- [Tricia Kitzmann] Hi, I'm Tricia Kitzmann. I am faculty here at the College of Public Health. I work with the Institute for Public Health Practice, Research, and Policy at the University of Iowa College of Public Health. Do note that this is being recorded for later viewing or for you to be able to share with your colleagues. Now I'll invite our guests to introduce themselves and then we'll move into our main topic. Kiki, would you like to go first?

- [Kirsten "Kiki" Lezama] Sure. Hi, everyone. My name is Kirsten or as most know me, Kiki Lezama. I am the director of public health workforce infrastructure at the City of Milwaukee Health Department.

- [Tricia] Thank you, Kiki.

- [Susan Vileta] Hi there. My name is Susan Vileta. I work at Johnson County Public Health in Iowa City.

- [Tricia] Awesome. Well, we have two wonderful speakers today. And so as we go through, please feel free again to put any information or any questions in the chat or the Q&A. Okay, here we go. Can you share your background and what led you to focus on health equity? Susan, I'll kick it off with you.

- [Susan] Great. Yeah. I've been working in local public health for 16 years now. I worked in a small, rural health department in southwest Minnesota for about six years, and I've been here at Johnson County Public Health for the last 10 years. A majority of my focus has really been in tobacco prevention and control. And that's where I learned that tobacco retailers in black neighborhoods and small towns have more advertising. They price tobacco lower than, if you're in a more white neighborhood or a more affluent neighborhood that companies gives money to LGBTQ groups back when some folks, you know, weren't doing that, to try to sort of get them in their favor and help them out. So that's kind of my background and what led me to be able to kind of point out those things and learn about all of those inequities, and then kind of apply them throughout my public health work.

- [Tricia] Wonderful.

- [Kiki] So it's kind of a difficult question, Tricia.

- [Tricia] Right?

- [Kiki] Like, it's hard to pinpoint. So I guess I can say I have over 10 years experience now in public health, which is weird to say. I don't even know what corner of the universe that time got shoveled into, but it started... My undergraduate degree is actually in nursing. And I would say the shift probably started when I realized that working in an acute care setting, I wasn't really making anybody healthier. I was just kind of circulating them throughout the system. And I didn't like that. And, you know, with the emotional intelligence of a challenging 22-year-old, right? I didn't know what exactly that meant. And so I turned to faculty and they were like, "Yeah, it's... "You know, I think you want to do population health." And that wasn't a thing over 10 years ago really, right? We didn't have all the terminology that we have now. So it was hard to kind of, like, pinpoint where that started for me. But I think that's where the paradigm started to shift, right? It's like I said, "Yes, I can be a great nurse, "if I work in the hospital "and I can give people medicine, "and I can do all of the things that "the paradigm says that a good nurse is. "But how great of a nurse am I, "if I can help someone from becoming sick to begin with?" So that's where it kind of moved. And then I moved into public health, found my way into the City of Milwaukee Health Department, worked in prenatal care coordination, STI, HIV, lead poisoning, moved to Florida, got my masters, did a little bit of tobacco prevention work. So Susan and I, we're twinnies on that. And then moving more into, like, the strategic planning community health assessment and strategy areas. So I always say, like, some people have their program areas that they really love and they cherish. And I am like, "Get me into everything," right? 'Cause everything is public health and public health is everything. So, yeah, I hope that... It's not very specific, but we can always connect more offline if needed.

- [Tricia] Perfect. Well, I think you hit the nail on the head. Public health is everything, right? Like, it's everywhere. No matter where you look at, it's everywhere. So tell me a little bit more about the organizations that you both work at, kind of the mission of your organization. I mean, granted, you both kind of indicated governmental public health agencies. So I think there's some assumptions on what those missions are, but what projects specifically are you guys in? What projects specifically are you engaged with within your organizations?

- [Susan] Yeah. Geez. Okay. So, first of all, for anyone on the call that doesn't know, Johnson County is about 156,000 people. To give you an idea, we have 50 staff. And I know people like to say, if you know one health department, you know, you know one health department, right? Because it depends on what grant money we get. It depends on what kind of community we're in. And so we do have a clinic, WIC MCH, immunizations, childcare nurse consultant, dental. I'm gonna forget somebody. So if anybody's on from where I work, don't shoot me. And then environmental health side, the food, septic well, pools, all that. And then the community health side, a lot of work was social drivers of health, whether that's in tobacco or dementia prevention, communicable diseases, vaccines, child CHIP, emergency preparedness. You know, I'm talking to the choir here, but just to give you a better idea of who we are. And our vision, I mean, it's so simple, right? A community where all can achieve optimal health. All, not some, not those that can, all. And then one of our values is actually let's... How is it said? We are intentional of our health equity impact of our efforts. That's one of our values. So the projects I'm specifically involved in, I already mentioned tobacco, opioid prevention, treatment, and recovery work, and then strategic planning. I think Kiki mentioned that as well. Accreditation and a lot of health equity thrown in there.

