Share Public Health Transcript: Tackling Equity, Place Matters

Season 1 Episode 24

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 When we began planning the Tackling Equity series, place came up as an important topic several times. Recently there’s been a lot of talk about your zip code being more important than your genetic code. Often when we look at maps or participate in discussions about place impacting health, we’re looking at city blocks or comparing neighborhoods and large cities for our region of Missouri, Iowa, and Nebraska, and Kansas. We are centering the beginning of our conversation on disparities and challenges experienced in rural communities and will finish the episode with a conversation about housing in Omaha. I’m talking with Danielle Pettit-Majewski this morning who is the public health director in Washington County, Iowa and Danielle also serves on Washington City Council for the city of Washington. So, Danielle thank you for joining us this morning.

Danielle Pettit-Majewski Thanks for having me, Hannah.

Hannah Shultz So can you tell us just a little bit about Washington County and where it is and kind of the demographics of your area?

Danielle Pettit-Majewski Absolutely. So Washington County is what we would call a “bedroom community” for the Iowa City Metro. We are about 30 miles south of Iowa City and our population as a county is about 22,000, little over 22,000, and we are actually one of the few counties that continues to grow in population. We have various communities within Washington county. Washington is is the county seat, but we also have Kalona and Wellman and Brighton & Ainsworth, the Mid Prairie School District the Highland School District and the Washington Community School District. We have a robust Hispanic population, we have a robust Amish population in the northern part of the county, so even though we are small we do have a diverse population and a really growing community.

Hannah Shultz Thanks, Danielle. So the topic of today’s episode is location matters, or place matters for health outcomes and while Washington is pretty close to Iowa City, it is a very rural county. Can you talk about what that means for the health of your community? I know recently a lot of conversation that you and I have had or been a part of has looked at lack of services and lack of access to things due to being rural, so can you address that and some of the other kind of challenges or opportunities you have being in a rural area?

Danielle Pettit-Majewski Sure, so I think one of the things that you most have to think about when you are working in a rural community is how to best reach the people where they are because, like you said, transportation is an issue. One of the things that we do is we try to ensure that every time we’re having a WIC clinic, so women, infants, and children, we are also concurrently having an immunization clinic. If parents are coming and they’re bringing their kiddos to the WIC appointment, we want to make sure that they can also head downstairs and get their two childhood immunizations. Additionally, at the same time that we have our WIC clinics we’ve coordinated to have a mobile food pantry come to the community that comes out of Hiawatha, HACAP serves Washington County and so that was a robust opportunity to say “can we have you come on the same day that we have WIC in the community” so that maybe families that are coming from Kalona or Brighton or Ainsworth can also then access the mobile food pantry on the same day. You know, getting out into the community, going into the schools, going into community centers, whether it’s providing blood pressure checks or immunizations or going into workplaces. One of the things that we do during the flu season is we actually walk around the square and we go into businesses and we do our flu stop and we provide flu shots to people in those businesses so that they don’t have to make an extra trip. We really try to think about how we can access people where they are. An additional thing that we do is we go to the city of Kalona, which is in the northern part of the county, and we provide services there immunization services there so that our Amish population doesn’t have to come quite as far, so that we can get closer to where they are to make our services more accessible to them.

Hannah Shultz One of the things you mentioned was food pantries or mobile food pantries. Many people who live in urban and suburban areas are surprised to learn that healthy food is hard to come by in rural areas. I lived in Washington DC for several years and people made the assumption that we all had gardens in our backyards and all these fields that are growing corn, are growing vegetables for everyone. Can you describe what the food landscape looks like in your area and why access to healthy foods is a challenge?

Danielle Pettit-Majewski You know, that is such a great question and it’s such an interesting idea because, you know, we are “the heartland”. I put in air quotes like “the heartland” and we are kind of feeding America and we’re considered a very agricultural state and yet a lot of times in our rural areas we do have these food deserts. Or like if you’re if you’re a community like Brighton, which is in the southern part of Washington County, you don’t have a grocery store. You only have a Dollar General. So lacking access to fresh produce you might be able to get some canned green beans, but you’re not going to be able to get a bag of fresh carrots. So we have looked at a number of different ways of how can we increase access to healthy produce. Now we are looking up – we have a couple of grocery stores here in the city of Washington, so Hy-vee, Fareway and Walmart all sell fresh produce. We have grown our Washington farmers market and we are actually trying to expand into the Double Up Food Bucks and be a SNAP provider for the entire market so that we can encourage families to come out to the farmers market to buy fresh produce when it’s in season. Some of the other things that we’ve also talked about is a community garden. That’s been discussed for about a year in our community wellness coalition, but those are things that of the topics that have been coming up over over again. The challenges with that is: who owns it, who’s responsible, what are the rules for it, who maintains it, and then who gets the produce. So trying to figure out some of the best ways to go about that, but we’ve really seen our schools step up in this arena. Every single one of our high schools has built a greenhouse so that they can start not only teaching kids how to garden, but then also giving them an opportunity to maybe sell their starts to learn more about how their food is grown and to help expand access to fresh produce. We’re seeing some school gardens and we had one in the Washington Community School District a couple of years ago, but it was just really challenging for the school to maintain it, especially when all the produce came in during the summer and so trying to find volunteers who are able to harvest that and take care of it, but we are seeing that in the Highland school district they’re getting in the Mid-Prarie school district that they’re putting in some gardens, so we are working at how we can increase access to produce, especially if it can be at a lower cost. Now I will say we’ve got a food pantry that’s open every single day, but the mobile food pantry has been great because there is such a robust access to produce, to meats, and to other things that are sometimes missing on pantry shelves.

