Share Public Health: Tackling Equity, African American Health Disparities

Season 1 Episode 21

Hannah Shultz Welcome to Share Public Health, the Midwestern Public Health Training Center’s podcast connecting you to public health topics, issues, and colleagues throughout our region and the country, highlighting that we all share in public health. Thank you for tuning into this ten-part series on health equity. Over the course of this series, we will discuss a broad range of topics connected to health equity. For additional resources and information, be sure to check the podcast notes or visit mphtc.org/healthequity.

Hannah Shultz Thank you for joining this episode of Tackling Equity centered on race, specifically on African-American health inequities. Next week we’ll continue exploring race by looking at Native American health. We’ll start today’s episode with an interview with Quinney Harris from the National WIC Association.

Derrick Willis Hello my name is Derrick Willis. I’m the director of Iowa University’s Center for Excellence in Developmental Disabilities and pleased to be a part of this health equity podcast series. We have Quinney Harris, who is the Director of Health Equity and Community Partnerships at the National WIC Association, directing community health and health equity projects for the association. Welcome Quinney.

Quinney Harris Thank you, very excited to be here.

Derrick Willis Could you tell us a little bit about your work?

Quinney Harris Sure, absolutely. So I have now been at the National WIC Association over five years. My work here at the National WIC Association generally falls into three broad categories, the first of which is community health. That work involves a lot of grant writing for the association, specifically focused on community health projects and policy systems and environmental change projects that enable us to partner with our members who are states and local WIC agencies across the country to improve community health. That work is done really to promote health equity at the local level and meant to improve health outcomes for WIC participants in the communities where they live. The second major category of my work is storytelling. I actually have a background in Photovoice, which is a methodology where you’re working with the community, you give them cameras, they go out into the community, and they are able to take pictures and they’re able to frame their life circumstances through those pictures. Those pictures become the data that you use for a project when you’re doing Photovoice. So with that background and also having done oral history in the past – I was actually an Africana Studies major undergrad, so that really has translated very well into storytelling work, which I’m able to do in my role here at the National WIC Association to really share the impact of the WIC program on communities across the country. Then the third major bucket of my work is really around health equity. As an organization we are at the beginning of our health equity journey and really we’re working to look at ways that we can really elevate the importance of health equity in our work and operationalizing institutionalized health equity in the WIC program. We’ve been focused on a number of internal activities as an organization to build knowledge among staff but we’re also working externally and collecting best practices from our members to see what is happening across the country. We’re hoping to really be able to amplify that work and build off of that work as we move forward with our health equity projects.

Derrick Willis Thank you. Great, great work and it is definitely work that is needed in this field and in this area. Are there any things related to what is perceived to WIC out there that, where your work is to dispel that and what WIC is all about. I mean it seems like you’re doing far more than what the average person would think about when they think about WIC.

Quinney Harris Well I think by in large the largest myth about the WIC program is that WIC is a formula program. The WIC program certainly provides formula to participants who are in need of formula, but WIC is a huge advocate for breastfeeding. Across the country, many of our clinics have breast feeding peer counselors and we hear over and over again from participants that the breastfeeding peer counselors have been a key support in their breastfeeding journeys because most of them are available 24/7. You can text them, call them if you are having an issue and they will walk you through it. They’ve been there, they’ve gone through, they’ve had that experience and they’re there to assist current participants who are attempting to breastfeed and might need that extra help to get them through the difficult process of breastfeeding. Then I think another myth is that people just aren’t – well, not necessarily a myth – but people just aren’t aware of all of the services that are provided by the WIC program. So there’s four pillars to the WIC program, the first of which is breastfeeding support, which I’ve already highlighted. There’s also nutrition education that’s provided in the WIC clinic and that’s individualized to the families that we’re serving because we know each family’s situation is different. So we have professional and paraprofessional staff on staff at each WIC clinic who are doing that individualized nutrition education. Then WIC programs also do referrals out to health and social services. There’s been a number of studies that have shown that WIC participants, because of those referrals out to health care providers, one, they have higher immunization rates. It also shows that because of those referrals out that WIC participants are less likely to have dental caries than other low-income families. So we noticed that the referrals are really important and we know that it’s really helping to improve the life circumstances of our participants. Then the final pillar of the WIC program is the healthy food package which we really try our best to make sure that it is culturally competent and it’s meeting the need of participants and the communities that we’re serving.