- [Kiki] All right. I hope everybody brought their pen and paper to write down the whole list. No, I'm just kidding. So kind of similar to what Susan was saying, right? Equity is a core value of our organization. It's one of the five that we list, right? Like, officially on our website. I would say in recent years, that's kind of expanded, so not officially on the website, but under that umbrella, we've went and expanded more into being explicitly anti-racist. So we have a anti-racism policy that specifically outlines, right? It helps hold people accountable in the organization. So I think that is really telling of our commitment to that, right? We're not just saying, because the organization made the proclamation in 2019, it was one of the first health departments to do so in saying that racism is the public health crisis, but, like, what does that mean? We didn't want that to be rendered hollow, right? So it's the continuation of that, right? Like, the manifestation of that, what does that mean? So it's an overhaul of looking at, well, how have we always done things? And is that rooted in the dominant narrative, right? Which is oftentimes parallel to white supremacy. And I know we're gonna get into that, so I won't go down that rabbit hole just yet, but it's really, you know, doing that self-reflection of, like, right, like, how much does this uphold white supremacy versus being anti-racist? And so a lot of that is very, I would say, actively, and when we mean actively being anti-racist, a lot of it is very against the grain and uncomfortable. It seems kind of... Against the grain is probably the best way to put it. I'm sure for some people it feels uncomfortable, like, right? Why are we changing? So with huge culture shifts like this too, we're also looking at, how are we managing change? So looking at change management frameworks and helping people move through those changes and feel supported, right? And I don't wanna get too far into that either. I'm sorry. I can go, can go on, and on, and on about it forever. But, yeah, I think just, like, the explicit focus in anti-racism for sure. Yeah. I guess I'll pause there. I'll stop there, 'cause then I'll get into all the other stuff.

- [Tricia] Fantastic. I know well that you can clearly tell the two of you are very passionate about what you do. So I love this. From your experiences, what are the dominant public health narratives around health equity? And what roles do these narratives play in shaping the disparities?

- [Kiki] So I think a good... I actually had this prepped, because this is... When we were discussing and prepping for this webinar, I was like, "This is so funny. "I just did a whole thing on this." Like, we're prepping another training for this. So I feel good in that, right? I'm kind of able to speak a little bit more in depth in this area. But I think the important thing to maybe start with is defining, like, what is a narrative? And for public health reasons, right? We say that public health narratives are these shared systems of meaning in a culture. And oftentimes they're invisible. They can even be conflicting sometimes, but they're manifested through how we tell stories, practices in our organizations that's gonna look like policies or just the way we do things. It's definitely reflected from an equity lens and representations, social rules, double standards, advertisements and displays, right? Like, who do we see on billboards? Who do we see in advertisements? But it kind of tells us how society works and helps us interpret that, right? So it's this overhaul of shared systems of meanings. But the reason why it's important to understand public health narratives is, because it matters which narratives are dominant. Dominant narratives tell a story about who is responsible for the production of health and illness. And that's really important, because that affects the choice of strategies, one, that we decide to go towards, and two, that seem possible or even imaginable, right? Because if there's certain dominant narratives that have always said, "Well, we do it like this," you might not even entertain this other set, right? Of potential strategies. And so dominant identities are usually parallel to dominant narratives and historically have included things like cisgender men, European ethnicities, strong English literacy, middle, upper class, heterosexual sexual orientation. That list is not exhaustive by any means. But for a peer reviewed article that I reviewed in developing this training said, these are the groups that tend to experience less explicit discrimination for "just existing," right? And so if we look at public health narrative, a lot of those are rooted in white supremacy and the cultures of oppressed and racially ethnic groups, usually those dominant narratives will say that they're responsible or at fault for their own health outcomes. That's what some of it is. So an example of that might look like, well, people aren't choosing to eat healthy, right? So public health narrative kind of features sometimes this self-determining individual of who makes right or "wrong" lifestyle choices. And then in that same vein, renders the social and political determinants of health inequity kind of invisible. And instead blames the individuals for their poor health. Not asking the right questions. Well, do they have access to a grocery store with fresh food? Do they have transportation to it? Is the store open at times that's accessible to them? Is the food affordable? Does the grocery store have foods aligned with their cultural values and preferences? And oftentimes when we're rooted in the way we've always done things, then we can't think of those strategies as even feasible or someplace that we even need to be, because for dominant identities, it might even not register, let alone be relevant or seem effective. So I think... I don't remember what the original question was, but I think that there's the importance in understanding. So when we talk about understanding narratives and the dominant narratives, it always starts kind of with us. Where do I hold dominant narratives? Where do I hold dominant identities in that? And a lot of that is done or should be done kind of at the individual, right? In an organizational level first before you're going out and working with communities, right? Like, you've gotta build your house first before you can go out and build somebody else's house. And I got that from Susan last time we were on a webinar together. So, again, I don't know if that... I forgot what the actual original question was, but I was just so excited to talk about dominant narratives. So hopefully--

- [Tricia] You nailed it. No worries. You nailed it.

- [Kiki] Okay.

