Share Public Health Transcript: Tackling Equity, Immigration

Season 1 Episode 25

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.

Felicia Peiper Hi, my name is Felicia Peiper and I’m a Master’s of Public Health student at the University of Iowa College of Public Health, and today I’ll be serving as host and this podcast episode dedicated to immigrant health as a part of the Tackling Equity series, and with me I have Dr. Michele Devlin. Dr. Michele Devlin is professor of Global Health and Emergency Medical Technician in the Department of Health, Recreation and Community Services at the University of Northern Iowa, UNI. She is head of the UNI Global Health Corps organization, and also serves as founding Director of the Iowa Center on Health Disparities, a model agency established by the National Institutes of Health to improve health equity for underserved populations. Dr. Devlin is an Adjunct Research Professor with the United States Army War College in Carlisle Pennsylvania. Dr. Devlin’s primary areas of specialty include refugee and minority health, human migration, maternal and child health, and disaster response. How are you Dr. Devlin?

Dr. Michele Devlin I’m doing just fine. Thank you so much for having me.

Felicia Peiper Great, thank you. Could you explain to us a little bit about what the history of immigration is in our region? Who comes, why do they come, and how and why does this change?

Dr. Michele Devlin Sure. We’ve seen some interesting human migration streams within the past several decades here in the state of Iowa and in the Midwest in general and a lot of that is driven by different patterns that we’re experiencing within the area. So to give you an example, a lot of our immigration, certainly around the 1990’s anyway and maybe even a bit before that, was primarily through the influx of people from Mexico that were coming into the area and there were push-pull factors, you know. Challenging economic situations within Mexico pushed people out and then in terms of the pull-factors, we had a number of different organizations that were looking for laborers to work with in the Midwest and it’s a wide variety of organizations. We’ve seen it within the meat packing industry, agricultural processing warehousing, other types of jobs and companies where people may be able to work that don’t need to have a lot of English language skills. They don’t need to have, you know, a lot of higher-level skills and basically a number of different repetitive movement-types of positions and jobs that they could be trained in fairly quickly. A lot of that that typical migration stream, it was primarily younger men, that all change really around 2008 and beyond. One of the major drivers of that change within the nation – actually not just within the midwestern Iowa – was the large immigration raid that occurred here in Northeast Iowa in Postville. At the time that was the largest single-site immigration raid within the United States and there were almost 400 people that were arrested. They were primarily Guatemalan indigenous workers. They were mostly undocumented but what made it different was not just that the workers were arrested, so were the managers, so were the owners, the Americans that hired them and allowed them to work there and that really that really scared a lot of different companies around the country that had traditionally relied on undocumented workers to do a lot of their labor, and so that that switched . . . that made a lot of companies try to hire people that can work here legally. So now we have what we call micro diversity or micro plurality within the state of Iowa, within the Midwest area in general. If you look at some of our communities, for instance, within Iowa if you take the towns of Waterloo, Denison, Postville, Storm Lake, there are so many of them small meatpacking towns you can, easily in a lot of those communities now, see 30, 40, 50, 60 different languages and unique cultures within those communities. Those are primarily refugees and legal immigrants that do have the documentation to be here legally and they are being recruited by companies as laborers. They are not showing up randomly in the state. They are very much being recruited here because we have a workforce shortage. So within Iowa, within large parts of the Midwest and other rural areas of the country you’re seeing an aging population. In fact, there are some counties within Iowa where you know they’re 50% or more of the population, a majority the population is actually over 50 years of age. You don’t have as many children, we’re below replacement fertility levels within a number of our different ethnic groups and cultures, including whites and including a number of our non-white populations depending on the state, depending on the region, the area. We can easily lose 50% or more of our young people when they graduate to other states and they may be going to, for instance, from Iowa. A lot of them go to Colorado for work or they may go to Minneapolis for work or Los Angeles or, you know, different parts of the country that are more urban, where they can get higher salaries and these kinds of things. We are urbanizing. Iowa now is technically – hard to believe but – technically an urban state. We have more people living in urban areas than in our traditional smaller rural communities. So we have, you know, lots of these different factors that are driving a workforce shortage in large parts of rural America, including again Iowa and a lot of our neighboring states where different public health professionals are increasingly serving refugees and immigrants in small towns and even larger towns that are coming from well over 100 different cultures. And to give an idea within the state of Iowa, we are now well over 180 languages within the state and again, that’s primarily driven by pull factors by companies that are recruiting people here legally so that they can work within our different industries.

