve faced?

The funding aspect is always a challenge.  How do you sustain an effort? We can create a good idea or a great intervention, but especially if you work with community partners how do we keep it going?

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

The glaring inequities in the U.S.!  So often we are told that we are the richest and smartest country in the world.  We are the top!  We’re the model for the rest of the world!  That’s not necessarily true.  Those of us in occupational health go crazy over the debate about jobs … because it’s not just jobs!  What kind of job are we talking about?  What’s the quality of the job?  What’s the health of the people in their job?  All of that links together.  Yes, some people are healthy but other people are not.  How did we get that way, and what do we need to address in society to fix it?

What is a persistent public health problem that concerns you?

Injury, illness and death on the job.  Overall, if you look at the statistics of death on the job, the trend is decreasing.  But that trend is not true for all subgroups.  For example, Latino immigrants have a much higher “death on the job rate” than white males.  Why is that? It’s the kind of work that they are doing.

It’s almost like we are coming back around to what Jane Addams and her colleagues at Hull House worked on.  We need to improve workplace conditions for specific groups of people who are on the margins, or those who are trying to integrate into society and don’t get enough support.  Liberty Mutual estimates that we lose $50 billion a year due to injury, illness and death on the job.  It’s important to look at where work happens, who knows about it, and who can create the structure and support.  A lot of effort went into creating OSHA but that’s for traditional work places. What about other work places?  What about day laborers, construction, family businesses?  We should place greater effort into addressing and enforcing non-traditional work.

What’s your ideal solution to this problem?

We should support the education of community health workers and peer educators. What kind of curriculum do they want?  There are some groups doing incredible grass roots work with communities to determine what those communities want and need. They collaborate to develop training and curricula that meets people where they are. How can we support workers to learn and share with each other, and put more energy into their organizations? How can public health teach them how to work in collaborative ways? How can we teach them to teach each other about being healthy and safe, and how can that expand and make their work more secure?  We have very vulnerable workers who are day laborers, or people that have just come in the country trying to find work, they are trying to survive.  We need to explore these issues in public health, and we should do it through workers’ centers, community health workers and peer communities. All these people need to be encouraged and supported.

Reflective: Looking Back On Volumes 4-6

Every four months we pause from conversations with public health leaders to reflect on lessons learned from their varied careers, and insights into persistent and emerging public health challenges.

We are Public Health has been honored to feature conversations with several groundbreaking, widely respected pioneers in the field.  The last three volumes highlighted Dr. Len Syme, father of social epidemiology, and Dr. Jack Geiger, a pioneer of the community health center movement in the US.  As Dr. Geiger acknowledged in his interview, “we all stand on the shoulders of others.”  The ripple effect of their unique contributions to our field is evident in the work of other featured practitioners such as Jim Bloyd, Dr. Sandra Witt and Dr. Bob Prentice, who are all working to operationalize Dr. Syme’s and others’ social determinants of health framework in communities and within government institutions.  Similarly, we see Dr. Geiger’s strategy of engaging, organizing and empowering community members to create their own solutions and successfully address public health challenges reflected in Emma Rodgers’ coalition-driven work in the Bronx, Laura Sanders’ advocacy for immigrants’ rights in Southeastern Michigan, Arnell Hinkle’s efforts to create youth-led and culturally appropriate nutrition and physical activity resources, Dr. Joe Zanoni’s work to improve the health and safety of immigrant day laborers, and finally in Dr. Joseph West’s community research on diabetes in Chicago’s North Lawndale network.

Drs. Syme and Geiger’s legacies extend beyond these amazing public health workers who continue to “stand on their shoulders”.  Their impact is also evident in current public health work and policies. These days, it is rare for public health students to graduate from any school of public health without a working knowledge of the social determinants of health. In the field, the determinants are widely considered just as critical to supporting and improving the health of communities and reducing health inequities as the delivery of clinical services. Additionally, community health centers are rapidly becoming the go-to places for many Americans to seek health care and community resources.  In the age of the Affordable Care Act, also known as Obamacare, these centers play a central role as the medical homes of low-income residents across the nation, and a growing number are finding creative ways to integrate the social determinants into primary care.

When we started this website we hoped that we would be able to feature public health’s well respected and renown pioneers. We are delighted to also see the connections between their groundbreaking work, and the current efforts of a diverse set of public health practitioners.  It is truly inspiring to witness the evolution of their audacious visions.

We are so excited about where the next three volumes will take us!  We look forward to reflecting on more trends in these public health histories.