Derrick Willis So, Quinney, when you speak of health equity, could you actually give us a definition that your organization has defined and give our audience a sense of understanding as when you say health equity, what are we talking about?

Quinney Harris Sure, absolutely. So we worked very closely as an organization to develop a health equity definition – this is something we did also in partnership with our board and with our members – and the definition that we’ve come up with for us as an organization is that health equity is the ability of all individuals and families to achieve optimal health irrespective of their identity, race, ability, or class. This requires equitable access to nutritious foods, breastfeeding support, chronic disease prevention and management services, safe living environments, and good jobs with fair pay. It necessitates removing obstacles to families short- and long-term health and well-being, including poverty, discrimination and institutional racism, and other forms of bias expressed through housing, health care, education, labor and other public policies.

Derrick Willis When you were defining what health equity means to your organization what were some of the steps that you took and what was the process that you used to come up with a definition related to health equity?

Quinney Harris So I think that the challenge that we face as we, as an organization, begin to think about how we would define health equity and what was important to us as we move forward with this work was really trying to narrow down on what specific topics were most important to us as a community because the field of public health is very broad. When think about health equity there is many different ways that you can approach health equity. You can approach it from a race lens, you can approach it from a class lens, you can kind of think about ability/disability status. And those were all things that we thought about and those were all things that we thought were important for us to include in our definition because serving such a diverse community as we do, we represent all 50 states, we represent Native American organization, and all the territories as well, so our community is extremely diverse. So we wanted to make sure that our definition could speak to the diversity of our community. But also being WIC and having the focus on maternal and child health, it was really important for us to really think about food, for one, because that’s one pillar of the WIC program, the healthy food package, and thinking about nutritious food and all of the equity issues related to food access and food security. Then also breastfeeding as being really critical to the work that we do as an organization and thinking about the fact that there are some communities that are not breastfeeding-friendly. And then also thinking about the fact that there’s racial disparities in terms of breastfeeding initiation and duration rate. That was something that was really important to us as an organization, to make sure that we could really pull that out and to be able to include that in our definition. The WIC program also works very closely with health care providers, another pillar of the program is referring out to health care providers and social services, so a lot of my work has really been working closely with healthcare providers, particularly partnering with the American College of Obstetricians and Gynecologists, also known as ACOG, to strengthen our relationships with health care providers through community clinical linkages. So a lot of the work that I’ve been doing at the local level involves coalitions, so really having health care providers to be a part of the coalition’s so that they could provide their expertise and also to really help to help to dispel some of the myths about the WIC program. Because something I’ve really been surprised by since I’ve been in the WIC program is that a lot of the key partners for WIC oftentimes are not fully aware of all the services that WIC provides, so that has been a really critical piece of our engagement in this space, is making sure that we can strengthen that relationship to health care providers so that we can facilitate cross referrals. We’re referring out to health care providers and they’re also referring to the WIC program so that we can ensure that the families are getting the best support that they need in order to live healthy lives. So those were kind of like the foundations for us as we started to work to put together our definition, but we also knew like thinking about the social determinants of health, we knew that our families don’t necessarily exist in a vacuum. When they go back into their communities, they’re also facing the social context of their local communities. So thinking about transportation and the role that that might play in terms of can our participants even get to a WIC clinic. That’s something I see a lot when I’m out in the field on site visits. I’m thinking about going out and visiting Appalachian communities in southwestern Virginia and them talking about the mountains and how that’s such a huge barrier for some of their participants to be able to drive to the local WIC clinic, particularly during the winter when there might be snowstorms and the roads become almost impassable. So transportation was one issue that was really important for us. Housing was another really important issue and just thinking about Baltimore – we funded Johns Hopkins University for one of our projects – so really thinking about all the housing issues that WIC families are facing and how that was really important and how if the families don’t have secure and safe housing, how that might limit their ability to even participate in the program such as WIC. So those are just kind of some of the things that we thought about. We also included education, labor, public policies, just really thinking about the fact that our communities, our participants do not exist in a vacuum and that they’re really having to operate in the social context in their local communities and how that was really important for us to be able to capture that in our definition. So for the WIC community, one of the things that’s really top of mind when we think about health equity is really thinking about the maternal and child health outcomes. Breastfeeding, being kind of an evergreen issue in the WIC community, always working to increase the numbers of the initiation and duration rate of breastfeeding in the WIC community, but also thinking about that through an equity lens and looking at the racial disparities in breastfeeding and thinking about ways that we can really tackle that work. One of the things that has really been coming out of the literature recently is thinking about first, food deserts. So those communities that may actually not be conducive to breastfeeding because there is really not the supports that mothers would need in order to breastfeed their children. They may not have access to healthy foods, they may not have the social support from family members or other community members to be able to breastfeed in public spaces when it’ll be necessary for them to breastfeed, or it might not even be safe in a neighborhood for them to walk about. So just really thinking about how some communities are not even conducive to breastfeeding, and then also thinking about infant and maternal mortality. Maternal mortality has been an issue that’s really been in the headlines a lot lately and it’s something that is very top of mind for the WIC community because this is an issue that is impacting the families that we are serving as an organization. We actually developed a task force, a maternal mortality task force. It’s something that we are really looking at as an organization and thinking about ways that WIC can play an active role in addressing this issue and really thinking about how it’s impacting communities across the country where WIC participants live.

