Share Public Health Transcript: Tackling Equity, Building an Inclusive Workforce

Season 1 Episode 23

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 On today’s episode of Share Public Health we are going to talk about how public health practitioners can implement some of the things we’ve talked about over the past eight weeks. This series has covered a lot of big issues and we don’t want to leave you without concrete steps you can take to decrease inequity in your practice and your community. My name is Hannah Schultz and I work with the Midwestern Public Health Training Center housed at the University of Iowa College of Public Health. I am excited to be your host for today’s episode. We’re going to kick off the episode talking about the importance of diversity in health professions. We’ll start today’s program talking with Dr. Denise Martinez. Dr. Denise Martinez is the associate Dean for Diversity, Equity, and Inclusion at the University of Iowa Carver College of Medicine, as well as faculty member and clinician in the Department of Family Medicine. Since her arrival to Iowa in 2008, Dr. Martinez has been an active participant in many diversity and inclusion activities across campus. Her professional interests include cultural competence education, chronic disease management, and women’s health. We’ve invited her to Share Public Health to talk about her diversity, equity, and inclusion work at the College of Medicine and in our broader community, particularly the work she’s done with the Summer Health Professions Education Program. Dr. Martinez, welcome to Share Public Health.

Dr. Denise Martinez Thank you so much for having me.

Hannah Shultz So to start off, I know I just shared your kind of professional biography but can you tell us a bit about what your interest is in these areas?

Dr. Denise Martinez Yeah, so I decided when I was really young that I wanted to be a physician and I decided that because I actually saw different family members telling their stories about how they were treated by the healthcare system differently. I identify as Latina and I come from a multiracial, multicultural background, and because of that and I know, for example, like my great-grandmother was scared of going to a physician because of how she was treated because of the color of her skin or her accent. I remember thinking that that’s probably not a good thing. So I’m the first physician in my family. I’m the first one to ever do something like this in healthcare, but I knew since an early age not only did I want to be a physician, but I wanted to help change and make medicine and healthcare better for all people.

Hannah Shultz So part of that is you’ve been really involved in the Student Health Professions Education Program here in Iowa, so can you talk a bit about what that program is, how it came about, and maybe some of the successes you’ve seen with that program?

Dr. Denise Martinez Yeah sure. So when I got to college, I was thinking I would probably be okay as a pre-medical student but I remember in my first class there was a class called general chemistry and I got a C in general chemistry. My pre-health advisor, I went to a school that was a PWI predominantly white institution. There weren’t any other minority pre-med students and my health advisor at the time said there’s no way that you will ever be a doctor. There was this random flyer in my pre-med office at that time and I saw it saying that there’s this program for minority students who are interested in going to medical school and so I decided not to completely not be pre-med, but I was, I would say, a secret pre-medical student and just kind of didn’t tell anybody, but still kind of pretended that maybe one day I could go to medical school, but I really didn’t believe it could happen. So I ended up applying to this summer program and you could apply to three of these programs nationally. So there’s 12 sites across the country it did him different medical schools and I ended up getting into all three of the sites. I thought, wow, nobody really applies to this summer program, which is actually not true, it was really competitive. The first day, David Acosta who is, was the Dean of Diversity at the University of Washington School of Medicine – we were in this huge auditorium which I felt so special to be in, you know, a medical school auditorium. Can you imagine, you know, and it was like I was just feeling like wow, why am I even here. He looked at each and every one of us and said, you know, one day we know that each and every one of you will go to medical school and I thought wow they are such liars here because there’s no way I will ever get into medical school, but really by the end of the six weeks I knew I could do it and actually I applied to medical school that next year and I got into seven medical schools. Programs like this help students like me who didn’t realize that, you know, that these opportunities were not just for people way out there, that they are, these opportunities are for people like us and medicine needs people like us because we are interested in treating all different types of people and people from different backgrounds.

Hannah Shultz So the Summer Health Professions Education Program, how long has it been at Iowa?

Dr. Denise Martinez The program, nationally, has been around for exactly years, but here at Iowa I was able to help write the grant and become the PI, the primary investigator, on the grant here. So this will be our fourth summer. This will be our last year. We’ve already had three cohorts of 80 students, which has been really awesome.

Hannah Shultz These are all undergraduate students from across the country?

Dr. Denise Martinez Yep, across the country. We have 80 students here during the summer. This is a grant, paid for by the Robert Wood Johnson Foundation, which really cares significantly about the culture of health and having good health care for all. The students apply to the program and are selected because we see significant potential in who they are. They’re either finishing their freshman or sophomore year of undergrad and they spend those six weeks with us.

Hannah Shultz That’s great. So that means you’re about to, you’ve had nearly 300 students go through the program here.

Dr. Denise Martinez Yes.

Hannah Shultz Do you know how many of those are now in med school and are there Health Sciences Graduate Programs?

Dr. Denise Martinez Yeah, so quite a few and right now it’s still a little early on the med side because a lot of students will take one year off before they apply to medical school and they did the program either their freshman or sophomore year, so it’s still a little early, but we have quite a few students in pharmacy school now, medical school, dental school, and then even more. I think a lot of students didn’t realize or understand what public health was until they did our summer program and significant amounts of the students have ended up going into public health or knowing that they’re gonna get their MPH before they go into health professional school.