Hannah Shultz That’s great and expanding farmers markets is also really great, but it’s another access issue if the farmers market is only open once or twice a week and that’s when someone’s at work or when their kid has a soccer practice. Then it’s hard to get there and get to that and farmers markets tend to be a bit more expensive.

Danielle Pettit-Majewski Right.

Hannah Shultz And only available some of the year.

Danielle Pettit-Majewski Right. We saw this actually. Last summer was a challenge with the weather, you know, even, we put in a garden and we had a lot of our stuff get drown out with the rain and then, you know, it kind of died in the heat. We saw a lot of our farmers not get produce to the market until the middle of July and so even though you know WIC passes out farmers markets coupons, it was really kind of hard for people to redeem those because we had such a hard year last summer for produce production.

Hannah Shultz I’m also really intrigued by your comments about all of the high schools having green houses.

Danielle Pettit-Majewski Yeah it’s super exciting. Very exciting.

Hannah Shultz How long have they had those?

Danielle Pettit-Majewski Mid-Prairie built their green house first and actually we had been working with them with our wellness coalition to see how we could partner. You know, what are some of the things we can do, how did they want to use that, how could we assist them. Then both the Washington Community School District and the Highland Community School District got grants to build their own. So that’s just really exciting because we want to be able to partner with what we’re doing in the city of Washington and I see the city of Washington because when you are working with a rural community, you play with whoever raises their hand and says “I’ll come to the table” and the city of Washington has done that, and so we have been actually collaborating with the Washington Community High School and also Halcyon House, which is a retirement community that are right adjacent to each other in the city of Washington to see if some of the produce that has grown in the high school greenhouse could be used in the community garden that Halcyon has offered to host on their property. So to see can we collaborate with you know this with this community and also with the high school students to really not only bring in the energy and their intergenerational connection, but also to benefit the citizens of Washington to increase produce access.

Hannah Shultz Wow that’s really great.

Danielle Pettit-Majewski We’re excited about it! We know it’s gonna take probably another year before we’re able to implement it but these are exciting things to have down the pipeline to implement.

Hannah Shultz Mm-hmm, and it’s important to you know use that example to underscore that change takes time. Healthy behaviors are habits and creating healthy communities is a long-term process. It’s not a one-size-fits-all or there aren’t immediate results.

Danielle Pettit-Majewski Right and I think about this a lot because I’m 35 and so I probably have 30 more years in the workforce and I always think to myself, you know, I need to be thinking about what do I want to work towards so that when I retire? We’re starting to see things really shift. Because I do, I think it’s gonna take time it takes investment it takes getting the right people to the table and I think sometimes especially when you’re working in community coalitions, which you have to do to get things done because we just don’t have capacity at local public health, to do it all. You know, it takes time for people to understand the investment, it takes time for people to say “yes I think that that’s valuable and I want to participate in that” especially when a lot of the people that come to the table are already really busy and really involved in other things. That’s one of the . . . it’s like two sides of the same coin. When you’re in a rural community you know everyone and everyone you know is working on a lot of different things and so it’s a lot of the same people keep getting brought to the table because we have these relationships. But we’re also trying to work on mental health or we’re trying to work on housing and we’re trying to work on , you know, pick a topic and we’re trying to work on it.

Hannah Shultz Yeah of course. One of the other topics that I’ve heard you talk about recently is access to emergency services like ambulances and it’s been, I grew up in a small town but it’s been a while since I’ve lived in a small town, so this wasn’t something I hadn’t even considered before you brought it up. Can you talk about some of the challenges with maintaining emergency services in a community like yours?