Derrick Willis Thank you. When I hear you talk Quinney, I think things that come to mind are things like the social determinants of health and looking at food deserts and looking at safe neighborhoods. I’m wondering if you could just speak to what people say in terms of racial health disparities are tied to class, access, neighborhoods etc., and not race. Do you think we must consider race as its own health determinants?

Quinney Harris Absolutely. So actually last year the NYU School of Medicine released a report showing that life expectancy is linked to racial and ethnic segregation in U.S. cities. This was most apparent in the city of Chicago where there was nearly a 30-year difference in life expectancy between neighborhoods and different parts of the city. The communities with the lowest life expectancy were lower-income and mostly black and brown communities and those with the highest life expectancy were more affluent and mostly white communities. While class, access, neighborhood and other factors contribute to the life expectancy gap, structural racism is a major driver. For one, redlining and US housing policies created racial and ethnic segregation in Chicago and subsidized the accumulation of wealth in white communities through profit income gained from home and ownership. Also many black and brown families in the city are crippled by trauma and toxic stress from gun violence, economic disinvestment from their neighborhood, school closings, police shootings, food deserts, and disproportionate rates of infant and maternal mortality. As public health professionals it is crucial to center race in our work in order to better meet the needs of the diverse communities we serve by offering culturally sensitive and trauma-informed care.

Derrick Willis Thank you. You know, you hear a lot of conversations recently that has highlighted and even talked about the importance of moving away from not racist to anti-racist. What does this mean for you, your work, the communities that you work in, and how can we see this play out in practice?

Quinney Harris So one form of racism is bullying. Imagine me as a black teenager going to my white college roommate’s house for Thanksgiving and being repeatedly called brownie-face by his five-year-old cousin in front of the entire family. Then imagine an entire room full of adults responding with indifference and carrying on with their Thanksgiving preparations. This actually happened to me in Long Island, New York. I’m sure many of the people in that room would have said that they are not racist, but in that moment by being passive bystanders, they were complicit in a racist act. In this moment in time, I think anti-racist work, which I define it as actively working to dismantle racist systems of oppression, it’s critical to move us forward as a society. Many health indicators suggest that the U.S. is on a downward trend and racial and ethnic minorities are being disproportionately impacted by poor health outcomes. Much of my work at the National WIC Association seeks to address these racial inequities through state and local community health projects. We actually funded a policy system and environmental change project at Truman Medical Center WIC in Kansas City, Missouri back in 2016. Their community needs assessment revealed high rates of obesity and diabetes and limited access to healthy foods in their target area, which was 70% black and 17% Hispanic. They started by building a community coalition with Children’s Mercy, Linwood Family YMCA, and other community organizations. Then they partnered with two mobile markets to bring low-cost high-quality fruits and vegetables directly to the target community and provided 200 families with redeemable produce prescriptions. Next, they focused on marketing and promotion through a 12345 Fit-Tastic! education campaign to promote healthy habits in the local community. The mobile markets were a huge success and at the end of the project they sought authorization from the state to get mobile markets approved in both Missouri and Kansas for the WIC program. I think this is a great example of public health being anti-racist in practice. They started by identifying an area of high need that was 87% black and brown, and then they made environmental changes in the community to address the high rates of chronic disease and limited healthy food access.