Hannah Shultz That’s great. So I know you’re in a med school and we’re in a College of Public Health so what do you see that are kind of trends or new things happening in the training of people in health sciences to help them have an increased understanding and more training and diversity, equity, and inclusion and some of these other things that are kind of buzzwords in public health right now?

Dr. Denise Martinez Yeah, I mean, I think a couple of things – I mean, first of all, we know, just take it a step back and talking about SHPEP, that if you come from different, underrepresented background, you’re more likely to treat people from those backgrounds. So obviously a diverse workforce is really the most important thing, but then also even if you don’t have a marginal history of a marginalized identity, understanding how to treat people from all different backgrounds is super, super important. So we talk about those things. We talk about why the system is the way it was and that so much of health disparities has to do with the system and how the system is propagating healthcare disparities. So for example, we know black women in the state of Iowa are six times more likely to die in childbirth than white women and that isn’t necessarily having just to do with the patients. It really has to do with how our system is treating the patients, and being open and honest about those conversations and not pretending like those disparities don’t exist. So I think talking about the health disparities is really important. The other thing is we talk about implicit bias quite a bit, so what are those unconscious biases that help people to make decisions that might not be what they really want to make and how they think about or treat people from different backgrounds. We talk about micro-aggressions, so what are those little slights that people can say that make people never want to see a physician again? If that is what the physician said to them and it was a micro-aggressive comment. We talked about being an upstander, so what if you see something happening either to a colleague, a patient, or a trainee that is something that is a identity-related, that somebody is saying something inappropriate? How do you respond to those things and be an active upstander to that person? So we participate in tons and tons of trainings regarding all of those things because unfortunately those are all muted.

Hannah Shultz How are schools and programs of Public Health, their medical schools, and other Health Sciences training our emerging workforce in these areas and having cultural sensitivity, cultural humility, understanding health disparities?

Dr. Denise Martinez Health disparities, as you all know, unfortunately, we have really really good data about health disparities and about how prevalent they are and how that not all health disparities have to do with the social determinants of health or the situations that the patients are in. A lot of health disparities have to do with how the system is actually treating the patients and a lot of that was built on racism and oh yeah and all sorts of things throughout many engines and systems of inequality. So, you know, the goal of our offices like mine or people in leadership like mine are trying to undo some of the systemic inequalities that have existed. Some of those things are talking about them and that it’s not just sort of blaming the patient for different health situations, but knowing that we as a system need to do better and talking about where those inequalities lie. For example, when black women are six times more likely to die in the state of Iowa giving birth, that’s a problem and that has to do with us. Other things are talking about implicit bias, so unconscious biases and how that can help contribute to people treating people from different backgrounds differently, to talking about micro-aggressions and those small slights that can be said to people, that even though are sometimes tiny, but it can have a huge impact on whether people seek care or not from that provider ever again. Same with understanding culturally-responsive care. Here we have Culture Vision – I’m not sure if you’ve ever heard of that before – but it’s a online software that gets updated all the time where you can look at potential norms, beliefs, and practices of different people. It isn’t to provide information to tell you how to do things, but it’s to provide you information so that you know how to ask actually better questions to the patient because you don’t know what you don’t know. So, for example, they started this culture vision because a certain labor and delivery ward had patients who believe very strongly in hot and cold. So there are certain ailments that are considered hot or cold and you treat with opposite temperature, food or drink and a lot of the women were getting dehydrated because pregnancy was considered a cold-state and what do you give on labor and delivery? Ice. Yeah, so I send ice water and so a lot of women were declining that but if you knew something about that particular cultural or background you could just ask the patient “What temperature would you like your water?” but you might not even ask that question if you didn’t have the background to ask that question to begin with.

Hannah Shultz That’s a really fascinating example. You touched on this just a little bit in your comments, but why is it important to have a diverse workforce?

Dr. Denise Martinez Yeah, so the data shows that people tend to treat patients who have their own identity. So rural people who have rural backgrounds tend to treat rural patients. Women tend to treat patients who are women. People with LGBTQ identities will tend to have interest in LGBTQ identities. Same thing with minorities or people who are speaking other languages. If you are, for example, if you’re a Spanish speaker you’re more likely to speak or have patients that are Spanish-speaking. So because we know that lots of patients don’t have access to care or that or always feel comfortable with the type of provider that they have, having people who identify with all different types of backgrounds I think are really important.

Hannah Shultz So going back to the story you shared at the very beginning about your grandmother being afraid to go to the doctor, one of the conversations we’ve had in planning this series is about the importance of patients being able to see themselves in their providers. It’s almost the inverse of what you just said about providers treating patients like them, patients need to be able to see themselves reflected and in the people treating them.

Dr. Denise Martinez Absolutely.

Hannah Shultz So, what sorts of training is available to you health professionals who have maybe been practicing for 5 years, 10 years, 30 years who want to increase their understanding of diversity equity and inclusion and social needs and gain some cultural training?