- [Susan] I'm glad you did, because that wasn't the direction I was going at all. So I see why you get multiple people. I'm like, "Oh, yes, that is what narratives are." Thanks. When I think of the public narrative, I think so much of the word "equality," right? That's a word that I feel like the public understands. Equity is not one that a majority, I would say, of the public understands. I love a quick, like, image learning opportunity. And we all know the Robert Wood Johnson, the bikes, the, what was it? The baseball fields first on the bikes. And I think now they have a nice crosswalk. I'm sure most of... I'm sure all of you on the call have seen those. But I like sharing those even outside, you know, my public health circles and even during presentations about all kinds of other things. I think that question's coming up. But I feel like our responsibility in all of the other spaces is to sort of bring this issue up, because not everyone does, and not everyone understands it, because we have either been academically trained or on the job trained like me, it's built in to what we do. And there are very smart, well-meaning folks in healthcare and nonprofit organizations, and city governments in planning and zoning that don't always necessarily get it. I was gonna tell a really quick story. So I was recently, it might not have been recently, it was right around Medicaid unwind. And these two folks work in clinic settings. They're the front desk person that keeps the places running, okay? And they were sort of complaining back and forth about folks showing up kind of out the window and finding out in that moment that they didn't have Medicaid anymore. And they were sort of grumbling about it. And I said, you know, they may not have had a stable place to live at that time. You know, they may have been staying with their sister, who knows what's going on with a rental. Maybe they didn't get their mail. Is English their first language? I'm guessing that's how the letter came. You know, just these simple things that other people... So when you take it out of, you know, public health people or other folks that kind of talk about this issue a lot, it's not until you shift that story of, what is going on in that person's life? Do they just not read their darn mail? Well, no. Other people kind of go, "Oh..."

- [Tricia] Great. Again, I love the passion. So as we talk, you kind of shared, like, what the dominant public health or public narrative is. Which populations are you witnessing most affected by these dominant narratives? And how can we work to shift those narratives to better support these communities?

- [Susan] One thing is having folks tell their own stories, right? We do our work with folks, not for them, making sure that they can tell those stories, or at least they've given us the privilege of sort of passing along some of that information as well when working with us. And what else did I say? I mean, also just kind of hinting at those other things that are happening, those social drivers of health in people's life. People don't say social determinants of health, but when you talk about where they're living or where they might be working or, you know, not being able to find a job or, or childcare, or a whole host of other things. People get it. So I think explaining things in those terms to people and finding folks to tell their stories is really...

- [Kiki] Yeah. I'm just gonna piggyback on what Susan mentioned, right? Is allowing people the space, right? To tell their story and actually be heard, right? Not be tokenized or just right kind of exploited. Because that also can very easily happen sometimes even without intent. But I think it's kind of the difference. Something I've been saying a lot lately. I couldn't tell you where it comes from or where it happened. It was probably along the way, like, in a really just kind of, like, organic conversation. But I heard somebody say, I guess it maybe wasn't even that recently either, somebody was saying, you know, "Stop saying empower communities." Like, "Stop saying we need to power empower communities." You are taking away their agency when you say that? Communities have power already, but what are we doing that has stripped power, right? Or stripped the agency from them. So instead we need to focus on elevating those communities. Communities have capacity, communities have power. And so I think it's kind of just looking again at that dominant narrative of, right, well, these marginalized or, right, minority communities, right? Or there's even different language, right, that we need to be saying, right? Like, we shouldn't say marginalized communities, because they've been made marginalized. You say marginalized communities. Again, it puts blame, right? So it's even, like, even those things I catch myself still saying, because it's part of the dominant narrative of white supremacy coming in and saving communities, right? Or, like, helping. And somebody else told me once, and this is a really good conversation starter, if you ever need one, that helping is the sunny side of control. And if you've come another piece of that, if you ever need something really difficult to read, I can give you a list. But a passage in a really great book is, "If you come to help me, "you're wasting your time." And I just think that that's really reflective of that, right? Like, how are we engaging with communities? What is our role? Are we doing it for the purposes of kind of, like, this back scratch train. And saying, "Oh, yeah, we helped, we did a good job," or is it really for the elevation of the communities and giving them that agency back that a lot of the dominant narrative has taken away. And that's really done a lot through lots of self-reflection, like I said, starting at the organizational level, the self-reflection, like, the individual level, and then moving up throughout right in the community. And I think to do that, there has to be a safe place for people to learn. Let me tell you, people do not like to talk about equity. They don't like to talk about equity, 'cause they think they're gonna get into two areas that are always, like, really uncomfortable for people. And that's racism and politics. And let me tell you, if you're not uncomfortable, you are not doing it right. So, if you're uncomfortable in those spaces, I think it's really important for your organization to make space for you to have those conversations. So one of the areas that we've done kind of in response to that is our caring conversations. And for those that were on that webinar that we had last month, I think, we talked about that a little bit, right? So there are these ongoing caring conversations that focus on equity, and focus on internal growth, and self-reflection around things like racism, roots of racism, microaggressions, bias, being an ally. So just really breaking those down into very digestible, very practical applications of how you can begin to identify that in yourself and then begin to address that, right? Even just making simple changes. So another example that is neutral of race or politics, right? Is violent language. So that's one thing that I've really been working on is trying to stay away from violent language, because while I didn't grow up in a very violent household or have, you know, tons of traumatic experiences, right? Like, where violence is a trigger for me. It might be for other people. So I try to stay away from phrases like, you know, they're a straight shooter or kill two birds with one stone, right? It's like, why are we using violence to describe success or something good, right? Like, let's find another way to do that. You can use the same thing. Same with, like, colonizing language, right? Saying, like, divide and conquer, right? Or let's pow wow. Well, that's racism too and all that, but do you know what I'm saying? So it's... So many things that we just say or that are just right. And it reinforces that dominant narrative and the dominant a lot like kind of an umbrella over dominant narratives of white supremacy. Yeah, and someone popped up in the chat and said, "Target population." Yes, yes. I don't like target population. That's right. It's like we're targeting them and it's that kind of negative, almost violent narrative that can be set in other ways. The same thing with, like, needs-based assessments, right? Needs-based strategies. And instead focusing on asset based solutions. There's frameworks for that. Community based participatory research. So I'm gonna stop saying lots of frameworks, but hopefully--