Felicia Peiper I’m more familiar with the term new destination. Is at a term that you use in your work?

Dr. Michele Devlin I certainly use new destination. We like to emphasize micro diversity because it really shows diversity within diversity. What happens for too long is that people have just you know . . . again in the public health field, we’ve thought of our patients as well. We have white patients, black patients, and Latino patients, and Asian patients and that may have been true at one point, again, where they were primarily from from one ethnic culture and from one race potentially. But, again, because of these new changes where the demographics are really, the labor, the globalization of a labor force, and the need for labor is really driving new people coming in, you know, sort of these new destinations we’re seeing micro diversity. For instance within the state of Iowa, yes we have Asian patients, but it’s very interesting – one of our largest Asian populations are the Burmese, which you’ll hear people say well we have the Burmese are here and of course they are not just the Burmese, they are people from Myanmar and they are ethnic groups within Myanmar, so depending on what community you’re in within Iowa, you easily could have people from Burma that are from a dozen or more different ethnic populations, speaking very different languages, not even dialects but languages that are different very different, unique cultural practices and beliefs and and backgrounds that all affect the public health status of their community and the way that public health workers need to work with them. So we like people to really understand the importance of ethnicity and understanding the cultural background of where people are coming. I should say too the other thing that makes us somewhat a bit challenging for the migration stream issue is because the state and the region now a lot of these companies are really trying to hire people that to work here legally we are seeing a lot of what we call secondary migrants. For instance, let’s take the Burmese. Often different companies here in Iowa, they’re not necessarily – sometimes they are – but not necessarily recruiting them from refugee camps in Malaysia to come here to Iowa, but they may be recruiting them from a different state, let’s say from Arkansas which does have . . . or let’s say Dallas, for instance, Texas. They’re recruiting them from that area to come up to Iowa, so they’re technically secondary migrants. We have thousands of them here in Waterloo. We have Congolese refugees, a significant population here. Waterloo, Iowa only has so many thousand people in it and those Congolese are secondary migrants. They were not recruited by the local meatpacking plant from refugee camps in Africa, they were actually recruiting them right next door from Illinois where they already were and they’ve been for a number of years and then they come here, so it’s a very very diverse pattern. We, again, really want public health workers to understand that level of cultural diversity and how that can play out in healthcare.

Felicia Peiper What are some of the unique health needs, challenges, opportunities of immigrant populations in our region?