Danielle Pettit-Majewski Sure, so I think the biggest challenge that we’ve really seen recently is because our existing county ambulance is a private business and that owner planned to retire. So what we had looked at over the last year or so is how do we respond to this? The decision is really to have this ambulance come under the Fire Department, but there’s a number of issues with that, one of them being the Medicaid reimbursement. Once the Medicaid privatized to the MCOs, that was actually a contract amendment that changed so that this private entity could get an additional influx from county tax dollars to essentially supplement the loss that they took from Medicaid privatization because we as a community needed to invest further into a private business so that we wouldn’t completely lose access. One of the other things that we’ve done just in this transition – and knowing just kind of how fluid things are and how easily this service can be disrupted – is the city of Washington is working on implementing a QRS or Quick Responder Service, a volunteer service so that we have additional folks. Because if we’ve got a couple of ambulances and one of them is in Brighton and one of them is on the way to the University then there’s nobody in the city to respond if you dial nine-one-one. I think that’s one of the things that a lot of people don’t necessarily understand is how long it can take for resources to reach you when you’re in a rural area. You know, you may have a police officer respond, you know, and they’ve got maybe an AED- all of our sheriffs would have an AED, you know, and the police officer may have an AED or they might have a Stop-the-Bleed kit but there’s only so much that they can do until you until an EMT can get to you or a paramedic can get to you. Depending on where they are in the community, it’s really important that we have those volunteer EMS and QRS people responding. But I do think that this is a challenge statewide, this isn’t just in Washington County. We’ve had a lot of conversations with some of our rural counties to the south of us, Jefferson County, Henry County having similar issues and a lot of them are tied back to that reimbursement and the fact EMS is a non-essential service. I know that there’s some work being done in the State House to basically change the sunset. Right now in the code you can do a vote basically letting the people decide if they want to increase tax levies to pay for it that would sunset after five years. I think the language that they’re looking at right now which would increase it to ten and that way you’re not constantly, you know, having to vote whether you’re going to say “yes we want to have this resource” or “no we don’t” because when I think about it, you know, to me we are on a continuum. The healthcare system is a continuum and you’ve got public health, you’ve got your primary care, you’ve got your emergency care, your hospital care ,and then you have your EMS services. Regardless of what our capacity is when you lose one arm of that continuum, there’s an additional strain. Whether we provide those services or not, there’s going to be additional strain to the rest of the system so it’s really important that we have this robust system. Personally I would love to see it be an essential service like police and fire but until then we are trying to work within our capacity and within our scope to provide the best services to our residents as possible.

Hannah Shultz Do you have a volunteer fire department?

Danielle Pettit-Majewski In the city of Washington? Yeah, we do. Actually all of our firefighters volunteer. We do have, I think, in the city of Washington, we have four employees and then everybody else is volunteer.

Hannah Shultz Okay and are the firefighters all EMTs?

Danielle Pettit-Majewski No.

Hannah Shultz Okay, interesting.

Danielle Pettit-Majewski But our EMS will be housed under the fire fire department and so we are hoping to do a conditional EMT level service. If you do have that QRS you can work up to your scope, but then otherwise you would only be able to work to the scope that you are licensed for.

Hannah Shultz Interesting, got it. So another issue that we’ve been hearing a lot about recently in Iowa is birthing centers. Since 2000 in the last 20 years, a third of birthing centers in Iowa have closed. Your county’s birthing center has closed in that period. The birthing center in a neighboring county closed in that period,

Danielle Pettit-Majewski Is closing.

Hannah Shultz Is closing? Okay, and three of your neighboring counties didn’t have birthing centers in 2000 at all. What impacts have you seen in your community on that and what does that mean for for Washington, for Washington County and for the people who live there?

Danielle Pettit-Majewski Yeah this was devastating I will say. You know, I got phone calls after we got word that our birthing center was gonna close and people said “you have to do something”. Like I can’t, like there’s not something that – I don’t have any control over this, you know, but I talked to our CEO at the time of our hospital to just have a better understanding of what is the problem. Oftentimes like you do lose money in birthing centers but because, again, I go back to the Medicaid reimbursements, had decreased. So, you know, where they were at their deficit have increased by about $200,000 once Medicaid privatized and so that was not sustainable. But what we have seen is and in this area, if you want to be able to deliver a baby, you have to go to Burlington or you have to go to Iowa City. Luckily we have seen some partnership between our hospital and the University of Iowa where they are sending midwives down to Washington Hospital every Friday so that people can at least get their prenatal care here in the community. That was a big concern for me, especially because we have a maternal child health program through our local health department that people would really struggle getting their prenatal care because if you think about the time it takes and how frequently you need to go in for those prenatal visits especially in your third trimester. You know, if folks who already have difficulty with transportation are having to go up to Iowa City every week or every two weeks that can really be a struggle especially if you’re trying to take off work, you know, where it maybe would have been thirty minutes before and now maybe it’s two hours, so having that disparity for our community members. I’ve been pleased to see that we’ve brought in those mid-levels or those midwives to come and at least do prenatal care, but it does make it more challenging. I think about it, too as a as an economic development issue. You know, if you want to bring jobs to your community, if you want to attract families to your community and it’s difficult to find a place to deliver a baby, I mean that’s not only a public health issue and a health care issue – that’s an economic development issue.

Hannah Shultz Absolutely. I think one of the other interesting things when we’re thinking about birthing centers is, in some counties that’s pretty low population. Washington County, I believe you said is about twenty-two thousand people, which by Iowa standards is not that small of a county. So when you have really really rural counties that may have less than ten thousand people in them and there aren’t all that many babies being born, having someone who’s, you know, capable and competent in delivering babies when they might only be doing it once a month is just not something that these really small counties can sustain.

Danielle Pettit-Majewski Right, right and I think to you that that makes it harder especially if you want to attract people to rural Iowa. I mean there’s a ton of benefits to living in a rural community like, you know, it doesn’t take long to get anywhere. You know, you’re not ever stuck in traffic, you know your neighbors. I mean, like, I’ve lived in big cities and I’ve lived in rural communities and there’s pros and cons to both, you know, but especially if you are trying to keep young people here and yet it’s really hard to access things and they have the ability to leave, you do. You see people going towards larger communities where they have access to some more things.