Derrick Willis Thanks Quinney. I am from the Kansas City area and I know the hospital you talked about and the Linwood Association as well. So, great work in that particular community and I understand the needs of that community as well. Could you also just touch on the difference between considering race as a health determinant and racism as a health determinant and how could that inform our practice as we move forward?

Quinney Harris Race is a social construct used to group people with similar physical and cultural characteristics. If one were to use race as a health determinant, you would falsely assume that poor health outcomes in black and brown communities are attributed to innate characteristics to these groups and direct services or individualized education is the best solution for improving their poor health outcomes. Racism, on the other hand, is an unfair system of structuring opportunity and assigning value based on physical appearance. When we use racism as a health determinant, it allows us to consider a range of factors such as policies, societal structures, socioeconomic status, geography, transportation, housing, social capital, and labor practices that impact health outcomes. In this instance, it is more apparent that social factors have a profound impact on health and this clearly aligns with academic research. Take, for instance, the study that indicates that people with black-sounding names on their resume like, Deshawn or Jasmine, are less likely to be called in for an interview than people with white-sounding names on their resume, like Connor or Molly. Less interviews translate to less jobs. Less jobs translates to more poverty. More poverty translate to more hunger, less health insurance, more substandard housing conditions, more homelessness, more trauma, and poorer health outcomes overall. Individualized education is no longer sufficient and must be combined with or replaced by policies, systems, and environmental changes such as cultural humility training for human resources professionals and ongoing checks and balances to ensure more racial and ethnic minorities are moving through the professional pipeline at organizations. This is anti-racist work and practice.

Derrick Willis For public health practitioners and public health students, what are some of the concrete steps that they can take to move towards anti-racist policies and practices within public health and also I also ask, why does this matter as well?

Quinney Harris So I think it’s really important that your anti-racism work starts with inward-facing activities before focusing on the external work. A good place to start is the Harvard University Implicit Bias Test. Also before your next retreat or team-building exercise, have all of your colleagues or your classmates take it and then discuss it as a group. If you have the resources to do so, consider conducting an organization-wide racial equity training with an organization that has expertise in equity, diversity, and inclusion, such as a local university or nonprofit. Use a validated racial equity tool to assess your organization’s policies and practices. The Government Alliance on Race and Equity has several resources publicly available on their website. You could also consider sharing articles, TED Talks, and other anti-racist resources in your staff newsletter. Use any findings or lessons learned from the internal work to guide your external activities. And be careful not to make assumptions. Engage and foster relationships with other anti-racist champions who can help guide your work. At the beginning you asked why does this matter. So for me, I think back to our last President, Barack Obama, who was the 44th President of the United States. Would that have even been possible if the civil rights movement never happened? And I think that in itself speaks to the importance of doing anti-racist work because anti-racist work will help us to build a better future that’s more equitable and inclusive.

Hannah Shultz Now that we’ve heard some of the activities and work happening with the National WIC Association and the importance of considering health equity in national policy, local practice, and everything in between, we’ll hear what Black Hawk County, Iowa, is doing to build a more equitable health department and community.

Derrick Willis Today we’re going to interview Dr. Nafissa Cisse-Egbuonye, who is a public health director for Black Hawk County Public Health. Just a little bit about her before we get started in the interview – she earned her doctorate degree in public health education from Texas A&M University and her Master’s in Public Health from San Diego State University. Dr. Egbuonye has worked with different organizations conducting research, implementing health promotion programs, and advocating for vulnerable populations. Furthermore, she is a person coming from a diverse background and is fluent in four languages, so she’s accustomed to various cultures, which is necessary when developing public health programs nationally and globally. We are honored to have her as a guest today and I will be asking a number of questions related to her work in Black Hawk County and then her thoughts on a number of issues related to health care equity, and health care disparities. So, welcome Dr. Egbuonye.