Len Syme, PhD

Len Syme, PhDDr. S. Leonard Syme has been pioneering research on the social determinants of health since the 1950s.  He is regarded as the “father of social epidemiology” for both his ground-breaking work and his mentorship of numerous leaders in the field, including Sir Michael Marmot, Dr. Lisa Berkman, and Dr. Nancy Krieger.  His body of work has focused on child health, job stress, social support, poverty, and social inequities on health.  He joined the faculty at the UC Berkeley School of Public Health in 1968, where he is now an Emeritus Professor and Co-Director of the Health Research for Action Center.  Dr. Syme was elected into the Institute of Medicine and has won numerous awards, including the Lilienfeld Award for Excellence in Teaching by the American Public Health Association and the JD Bruce Award for Distinguished Contributions in Preventive Medicine from the American College of Physicians.  His pioneering work on the social determinants of health, and his commitment to translating this research into successful interventions, make him a clear choice to profile as a public health hero.

Career in Profile:

  • 1953: Completed BA in Anthropology and Sociology from UCLA
  • 1955: Completed MA in Sociology from UCLA
  • 1957: Completed PhD in Medical Sociology from Yale
  • 1957 – 1960: Sociologist, Heart Disease Control Program, US Public Health Service
  • 1960 – 1962: Executive Secretary, Human Ecology Study Section, NIH
  • 1962 – 1965: Sociologist and Assistant Chief, Field and Training Station, Heart Disease Control Program, US Public Health Service in San Francisco
  • 1966 – 1968: Chief, Field and Training Station, Heart Disease Control Program, US Public Health Service in San Francisco
  • 1968 – 1993: Professor of Epidemiology, UC Berkeley School of Public Health
  • 1975 – 1980: Chairman, Department of Biomedical and Environmental Health Sciences, UC  Berkeley School of Public Health
  • 1993 – Present: Professor of Epidemiology and Community Health (Emeritus) and Professor in the Graduate School of Public Health, UC Berkeley

 

You are often called “the father of social epidemiology.” How did you get into this work?

In graduate school, I came across Emile Durkheim’s work on suicide.  He observed that the causes of suicide are thought to reside within individuals, but certain groups have consistently high or low rates of suicide.  If individuals come and go in a community, then why do group rates stay high or stay low?  He proposed that there must be something in the community that increases the rate of suicide, even though it doesn’t predict which individuals will succumb.  I said, Whoa.  It’s like the symphony orchestra.  You can study the violin or the trumpet or the drums to become an expert on the individual instruments, but that won’t help you understand symphonic music.  That’s when I began to get into community stuff.

My early work focused on social class as a determinant of health.  Michael Marmot’s work with the British Civil Servants was the breakthrough.  The Civil Service is divided into different Steps (with higher pay grades associated with more prestigious steps), which means you’ve got a cross-section of socioeconomic strata right within the Civil Service.  Marmot’s initial research focused on heart disease, and he showed that the Ministers at the very top of the Civil Service hierarchy at Step 1 have half the rate of heart disease as those who in Step 2 – Professionals and Executives – doctors and lawyers – just one level down.  This gradient existed throughout the Civil Service.  The lower the Step, the higher the rate of heart disease!  But the higher rates are not just among people at the bottom.  They exist from top to bottom.

When I was with Marmot in London, we decided to look at all diseases.  It turns out this gradient exists for all diseases in the Civil Service.  When I got back to Berkeley we reviewed the world literature, and we found that the gradient exists for all diseases, in every industrialized country.  We controlled for blood pressure and cholesterol, smoking and physical activity, but there’s still a three-fold difference.  If you don’t control for social class, it overwhelms everything.  So we control for social class so that we can study other things, but that means that the elephant in the room – the most important determinant of health – sits bright and unexamined.

So then let’s just get rid of social class and everything will be fine!  That’s not going to happen tomorrow.  In fact, there’s evidence that it’s impossible to get rid of social class.  In the 1930s the Israeli kibbutz tried to eliminate social class, but that failed.  We have evidence that social class divisions begin in nursery school.  But what is it about social class that really matters?  Is it low income or low education?  Is it poor medical care, poor housing, poor jobs?  It’s a whole list of things associated with low social class, and they’re so hopelessly intertwined that you can’t tease them apart.  Many of us – Marmot and others – hypothesize that the most important factor is whether or not you have control over your destiny.  We now know there are biological changes in immune function when people have less control.