Hannah Shultz Yeah. So birthing centers aren’t the only medical services that are getting harder to come by. We hear about specialist and specialized care being harder to access. There are shortages of all kinds of specialists from mental health to dentists and others and people with special healthcare needs like individuals with disabilities or other issues have a really hard time finding the care they need in rural areas so what are some of the things that people in rural areas can do to address this or what are some of the ways that people are responding to this challenge?

Danielle Pettit-Majewski So let me touch on mental health first. I know a lot of the things that they’re talking about right now it’s focused really around telemedicine and how can they do, like especially more prescribing like for psychiatrists over telemedicine, which I think is definitely an improvement to not having access at all. Trying to see how can we expand that, how can we make that more robust, you know. I do think we are lucky that we have a a great minibus system in Washington County and so, you know, for transportation for people with special healthcare needs. If they do needs access to like, if they need to go to the University for an appointment or if they need to go to Iowa City for an appointment, they are able to access that transportation to get them there. It does take some coordination and it does take some time but there is that ability to get to those appointments. Dental is a challenge and I will say again you know, relatively, Washington County is well-placed. Even though we do have a dental shortage, we are close to the University and so we send a lot of people to the College of Dentistry. Unfortunately sometimes that line is really long because a lot of our surrounding communities are doing the same. We also have a community health center on either side of our county. So just to the west and the east of us just across the county line, we do have community health centers that can assist with those services as well. Through our I-smile program we’re really trying to connect people with dental care and access to dental care. But I think that there’s also been some good things that have been happening to expand that, especially in those areas like ours which is a dental shortage area. That is changing some rules and regulations regarding where registered dental hygienists can practice, to expand it to nursing homes. I know that’s something that’s being discussed which would really help alleviate some of that issue. I know one of the things that we saw was changing, the requirements for I-smile coordinators to go from having three years of experience to one year of experience, which helped a rural community like mine hire an I-smile coordinator because that was really cheap. That was a big challenge, that rule kept that position open for us for seven months. So we actually had to sign a waiver and once we had done that then they really push to change the requirements because other, you know, rural counties don’t have that same flood of applicants that you might have in larger communities and so we do the best that we can to respond to that. Again one of the things that we’re trying to do is dental sealants in the school, preschool fluoridation. So we go in and we do fluoride-varnish applications through funding through our Early Childhood Iowa grant dollars and but there is  there’s still money. We talk about community water fluoridation and how that’s a good gap filler but that can sometimes be a controversial issue as well. So there’s a number of opportunities to kind of tackle this challenge from and so we try to look at them all.

Hannah Shultz Is there something that you think we should talk about when we’re talking about issues with health and rural America in rural Iowa that we haven’t touched on yet?

Danielle Pettit-Majewski I think even just housing and I, we recently got a homeless shelter in our community and it was like the day it opened it was at capacity. You know we also provide home health and there’s been times when we provided service is in the park. If you are being discharged from the hospital and you don’t have a safe place to heal, that’s the complication that’s a problem that’s going to impact your ability to get better. Affordable housing is an issue. You know we especially we see a lot of the folks that are from here a lot of we are an aging community as well I mean we’re growing but we also have a rather large aging community and you know sometimes you see people with all of these chronic illnesses and they just really struggle. They struggle to get by on you know, Social Security they struggle to get by and being able to pay for the medications and they’re making decisions about you know “do I do I get this care or do I um you know buy food?” like which, which do I do. Just even some of those gaps that we see and all the time really where you know we have programs and criteria and then there’s a person who just falls through. You know they really can’t afford to maybe get the kind of maybe they don’t meet the skill level for Medicare and they’re not homebound but they really need somebody to come in every day and just help them with their meds and then they maybe they don’t have the funds to pay for it, you know. And so we do have some grant funds that can assist us with that but just understAndyng you know that we are a safety net but that has holes you know that’s, I mean you think about a net, it still has holes and people still fall through these cracks and you know we try our best as a small community to try to gather together and and help those of us around each other. but I think that there’s still a lot more work that needs to be done. And you know just thinking about because a lot of the people who do live in rural areas the people who have stayed are older and so there’s a number of additional complications and so that can really exascerbate some of those issues so yeah there’s there are complications there’s there’s pros and cons like I said to living in a rural area but we do see those we do see those gaps and services and how do we how do we fill those gaps and how do we create a more robust system that is going to you know lift all ships.

Hannah Shultz Yeah, thank you so much for that. Thank you so much for your time today and for sharing more about Washington County.

Danielle Pettit-Majewski Yes, thank you so much for having me.

Hannah Shultz Danielle give us a good overview of some of the concerns and challenges rural communities face. Now we’re going to go to Andy Wessel in Omaha and get hyperlocal. Andy has been working with community partners to undertake a systems level approach to housing. Today I’m talking with Andy Wessel, a community health planner from the Douglas County Health Department in Omaha, Nebraska about some of the housing work that he has done in the community. Andy you’ve done a lot of interesting work in the Omaha area. Could you tell us a bit more about that and why you, as a health department made housing a priority?