Dr. Michele Devlin Sure. There are many. Of those things, very often what we hear at first . . . [what] people, health workers, or health agencies talk about first are some different challenges that we see because it is relatively new for them and, again, you can have communities that have primarily been made up of maybe one or two or three racial groups for many many years, for many decades and then suddenly within a relatively short amount of time you’ve got 20, 30, 40, 50 or more different nationalities within a community, again all driven by this workforce shortage and the need for labor. So one of the biggest challenges you’ll hear a lot of public health folks and medical people as well doing clinical care, you’ll hear them talk about the language diversity. As I mentioned before, within the state of Iowa we are well over 180 languages now. The other thing that we’re seeing kind of within the whole region, the Midwest region, is the language, the level of language diversity is very significant. For instance, depending on what community you’re looking at and what area you could easily have a third or more of the languages spoken technically classified as rare languages. So it becomes very very difficult to find interpreters to do the verbal translation of information or, of course, people do the written translation of information, but it’s very difficult to find interpreters for many of these different languages. In-person is hard as well as even if you call up and you have a contract with a for-profit language interpretation service and you call them up and say “hey I’ve got these people from the South, the western Pacific and they’re speaking something from the area Palau, do you have anything?” They may not and even though they’re pulling on interpreters that may live in New York City or LA or Arkansas – in the case of the Pacific Islanders, they have a huge group of Marshalese down there from the Marshall Islands – you just cannot always find an interpreter. So yes, we do have people doing charades, I mean that does [happen]. It’s very sad. There would have been a time that, you know, it could have provided you with different referrals and resources, but people are doing chirades at some point trying to act out and explain different symptoms and signs and clinical health issues and all these challenges. The other thing we see too with the language is that we have an increasing number of people that are coming in that are not literate in their native language, let alone in English, so you’re several languages away from being able to communicate, let’s say through writing, you know by using websites or handing out brochures or “gee, you’ve got this disease or condition”. We’ll do a public health education campaign and we’ll hit the have a lot of stuff on our web sites and we’ll do Facebook pages and then blah blah and all this stuff. Well that doesn’t work if people can’t read in their native language, let alone in English and that’s not something that can be fixed within a day or two. That’s going to take a very long time to get literacy levels up, so that’s a significant challenge. We also see a lot of issues going on just in terms of differences in cultural health beliefs and practices and understanding and levels of knowledge and hmm these kinds of things. For instance, different cultures, different populations within different cultures will have different beliefs and how, in health, period. What is health, how is health defined, how do you obtain health, how do you maintain health, and what causes non-health or disease or illness. A lot of our cultures coming in for instance can view health from a very very holistic standpoint, they’ve been doing that forever, well you know far longer than anything when we started to look at it in Western medicine much more recently, but you know healthy, very holistic and includes not just physical and mental, but emotional health, social health, health of the family, health of the community, and health of the spirit, so much much broader. Then they come into the West and into the U.S. and our health often is looked at very much from a viral standpoint or a lifestyle standpoint. Smoking causes cancer, you know, this kind of thing, which it obviously does but they tend to be looking at it much more broadly. They’re using different traditional health practices. For instance, we see within a lot of our refugee and immigrant populations they may be going to Western medical providers, but a lot of them are also simultaneously – or maybe initially – using traditional health practices, so maybe medicinal remedies that people are bringing from the homeland here or that they’re getting in ethnic stores where they shop. There are shamans within these communities, bone setters, careened arrows, traditional healers in a lot of their different communities that they may be utilizing as well in addition to anything that we’re doing from a Western medical standpoint. Of course we’re also seeing financial barriers to care. This is significant although it’s changed somewhat when our migration stream in earlier decades was primarily made up of people that were undocumented, that did not have the legal ability to work in the US, but nonetheless they were being recruited and were finding or coming themselves through push-pull factors and working in a lot of different industries around the country. There were different challenges with them, but now that you . . . financially they did not have enough money for medical care and they may have feared getting arrested by authorities and deported in all of this. But we’re seeing with a lot of these new populations within our community, they are overwhelmingly here legally and the companies know that that’s why they’re recruiting them from legal populations is why refugees are here. By definition they have the legal ability to be here and so because of that, absolutely a lot a number the companies now have health insurance benefits. We didn’t always see that for instance in the agricultural processing industries in the Midwest, but we see that today a lot of the companies are providing health insurance, so that’s terrific. That’s been a great improvement, but we still see challenges with people not understanding how to use insurance, not understanding where to go for medical care, or if they do go even if they have insurance, the deductibles may be too much for them to afford or the co-pays or different things like that. So those are probably some of the most commonly cited challenges that we see within our refugee and immigrant workforce within the regions.

Felicia Peiper So Dr. Devlin, you’ve done a great job explaining to us about the immigrant and refugee populations that we have in our area and some things that public health practitioners should keep in mind. What are some things that health departments should keep in mind when working with new communities?