- [Susan] No, I, you... So I have to say, we all make mistakes and that's something that we have through our training process and we do a continuing conversations, too, at our organization where we hold space to have those really hard conversations. And we've sort of measured over time, are people more comfortable, more confident about talking? And the University of Iowa College of Public Health folks sort of helped us tailor that evaluation. But that's what's been fun for us to see. And I used the word "shoot" at the beginning of this conversation. And as I was saying it--

- [Kiki] Oh, did you?

- [Susan] I did.

- [Kiki] Oh!

- [Susan] And I heard... No, this is great. I heard myself say it, and my brain was searching for a word, and that's the word that came out of my mouth. And I went, "That was not a great word choice." And then you panic in the moment of, like, you know, do I say something now? Or what do I do, right? And so you brought it up. So there's an opportunity for me to say, I wish I would've chose a different word. We mess it up. We're all learning for forever.

- [Kiki] Forever.

- [Susan] Just because I've taken some training or I'm helping to lead things. And I tell that to my coworkers all the time, I mess up and this is how I messed up.

- [Kiki] And, you know, I think that's so important. That's another piece I think of self-reflection that I felt help others feel safe and helps you then feel more comfortable to make mistakes in the future. So when you simply are self-reflecting, right? 'Cause a lot of that is internal dialogue, right? That we have with ourself. And going, "Oh, my gosh, I shouldn't have said that." Right? But when we say, "Hey, you know what? "I mentioned something earlier, "and I wanna just go back to that really quickly, "because I wanna explain, you know, why that wasn't right." Like, I made a mistake and I wanna explain to you why, because that helps others learn too. It's kind of like when, you know, the kid raises their hand in class, somebody else was probably thinking the same thing, right? And now they're able to learn from that person asking the question. So you modeling that is also what I talk about in this training that I just developed about being, like, authentic and vulnerable. And people in the organization or within, you know, just your family or your circle, they often follow in stride. So if you're making that place authentic from an authentic and vulnerable space, then you're making it possible for others to be vulnerable and authentic in that space too, which is needed. It's the soil, water, and sun that you need to have that growth.

- [Tricia] Absolutely. And I think that's one of those things like changing systems, changing, and changing, changing the narrative is also being able to acknowledge when that narrative is something that's been ingrained in us. When I think about, like, I'm 50 years old, right? And I've used certain language for a very long time, but now understanding how that language can be damaging is definitely eye-opening. But I also, like, I'm gonna make mistakes when I'm sitting there chatting with folks. And to be able to show I acknowledge that I screwed up, so, "Sorry about that," and moving on and acknowledging we're human. And I think that's where compassion also comes into as we shift and go through this process. Oh, my gosh, so much, so many good... So much good conversation here. I think you both kind of touched on this. Kiki, I know you have. Susan, I wanna offer space for you to be able to discuss this. And Kiki, you can dig in a little bit deeper. So, what strategies have you and your organization employed to create and disseminate new, transformative narratives around health equity? What are some of the key components of a successful strategy? What sort of things can we tell our audience that, you know, these are some of those benchmarks that will kind of show you some success or model successful strategies after? And how do these methods continue... Contribute, excuse me. Contribute to changing a broader narrative around health equity? And again, that's a lot. So if you need me to repeat anything, please let me know.