Andy Wessel Sure, so part of this goes back to just sort of the professional side of my work so community health planner. I, you know, I try to explain to people what the heck that actually means and and there’s a term that Dick Jackson used to use where he would talk about like built environment work is about health policy and concrete. It’s basically that when we make housing decisions or transportation decisions real estate development decisions all of those sort of things as a community the impacts are going to last for decades and so we need to make sure that we’re figuring out what those health impacts are gonna be. That’s the sort of professional connection of like, we’re making these really important long lasting decisions, but on the personal side after I got my master’s in public health I ended up going to Detroit. I joined the Jesuit Volunteer Corps, which is like the Peace Corps, AmeriCorps but Catholic and went to Detroit and worked for five years on homeless issues there and obviously you can imagine the housing struggles that Detroit has. It was really eye-opening experience both in terms of you know the poverty realities and the political realities of the United States the, the piece around racial dynamics, because it was interesting you know being a white guy living in an 85% black city so all of those things were fascinating and and it got back to that peace of like just this was part of when housing first was first becoming a thing across the nation and so that piece of just how critical housing is to somebody being successful in their life was a big part of what I ended up getting exposed to. What basically happened is here at DCHD we ended up getting selected for the Kreski Foundation’s Emerging Leaders in Public Health and that was a leadership development opportunity for the health director and then a staff person which was me. We decided we wanted to really focus on housing affordability and the reason why I was, we saw so much of what was going on around the nation and we know that you know things happening at the coast you wait a little while and they’ll get to the middle of the country and we wanted to try to be out ahead of it as much as possible. Yes, that was a little bit of a different sort of role for the health department but a big piece of that was this idea of “How do we serve as the Chief Health Strategist for our community?” “What does that actually mean?” and was sort of when we thought about it we thought of well, who serves as a sort of chief strategist for our community and we felt like the Chamber of Commerce was probably the best example of that. They do that for the business community and and start working on sort of like how do you have a strong business climate well that similar sort of role to what we’re trying to do for Public Health how do we make sure that we really have a healthy vibrant community how do we make sure that all parts of our community really start strong and provide people with the opportunities they need to be healthy and so that was a big piece of like if we want to be in that kind of role then sort of a leadership capacity that we need to be addressing issues that are really key to how successful our community is, both in terms of health but just an overall like are we succeeding as a community at all.

Hannah Shultz That’s really interesting. So I know as part of that work you brought together a big coalition and some partners that people might not often think of as being public health partners, so can you talk a little bit about bringing that coalition together and what some of the challenges and opportunities were with creating such a broad, diverse coalition and what the kind of impetus for that was?

Andy Wessel Sure, part of it was that we were using a process that was developed by a by a group called Engaging Inquiry that had been done in partnership with the Omidyar Group and it was basically a systems practice systems thinking, you know systems mapping process. What was nice about that and what worked well is that the invitation for a lot of people was “come to these one-day workshops” where we really like worked through what are the dynamics going on you know with housing affordability, housing quality that was sort of what we did the first workshop we had 30 people there for that first one and it was really like okay what are the key issues going on and we heard everything from like lack of political will to you know rising building costs to issues around racism and segregation. Then we worked through like what are the downstream impacts of those things but what are the upstream causes of all of those things and then ultimately build that into a systems map where you have sort of the different dynamics going on. What are the virtuous cycles, the vicious cycles, what are some stabilizing loops that are all at play in that and then after we did that that was sort of our you know our theory of context “here’s what’s going on” then what we did was bring people back for a second workshop that was our theory of change like where they’re leverage opportunities where the things that we could do that would have an outsized impact and then we had about 40 people for that one. Then the last one we ended up bringing people back together and said what really can we actually like get done like what does it look like to prototype solutions and start building those things out and that workshop we ended up having 60 people there for that and again it was nice, we had people who could facilitate at the tables, you know we had the way to be able to dig in on all of this. The thing that worked well is that it was getting everybody, from the people who were the community organizers and the housing advocates with sitting down with the landlords and talking through how they see things you had the homeless agencies sitting down and talking with real-estate developers, you know the urban and regional planners you know talking with neighborhood association groups, all of these sort of things. So we had really a good mix of people there and that was part of the intent was you were trying to get as sort of broad and as complete a picture of the system as possible and it we kept using if you know the the story of the blind men and the elephant where people touch different parts the elephant and then either you know figure out how to combine their knowledge to get an accurate picture of the elephant or get you know arguments over well you know know an elephant’s like a fan for the person that that’s the ear or know an elephant’s like a tree trunk for the person that touch the leg, like that was what we’re trying to do is bring people together and get sort of that complete picture. It took having folks from different part of the system who experience it in different ways because obviously you know, the homeless individual experiences the system quite differently from the person who’s a real estate developer. We just wanted to reflect that and build that in. That’s the one of the challenges is combining all of those different perspectives but the systems mapping process allowed us to do that really well. The other you some of the other challenges is of course is there’s Franklin Covey talks about this this thing called the whirlwind that we all have our day jobs that are just the thing that we’re responsible, for the thing that people will hold us accountable to, and whenever we do something that’s sort of new and innovative there’s not those same sort of accountabilities built in to make sure that we get it done so a lot of times that new and innovative work gets overwhelmed by the whirlwind of the day-to-day responsibilities and so how can you keep things focused enough and moving forward enough where people will be willing to make the time and where, with the small amount of time that they can cobble out from the day job that you can make some real progress. That’s really what we push for and try to find a way to build out.