Dr. Denise Martinez Yeah so here at UI health care we offer, our office offers quite a few trainings but I also know that a lot of these trainings exist in in many different locations. So we have trainings on LGBTQ care and what are some of the best practices particularly around transgender care. So here at the University of Iowa we have over a thousand transgender patients in our LGBTQ clinic, and so understanding the needs and best practices is really important. We have trainings on micro-aggressions, implicit bias, upstander so what happens when you see things that are not that people are doing that are probably inappropriate and not culturally responsive and how do you, how do you address that in the moment, is actually our latest training. So with a more diverse and inclusive workforce the majority of discrimination that happens to people who are training to become physicians or are physicians actually didn’t come from the environment it comes from the patient’s directly and so we actually have now a specific training because patients unfortunately have done things like told physicians to take their hijab, off or get out of their room or if they’re certain race, refusing to have them be their health care provider or so anything that is regarding to somebody’s identity and how do you how do you deal with patient related identity harassment.

Hannah Shultz So do you have any tips for how to do that?

Dr. Denise Martinez Yeah I think it’s a hard conversation and I think that you know, as care providers we often are told it’s not really about us it’s about the patient and just taking care of the patient and what the needs of the patient are and so a lot of people, even our trainees would often just take the harassment, even sexual harassment, which happens quite frequently as well because they felt like they weren’t empowered to say or do anything in that position or our student provider role. But actually that’s not the case that it is important that people speak up and are able to say things and so some of these trainings we give people the language to do that. Sometimes you just don’t really know what to even say. The other thing that I’ve really appreciated it here at UI Health Care we have an amazing legal team that if a patient is discriminating against a certain provider or person, oftentimes the easy thing to do would just be to switch that person out for somebody else, but UI health care has really stood with its providers and trainees and staff and if something happens that they will ask that patient to leave.

Hannah Shultz That’s a pretty strong stance. I bet they can provide care some pretty strong…

Dr. Denise Martinez Correct rather and just thanks or this just flipping it under the rug that we take that really seriously.

Hannah Shultz I think you mentioned micro-aggressions earlier in the conversation I think especially people of color experience those on the daily basis-

Dr. Denise Martinez No matter what the situation our environment.

Hannah Shultz Yeah no matter what kind of workplace area when you’re in such a intimate and sensitive area like a doctor’s office or an appointment that adds a whole new level of complexity.

Dr. Denise Martinez Absolutely, absolutely. In both ways but from the patient to the provider but also the provider to the patient and a lot of times, especially with micro-aggressions you know people don’t realize even the comments or things that they do even though they’re not- the intention isn’t to offend or cause harm, you know the impact is really true and it’s there and so it’s bringing awareness to those things that a lot of people haven’t ever even thought about and their own behavior.

Hannah Shultz One of my favorite analogies for this is lifting a ton of feathers.

Dr. Denise Martinez Yeah, yes. That’s so true.

Hannah Shultz Once they might not matter but yeah the ten-thousandth you’ve heard this week makes a big difference.

Dr. Denise Martinez Yeah. I think the originator of the term micro-aggression, she said it was like death by a thousand paper cuts.

Hannah Shultz That’s another good analogy. So one of the things that we’re trying to do partly with the series on health equity but also in all of the work we do as a training center is to try to infuse all of our work with an equity lens or an equity mindset. So what is something that healthcare providers or public health practitioners can do, like an easy step for an easy couple things to think about so that equity is constantly something they are striving for?

Dr. Denise Martinez Yeah I mean I think people don’t understand, often in positions of power and the leadership that when you are a first generation college student or you are the first in your family to ever go to medical school. So for example at my white coat ceremony they asked all the doctors to just stand up in the white coat ceremony for the medical school that first week of medical school and say the Hippocratic oath and so if anybody in the audience was a doctor that they should all stand up as well and like three-quarters of the audience did that because everybody’s parents except mine were doctors. And so a lot of people think that they’ve made it just on their you know on their own and all the work that they’ve done to get there but there’s been a lot of obstacles and barriers for people from lots of different backgrounds to access and become leaders or even get into places like medical school. And so I think thinking holistically about you know who is in leadership and why and and who maybe should be in leadership and why or who should be chosen to get into medical school the- you know there’s a huge emphasis on MCAT scores for example to get into medical school. But the data shows that the strongest indicator of how high somebody’s MCAT score is is their family income and so we often choose students a lot based on how high their MCAT is. So people often think in this work oh you know these certain people are successful because they deserve it most or work the hardest but in reality there are so many barriers to so many others that in these, these halls of power that we need to be thinking more holistically about.

Hannah Shultz Well that is a good note to end on so thank you so much for your time today.