- [Susan] Well, I'm thinking about... I've had the 10 essential public health functions taped up, the wheel as I lovingly, and, well, many people probably call it that, on my wall right here next to my desk my entire career. And so if I'm doing something internally and we decided to start internally like Kiki said, because we needed to, you know, and that wheel, what do I do first? I gotta figure out where everybody's at. And that changes, because people leave, right? That happens. Unfortunately, there's turnover. And so it was really important. At this institution, I've seen a lot of folks come and go, I've seen a lot of trainings come and go. And then what? Then what? So we tried to make it sustainable and sort of institutionalize it by kind of adapting the UI College of Public Health's training, building health equity training into our own online system. So we have an asynchronous version, and then we do kind of a condensed in-person version. And then we've started these continuing conversations like you mentioned before, so that we have a common language even when you mess it up to share and to use. And that we talk about how that language changes and what to do about that. So just throw out a couple of activities, if you're ever looking for something different to do, ask me about a plastic bag example. Sometimes it's too hard to explain, but if you wanna know, holler at me. The other ones we've done... We've done... Oh, 400 years of inequality. If you've ever seen that giant timeline, and sort of printed it up, and talked about that. We've done some actual scenarios. What happens when you're on site, or this happens, or you hear this conversation from your coworkers? Inclusive language, you already mentioned that. And then recently we stumbled upon 50 reasons you might be more privileged to talk about a word that bothers people. It starts conversations within your co-worker that you didn't even realize, right? So keeping doing those things and building it into everything that we do, it's part of onboarding. They come talk about health equity with somebody from our health equity work group. Having a group is really important. And getting, moving, starting, pick something, you know, pick a framework. Framework is a fancy word in my opinion for categories. What category are you? Are you worried about data? Are you worried about culture? You want more community voice? Like, what are your categories that you're working on in health equity? I wish, you know, sometimes I think I'm a little, well, it depends on the topic, if I'm glass half full or glass half empty, and who you talk to. But while you think everybody is in public health, right? Because they know and understand all this stuff and they live, breathe, and they wanna be better, and they want to admit their mistakes, that ain't everybody. It's not. And I'm hearing that around the country. Is it just a few? Yeah, most likely. And are some of those people that are sitting in those continuing conversations going, "Oh, my gosh, "I've talked about this 1,000 times." Well, maybe the person next to you hasn't, you know? So that's helping us change our whole, like, all of us kind of hopefully have that same story to tell when we're working with folks in the community.

- [Tricia] Kiki, do you have anything else you wanted to add?

- [Kiki] Yeah, I mean, that I agree. I second, I co-sign all of that that Susan just said. I did mention a lot already. I'll just kind of reiterate. I think accountability is huge and that comes from multiple levels. So it's codifying it, right? It's putting it into policy. So it's not just this unspoken and unwritten rule, but then that way you have leadership buy-in and people feel a lot more safe to take risk when they're being told formally that it's okay for them to take risks. So it's just, even if that can't happen, I think a great way to go about it is, this is a term that they used in nursing school, but I think it applies to public health too, is having a spirit of inquiry and that that kind of... It's kind of the umbrella over, right? Like, assume best intent, reflect on intent versus impact kind of thing. But the thing about dominant narratives is that they really attempt to discredit and prevent counter narratives from gaining momentum. And so just learning even to notice and question narratives is the first step to disrupting them, right? So even if you can't, you know, have an anti-racism, you know, policy and training, you know, questioning, you know, I wonder if, you know, if this was a different person doing this, would it be the same reaction? I wonder if we were doing this in a different community, would it be the same approach? Like, so just beginning to ask those questions, because then that spirit of inquiry becomes kind of contagious, right? You're setting a counter narrative of saying, we're gonna question things, we're not just gonna accept the status quo. It's just kind of like a different, I guess, maybe strategy and going about it in saying, you know, like, "I'm not an expert in this. "Can you help me understand?" I think the humbleness, right? Like when you're, I don't know if that's the word, humility, humbleness.

- [Susan] There you go.

- [Kiki] But a science major, not an English major. So, sorry. Even in Spanish, it's not good for me. So the punctuation, and spelling, and all that stuff. But I think it's really important that when we're working with communities to sometimes know then that we might not have all the answers, right? We're a bridge in a lot of ways to say, here's a framework, we could help you organize with that. But communities are their own experts. We're just there as a liaison. We're there as maybe a resource, a tool, a mechanism, a vessel, a conduit, a convener. But we are not the be all end all or the solution. And I think one thing that I learned really early on when I made the shift from nursing, right? This kind of caring, right? It's an inherently caring profession into more public health and being more strategic was sometimes you've got to know when you're not the right person for the message. And that is the most equitable thing that you could do. And sometimes it's asking, I've never even been in this space before. I really wanna make sure that I'm supporting the community in what they need, right? Like, you know, where can I go, what can I do? What would you recommend? And sometimes just to let people know it is just like, "I'm here to hold space however you need." I've said that to stakeholders. And guess what? They bookmark you. Sometimes they come back to you later. Sometimes they're like, "No, no, no," like, "You're crazy. "We're gonna do this right now," right? But you are not assuming that you are the expert, you are not assuming that you're leading the charge. Communities lead their own charge. You're again, just there as that extra maybe, like, mechanism or gear that gets things going and can also help bring people to the right spaces. And that goes back to elevating, right? I think... There was one other thing I was gonna say and I lost my train of thought. I don't remember. It'll come back to me if it's important.