Hannah Shultz This is a related question. You’re in Omaha, which is a fairly large city especially for this region.

Andy Wessel Sure.

Hannah Shultz What do you see from one part of the city or from one neighborhood to another and how was that part of these conversations and how has your work addressed those differences?

Andy Wessel Sure. One of the things that’s interesting with like a systems approach is that you end up with a lot of things that can be either a virtuous cycle or a vicious cycle depending on kind of which way they the dynamics start going. One of those things that was sort of at the heart of the systems map we created was this piece around like do people feel like the this particular place whether it was a whole community, whether it was one particular neighborhood even down to a block or a house, like did people feel like this place had a future and if they did then they would make investments in it. Whether that was choosing to live there, whether that was putting money into it, those sort of things but if they then make the investments in that place then the quality of that place improves. The quality of that place improves and then more people are gonna feel like “oh this place really does have a future” and you get into that virtuous cycle but part of what we also heard was that for many parts of Omaha, particularly the the parts of Omaha that were redlined, you end up getting a vicious cycle that you had this thing where partly through federal policy it was “no this place doesn’t have a future, we’re not going to secure mortgages here people can’t make those kind of investments around homeownership housing stability all of those sort of things” so then you end up with the quality of that place diminished and more people feeling like “this place doesn’t have a future” and that I mean yes Omaha’s a big city but that’s one of the things where there’s some overlap that you see going on with rural communities is you have some of those those economic dynamics going on some of those social dynamics going on where there is some of the challenges of like how can you turn around what in some ways gets to be working as a vicious cycle.

Hannah Shultz I’m going to take a step back a little bit. For those of us who are working in public health day in and day out housing, has become a big topic in the last few years the last couple years in to the point that the annual message from the Robert Wood Johnson Foundation last year was called “Our Homes are Key to our Health.” So why is it important for us to talk about housing when we’re talking about health?

Andy Wessel One of the things I love to share with people is like, it’s called the BARHII Framework, so Bay Area Regional Health Inequities Initiative, the framework they developed because it really does a great job of showing sort of the the range of places where people can be working in terms of public health and they identify what’s sort of current public health practice and what’s emerging public health practice and sort of the upstream challenges we have to face. That’s part of where we’re at with th whole piece over I’m talking about social determinants of health and health equity issues is it’s pushing us further upstream in terms of our work. One of the interesting things is a lot of times I’m doing presentations and I’m going out and like you know doing a presentation before a bunch of bankers or a Kiwanis Club, that sort of thing, and one of the first things I like to talk about is like let me explain why you have a public health guy, a guy from the health department here talking to you about housing and my sort of way of getting you know into that conversation is saying you know “if you think about what gets a sick, housing is probably not gonna be the first thing that you think about you know maybe you go to lead stuff or maybe you go to safety stuff and you can make that connection but when you flip that and instead think about what is it that we need to have in place in our lives in order to be healthy you know, to live a long and full life like then you’re gonna see that that housing is foundational, that it’s a critical piece” so that that piece of like if we make that shift to what do we need to be healthy instead of what gets us sick then it’s easier for people to understand what makes housing so important. Another way to think of that that connects to sort of the upstream downstream piece is like for Public Health is “are we playing offense or we playing defense” and the challenge is the downstream stuff ends up being largely reactive it’s largely defensive and, to some regard like as a field we’ve lost that piece of playing offense. We’ve gotten good at doing the health education stuff, not that we’ve had nearly as much success as we would like, but that piece of like “do we again have a leadership role in our community, do we have a policy role, are we look to in terms of like a key role in terms of when our community’s making decisions” and if the answer on those things is no, then we’re not playing offense enough. Our community needs us to be strong advocates for what it takes to make sure a place is healthy and if we’re not playing that role then I think that’s part of the challenge of what we’re missing right now in public health.

Hannah Shultz What are some of the actions that are coming out of this work you’ve done with the coalition to address housing and health disparities related to housing?

