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.