Dr. Michele Devlin Yeah, great question. I think one of the most important things that we’ve seen traditionally here is that they have to know who their public is. They have to be very actively aware of what kinds of populations that are coming in and out of a region, of a state, of a community and how this could affect their service population. What services and programs are ultimately going to need to be developed. We’ve worked with a number of different public health departments that initially brought us in as consultants or trainers and saying “hey, we’ve got some new people here but we don’t know who they are, where they’re from, what their deal is”, you know, and all of this kind of stuff. So you really have to get into almost medical anthropology and be an ethnographer and get out of the office and walk the streets, go to the neighborhoods, go to the markets, go to the soccer festivals, go to the the ethnic celebrations, and the holidays and just start talking to people and having conversations with them. Sometimes we find that that can be difficult for some agencies to do. When you’re working with rapid ethnic diversification, which is what we have, and when you’re working with micro diversity as your overall demographics theme, we don’t have the luxury of just being able to sit in our offices and run data and look at numbers and look at written reports. We have to get out of our public health offices and get into the communities and start talking with people and really understanding the level of diversity that we’re seeing and then keeping track of that and understanding that these populations within our communities are changing all over America, not just in Iowa, not just in the Midwest, but all over America. Different streams of newcomers are, you know, they’re very fluid. They come in, they come out, some stay, some don’t stay, but you’ve got to understand the push and pull factors, the drivers are the certain companies for instance within a region that are the key employers that are driving the pull factors to bring in refugee and immigrant workers, so those are good agency, good companies and to talk to. Who are they hiring, what kinds of populations are they bringing in, and what do they need in this kind of thing? We also do a lot of work with school districts because they are very good partners, usually you know in general with public health agencies and schools are . . . it’s a critical collaboration there, but the other reason we like to work with the schools is because they are some of the first agencies and organizations that will see immigrants and refugees. We often talk with their teachers that do the English as a second language or dual language learner types of classrooms. They can tell you right away what communities and what new populations are in the area and they have a very very good feel for who those populations are, why they’re here, what their needs are, what their challenges are. They’ll talk very openly about language barriers, literacy barriers, financial needs, you know, anything unique to that community. They usually have a really good feel for that. Then we do like to work also with social service agencies, you know, DHS group, even nonprofits that serve low-income populations, for instance, local food banks. They have a very good feel also typically for what populations may be in a community that may be under the radar but they’re there and they need help and why are they here and what’s going on with them. The other thing I would say too is that a lot of these different cultures that we’re seeing in the area today, in the region today, these are classified as high context cultures really from an anthropology standpoint. They’re group-based cultures, they don’t focus on the individual as much as they focus on the group or the large family, so they’re coming in as large extended families. So it’s very rare that you would find one immigrant or one refugee in a community or in a neighborhood. They are typically here as groups of people and again, it’s a different demographic than what we saw maybe back in the 80’s, where we had young single men coming in primarily from Mexico as laborers. These are large families being recruited here and so public health departments are not serving individuals, they’re serving groups of people. These are secondary migrants primarily – not always – primarily in our region again, so they came from some other state in the US or multiple states in the US before they came from refugee camps, before they fled the war conflict in their native home. The Public Health Department can also just pick up the phone and call the public health department in Chicago or the public health department in upstate New York or these kinds of areas where these folks came from and talk to their colleagues, ask them what you know, what you do with this community, what did you do for this group, what were their challenges, what worked well, what didn’t work well, what do we need to know? Again, I use the case of the Marshallese from the western Pacific. They’re not absolutely here in refugee status, their on territory status. There are all kinds of different categories of people that are here, but they are legally here. There’s a huge population of them in Arkansas, there’s a huge population of them in Orange County, California and parts of Southern California to talk to the colleagues in those communities to find out what the needs are. In terms of strengths, we have seen that these populations have brought so much to our communities and they brought really good things, again because they’re coming in as families. They have literally revitalized and repopulated dying towns, small communities that really lots of people had left. There were primarily older people living in the smaller rural areas. They were not doing well from a population standpoint, even from an economic standpoint, but because these new immigrants are coming in you often see a lot of entrepreneurship in addition to them working in whatever the anchor company is that recruited them. So some of our smaller rural towns that were really dwindling in population have now been revitalized. Their school districts have more children and are staying open. Churches literally that may have closed down, religious organizations that may have closed down from just not having enough members may have growth in their congregations. It’s really exciting to see. We’re seeing lots of new businesses open up in different communities that are ethnic, you know, immigrant-owned, entrepreneur kinds of businesses and so lots of really exciting things with that. Lots of different skill sets coming in, different languages that can bring a richness to a community, and different beliefs and values again that contribute to that overall mosaic of diversity that we have here in the United States.

Felicia Peiper Could you share some positive stories or practices of public health departments or communities more broadly responding to meeting the needs of immigrants?