- [Tricia] No worries. I like the word "convener". That's one of the things that I talk about a lot is that, because I'm not the expert, I'm not necessarily leading the charge, I'm just bringing people to the table to start moving us forward, right? Like, that's kind of the intent. I wanna pause for a moment, and reach out to our audience, and see if anybody has any questions. If you wanna throw that in the chat or feel free to put it in the Q&A. But I wanna make sure that I'm leaving some space for everyone to pick the brains of our two fabulous folks this morning. I guess it's afternoon. Sorry about that. I'm still in morning mode.

- [Susan] Talk to us, people. Talk to us or type to us.

- [Tricia] Right? I'll go on to the next question, but please note that I'm watching the Q&A and the chat. So if anybody has any questions, I want to make sure I leave space for that. So feel free to shoot those over, but we will continue on. Love the idea that you might have the right message, but you may not be the right messenger for the situation. Absolutely. I love that. Okay, next question. How can local public health agencies take a leadership role in changing the narrative of health equity? And I think it kind of goes back to that quote that I just read, that Erin shared, what actions can they take to ensure that health equity becomes a central part of their work? I'll let you ponder that for a second and see who wants to kick it off.

- [Kiki] So, sometimes, not always, but sometimes it's really helpful to get a pair of fresh eyes on the situation. I realize that this is speaking from a level three health department that has lots of grant funding and lots of other, right? Like, even probably more levy than some health departments even dream of. But if you're able to at any point bring in a consultant to help you kind of do a very objective baseline assessment, sometimes organizations feel like they need to start in a certain way. And that can come from a lot of things, right? It can come from officials, right? That are saying, like, "You need to focus on this," so there might be pressure, right? And so you might feel pulled to go in that position. But the good thing about using, like, a consultant or even just like an outside organization, like a partnering organization, is you could really kind of change the lens then in saying, "Well, here's what you think," right? Based on the dominant narrative is the issue, but here's what it actually is. And people, like, governing officials, right? Decision makers, policy makers are more likely then to listen to that third party than somebody internally that they're kind of just seeing as kind of this pushback. They see it as this, you know, we're going with what is happening, right? In the outside world. We're going with the times. We're going with these emerging public health needs, right? That's huge. That can get you actually a lot further, even if they're not gonna do the work for you, just opening that perspective. That being said, there are a lot of public health consulting firms that will do pro bono. I know. I've worked with some before. If you do not have the means to do that again, even as, like, just a consulting piece of, like, asking them, like, "How would you approach this?" It's always good to have a fresh set of eyes, but you can do the same thing and leverage that knowledge from other stakeholders within the community. Also don't get too confined by roles and titles. Lived experience is very valuable. And if you leverage people within your organization that have that lived experience, it is so invaluable. It's worth more than a million frameworks combined in a lot of cases. So again, that's a dominant narrative, right? That we've been even trying, right? Like, in our workforce area to kind of dismantle and saying, like, "When did we decide "that you needed a degree for this position," right? Because back in the days, like, here's how it was done, right? And so there are certain exceptions for that, right? Like regulations, right? Like medical license, social work license, things like that. But if you look at kind of, like, the trajectory in history of America, and this is something that I could, like, have coffee with someone over to discuss, but the majority of jobs you did not need a college degree for up until about the '90s. And that was mostly a switch to kind of during the Reagan administration to get away from hiring certain individuals and to make sure that those opportunities are more available for the dominant, privileged society. So again, I'm not trying to get political, just trying to get just little connection to the path there of why that is, right? So you have to question like, well, why are we saying it? Who came up with these standards? Who came up with these, right, requirements or prereqs to be able to be qualified for this? Like, let's reexamine what are the knowledge, skills, and abilities that are needed to do this job? So even looking at that from that perspective and just self-reflection, challenging dominant narratives. All right, I think I kind of went off a little bit.

- [Susan] No, that was amazing. I wanna say too, even within your current workplace, whether that's a county, city, or anything else, first of all, the other municipalities around you, sometimes if they're bigger or they have more robust departments, I know that we've been able to get involved in their training and their conversations as well. So look around for that. Partner up on it. If you can't afford it, you all can afford you come together, and pay that consultant or something? And then be that leader in that organization if you can be, not by necessarily your title, but, like, so within the county here, public health is always like, "We'll try that." Like, we did a language study. One of the things we don't do here that we need to do is pay people for their language skills. I've been preaching about this for years. A lot of people have. It's not fair. You hire them for that reason and then you give them nothing for that expertise. Anyway. So the county is still looking at that, but we have kind of helped push that stuff forward. So when you talk about, you know, how can you help others or kind of, you know, be the leader there, like, just offer yourself up, offer your department up or a small group, and say, "We'll try that for you," or, "We'll tell you what we're doing." The other simple thing is talk to the staff. What are you doing in the community right now? You're doing some sort of work that touches health equity in a number of ways. And so how do you showcase that? How do you talk to one another, and say, "Well, we're doing this," or, "We're doing that." It doesn't always have to be so complicated and it doesn't have to start an end somewhere. Pick something. Pick something and start.