Hannah Shultz The Summer Health Professions Experience Program is an impressive and extensive program that has helped to pave the way for thousands of underrepresented health professionals. Diversifying the Health Professions workforce, including public health is a vitally important part of decreasing inequities. We also need to work with the existing public health workforce to advance equity in our health departments and communities. The Lawrence Douglas County Health Department in Lawrence Kansas is working very intentionally within their health department and community on diversity equity and inclusion. I’m very excited to have three representatives from the health department join us today. Christina Gentry is a community liaison at Lawrence Douglas Health Department. Her professional background is in Early Childhood education with an emphasis in STEM based early development curriculum. She is a staunch advocate for Black Womxn & WOC and works aggressively to bring awareness to the health issues affecting our underrepresented & minoritized identities in Douglas County. Christina’s equity lens focuses on eliminating the structures that make certain identities the consequence of the vehicle for vulnerability. She is an educator, a mother & a lifetime student. Sarah Hartsig, is a Community Health Planner at the Lawrence-Douglas County Public Health. There, she works in community health policy and planning, where she coordinates and implements initiatives to improve health equity, address social determinants of health, and support healthy behaviors. Prior to working at the health department, Sarah worked at the Kansas Health Institute, where she contributed to and led projects in health impact assessment, Health in All Policies and community health assessment and improvement planning. Sonia Jordan serves as the Director of Informatics for the Lawrence-Douglas County Public Health. She is passionate about using data and analytics to make a difference in the lives of Douglas County residents. She has worked in public health informatics, health equity, infectious disease, and public health preparedness. She has committed to a career in public service with experience at the Kansas Department of Health and Environment and the Assistant Secretary for Preparedness and Response with Health and Human Services. Sonia lives in Lawrence, KS with her husband James, and two boys, Leo and George. So Sonia, Cristina, and Sarah thank you so much for joining Share Public Health today.

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Hannah Shultz So before we get started into kind of the meat of this conversation I’d really love if you could just share some context for our listeners. So tell us a little bit about the Health Department you work with in your community.

Sonia Jordan We work at the Lawrence Douglas County Health Department which is the Health Department for the city of Lawrence in Douglas County in northeast Kansas. It is where the University of Kansas is located where some people may be familiar with that. We are a fairly large county for Kansas standards. We have about a hundred and twenty thousand people which I think makes us about the fifth most populous county in the state. Racially and ethnically we are not very diverse. We are still about 80% percent white in our County. Our Health Department is what we would consider to be a medium-sized Health Department. We have about forty to forty five people at any given time, but within the past three to five years we started to really focus more on how we can move the needle with our efforts on not only the community health, community’s health but on issues like health equity.

Sarah Hartsig Or it was the site of the big fight to make sure that Kansas would be a free state and not part of the Confederacy right so Missouri next door was, was part of the south and so I think people here are really proud of those roots and those anti-slavery roots and see themselves as you know very, like Sonia said, progressive and equitable and welcoming of everyone but when you really get down to it we struggle with the same issues of racism and discrimination that any community does and I think that our identity and being proud of those anti-slavery roots often gives us an excuse to look the other way and say, well we don’t have a problem that doesn’t happen here and and and that’s really not the case. Similarly with Haskell, the Indian Nations University that that’s nearby we’ve got, we’ve had historically a large population of Native Americans who lived in and around Lawrence and and you know there was a boarding school for Native Americans in Lawrence, that have very negative consequences that people don’t want to talk about or think about and so I think when you layer that really interesting history with our identity, and also reality, and you get the opportunity for some interesting conversations.

Hannah Shultz You in your health department put together a kind of committee to work on some of these topics. So could you describe what that work was, what the kind of charge for the committee is, why you decided this was important?

Sonia Jordan Our health equity committee started a few years ago and the, the charge was really to identify what we can do as a health department to promote health equity so it was pretty vague overall and we encouraged staff members to apply to be on the committee. The application was simple, it was just a question of why this mattered to you and what we discovered after getting the group together was that this work was not as simple or as easy as we thought it would be and would require a lot of learning and a lot of building of trust and building of companionship and so we really spent about, I would say close to six months to a year, really focusing on those things. Shared learning, coming to a shared definition of health equity coming to a shared perfect purpose for our committee. That purpose ended up being trying to focus on some of the internal policies within the health department and then trying to focus after that on some of our external features or I guess I should say maybe more of our external policy after we had taken the time to look internally first.

Christina Gentry Thank You Sonia. So I was introduced to the group by a man who’s no longer with us named Jonathan Herrera Thomas. He came up to me and asked me if I would come and be a part of the group and I agreed because he made it sound like it was something that would definitely speak to the work that I do. I work as a Community Liaison here at the health department but with a grand Kansas Health Foundation that makes me in my office be the community so in order to understand the community I need to listen to the community and my voice here at the health department has been one of raising community awareness as issues as they pertain to our most marginalized identities. So we understand that equity and equality are different, right. So understanding that equality is the outcome of a process that involves equity and to me being a black woman and being a woman who’s lived in Lawrence for a number of years I realize there’s some inequitable things going on personally, but understanding our health equity report data reflects that data being as our marginalized identities are identified as having a racial background for instance is eighty percent white and are home to Kansas University. We also have Haskell nations Indian nations University so the demographics speak to our our Douglas County as being progressive and and trying to incorporate diversity and so I think my position is as the chair now for about a month and a half has been to continue to promote diversity as it looks on the outside topically and then explore ways that we can delve into what diversity and true inclusivity looks like.