Dr. Michele Devlin Yeah. Often, you know, sometimes we think of – especially our smaller communities – as being places that are maybe resentful of outsiders and don’t want all this diversity and I just want to be who they’ve been you know kind of thing, even though all of our communities in the US have really been built up of immigrants throughout the centuries of different waves of migration streams other than within our indigenous population, but there are actually we have seen, for instance, within the state of Iowa there have been some terrific model communities doing model programming for refugees and immigrants. One of my favorites frankly is Postville. They went through they, you know, obviously got a lot of bad international attention because of the huge raid in and with the workers there at the meatpacking plant, but they had probably or more different nationalities for a very long time within their community. They would do events like the Taste of Postville and all those cultures would come out, including the local Iowan, a primarily white population from different European immigration streams. So people would literally celebrate diversity and have all types of different events going on. School districts are having simultaneous language interpretation, even sign language learning going on in those communities. From a public health standpoint, I think Black Hawk County now has long had an interest in its refugee and immigrant populations and, in fact, its current director, her family comes from an African immigrant background as well. I think Dr. Nafissa, as we call her, I think she’s done a terrific job in trying to identify a lot of different challenges with refugee and immigrant health. She’s brought in large members of the community to look at these issues and to that end, actually Black Hawk County with Waterloo and different meatpacking businesses there has long used immigrant and refugee labor. For instance in the 1990’s we had a large influx of about 5,000 Bosnians to the Waterloo, Cedar Falls area, and Black Hawk County area. Then we’ve had many other refugee populations since.The Liberians and different African populations of people from Burma. Many different ethnic groups within Burma now live in Waterloo and so I was always very impressed with Black Hawk County because we’ve done refugee influxes, I think, well and we’ve done it often. So if there was a new group of people coming in, they were being recruited by companies and we knew they were coming in or they showed up and were going to be there for a long time, we would get everybody together again in basically a refugee response collaborative network. So the public health department would often lead it or at least be one of the key players there, but you’d have school districts involved, you would have law enforcement involved, you would have different nonprofits there, you’d have our large People’s Community Health Clinic that I love, they would be involved. All kinds of different key players would come in and they’d all have different roles and well-defined things that they need to do and that they’re in charge of, Visiting Nurses Association and all of that and they would collaborate and people would figure out what was needed, what was going to happen, what agency would be doing what, and how data and information would be shared. I think setting up sort of these rapid refugee response collaborative networks, I think there’s a lot to be said for that and that can be very very very helpful. Then, again, I think agencies that do a lot of footwork that really get out of the office and are intimately connected with these large communities and families and they identify the key players, they identify the local leaders or community representatives, and of course those people should be actively involved in any type of collaborative programming. Some of the best work I’ve seen done, for instance, with our African immigrants was done by the African refugees themselves. A number of years ago, when we had the large Ebola outbreak in western Africa, and we were concerned about that disease spreading obviously across the world and to communities within America that had large African immigrant populations from West Africa. Well ironically Iowa is one of those states and we’ve had Liberians and other West Africans working in the state for well over a decade and they themselves, those immigrant populations themselves and their networks and their nonprofit organizations that represent them like AC in Des Moines, approached us as public health consultants and saying “we need your help, we are concerned about our own family members coming over in and out of the US and into our communities and potentially inadvertently spreading the risk for Ebola, how can we work with public health agencies to change this?” So they were terrific and that was all driven by the immigrants themselves, you know it’s being really central. We’ve got EMBARC. They are a fantastic nonprofit organization. They’re located in Waterloo, Marshalltown, and Des Moines in Iowa and they’re active in large parts of the state. Their sole purpose as a nonprofit organization is to assist and provide services, health and education and resettlement assistance to immigrants from Myanmar, from Burma and that’s what they do. So if you’re a public health agency and you have people from Burma in your service area, you shouldn’t be moving unless you’re already involved with EMBARC and they’re going to help drive a lot of your programming because they are from those populations, they know those communities, they are from those communities, they have language assistance, they understand the mentality and the culture, and they need to be active partners with public health in providing services to their communities. Then if I could also mention northwestern Iowa. We have a wonderful community called Storm Lake. It’s been addressing this issue of rapid ethic diversification and micro diversity probably for several decades, now really longer than any of our other smaller communities and even our larger towns. They have had many refugees and immigrants working in their AG processing industries out there and in northwest Iowa. Storm Lake has done fantastic work with its public health agency who’s always playing a lead role in a lot of the collaborative efforts. For instance they have partnered with the local police agency there and other nonprofits. They worked directly with the companies that are bringing these workers in because they are key to programming. They know who these populations are, they know who they’re hiring, and what’s going on with them. For instance, for many years when I was working in the Storm Lake area, the local meatpacking plant on a very regular basis – often weekly or you know bi-weekly whatever – would bring in a coalition of speakers, for instance, from the police department, from the public health department, from the schools and they would all give their spiel and their talks to any of the new-hire refugee workers to let them know “welcome to the community, it’s great to have you, this is what goes on here in Storm Lake and this is how things work in Storm Lake and in the US and in Iowa” because these immigrants don’t necessarily know and they were often new to the US and new to the Midwest. They did orientations for them. Really basic, really good information basic information that newcomers need about their community so there are many many different towns where if you’re a public health agency you now have refugees working within your area it’s worth calling your colleagues in those communities. I would also look outside the state of Iowa. For instance, if you live in Iowa your public health worker you’ve got new immigrants in your community but you don’t know who they are kind of you know where they are but what you know what to deal with them again find out where they came from before they got to your local service area and then pick up the phone or email the Public Health Department in that region, maybe in another states in your neighboring state or maybe they came from large cities we are seeing that they are sometimes recruited from large cities to come into smaller rural areas in the U.S. to do work and they like the rural areas for the same reasons Americans do. It’s cheap living, it’s a lower cost of living, it’s usually safe, cleaner than sometimes working in overcrowded urban areas. Talk to your colleagues and I would take it even one step farther work with your colleagues internationally as well because these are refugee and immigrant populations. They have homelands, they have native countries, they have agencies that have worked with them in their native countries. You know, again, the Marshalese, you know I would you know look into data sets look into what’s been done in the Marshall Islands by the you know Ministry of Health in the Marshall Islands. They know all about the disease patterns, they know all about the health beliefs of these populations. Tf you’re working with, I you know some of our refugees that have undergone horrible horrible things in genocide and ethnic conflict, you should be contacting UNHCR you know the United Nations Agency that works with refugees, because they worked with those populations during the war, during the conflict, during the phase of their lives when they were in refugee camps for years and they understand those populations. It’s important to understand the migration stream- the beginning, the end, the continuum where they’ve been from where they’re going to next and reach out and learn from those agencies what kinds of model public health programming has gone on and how can you take those models and rework them for your local community that you’re now in charge of in your service area trying to serve these populations as they resettle in our communities.