- [Tricia] So, we have two questions. Thank you for entering questions into the Q&A. So first question, Kiki, please say more about the efforts that lead to using anti-racist framing, public elected officials, colleagues.

- [Kiki] Okay, so I feel a little unqualified to talk about this only, because I didn't do that work. I wasn't part of the organization when they kind of did that trailblazing work. I think a really great starting point is to help public officials, one, understand what public health does. If they do not understand what public health does, they are not going to understand why you are concerned about racism. So there are still so many public officials that think public health is healthcare. And I'm like, "They are very different." We get intern applications saying, "I really want to work in the healthcare field." And I'm like, "Okay, then you need "to go to a hospital system." This is not healthcare, this is public health, right? So I think there's a very huge misunderstanding already that needs to be clarified. And the challenges with that is, now we're gonna be moving into this public health 3.0 model, which turns us into this major convener and this major strategist kind of at the hub of everything that's happening in the community. That's gonna be even more abstract for them to understand. So don't start with that. Don't lead with that. Help them understand basic core public health functions. Once that's done, then you can say, "Here's how racism impacts health." Once they make that connection, you can say, "Here's how that impacts everyone." If you focus on universal harm that racism causes, I have a couple little, like, resources and TED talks that you can kind of maybe send out as, like, a training, or a webinar, or, like, a lunch and learn. Really great to get a conversation started of, "Oh, did you know that racism actually "hurts white people in lots of ways?" So really great example that I always like to talk about is public pools, right? So after the civil rights movement in the late '60s, right? And then that act was passed. They gave access, right? To public public goods, right? So one of those public goods was pools. But then what happened is, states took that into their own hands, right? You had Jim Crow laws, things like that, that kind of trickle down, and nothing really ever goes away, right? You just kinda, like, recycle it when it comes to policies like that. That's a whole nother coffee date, whole nother conversation. But then what wound up happening was, is they closed all the pools, because they didn't want, right? Anybody who is not white to be using the pools, but, well, what happened with that then? Now you have, right? A property that's not being used, it's not being maintained, it affects housing prices in that area, right? It creates blight, because maybe it's on a piece of land that also could have been used for something and now it's not, because it's been back to the city. So there's so many ways and so many areas, right? In the social determinants of health that you can talk about how racism has historically been really bad for white people, and yet we continue to make these decisions, again based on dominant narratives. So that's kind of like a can of worms. You've gotta be prepared to kind of do that, I feel like in increments. But it's a really just good, like, reflection point of, right? Do we all agree, like, shared values, do we all agree on that we wanna be healthy? Yeah, that's pretty much a shared value, right? Do we all agree on the ability to live our life in the way we want to? Yeah, that means different things to different people, right? So if you filter down from shared values and you go based off that without using some of those, what people kind of consider kind of loaded words... See, "loaded," that's a violent term to use. There I go. See, I didn't mean to use that. It's kind of a heavier situation where sometimes some of those words that make people kind of their ears perk up or maybe they have that visceral reaction, you can use things more objectively, right? Like, you can talk about those areas more objectively. But, again, codifying it is a way to really protect it, right? So when you're embedding it then, and you like your vision, you don't just have an anti-racism policy, you're redoing all your policies to have that. It's really hard to go back, and say, "Okay, we don't wanna do this anymore," right? Because now you've done so much work that they're like, "Yeah, that's probably not gonna work. "We're probably not gonna be able to do that, "'cause it's too much work." So I would just say helping people understand what public health is, helping people understand how racism impacts health, and helping people understand how racism impacts the health of everyone. So, therefore, it is your lane, it is your job. And they'll be like, "Oh, cool, let's have coffee. "Let's talk about this more." Because somebody will be interested, maybe not everybody, and they might not talk to you at, like, the council hearing or whatever it is, but somebody will slip into your email and be like, "Can you tell me a little bit more about that? "I had no idea." And that's your window. That's who you want to be your buddy, your champion in that space.

- [Susan] For us, for it to be authentic too. We haven't done one of those policies and I know other places have, and the pushback here was, well, we hadn't done that work yet, the work that Kiki's talking about, and we hadn't done enough internally. And so you have to be ready to talk about what you're gonna do or something like that will fail miserably.

- [Tricia] So our next question from the Q&A, how do you change the narrative of health equity, public health when so many local state level legislators, specifically in Iowa, and Iowa's not unique, right? Are against those concepts or see them in an extremely partisan manner? That's a heavy question for sure.