Nafissa Cisse-Egbuonye Thank you, thank you.

Derrick Willis I would like to start just by asking you to tell us a little bit about yourself and some of the work that you do in Black Hawk County.

Nafissa Cisse-Egbuonye Okay, a little bit about myself . . . as you can tell my name is unique, I am originally from Niger, which is located in West Africa and I arrived in the United States in 1989, and I’ve lived at what I consider in most parts of the region of the U.S. So I’ve lived in the Midwest, in the East Coast, Vermont, Texas, California, and now I’m back where I started my U.S. journey. So, I’m in the Midwest in Iowa and it’s just been an incredible, incredible journey for me. Just being here I consider myself, you know, starting to become an Iowan. I have been with the Black Hawk County Public Health Department for three years now. We’ve gone through quite a bit of transformation, but it’s been an exciting journey. So Black Hawk County is located in the northeastern part of Iowa. We are approximately 132,000 in population. Our population’s predominantly white-Caucasian. We also have one of the largest African-American populations and influx of immigrant populations. We have Bosnian, Congolese, Liberian, Burmese, Hispanic populations.

Derrick Willis Thank you for choosing Iowa as a place that you have been for three years. Definitely see a need for diversity and people who, especially in leadership positions, that come from diverse backgrounds, so welcome and thank you, thank you for being here. I guess the other question that I would like to gain a little bit more information on is around just equity and some of your work in Black Hawk County. Can you tell us a little bit about that and what was the catalyst for some of this work and why do you see it as so important?

Nafissa Cisse-Egbuonye So one of the things that attracted me with this role at Black Hawk was the demographic changes that are occurring. One, I think they’re there for several years, there’s been an influx of immigrant population, but outside of that also there’s a large African-American population that has been in Black Hawk County for several decades, originating from Mississippi, so those things really attracted me. I love diversity, I love the idea of having a community that is inclusive and engage with each other and embrace the different cultures that we have. I think that’s actually the beauty of this country, the diversity that is in the United States is something to embrace. And so with that, our Board of Health was very intentional in recruiting someone that understands public health, understands the demographic changes, and is intentional in reaching out to the different populations and seeking their input and strategies in terms of how we can effectively implement public health programs that is tailored to their needs. So that was an exciting opportunity to come to. The equity journey really began when we applied for the Kresge Foundation Emerging Leaders Program. It’s a program that really helps to transform our health department and I’m truly grateful for the Kresge Foundation. But when we originally submitted our proposal it was to become a Chief Health Strategist. I like to use the term Community Health Strategist because the term “chief” makes it seem like you’re the leader, I guess, you know more, and I find that to be slightly elitist. I like to use the term Community Health Strategist because I feel it’s more inclusive. We were trying to understand what are some of the factors, the determinants of health, that the health departments can really zoom in on to change health outcomes for Black Hawk County. We first started thinking about education and how everything we do has education, whether it’s a sector or whether it’s using education to inform people was such a big factor. In November of 2018, we received the unfortunate news from the 24/7 report that we were considered the worst place to be black and to reside in Waterloo and Cedar Falls. So that really impacted the community, it impacted us morally. It was . . . you can just see the negative emotions and sadness that came out of this, but it also was a wake-up call that we needed. I myself, as a newcomer, the information wasn’t surprising to me. The inequities in Black Hawk County – they’re so visible and that’s what every newcomer comes in and sees, how segregated the community is, how we have an abundance of resources, but the struggles that people have in terms of navigating those resources are pretty visible. So sometimes you have to be able to use bad news for good. So that’s the approach the Health Department took to say “okay we have this bad news now, now what?” It gives us an opportunity to invite our stakeholders and community partners and really engage in a conversation around equity in such a way to start thinking about transformation. It’s not just transformation at the organizational level, but it’s transformation at the individual level. So even as leaders, when you think about equity you have to also be willing to take some time and evaluate yourself, your perspective, and the way you yourself navigate the world and your system. So that’s really what started our journey.