Felicia Peiper To wrap up, you’ve given us a lot of information and best practices throughout our episode today from connecting with and learning about our immigrant populations to cross sector collaboration. Could you identify for listeners what you think are one or two of the most important action steps for individual public health practitioners, students, community members, to do to advance health equity in immigrant populations?

Dr. Michele Devlin I think for individuals at the individual level we’ve been talking a lot about what public health agencies you know should do or hospitals or those kinds of things, but I think from an individual standpoint we need to realize just how diverse our communities now are. We were used to that in the United States like it became you know, if you’re from a large city you know that you get that you know I grew up in Los Angeles you know one of the most diverse cities on earth. You just grow up with it, and for you it’s very very natural but if you- if you’re someone who is you know lived primarily in the Midwest and potentially in smaller rural communities we did not always have exposure to lots of different new populations, so I think one of the best things that students can do and even individual workers is go out and enjoy that rich that incredible richness of diversity that we have. Get involved in your local community, volunteer, help out. For instance, and related a public health and stuff help out with the local you know immigrant organization because they may need help on Saturday mornings tutoring you know some of the moms or kids. Help out as a driver, go to some festivals a lot of these different groups now have been here and they recreate their cultures to the best of their abilities so they often have ethnic festivals and holidays and celebrations and really fun things that are very much open to the public. They very much want to connect with us as much as Americans want to connect with them and figure out what’s going on and how do we all kind of operate you know within within this new you know new United Nations almost you know new level of diversity that we’re seeing in large parts of the country so I think that’s really important if if an individual has the ability financially or with time and stuff, I think nothing is more transformative than actually going back to the homeland of different populations that you may be working with. If you have the opportunity for instance, you’re working with Southeast Asians go to Southeast Asia take a trip go to Vietnam go to Cambodia go to Myanmar go to you know different parts of that world and actually see these populations where they live. Obviously if it’s safe you know don’t you know don’t go into a war zone unless you’re actually working with an agency where that’s that’s kind of work that you do, and I’ve certainly done that, but you know there’s so many of these different places now that you can go to and actually see them on-site. So I think that becomes very important too and then if you’re involved at you know want to be involved in health equity issues again and really try to understand them, I would get involved in lots of different organizations on the local level, national, international level, depending on what you would like to do where you can become an advocate for the needs of special populations, vulnerable populations and this includes our refugee and immigrant groups and it includes our local Americans. I mean you can’t really talk about addressing refugee and immigrant health disparities in the Midwest, in Iowa, in the U.S. unless you talk about addressing health disparities and inequities for rural Americans period. Ones that have you know that are native-born Americans and where we have large numbers of our counties in the state of Iowa for instance large parts of these counties are classified as being medically underserved or health provider shortage areas and that’s for Americans that’s for Iowans that live here let alone for new immigrants and new migrants that may be coming in so a lot of the health equity issues go well beyond just those that effect immigrants and refugees and really impact lots of different vulnerable, at-risk populations so cool you know collaboration will be key, advocacy will be key, and then getting the messaging out about what we need to do to improve the health status and reduce health equities for all communities and all populations within our country.