- [Susan] I mean, we've been talking about this since COVID. I mean, we had, you know, direct instruction... Direct instruction that differed from public health advice that we had to navigate. And so I don't know that we've still figured it out. I hope, Kiki, you can be articulate about this as somebody in a different state, but. You do the work, you show what it's doing, but sometimes folks are not gonna see it. I think those things you can agree on with anybody can be the best place to start. But sometimes it feels like there's no place to agree. But finding that and trying to talk through that, it's tough. It's tough. Don't talk about it like we would talk about it. I mean, I think that's the other thing. Talk about how it benefits you and your life, if there... Don't, you know, there's folks that don't care as much about everyone else. That's just the case. And how do we talk about it in a way that, even if that's not what we feel in our heart, right? Not that it's disingenuous, but it's a way to present the topic or the issue to somebody else that has different goals in mind.

- [Kiki] I think if you are talking about certain initiatives, it's helpful, I think, to start with a shared understanding of certain core terminology. So you're gonna go back to your spirit of inquiry and you're gonna ask, "Well, "what do you think equity means in this situation? "How are you perceiving that?" 'Cause perception is reality. It doesn't matter how we intended it, it matters how it lands. You could ask that question, or in the beginning you can define what that means, right? So that it kind of dilutes, right? Kind of the power, right? That it has to have that emotional reaction from people. So you're doing that right away in the beginning of whatever you're proposing or discussing, or you can do what's called beautiful community. It's a governing style where you decide what that word means together and that's your opportunity to kind of include them in the process and people don't critique what they create. So if you are educating them in the process and then they kind of come to an agreement of, sure, I agree with that, right? And so you're asking very objective statements about what equity can mean. And in that, you can ask questions and reinforce maybe concerns or areas that people are really worried about. So, for example, usually with a program or initiative. It's, well, everybody needs this, everybody needs access to... I'm gonna make something up off the top of my head. Everybody needs access to doula services, right? Why are we creating, you know, this program that is just focusing on a certain subpopulation? And then your answer could be, "I agree, everybody does need doula services." The evidence points out that this is an extremely effective way to reduce infant and maternal mortality. But I'll ask you, right? You know, senator or assembly person, whoever representative, like, whoever it is, councilman, "Who needs it first?" "Who needs it first?" We have every intention on being able to offer this to the general public, but here's what we know about communities, that they can only be as healthy as their most unhealthy group or person. So here's how this is gonna help everybody. And you go back to that universal benefit component. I know that's kind of, like, surface. I don't know if that's very helpful, but, Susan, I'm speaking for you a little bit, I know that either of us would be really happy to kind of flush out some ideas, go more into depth, be a little bit more contextual with the questions that you're asking or the initiatives that you're trying to have conversations about, 'cause public health, one thing about us is there's no copyright, right? Like, we all borrow ideas from each other, which is great, because then we all get to kind of titrate and adapt those responses then to be applicable to our communities and to the people that we're working with.

- [Susan] Having somebody from the outside, like you said... Oh, sorry, Tricia.

- [Tricia] I'm gonna jump in.

- [Susan] Yeah, say these things is helpful, because--

- [Tricia] Yes. Sorry, we have less than two minutes and I wanna make sure, A, we don't have any more questions, but, B, just to give a couple actions steps, for organizations or individuals that really wanna start this work, what should they do to make a meaningful impact or some of the first steps that they should be taking? So in less than two minutes, how would you answer that or what would be the key pieces that you would wanna make sure they take away from today?

- [Susan] You ready? I'm ready. Go. Assessment. Figure out where you're at internally. That's what I think. And figure out how to institutionalize what you all know, that you have a common language and that you've talked about all these things, and folks internally feel more comfortable about moving forward with it. It ain't easy, but that's a good starting spot.

- [Kiki] I have a couple things. Again, please feel free to reach out if you have questions. I don't have all the answers by any means, but I might have a response or a resource that then pings you and bounces you off to get to the right thing. It's all about paths in public health. But I would say please check out a resource. I can give it to Tricia to give out to the group afterwards. Please check out GEAR, The Government Alliance on Racial Equity. They have a resource. So it's all about, like, integrating that into your governmental entity that you work for. The public health training centers, racial justice competencies, that also has a toolkit for you to be able to reflect and see where you're at in an organization. Because I'm all about frameworks and toolkits, right?

- [Susan] Yes. Bar high.

- [Kiki] Yep. Love being able to just look at something and say, like, "Where are we at with that assessment." So that's what I would recommend.

- [Tricia] Awesome.

- [Kiki] There's just a couple books and stuff, but anyways. Yeah. Yeah.

- [Tricia] So, yeah, so Kiki, Susan, whatever tools you use, feel free to share with us so we can get those out to all the participants. I want to thank everyone. And Susan and Kiki, thank you for your expertise spending time with us today. Also a reminder, if you haven't subscribed to the university's building health equity webinars and so you'll get announcements on when the next ones are available. And let me see, I think I covered everything. Again, thank you to our speakers. I appreciate everything you have done and thank you for all the participants. It is been a great opportunity to connect and share some strategies moving forward. Have a wonderful day. Take care.

- [Susan] Take care.

- [Kiki] Yeah, stay in touch, LinkedIn. Email if you need. All of that. I always love seeing what everybody's up to, so.

- [Tricia] Awesome. Thank you.

- [Kiki] All right, bye.