Derrick Willis I’ll ask you to talk a little bit about some of the things that you have done to reach out and engage and have conversations with folks that represent diverse populations in your county. In your work, I was curious to know if you’ve reached out to populations and had conversations? I, as a researcher, like the participatory action approach to that and wanted to know if you have done any kind of work in that area to really kind of convene an opportunity for people to talk about what are some of the needs and some of the concerns in your communities.

Nafissa Cisse-Egbuonye Mm-hm, yes we have. I’ll give an example. I’ll give two examples. One is our community health needs assessment. Currently, we are going through the process and so originally when it was sent out and you run the analyses, you see that is predominantly white upper class that were responding to the survey. So I talked to the team and I said, you know, what are some of the strategies that we need to implement to ensure that this assessment is reflective of the demographic that is in Black Hawk County and to make sure that we are intentionally trying to reach and hear the hear the voices of others? We’ve had to implement different strategies with our partners. We had Head Start, for example, Tri-county Head Start that took this survey to people, . . . and that’s another thing as we do equity work, there is the expectation of people coming to us, and this has to be changed, so for public health we always have to take an approach of how do we get to the people versus just waiting for the people to come to us. So our partners at Tri-county, they took the surveys to the homes as they were doing the home assessments. I personally went to the churches, African-American churches, to talk to them about the importance of the surveys. I’m meeting with the African-American pastors. We’re able to do some of the data collections there and looking at different strategies of where to place those surveys so that people can take that. We’ve taken this systems approach to understanding equity and we, working with engaging inquiry, we asked our stakeholders what accounts for the level of equity within our community, so we created this equity map. Right now the strategy is to socialize the map with our community members and so we’re going to take it out to them and ask them if they resonate with the different factors that they’re seeing on this map and what is their story. So if they say like yes they resonate, right? We ask them like “how do you resonate?” or just open-ended, “how do you navigate this environment, what has been some of your positive or negative experiences?” So for us, it’s also taking that approach of empowering people and ensuring that they understand the importance they have in contributing to this process and really taking an angle that the solutions that we will implement for this community is collective so it’s no longer us leaders saying,  “Oh this is what we think you all need” but ensuring that they are able to say “this is what we think we need“. That’s just been exciting. It’s been hard. It’s a hard process because as leaders we’re trained to be very solution-oriented, quick to solving problems and sometimes with equity work it requires patience, it requires understanding, it requires meeting people where they’re at. It’s just been a humbling experience, I believe, for myself, my staff, and also our community partners and organizations.

Derrick Willis I appreciate you taking time to explain that process and I value it and I understand, too. I do a lot of this work as well and I know that it is a journey but, people are quick to rush to solutions. So finding the individuals who are willing to work with you and to stay with you on that journey sometimes can be a challenge. Some of those – can you speak to some of the surprises that you’ve seen so far, anything that could stick out to you in terms of, you know, as you are doing this work, what are some things that surprised you through the process?

Nafissa Cisse-Egbuonye I think one of the things that surprised me is the realization of how much equity work is close to the heart and it’s value based, so you can’t work at Black Hawk County Health Department and say you believe in equity while you’re in the department, but then once you leave you don’t, right? It’s just you can’t do that because the more and more we train about equity, the more and more we’re engaging, the more and more some of our personal biases just start to be highlighted. I think for myself as a leader is how do I create that space also in our organization so people are able to be vulnerable. Equity is about vulnerability. It’s about also being able to say I actually don’t know, right or I’m willing to know, I don’t understand, being able to be uncomfortable. So I think for us that’s been the hardest part is how do they always ensure that people’s emotions are – not necessarily protected – but we have strategies to deal with when there’s those emotional breakdowns. Now even in recruiting staff we do ask questions that can help us zoom in a bit, in terms of okay, is this person a right fit for this organization? We also give enough information for the person to determine whether they want to work at a health department in particular with this framework.

Derrick Willis Dr. Egbuonye, if you could, speak to the whole issue of race and health disparities, many people say racial health disparities are tied to class, access, neighborhood, etc. and not necessarily race. I know this article that we were speaking on earlier really specifically identified African-Americans and so if you could talk about your thoughts related to health disparities being tied to class, access, and neighborhood and not race, I’d like to hear your thoughts.

