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.

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.

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.

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.