Hannah Shultz Thank you Dr. Devlin for sharing demographic trends and information about how immigration looks in our region. We’re going to shift gears a bit and talk with Vivian Aldridge, a Health Navigator in Dallas County, Iowa. Dallas County is located near Des Moines, Iowa and many of the towns are bedroom or commuter communities for people who work in Des Moines. Vivian has worked in Dallas County for more than two decades and has seen these communities grow from very small towns to rapidly changing in communities. Vivian, thank you so much for joining Share Public Health today.

Vivian Aldridge Sure, thank you, thank you for inviting me.

Hannah Shultz Yeah, so before we really dive into this conversation could you share a bit with us about your work as a Health Navigator? Specifically, I think people might not really understand what a Health Navigator is. So, what is your position, and what do you do, and who do you work with?

Vivian Aldridge Sure, well as you mentioned my name is Vivian Aldridge. I have worked at the Dallas County area a little over 25 years and going on 21 years working for the Dallas County Health Department. I started working at the health department as a bilingual home visitor program for prenatal parents with children up to the age of five, and as time has passed my job since has since then has evolved as a result of result to the community needs assessment and the health improvement plan, known as the CHINA/HIP, which I can explain a little more later. My job is reaching out to the population, population a little over 90,000, residents in our Dallas County area. I’ve been working as a health navigator since 2012 so, the question was what does the health navigator do. We assist residents to solve problems and access resources in the community so that they can live a healthier life. So that’s pretty much it, that’s what we’re doing here in our county.

Hannah Shultz That sounds great! It sounds like a really interesting role to have and a position that many people might not think of when they first think of Public Health and the services Public Health offers. So you mentioned you’ve been a public health navigator since 2012, but you’ve worked for the Health Department for 21 years. So how has your role changed and specifically your health navigator work and has it changed with the community have the things that you’re dealing with are the issues that you’re experiencing with the clients you work with changed?

Vivian Aldridge Because of our growing communities, which is a great thing, I would have to say we started our focus only in one community and now we’re serving like a whole county the whole county and during the past year I have had the opportunity to complete the committee house worker course in central Iowa. We have grown as a program. We are now a team of three health navigators covering the county and Cochran is a licensed social worker in Ronda Shedffield is a nurse, and together we have been serving the Dallas County area. The changes that I’ve seen is that definitely were growing County. Dallas County has grown not just in the population but diversity as well, and among the Dallas County residents 10% speak a language other than the English in their home and so the estimated population is ninety thousand one hundred and eighty residents strong. Dallas County is the fastest growing county in the state and among the fastest growing counties in the nation. The census information is that in 2010, the census shows that the Dallas County has seen like a thirty six point four percent increase in population with the growth and that’s been largely focused on the western Des Moines suburbs found in the southeast quadrant of the county. So we’re growing!

Hannah Shultz Wow, that is a very large change in the population.