Hannah Shultz Sonia you mentioned that the first year or so was a lot of internal work and emotional work in building trust. Could you describe some of the tactics you used within the group to build that trust?

Sonia Jordan One of the things we did was to come up with a charter, and that charter was to guide how we interacted with each other in meetings. So for instance, being respectful to each other’s voices or trying not to over speak or interrupt someone. These things that would allow people to feel comfortable bringing their self to this meeting. You know the adaptive work is building the space of making sure that that is actually honored for people. We did a lot of shared learning. We read a book, it’s actually a graphic novel called “March” from the civil rights era. We watched a TED talk by Dr. Jones on race and racism which gave us a fantastic framework for which to work from to understand racism as it exists in society today. We read a couple of articles as well because a lot of our members of our group were coming to this with not even a true understanding of what health equity meant, including myself. So I needed to just put in the work of understanding academically what we were talking about even, much less emotionally. We just tried to take a lot of opportunities to give space for both shared learning, but also emotional learning about each other. One of the strategies that we did was to meet off-site. We would meet in different locations around the city to just try to increase the sense of companionship with one another.

Christina GentryWhen I joined the group which was in January of 2019 the kind of original health equity committee had put together- they had done a survey of staff members about kind of their concerns related to equity and from that they had put together kind of a prioritized work plan. So when I jumped in it was a lot of like action-oriented, like get things done, accomplishment type stuff. When I jumped in there was a lot less of the kind of emotional and personal learning I think that that had happened in the first year and so it was it was exciting though because very quickly after I joined the group there were some accessibility modifications approved and implemented in our health department, a living wage was passed, and we put together a tool to assess policies in the health department. A health equity impact assessment tool I think just to realize kind of the magnitude of the divides and the magnitude of wealth distribution in a country and then we went from there to a book called “Hope in the Dark” by Rebecca Solnit, which was sort of lessons on activism and making a difference and then after that the next one we read was of “The Book of Unknown Americans” which is about immigration, immigration into into the United States and just kind of stories of immigrants particularly from Latin America.

Hannah Shultz So this health equity book club sounds really great. You mentioned earlier in in this conversation about some of the internal structure things that you have focused on including accessibility changes, living wage, and a health equity impact assessment tool that you’re using internally. Could you talk a little bit about that and why you decided to focus on internal things instead of looking to what you can do in your community?

Sonia Jordan I think it’s important when you’re doing health equity work– equity work in general to be introspective and to under, to understand your, your own underlying identities and how they intersect. So I think the internal a process comes with understanding how adaptive you’re going to have to be. So as an understanding of the books you can read is it’s really understanding how as a Health Department you go out and use you are looked at or you look at yourself or how you deal with it and communicate with your community. So you have to understand a little bit about how you present yourself and when you’re going into spaces, understanding how if we understand inequities and understand the community what we are presenting and in the we go out into community. So I think it was taking the emotional aspect of it and taking the interest of understanding internal structures that are come our community represents. I think it’s important to do some work within your group, understanding your own identities as what you present when you go out. So in order to really kind of understand that even if you’re not outwardly presenting an inequity or a hardship or a structure like I can’t look at you and tell that you have maybe a you suffer from bipolar over being a person who suffers from depression or of a person who’s not outwardly a handi-capable or someone who just has a learning disability or ability we like to say is disability with capital “A” and understanding those things you may not be outwardly looking or presenting to be a person who’s from a Latin X, but those are things we need to understand about each other. So I think it’s great to ground yourself as a group when doing an equity work to realize your own perceptions of who you are and to own those in a way you’re outwardly talking about those so that we can do the work as it pertains to understanding how each other are, but we also were structurally, we are working on making our access to our building more accessible. So we have people coming into a checklist tomorrow morning that in fact to come around and make sure that if you were walking or walking around our structure that we are able to provide access to the facilities in a way that the person using a wheelchair it has access to. That would be what I would really kind of make of stress on it’s like into account you’re working with equity words but also doing the work that you need to do to strengthen yourself in that group and that’s really important because you are doing work outward but there’s still so much that humanizes this work that needs to be addressed, too.

Sarah Hartsig As an organization we really decided to focus on kind of our own internal policies, the living wage and and things like that because we’re also, of course, we’re thinking externally too and you know it we’ve had conversations of well if we’re championing these things in in public if we’re championing a living wage policy for our community or were championing family-friendly workplaces and we’re championing talking about diversity and embracing diversity among employees and recruiting employees who are historically underrepresented in in the public health workforce. we have to start with ourselves and so we can’t point the finger at somebody else and say you should do this because we don’t know all the ins and outs of what that it takes to walk that. So I think starting with our own internal policies was really an intentional place to to set an example for peers.

Hannah Shultz One of the reasons I was so excited to talk to you all today is because I’m really impressed by the way you, you’re really trying to practice what you preach and not go out and promote all kinds of policies or programs or changes that you’re not willing to, you know deeply consider and implement in your or own organizations or in your own life so, I’m wildly impressed by the work you all are doing and very grateful that you’re sharing some of your work and some of your journey with our listeners today. One thing that was mentioned was accessibility and I think, because of the Americans with Disabilities Act (the ADA) this is a topic that a lot of people might not think about as still being something that we need to really be thinking about within our buildings and our spaces. So can you talk a little bit about what some of those accessibility considerations or changes are that you’ve all looked at?