Health Research for Action is devoted to helping people have more control over their lives.  We have guides for new mothers, we have guides to help older people avoid falls, we have a guide for disability.  None of these guides deal directly with diseases or risk factors, but they do help people deal with the problems that they face in their daily life.  Our theory is that when people have more ability to influence the events in their life, better health will follow.  So that’s what the center is about.  Our evaluations show that people keep the guides and refer to them, they share them with their friends, and they’ve changed the way they think about life.  But you can’t show a change in health because we’re talking about a change in immune functioning, so we’re talking long-term.  This is not the type of work we do in public health.  It’s very hard to get outcomes information, and it’s very hard to get a grant that is not focused on one disease or another.

Translating research to practice is really, really hard.  First of all, we “authorities” always pick the wrong topic to focus on, because we never pick the topics that people care about.  We rarely think about health literacy.  Almost all of our interventions have failed.  We’ve done two things well.  Smoking rates have declined, and seat belts have saved lives.  Most of those successes are due to changes in laws and policies, tobacco price increases, and limitations on where you can smoke and how you can drive.  Rarely has our brilliant statistical work on risk factors translated into successful interventions by itself.

What’s been a challenge in your career?

A major flaw in our field is our focus on diseases.  We’re really talking about psychosocial risk factors and compromised immune functioning, and while these don’t cause one disease, they increase the risk of all diseases.  Once you pick a disease, you’ve lost the power of the approach.  But where would you send a grant to study discrimination diseases?  Or hopelessness diseases?  We don’t have a way to do that, because all the money is focused on clinical outcomes and risk factors.

Awhile ago, the CDC offered a grant to study kids in fifth grade.  The CDC was interested in violence, smoking or drugs, inappropriate sexual behavior, school performance, things like that.  We submitted a proposal to study “hope.”  Our prior work with fifth graders in Richmond, CA – a very poor community – showed that many of them didn’t think they would live beyond the age of 20.  If you don’t think you have a future, smoking and drugs and school performance don’t matter that much.  So we wanted to see if we could help these fifth graders achieve a goal they’d set for themselves.  We thought improvements in smoking and violence would follow from that.   I’m really amazed, but the CDC made ours the #1 rated grant in their program.  So that was very nice.  We did that for 3 years, and we really did a good job.

We used Photo Voice, where we gave out cameras and asked the students to take pictures of the things they cared about, and that started the conversation.  For example, one group was embarrassed by graffiti in their school.  We worked with them on removing the graffiti, because you don’t just go out and buy paint brushes and cover the graffiti, you have to get permission from the principal and the school board, you have to get money for paint brushes, it’s a whole thing.  That was just one group.  We had a lot of groups, and they all had their own thing.  At the end of 3 years, we talked to the students and it was clear their lives had changed.  I’d like to follow them and find out what difference it made, but where do I get money?  The CDC did “hope” once, but what foundation is interested in hope?  It’s one of the most fundamental risk factors, but it isn’t diabetes or obesity, so it’s very hard to get money.  I’m sitting out here in the wilderness concerned about things like hope, and my field is not with me.

What has been a career success for you?

The students that I’ve worked with.  I do medium research.  I do medium teaching.  But I’m really fortunate to mentor a group of the world’s best people, like Michael Marmot, Lisa Berkman, Nancy Krieger, George Kaplan.  They’re just a group of outstanding students who are now leaders in the field.  Everybody attributes their success to me and that’s just not true.  They’re all fabulous people, and I was just fortunate enough to be involved in their work.

The fact that Michael Marmot is knighted is a reflection of the fact that his work with the British Civil Servants has changed everything!  He’s now the most famous public health person in the world, and he’s changing the agenda everywhere.  Or the work of Lisa Berkman – these people are changing everything.  And I just get to sit back and watch.

What’s a persistent public health problem that you see?

Inequalities in health.  Inequalities are not just devastating to the people involved, they’re devastating to the entire country and society.  It’s also a toxic issue for all of us.  When some of us don’t thrive, none of us thrive.  That keeps me up at night.  When 1% of society has 50% or 60% of resources, this is not a good society.  We really need to pay attention to income inequality.  If you think you can get away with being the winner and not caring about other people … you’ve seen our statistics! The U.S. has a fancy, expensive medical care system but we still rank 37th or 38th in the world.  We’re behind Slovenia!  We need to study all levels of social class, because all of us still have higher rates of obesity and diabetes than other countries.  We need to refocus to wellness.  We’ve got to get our country back.  It’s not a question of being nice to poor people.  It’s good for all of us.  Being on a losing team is not good for any of us.

What is your ideal solution to this problem?