Vivian Aldridge Yeah, and just add on that you know when you ask about like what kind of changes that we’re dealing with, I would, I see because of our, the communities are growing which is like I said a great thing, I have to say that housing it and not just any housing I mean affordable, decent housing for all, a place where people can call home and feel safe and take pride in their community, people are willing to travel to work, if they can, just to have a clean and a safe and affordable housing. Financial stability you know if it provides access to health related resources, healthy foods, healthy care, safe environment to live, if the housing is available. Those are the challenges I think that our county is facing as our county is rapidly growing.

Hannah Shultz That’s an interesting point. On last week’s episode of Share Public Health we talked with Andy Wessel from Omaha about some of the housing work he’s doing, looking at housing as a public health issue, so it’s nice to tie that back in here, as well. You mentioned a minute or two ago that 10% of residents in Dallas County, it’s estimated 10% of residents in Dallas County speak a language other than English in their home. That’s a pretty big number. I’m guessing that you work with a lot of immigrants in your role. Do you see unique health needs or challenges with the immigrant communities that our listeners might be interested in, especially those listeners who are also working in counties that have seen some demographic changes recently?

Vivian Aldridge Yeah, I think that I think that regardless of who you are, stress is a factor that plays into everyone’s health at one point or the other. I’ve see the challenges in Dallas County residents through a small and very short time lens as a health navigator and having the opportunity to work with the immigrant community, there is no doubt in my mind that managing the care system requires more steps. What I mean by that is, how do you manage the health system if you’ve not yet learned the language. What comes first, immigrant families immigrants that have come to have a better life and we also know that life happens. Some situations can be catastrophic. Some can be circumstantial and I’ll give you a few examples. For example, if you lose your job it might trigger anxiety or depression, or what if you become disabled and there you have no social support, maybe you carry a baby full-term and it’s stillborn delivery, or now an elderly parent might just have been diagnosed with Alzheimers and now how do you try to figure out or understand or manage your elderly parents well-being and the health care plan so when you ask me what are some of the unique health needs challenges, I think of the things that we can take for granted. For example setting up an appointment, knowing what questions to ask, it could be for yourself or for your loved ones care plan or even knowing or understanding what payment plan system can be for you. What could that look like for you, you know. You might have been on your parents health insurance you know and then now in your adult life you’re needing to access health insurance, not knowing where to go for assistance or how to apply or even knowing if you qualify can be the challenge. I recently did a presentation with young parents and sharing how to manage their own health care plan and one of the things I heard was how stressful that can be we you know when you’re sick, our stress levels seem to rise and everything can get very confusing fast. So those are the things that I see as a unique health new college and in the immigrant community.

Hannah Shultz Those were some really interesting examples you shared. Thank you for that. I think it’s especially interesting to underscore that you didn’t share any needs or challenges that are really different from the general population, but the compounding factor there is not knowing how to navigate a new health system or maybe having language barriers that make it harder to learn how to navigate that health system.

Vivian Aldridge Mm-hmm

Hannah Shultz When we’re thinking about the work you’ve done and what you’ve shared with us today, do you have a couple of tips or practices that our listeners can implement into their practice as public health practitioners to advance equity for immigrant communities they work with and also just the general community they work with?

Vivian Aldridge Sure. I’d like to think about them as, I try to use this on a daily basis um, just gonna assume that because the services are there that everyone can access or that they meet the criteria for the services. Every program has its own unique process and there’s no, there’s no program that is the same. There’s no one-size-fits-all, so don’t assume. I really think that empowering consumers is a key. Letting them know it’s okay to ask questions to be well informed with the right information. I also think that that we keep in check that the social determinants of health have found that health behaviors as I mentioned earlier, social and economic factors are the primary contribution to health outcomes. I would like to share to please, kind of if you have the time take time to review our Dallas County community health needs assessment that was conducted in 2019 and if you have any questions feel free to contact the Dallas County Health Department Abigail Sheawk our Community Health Administrator of our Dallas County Health Department can answer your questions.

Hannah Shultz Yeah, great. Thank you so much Vivian for joining us and for sharing more about your experience and thank you for all of the work you do to ensure the health of residents in Dallas County.

Vivian Aldridge Thank you, thank you very much.

Hannah Shultz 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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