Sarah Hartsig The big one that kind of we started with I think was kind of a, it was a situation where we realized we didn’t have the electronic assist on our clinic doors, and we thought oh my goodness we really need to have that. It was almost like “oh we’re a little bit embarrassed that we don’t have that already” and so that was that was kind of the first step in getting to where we should be, but then also kind of made us aware that there are other steps that we could be taking to be more welcoming for people of all abilities and that was part of the checklist that Christina mentioned that’s going to be happening tomorrow.

Christina GentryI think another thing that occurred when we released the health equity report in November of one 2018, of the things that we neglected to put in with anything regarding persons or people with a disability and it was not an intentional oversight but it was an oversight nonetheless. When some of our partners who work in the field reached out to us from the University Kansas one of the things that we discussed was beyond you know myself feeling kind of embarrassed for having incidentally left that out, we discussed okay so what are some ways that we can move forward to make progress in this area. So then the new version of the health equity report will include a section on health inequities and outcomes related to persons with a disability here in Douglas County. We also invited some of our colleagues to come and speak at a general staff meeting and this also led to the checklist that Christina mentioned which is occurring tomorrow and so they will, we have an intern who works in the field but our checklist looks to be like things like a structure: how large is our room so that if someone is using a wheelchair that is accessible and they can fit through and so it could be able to be mobile in between the corridors and how accessible is our sole structure and our health department as a whole. We are three floors so we have to really realize that that’s able-bodied accessible is just not where we want to stop we need to make sure we go deeper into making sure that even the offices where we are examining our patients are easily get- you know there’s some getting up to it has to be something that we had to move electronically. Even the desk where we welcome our patients needs to be accessible to someone who is in a seated position. So these are all things that we’ll be looking into and I’m sure be making adjustments. This is a process and unless you’re willing to really kind of forgive yourself for the things you don’t know and understand that we as a group have to go together and learn together then I think that’s the foundation you build upon by saying hey we understand this now what can we know and knowing that what you don’t know is the process that is really meeting is got to be something as a group you come together and kind of make sure that there’s synergized energy around, right. Because it’s overwhelming when you realize “Oh, we didn’t have that how could we not have that?” but that came as a process to understanding. Like some of the information that you know you’re reading in the books and we’re sharing someone knows that like the back of their hand, they live that experience so it’s not going to be something that they don’t know but until you get into the spaces and have those conversations you don’t really understand someone’s narrative.

Sarah Hartsig Yeah and I do think it is nice that it was something that started as a mistake. It was something that was started as an oversight and oversight yeah that’s perfect word and you know because both parties were willing to come together and work on something now we’ve had these new exciting things happening and you know it could have easily gone in a different direction, so, but it didn’t, it went in a positive direction.

Hannah Shultz All right. Yeah, this is such an important point because health equity and health equity topics can be so big and many of them are uncomfortable for a lot of people. So, it’s really important to recognize and understand that there will be oversights and you might be embarrassed if you don’t think about something at some point but being patient with yourself and forgiving yourself and just trying to move in the right direction is really important and there might be hurdles along the way and keeping going in that right direction is really important despite those oversights.

Christina GentryI think that’s important like both personally and organizationally just to kind of have that humility to realize that you don’t know everything and you’re willing to admit mistakes, but then to also give other people grace too and and realize that we’re all on a journey together and to be willing to engage. I think I would be remiss if I didn’t mention that we have the director of the health department who’s pretty supportive his name is Dan Partridge, and he is supportive of the health equity team and of things like, you know the living wage for instance I think it could be easy for an administrator or a director of a local health department to, you know pretty easily block a lot of this kind of stuff or just find it threatening. He’s been more often than not open to that and to making progress and to trying to push some of the messaging and I remember specifically, when we were talking about the health equity report and we were going out into the community and we were talking about some of the root causes of health inequities that occur within our community and I remember asking him, “Is it okay with you if I explicitly talk about racism?” and his response was: “Why wouldn’t you?” And so that may seem like an obvious answer but I have heard stories and anecdotes from colleagues at other health departments where that is not allowed or they are not allowed to talk about that in such a frank manner. So that is really a blessing.

Hannah Shultz Yeah, that’s great and it’s it’s good to hear that you all have such a supportive director and also good to see that this is kind of grassroots work happening with staff coming together on this committee but kind of meeting in the middle between the director and you all. So you’ve mentioned a couple of times a living wage change. Can you talk
a little bit about that and why you saw that as being part of health equity?