I would study kids, from birth to age five.  What happens in the early years doesn’t necessarily track into adulthood – you’re not necessarily doomed – but birth to five is tremendously influential.  By studying kids, you would discover the important early life risk factors.  You’d also have a fighting chance with your interventions, because parents care about kids!  The problem with studying children is that they don’t have enough disease.  But we now have a whole slew of biological markers that measure adult immune function – like interleukin – and I’d try to understand if those are appropriate markers in young people.  Or I’d look for a series of new biological markers that show up in early childhood.  They wouldn’t be diseases, but they would be things that lead to diseases.  I’d investigate what really matters to children, so that we can intervene early in life.

Causandra Gaines, BSW

causandra gainesCausandra Gaines, BSW has worked in Westside Detroit for 27 years.  A social worker by training, Ms. Gaines’ passion for working with young people – spanning from infants to elementary and middle school students to young mothers – clearly comes through when she reflects on her work in the Brightmoor community in Detroit, MI.  Her commitment to community-based participatory research partnerships, and to improving the ability for all community members to live up to their full potential, are evident in her reflections on her thirty-year career.  Ms. Gaines recently retired from a leadership role at the Brightmoor Community Center in Detroit.

Career in Profile:

  • 1974 – 1978: Completed her Associates in Applied Art Social Service Technician Corrections and Bachelor of Science in Human Services at Ferris State University
  • 1982 – 1986 – Counselor, Vista Maria
  • 1986 – 2003 – Group Social Worker, Brightmoor Community Center
  • 2003 – 2005 – Vice President/COO, Brightmoor Community Center
  • 2005 – 2012 – President/CEO, Brightmoor Community Center
  • 2012 – 2013  – Director of Operations, Brighmoor Community Center
  • NOW: Retired

 

What are some of your best career successes or career highlights that you’re really proud of?

I really liked our Zero to Three program, where we worked with mothers and their children aged zero to three.  That’s the point where you can help a young mother who has nothing and give her some of the things that she needs.  It could be a car seat, diapers, or formula.  Or, show her that there is potential out there for her.  That she can get a job, be successful.  Help her to navigate the system so she can get the things that she needs.  Through that program, we have helped people get housing, jobs, and make sure that kids have formula, diapers, and clothes.  It is just a joy to see a person’s face when you are able to give them those things.  That’s what’s important.

One career success was through all of the economic downfalls, and all of the money that the Community Center lost, I was able to keep these doors open.  We survived it.  It was a rough five years, just figuring out how you’re going to keep the place open.  Sometimes I was the only person who was working and I did most of it by myself.

When it comes to public health, what matters to you?  Why?

I think our biggest health challenge in Detroit is exercise.  I think that the best thing that we (the Healthy Environments Partnership Steering Committee, a community-based participatory research project) did is that our walking groups allowed folks to make a change.  We used a participatory process from the planning stage to the implementation stage, and participants really enjoyed the walking groups.  They understood how important it is for people to be healthy.  Exercising and eating the right food does prolong your life.  When you get to be 60, 70 and 80, you want to be an independent person able to take care of yourself.  The way to get there is to take care of your body, especially as we get seasoned.  There are a lot of groups, like health plans and health centers, who are willing to help.   I still believe that we have a long way to go.

What do you think it will take to address these public health challenges?

It’s good to talk about good nutrition and healthy things, but we have to have to access things.  In the summer, we have the farmer’s market.  Now, it’s getting cold.  Fresh vegetables are gone.  How can we continue to bring fresh fruits and vegetables into the community?  How can we leverage the big retailers to want to come and do that?  Also, we need to educate the people in the community.  When you get these wonderful things, you have to educate the community.  Sometimes it’s about educating one person at a time or working with one group at a time.  Once you teach that group, they can spread it on to the next folks.

My main focus over the last 8 years has been to make sure that the Brightmoor Community Center succeeds.  Right now, we’re on our 88th year.  My goal is that it succeeds to be 100, plus.  The community built the Brightmoor Community Center.  This is a focal point for the community.  We want to be a place where we are a one-stop shop, where you can access everything.  We want to take care of your health needs, nutrition needs, and offer a space where you can exercise.  We have a daycare.  We want to make sure that you have a place where your kids can go while you’re at work.  If you have an addiction, you can come get help with that.  If you have spiritual needs, you can come here to church.  We just want to make sure that we can help you to access anything you need.  We may not have a program, but we want you to know where you can go to address your health and other needs.  We’re like a community center that has all of these legs that go in one direction.  The legacy that I want to leave is to make sure that the community center is here, serving the community, and doing what it needs to do for 100, plus years.