Andy Wessel Yeah, so there’s a couple of really practical pieces that have come out of this and one of them goes back to you know I talked about those different workshops that we were doing. The last workshop that we did when we had 60 people ended up happening a week after there was this evacuation of 500 refugees that were from from Myanmar, from Burma, here because there were what what ended up being over you know around 2,000 code violations in the place and so the the the city and the other agencies like went in and actually evacuated everybody out. That took place a week before our workshop so obviously we’re coming together talking about housing issues at this workshop and people wanted to make sure to talk about that. The group in particular that dug into that what they discussed a lot was that the the the challenge with just sort of legal and enforcement mechanisms is that there’s a lot of disincentives, certainly for for landlords for property owners but also for tenants, to actually report things going on and to report them early so what could be done to actually make it so that people would be able to like work together to come up with solutions and address things early before they became bigger problems. What we’re actually working on right now is a housing Ombudsman position, housing Ombuds position and then we actually had Creighton University there, they have a negotiation conflict resolution program that they just wrapped up a needs assessment around that position for us and then we’re going to be presenting that to our board of health next week and that’s that’s a big piece of the way we’re trying to address this is, instead of an enforcement or legal mechanism can we go ahead and build in a conflict resolution or a real sort of collaborative problem-solving approach that works on these issues because so much of what happens yes, between landlords and tenants it can be adversarial or at least has a lot of conflict and tension in it, but those sort of things happen between government agencies and nonprofits and all of those sort of things too. That’s one big piece is the housing Ombuds that that’s a practical follow-up on what we’ve been working on. The other is that the health department’s actually in the middle of a racial healing project. We ended up getting selected by by City Match, that’s a national maternal and child health agency that just happens to also be located at the University of Nebraska Medical Center to work on like discussing “what are the sort of the the issues around race that have gone on in your community that end up affecting health outcomes and how do we end up talking about those things” and part of the challenge is that when we just share disparity data a lot of times what that ends up doing is just sort of reinforcing a story that that people as individuals are responsible for all of this and that’s because by default people you know most naturally think of health as sort of an individual behavior issue like “are you going to the gym, you know work it out being active are you you know on a diet” all of those things are sort of what we understand most easily about health but that piece of like the the context in which we make decisions the opportunities we have or don’t have all of those things are harder for people to naturally go to. The historical piece of all of this of the the ways in which things like redlining, other forms of segregation and discrimination the the way that those have had an impact, very consistent impact on health outcomes isn’t necessarily always seen so sometimes the challenge is when we’re communicating about health disparities it ends up creating those sort of blaming the victim problem instead of a challenge of “here’s a disinherited legacy we have around this issue, what do we want to do about that like what’s what’s our responsibility now as as the people working on these issues to make things better to ensure that we really do have a healthy community.”

Hannah Shultz What impacts, what health impacts have you seen from this work? I know it’s a little early to be measuring, that so I’m curious if you have some anecdotes or any data about this work and the impact it’s having on your community or on the health of individuals or individual populations.

Andy Wessel This is the part where I would love to say that we did this work it’s you know now the like you know 12 plus years of of difference we see between our, on the low end for zip codes you know and an and then between between that the low end and the high end of zip codes that that you know that difference has been erased and and you know life is expectancy is improving all around and all of those sort of things and of course we’re not seeing that and part of this whole thing is of course these these issues have been things that we’ve struggled with for for decades, for generations and so they won’t be turned around overnight. However there are definitely signs for, reasons for hope and things that were excited about so part of this is that the City of Omaha actually passed a like a landlord registry and proactive inspection. We didn’t have any proactive inspections so you know the analogy that gets made is we make sure as a Health Department to go out and inspect restaurants on a routine and we’re proactive about that and so we’re good about making sure we’re protecting people’s health when it comes to the food that they eat. We’re not as good not as strong about protecting people’s health when it comes to where they’re living and what does that mean and yes there’s tricky sort of legal and ethical issues that come in around all of that but it is this piece of like what do we need to do to make sure we are protecting people’s health. We do have an ordinance now that was in place that was partly passed in response to that that incident that happened with Yale Park, the Yale Park Apartments that I mentioned. So that is one part in place the other thing is that we’ve just seen our partners working on these issues in a different sort of way, and the easiest example is like our largest healthcare system CHI Health that they’ve really gone after housing issues, they’ve started partnering with our health care with we figuring out things like how do we have social workers and housing advocates in our emergency rooms so that we can get people connected with services right away instead of just turning them back out on the streets. They’re in the middle of what’s called a medical respite grant right now that is if somebody is not so sick that they need to be hospitalized but still isn’t ready to go back instead of just turning people back in a shelter or something, what kind of housing do we need to have in place so that they have the stability to actually recover from all of those sort of things. We’ve also been seeing a lot of work in terms of like what are the things that we need to address in terms of like zoning issues you know how do we make it so it’s possible to build in what’s called missing middle housing so the housing that used to exist between single family housing and a large scale apartment you know whether that was duplexes, fourplexes, courtyard apartments places where people would live up on the top floor and work on the downs the bottom level, all of those sort of things that used to be what we built in place and you can see in older neighborhoods that’s what we had that was provided sort of different steps in terms of affordability, and how do we go back and make sure those are things that we can build back in. So we’re grappling with that both as a community and as a state so those are things that are signs of progress and and it’s good, there’s a good bit of momentum right now but yet we’re not at the point where we can say here look we’ve we’ve done this and now people are you know noticeably healthier.

Hannah Shultz Well it takes time to build houses and it takes time for people to live longer.

Andy Wessel Yeah.

Hannah Shultz It’ll be interesting to watch this over the coming years and decades to see what impact this all has.