Sonia Jordan So I think you know when we talk about a lot of what’s in our community health plan here in Douglas County we talk about issues that go into kind of the social determinants of health such as housing affordability, poverty, and well paying jobs. Of course the the issues of kind of discrimination connected with that but just a realization that in many parts of the county people aren’t being paid what it takes to afford decent housing and the basic necessities of life. Just thinking about again what’s needed in our community is really a realization that that we should be paying people a living wage so that they can for the decent living for themselves and their family, and this was a priority for for our director to make sure that the Health Department was, was leading in that way. We’re not the first organization in Douglas County to adopt a living wage but it was it was a priority for him and so there’s a lot of different iterations of how it can be calculated and resources online and inputs into a living wage but in the end we went with a quote unquote kind of housing wage. The the universal living wage calculator which is the wage that’s needed to afford a two-bedroom apartment in Douglas County and so so that’s what was adopted by our admin team. The board recommended that Dan, our director, put together a budget that reflected that and then that was approved and will go into effect January of 2020 and so that affects primarily our folks who are working in hourly, kind of front desk, entry-level jobs and is for some people of a substantial difference in what they were being paid before.

Christina Gentry And understanding equity as it pertains to our population, we understand that statistically significant higher rates of poverty are in our people of color, so we understand that there’s health disparities by race, there’s health disparities and gaps that exist by place, and we understand the disparity as an education. Taking all those into account, Douglas County not being substantially large but our black population makes up 4.6 percent, currently 5.4 percent of our population so we have to understand that we have a responsibility to take this information that we’ve been collecting and data that we’ve been collecting as far as our disparities and do something actionable to resolve that and so I am kind of happy and proud to be a part of the health department that makes that initial move. But to know that as we’re making those steps actionable to set the bar high for ourselves so that we can become an anchor institution that makes those changes and hopefully spread that emphasis and that importance out to our community and making ourselves be a model for that action.

Hannah Shultz I think a lot of these kind of topics that you’re bringing up aren’t what people initially think of when they think oh we need to do some there we need to think about health equity. Wage isn’t frequently the first thing that comes to mind although, you know, someone’s income has a huge impact on their health. You’ve also mentioned, I believe you called it a health equity impact assessment that you’ve been implementing. Could you talk a little bit about what that is and what it means for your work?

Sarah Hartsig Sure so this is Sarah, and Sonia was really the one that kind of started the conversation about a health equity impact assessment. I jumped in and and kind of helped out with that. My background in my previous job I did a lot of health impact assessment, so HIA work, and this was kind of a similar approach a similar idea and really the idea was to when decisions are being made ensure that health equity was being considered as part of that decision. So that’s, that’s kind of the basic idea but we put together a tool that asked kind of some guiding questions around what aspects of health equity could this decision impact, what different geographical regions what specific populations in our community could be affected by this decision and then backing that up with available research and experience from other communities with data that we have. With kind of subject matter expertise and then also the voice of people who are impacted by whatever policy decision is being made and then to kind of distill that into a summary and some recommendations. Initially this was put together as a policy review for internal policies which is still be being used for that but we’ve also seen it gain some legs for external policies. Community policies and budget decisions that are being made. We have an example from this summer when our Parks and Rec Department was making a decision about user fees at their facilities and we were able to bring this tool into that conversation to kind of systematically walk through thinking how health equity could be impacted by that decision and so it’s it’s really you know, it’s not magic it’s a tool just to make sure that that health equity is being thought of and is being prioritized as one of the decision points when policies are being developed or when decisions are being made because that’s really where you know we see health inequities come about is either because intentionally or unintentionally those impacts weren’t considered in you know prior decisions and and people may not have thought of you know what the impacts would have been and just given a little bit of prompt and a little bit of reflection, we think that this tool can can pave the way for some more intentional reflection.

Sonia Jordan One of the things that I heard recently that has really stuck with me and resonated with me is this idea that we have historically in the United States had 50, 60, 70 plus years of policies that were intentionally discriminatory. Moving forward it is not good for us to just pass policies without being intentional to that and so it is really important for us to consider the intended and unintended consequences of policies if we are to try to dismantle that in an appropriate way and I think that is what is so beneficial about a tool like the health equity impact assessment.

Hannah Shultz That’s a really good point.

Sonia Jordan A of colleague from the health department and I were able to meet and listen to a doctor Abram X Kendy speak and he has a couple of different– I mean a couple of really great poignant resources to read but as it relates to being an anti-racist. So it’s not enough just to be raised our against racism you have to be progressively anti-racist. So giving you a little bit of context on how like your resources that you can create for your health equity work that you do internally in the structure of your group some of the resources I get we’re trying to understand as like somewhere where they’re starting from and where you are. So if you are ready to have a conversation about how to be progressively anti-racist, well you can just kind of follow the path of where your comfort level is, right? So we have people who are talking about really making revolutionary statements and doing the work intentionally in a way that makes people uncomfortable like so what may be your comfort level is maybe not someone else’s. Maybe they’re uncomfortable with you being stabbing it they feel so I think it’s important if you have resources that you divide them too into like what’s really like super revolutionaries to you and what’s something you can deal with in a small small kind of way in a way that makes a difference still but it’s not running to where you’re feeling like you’re overwhelmed with the catch up, right. So I think it’s really great to have a health equity book club to do that. Kind of take you in that process and you can go there in a way that’s private in a way that you can kind of isolate yourself if you need to and then come back together as a group, but understand there’s a lot of great resources that can, and speakers if you can as a group I try to put yourself in spaces and sit down and listen to those speakers and those authors of those groups of those books so that way you can understand as a group where you want to go when direction you need to take. So yeah if you start understanding how intersection and your identity affect yourself then you can understand how even as a person who’s say multiracial that has a disability you can understand how those different aspects of your life come into play when you’re moving around our community.