Nafissa Cisse-Egbuonye So just to simplify, for me, race, the color of our skin . . . I mean, first of all, race is a social constructs right? It’s something that has been defined by human beings and so that’s number one, I think that’s where some of the issues stem from, but I want to talk a little bit more about racism as a determinant of health. I think when we – and this is from a practitioner perspective right – so when we as practitioners if you say race, most of the time the practitioner just sees, oh it’s the color of the skin, you know, and so what it does is that it just shows the data and comparison to white and black, white to Asian, white to Hispanic, but what does that actually mean right? We’re just highlighting these differences, but when you talk about racism as a determinant of health, now you’re starting to look at the deeper issues right? So that’s where the issues of access to quality housing, access to health care services, access to good education, that’s when we start to have meaningful conversation about okay, why is there barriers to that in the first place? So when you look at just race with data, it just says there’s differences, but it doesn’t push the practitioner to ask why are there these differences. I think that’s why even today you see programs that are just tailored to like okay, let’s do diabetes prevention in the African-American community, but we’re not getting funding to look at exactly why is there high rates of diabetes within the African-American community? So it goes into just the transactional approaches that we take instead of solving the root cause of the problem. I think that’s why we continue to see the differences in our health outcomes.

Derrick Willis Dr. Egbuonye, a lot of conversations recently that we’ve heard have highlighted the importance of moving from not racist to anti-racist. What does this mean for you and your work and how can you see it playing out in practice?

Nafissa Cisse-Egbuonye I think that’s a very good question because I think that mainstream when there’s discussions about racism or maybe for perhaps individual conversations occurring, there’s an immediate reaction of – in particular from whites that – I’m not a racist, but what does that mean? What does it mean? It’s like a person saying I’m a good person, well actually what does that mean right? I think it just, it’s a statement that totally doesn’t have a meaning. It’s more of a defensive mechanism. It’s like when somebody says I’m a good person. What’s the reason why you’re saying I’m a good person right? It’s the same thing when you’re saying I’m not a racist, why are you saying that right? But I think that the statement, anti-racist, when someone says to me I’m an anti-racist it means that they’ve actually thought about racism. They thought about racism. And Ibram Kendi, he’s one of the historians that is leading in this movement, he says that the opposite of a racist person is an anti-racist right? So just for me it resonates more because it means that okay, this individual at some point thought about racism and decided “no I’m actually anti-racist” and is willing to look at their self, their action, and also the policies or systems in place that have created power imbalances. I think it’s just even for us, I guess I said at an individual level, that’s even something that even for myself of being a person of color, I have to say out loud I’m anti-racist because I am. So I think that’s the difference for me.

Derrick Willis Yeah thank you. If you look at public health practitioners and public health students now, what are some concrete steps that they can take the move towards anti-racist policies and practices in public health and why does that matter?

Nafissa Cisse-Egbuonye When I was a public health student, health equity wasn’t a part of our curriculum. It was actually, I think it actually promoted some of those structural imbalances that we’re trying to fight because even when health outcomes are discussed in classes, we start to talk about how there are the vast disparities in the African-American population or the immigrant population right? So even myself as a person of color, I didn’t even understand as a student how some of that I was internalizing because it’s such a negative data that is infused within our curriculum. It’s always talking about how negative people of color are doing, and so I think that there’s opportunities for us to take a step back and change our curriculum because even for white students, the notion of white privilege is very important in public health. What does that mean? What does white privilege mean or what does it mean to come from a group that has had advantage, historical advantage? So being able to understand that as they go into the field that the lenses in which they look at things are very different. I think that public health, if we are going to achieve public health 3.0 and become the community health strategists with the equity focus it’s also important for us – those in the practitioner roles – to work with those in the academic environment so that we can look at our curriculum and strengthen that so that the students are prepared to serve all populations in an equitable matter.

Derrick Willis Very good. Speaking of an academic environment, I’m currently in an academic environment and sometimes I find myself a little confined and have a need to do the ground works more so [inaudible] participatory action process and so a question to you is are you still in the academic environment and as well a practitioner? If you had your choice which one would you rather have?