Andy Wessel Well, and again that’s part of our challenge is that some of the reason why, you know the the work of going downstream ends up that’s that’s an easier place to research that’s an easier place to like you know go ahead and do a you know an actual study on those sort of things to the at that once you go upstream the complexity of everything makes it really hard to tease out and and then the fact that any sort of thing that you’re doing is gonna be collaborative you know being able to evaluate what kind of impact you had is really tough. That’s one of the pressures that pushes us downstream even when the the solutions are would come from working upstream but that part of that’s just like let’s admit we don’t have all the answers and we’re you know trying to figure out sort of our best theories of change on what would make a difference and yes we need to have that grounded in as much evidence as possible but we also, there’s that story of you know looking for your keys where the lights better rather than where you actually lost them. That’s part of the challenges we know that we have lots of issues around housing and other social determinants of health that are ultimately responsible for health disparities, but finding ways to work in those issues and make changes around those in those areas this is new and tough work.

Hannah Shultz Yeah and I mean one of the big issues is funding. How do we fund that kind of work?

Andy Wessel How do we fund that work and, and support it long enough that that we can make it real difference and I mean that’s that’s part of what’s been nice for me is that for a long time I was I was on soft money grant money where it was write the new grant and work on a new thing and you know finally got to the point where it was like no, we’re gonna put you on county dollars so that you have the flexibility and the stability to continue working on the equity issues and the housing issues.

Hannah Shultz Do you have other things we should talkabout related to this work or related to housing in place as a determinant of health?

Andy Wessel You know the thing that I would say sort of, two things that I think are really helpful and part of this is that there’s a role for public health in terms of being a subject matter expertin terms of being a content expert that I think we can do a good job with and we should stand on the evidence that we have and all of this and part of my lesson learned is that I was originally one of my original jobs with health department’s doing health impact assessments and you know with an HIA you would be producing some report that many cases was you know 30, 60 pages that sort of thing and I learned quickly that you should you really need to get that down to something small but I I remember being very proud of myself getting what would have been like a 3 page reportdown to like a three page summary and then going and sitting down with a city council member and talking about it and hearing like yeah but I’m still not gonna read that you like you still, you’d like, one page front like that’s what you can get from me becuase that’s how little time I have and so there’s a challenge with that and that like though we in public health really pride ourselves on being evidence-based, the reality is thata lot of hardest, the decision-making that’s going on the shaping our communities, it’s not nearly as evidence based as we would like it to be. That presents a challenge of how do we make sure we take the all of the research and best practices that we have, but yet be able to to be part of the decision-making processes to be able to influence those to have a role to play in those things and so that’s a whole struggle to maintain our credibility yet be unapologetic about the work of Public Health and what the needs are around creating a healthy community. The other thing in addition to that sort of content expert pieces like how can we be process experts how can we be people who can figure out ways of doing this work that really can create solutions that can create true collaboration, that can build trust, and I think that for that like learning somesome facilitation skills and practicing those on a regular basis so technology of participation or whatever you find that works like is invaluable that’s something I found that’s been so critical to doing this kind of work and the other thing I found that’s been really invaluable is the International Association for Public Participation. Their foundation’s training is really built around these sort of challenges of when you have a decision-making process, how do you engage people, how do you how do you let them be part of coming up with the answer of shaping the answers that you have to an unanswered question which is really what a decision is. A decision is we if it’s it’s a genuine process and you haven’t made the decision already then you have an unanswered question and that’s a whole challenge to like really involve people and being part of that but the that foundations training from the International Association for Public Participation is really phenomenal for for digging into that so I would highly recommend if anybody has a chance. Nebraska just got started with having a chapter of IAP2, as it’s known. And so it’s it’s something I highly recommend along with facilitation training.

Hannah Shultz That’s great and you know both of those points you just made really underscore the importance of relationships and building coalitions so that people can come to you or partners can come to you or the Health Department with help getting answers and will help getting that evidence, when especially elected officials many many issues they’re working on so making sure they know who you are and who to come to to get the answers related to health is very important to the success of our work.

Andy Wessel There’s, there’s a whole thought called agenda setting that’s basically like there’s only so much bandwidth that policymakers have and how do you make sure that your issue something that they’re going to consider and and that’s a thing that we have to figure out as a sector how do we make sure that that’s part of what we understand how to do in a way that’s still credible, in a way that’s still you know, true to our evidence-based roots but also again it fulfills that role that we have around being unapologetic advocates for what it takes to make healthy community.

Hannah Shultz Yeah that’s great and that’s a great note to end on. So you’ve shared, we’ve shared some resources throughout this episode including the 2019 Robert Wood Johnson Foundation Annual Message, the BARHII framework and the IAP2 toolkit. Is that a toolkit?

Andy Wessel They have lots of tools and resources but the the foundation’s training is really a great place to get started but I can also share like they have this, it’s called the Pillars of Public Participation that’s sort of a good summary of what public participation is all about.

Hannah Shultz Yeah, so we have all of those resources in the Health Equity Toolkit on our website so visit mphtc.org/healthequity to find any of those resources. Thank you so much for joining us today Andy.

Andy Wessel Okay, glad to be here.

Hannah Shultz Danielle and Andy provided a lot of great information about place as a determinant of health for more information please visit mphtc.org/healthequity

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.