Hannah Shultz You have a bit over 40 people in your health department and a much smaller group as part of this committee. What has the response from your colleagues been as you’ve been talking about some of these topics and implementing some changes?

Sarah Hartsig So part of our conversation that maybe if most of the people who are on our committee work on the second floor which is administration, community health, the folks who aren’t seeing clients every day all day. We tend to have more flexible schedules to do things like have meetings and work on research projects and there are folks down in our clinic who I think, have really important perspective who aren’t able to engage in this work as meaningfully just because of the way that their time is structured. I don’t know that I have experienced any outright kind of like resistance to most of what we’re doing but I do think that there are some folks that feel maybe a little like outsiders to some of the work and so that’s that’s something that I hope we can improve on.

Sonia Jordan I would add that we meet early in the morning at 8:30 and we have a bi-weekly twice one for an all staff all group and then the second one is individual group so we have subcommittees that work on different aspects and different areas of strategic plan per se for our work group. We don’t have and we would like to have I would say a more flexible schedule for allowing staff who are hourly to come in for that extra hour so that comes with the supervisors approval and, you know, understanding that some of the things that that even as a structure that we’re doing seem to be putting a gatekeeper in the way of progress to like even initially participate in ours in our meetings seems to be something that we need to look into. So looking into our future we need to try to look into ways we make our equity team more equitable, right? We make opportunities for us to meet and spaces just like we have for our book club but also for meetings and looks making those accessible to folks who don’t have that opportunity to be there at 8:30 in the morning.

Christina Gentry I think I think from a community perspective the response has been fairly positive as well obviously not everyone is always comfortable with the things that we’re talking about and you can see it very clearly on their faces when they’re uncomfortable or at least I can I feel like and I think one of the things that I’m still trying to figure out and one of the things that I’m still working on balance for is you know at what point do you stop and try to get everyone comfortable on this issue I don’t know I mean do you even do that do you or do you just continue moving forward with the people who are willing to stick their necks out to also engage in this kind of work? I think that’s a balance that a lot of communities are going to have to figure out if we wait for everyone to get on board we’re going to be waiting a long time.

Hannah Shultz Yeah that’s that’s a pretty strong good note for us to wrap up. Thank you all so very much for joining us today I think this has been a really good conversation and I’m very excited to get it to listeners of Share Public Health. Do you each have a suggestion or a tip of one thing that people working in health departments can do to be more equitable in their practice?

Sarah Hartsig I mentioned in my former job I worked on health impact assessments and we put together some resources to work with state legislators to think about health and decisions that may not have always been obviously connected to health. The tagline was always “What about health?” and when I got here at the Health Department I think my challenge was, to myself, was to think about in everything I do “What about health equity?” so I wrote it on a sticky note it’s on my computer and that has just reminded me to think about you know when I’m working on something that healthy eating, active living, tobacco cessation, you know what what aspects of health equity are playing into this work and how can I be more mindful of that. I think that’s that’s one, is just to keep it top of mind. Then two is is really to dig deep personally and to find books and resources out there that challenge you and and really kind of open your eyes to perspectives other than yours.

Sonia Jordan I would build off Sarah’s second suggestion and say to take the time to not only get to know yourself and the identities that you are bringing and the identities that your colleagues are bringing with you to work, but if you are somebody of privilege to really take the time to critically examine what that means for you and what that means for other people in your life and to be open to the potential that you are potentially incited in that situation so the interpretations that are occurring are not always going to be positively reflecting on you, and to be open to that to be open to things like implicit bias and how that manifests in your job, how that manifests as a clinic worker, how that manifests as an epidemiologist. Just taking that time to be very thoughtful and critical.

Christina Gentry I would go back to that definition of equality and equity right and I’ll constantly challenge yourself to make sure that the process is part of the work that you’re doing to create the outcome of equality, and to understand that we’re not all starting from the same spaces and are all starting from the same starting line and a lot of us have different aspects and realities that narratives that you may not understand but like I said, being open I think, like Sonia said is serious about being open to be introspective and always really looking into yourself to see why is that you are feeling away about something. I would say also you know there’s just constantly I mean as a woman in my life I have to constantly challenge myself with making sure that I’m speaking the language that people are wanting to be said or be respected as, right. Using pronouns is becoming like something I challenge myself to do to constantly not associate genders with people. I think it’s always a process that you’re constantly learning and can be exciting for you to try to challenge the narrative of your own life and your own perspective of your lived experiences. So I think taking that into account and understanding that you don’t know like some things even if your position of power and privilege those words like mean something and you have ownership and you could take ownership of those things.

Hannah Shultz Thank you for joining us on the podcast today.

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.