Nafissa Cisse-Egbuonye Oh, wow I was trained to be a researcher, but I got my undergraduate degree in public administration. Throughout my undergrad and graduate work I volunteered, I was involved in community-based organizations, and it was until the final year of my doctorate I felt an absence because, you know, in academia they’ll tell you that publications are the currency to your success and I love writing, I absolutely do, but I felt that if I stayed in academia the more and more I’ll be disconnected. I’ll write, I’ll do some research, I’ll publish, but I’ll be disconnected with what’s going on in the field. But it’s fine in the field. I can still be in tune with what’s going on in academia. I think that being trained in research has helped me to infuse some of that into practice. I do believe that we do need to have people that have the research background, the community participatory research that you’re talking about. My favorite methodology is mixed method. So I love to do the assessments in that way. So I’m in a very good place right now because I can always infuse that. I have a relationship with University of Iowa, with the University of Northern Iowa and so I’m very fortunate in that regard, but I do think that in order for us to change our approaches we have to unite. Those in academia really need to spend time understanding what happens at the practitioner level because it’s day-to-day. I mean I can have a schedule for my day and then next thing something happens and that’s some of the stuff that excites me, right, then my schedule is changed. Right now what I wish to have is space to be able to write everything that I’ve learned because it’s just been such an incredible experience. And so I take that opportunity, any student that’s doing graduate work, I’m willing to just sit down, talk to them, and just share.

Derrick Willis As one person of color talking to another person of color and both of us in leadership positions, I find it almost an obligation for us to – at least for me – to dig back and to create opportunities and a pipeline, so to speak, for other people of color. In episode 9 of this series, we will talk with Dr. Denise Martinez, Dean of Diversity, Equity, and Inclusion at the University of Iowa College of Medicine, about the importance of having a representative workforce and the value of programs that introduce students from historically underrepresented groups into health professions.

Nafissa Cisse-Egbuonye For me, a health department should be reflective of the population it serves, so we are very intentional about diversifying our departments. We look at our recruitment strategies, we look at how we’re even advertising our job vacancies. Also, we don’t do recruitment. It’s not just a manager going out and doing the recruitment on their own, we do it in a collective manner because I think that has helped to hold each other accountable and we always just ensure the best candidate is the one that we recruit. Beyond that, you know, one of the things we’ve implemented that has been exciting is the Community Health Worker Model and recruiting people from the particular populations we want to serve and so I’m excited to see how that’s going to launch, but it’s a job that we just developed. So those are some of the strategies. My hope is that equity is institutionalized at Black Hawk County to whereby it doesn’t need a person of color to be there for it to live, it just naturally is in our walls and how we work and how we do things. In terms of giving, providing opportunities, you know, you make a statement, Derrick, that has really also [inaudible] a burden, but I’ve had to also recalibrate myself to understand that as a woman of color. I believe I’m the first woman of color to lead this health department. With that, you know, you go in with really a lot on yourself and saying you know if I fail at this job like that other person, another person of color might not have this opportunity. But it also took for me to do some of the equity training and realize that that’s even wrong for this system that has been created, like it has created a trauma even in us as leaders because we’re constantly ensuring that we don’t fail because we want to give that opportunity to others, right, and not allowing us to be human. That to me, that’s a problem in itself and so I’ve had to recalibrate myself to say that I will do the best I can and not really carry that burden but ensuring that our policies and the way we’re recruiting is equitable.

Hannah Shultz Thank you Quinney and Nafissa for joining Share Public Health and the work you do to promote health equity. Tune in next week to learn about Native American health in the Midwest region. Thank you for joining us today. Special thanks to Rima Afifi, Anne Crotty, Alejandra Escoto, Paul Gilbert, Kaci Ginn, Mike Hoenig, Kathleen May, Felicia Pieper, Melissa Richlen, Hannah Shultz, and Laurie Walkner. Theme music for Share Public Health is composed by Dave Hoing and Roger Hileman. Funding for this webinar is provided by the Health Resources and Services Administration. Please see the podcast notes for an evaluation and transcript.

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